Inspection Reports for Azalealand Nursing Home

The document is a statement of deficiencies and plan of correction for Azalealand Nursing Home following a survey completed on January 14, 2025.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard survey concluded on November 7, 2024.

All deficiencies cited in the prior Standard survey were found to be corrected during this revisit survey.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted during the follow-up survey.

An unannounced Emergency Preparedness survey was conducted following a State Agency Annual Emergency Preparedness Survey to assess compliance with emergency preparedness and life safety code requirements.

The facility was found in substantial compliance with 42 CFR 483.73 for Emergency Preparedness and with Medicare/Medicaid participation requirements related to Life Safety from Fire under 42 CFR Subpart 483.90 and NFPA codes.

A State Licensure survey was conducted at Azalealand Nursing Home from November 4, 2024, through November 7, 2024, to assess compliance with state health regulations and facility policies.

The inspection revealed multiple deficiencies including unsecured medication and treatment carts, failure to implement enhanced barrier precautions during wound care, improper food safety practices including unlabeled and undated food items, failure to wear beard restraints in dietary services, and incomplete background screening documentation for licensed practical nurses.

A standard survey was conducted by Certiserv LLC on behalf of the State of Georgia Department of Community Health at Azalealand Nursing Home from November 4 through November 7, 2024, to assess compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to conduct required background checks for licensed nurses, inadequate wound care infection control practices, unsecured medication carts, failure to use beard restraints in food service, unlabeled and undated resident food items, and failure to implement enhanced barrier precautions during wound care.

A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness requirements for participation in Medicare/Medicaid.

The facility was found not in substantial compliance with fire safety requirements, including failure to perform required smoke detector sensitivity testing, fire sprinkler heads obstructed or dusty, and improper materials used to seal penetrations in fire walls and smoke compartments.

An abbreviated/partial extended survey was conducted to investigate complaints GA00232449 and GA00240903.

The complaints GA00232449 and GA00240903 were unsubstantiated with no deficiencies cited during the survey.

Complaints GA00232449 and GA00240903 were investigated and found to be unsubstantiated with no deficiencies cited.

The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility failed to report complete information about COVID-19 to the CDC's NHSN between 06/05/2023 and 06/11/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 05/08/2023 and 05/14/2023 as required by CMS and CDC regulations, potentially causing more than minimal harm to all residents.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted during the follow-up survey.

The inspection was conducted as a Licensure Survey from November 15, 2022 through November 17, 2022 to assess compliance for facility licensure renewal.

No deficiencies were identified during the Licensure Survey conducted from November 15, 2022 through November 17, 2022.

A standard survey was conducted at Azalealand Nursing Home from November 15, 2022 through November 17, 2022 to assess compliance with Medicare/Medicaid regulations.

The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.

The facility was found not in substantial compliance with fire safety requirements, including failure to ensure the fire alarm breaker was red and locked, lack of proper maintenance and inspection of the sprinkler system, unsecured open spaces in electrical panels, and improper use of extension cords and multi-plug adapters.

The facility was surveyed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 10/31/2022 and 11/06/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.

An abbreviated survey was conducted to investigate complaint #GA00222333.

The complaint #GA00222333 was substantiated but no regulatory violations were found.

Complaint #GA00222333 was substantiated with no regulatory violations.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.

A revisit survey was conducted to verify correction of deficiencies cited in the 8/4/2020 COVID-19 Infection Control Survey.

All deficiencies cited as a result of the 8/4/2020 COVID-19 Infection Control Survey were found to be corrected.

A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations related to COVID-19.

The facility was found not in substantial compliance with infection control regulations due to failure to ensure staff followed transmission-based precautions for a COVID-19 positive resident, specifically improper handling of a contaminated drinking cup by a Certified Nurse Aide.

A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on June 2, 2020 to assess compliance with emergency preparedness and infection control regulations related to COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, having implemented CMS and CDC recommended practices to prepare for COVID-19.

The document is a statement of deficiencies and plan of correction for Azalealand Nursing Home following a regulatory survey completed on March 5, 2020.

The report contains initial comments and a summary statement of deficiencies identified during the survey; however, no specific deficiencies or findings are detailed on this page.

A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2020-01-09.

All deficiencies cited as a result of the 2020-01-09 standard survey were found to be corrected during this revisit survey.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

The inspection was conducted as a Licensure Survey for Azalealand Nursing Home.

No deficiencies were identified during the Licensure Survey.

A standard survey was conducted from January 6, 2020 through January 9, 2020, including investigation of Complaint Intake Number GA00201125.

The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to ensure a medication order for levothyroxine was correctly transcribed upon admission for one resident (#70).

Complaint Intake Number GA00201125 was investigated in conjunction with the standard survey.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance due to failure to maintain smoke compartment doors that close completely and failure to segregate empty oxygen cylinders from full cylinders, placing residents at risk in the event of fire.

An abbreviated survey was conducted to investigate complaint GA00195559 at Azalealand Nursing Center.

The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

Investigation of complaint GA00195559; facility found in substantial compliance.

A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted from August 6, 2018 through August 9, 2018.

All deficiencies resulting from the annual survey were found to be corrected during this revisit survey.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.

The facility was found to be in substantial compliance with the Emergency Preparedness plan requirements and Life Safety Code standards.

A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.

The follow-up survey found that all previously cited deficiencies had been corrected.

A standard survey was conducted at Azalealand Nursing Home from September 18, 2017 through September 21, 2017 to assess compliance with Medicare/Medicaid regulations.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.

The facility was found not in substantial compliance due to failure to maintain proper access to an electrical panel in the Physical Therapy closet, where walkers were stacked in front of the breaker panel, posing a fire hazard risk to residents and staff.