A list of the most recent deficiencies for Azalea Health and Rehab Center. 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? |
|---|---|---|---|---|
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-06-23 | 2023-07-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-23 | 2023-07-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-23 | 2023-07-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-23 | 2023-07-19 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-23 | 2023-07-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-23 | 2023-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-23 | 2023-07-19 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-01 | 2023-04-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-09 | 2023-01-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-09 | 2023-01-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-09 | 2023-01-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-09 | 2023-01-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-09 | 2023-01-04 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-09 | 2023-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-09 | 2023-01-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-09 | 2023-01-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-09 | 2023-01-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-03 | 2022-06-29 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-06-03 | 2022-06-29 | Y |
| Keep all essential equipment working safely. | Health | 2022-06-03 | 2022-06-29 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-06-03 | 2022-06-28 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-03 | 2022-06-28 | Y |
| 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 | 2021-09-23 | 2021-10-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-23 | 2021-10-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-23 | 2021-10-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-09-23 | 2021-09-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-23 | 2021-09-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-28 | 2021-05-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-28 | 2021-05-01 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-12 | 2019-12-30 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-12-12 | 2019-12-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-12 | 2019-12-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2019-11-08 | N |
