A list of the most recent deficiencies for Azalea Health and Rehab LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2022-01-12 | 2023-09-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-28 | 2022-11-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-28 | 2022-11-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-28 | 2022-11-27 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-12 | 2022-02-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-01-12 | 2022-02-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-01-12 | 2022-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-12 | 2022-02-15 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-01-12 | 2022-02-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-12 | 2022-02-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-12 | 2022-02-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-07 | 2022-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-02-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-15 | 2021-08-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-08-07 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2021-06-15 | 2021-08-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-15 | 2021-08-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-15 | 2021-08-07 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-02 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-02 | 2019-05-17 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-05-02 | 2019-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-02 | 2019-05-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-02 | 2019-05-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-12 | 2018-05-07 | N |
| Post nurse staffing information every day. | Health | 2018-04-12 | 2018-05-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-04-18 | 2018-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-18 | 2018-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-18 | 2018-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-18 | 2018-05-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-18 | 2018-04-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-04-18 | 2018-04-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-18 | 2018-04-18 | N |
