Azalea Health & Rehab Center

Inspectors wroteBased on record review, staff, residents, and Nurse Practitioner (NP) interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of taking psychotropic medications prior to the administration of psychotropic medications for 5 of 5 residents reviewed. (Resident #23, #32, #72, #80 and #105). a). Resident #80 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder. A physician order written on 12/19/25 until 06/26/26 revealed Sertraline 50 mg one tablet daily for depression. Review of Resident 80's electronic health record revealed there was no psychotropic consent signed for the medication prior to administration on 12/19/25. [...]

Inspectors wroteBased on record review, staff and resident interviews, and Nurse Practitioner interviews, the facility failed to inform and provide written information to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive (a form that indicates a resident's wish and what action to take for their health if the residents were no longer able to make their own decision). In addition, the facility failed to ensure code status was accurate throughout the medical record. This failure had the potential to affect 15 of 23 sampled residents (Resident #8, #9, #11, #12, #13, #16, #47, #71, #75, #80, #102, #103, #104, #105 and #107).

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure expired food and food items with signs of spoilage were removed from 1 of 1 walk in refrigerator. This failure had the potential to affect food served to residents.

Inspectors wroteBased on record review, and Physician and staff interviews, the facility failed to thoroughly review the hospital discharge summary and clarify physician orders for a newly admitted resident (Resident #231) resulting in the failure to transcribe and administer an intravenous (a catheter inserted into a vein for medication administration) antibiotic medication listed on the discharge summary. Penicillin G (antibiotic) was not administered from 03/29/25 through 03/30/25 resulting in 6 missed doses of the antibiotic treatment. This deficient practice occurred for 1 of 1 resident reviewed for significant medication errors.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to hold a blood pressure medication according to the physician ordered parameters and administered the blood pressure medication unnecessarily to 1 of 5 residents reviewed for unnecessary medication administration (Resident # 55).

Inspectors wroteBased on record review and interviews with staff and Nurse Practitioner, the facility failed to have a complete and accurate medication administration record related to a blood pressure medication. This was for 1 of 5 residents (Resident #55) reviewed for unnecessary medications.

Inspectors wroteBased on record review, observations, resident, staff, and Nurse Practitioner interviews, the facility failed to prevent Resident #1 from being left unsupervised in the facility ' s transportation van when Transporter #1 left the resident in the van with the doors and windows closed and the engine turned off midday in the summer heat ([DATE]) for approximately 10 to 30 minutes. The temperature outside was between 92 and 94 degrees Fahrenheit (F). The facility staff did not identify Resident #1 was not in the facility until his family member arrived at the facility and was unable to locate him. Resident #1 indicated he was yelling for help, he was panicked, became short of breath, was scared, and thought he was going die. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to maintain complete and accurate medical records by not ensuring Nurse #1 documented the vital signs in the medical record for 1 of 5 residents (Resident #1) reviewed for medical record accuracy.

Inspectors wroteBased on staff, Nurse Practitioner, and resident interviews, the facility failed to treat a resident with dignity and respect when Nursing Assistant (NA) #2 spoke to Resident #1 in a manner that made her cry, feel nervous, anxious, and as if she was going to have a panic attack. Resident #1 was observed by staff crying inconsolably (unable to be comforted) following an interaction with NA #2. This deficient practice affected 1 of 3 residents reviewed for dignity and respect.

Inspectors wroteBased on observations and interviews the facility failed to have sufficient dietary staff to ensure meals were delivered at the posted mealtimes. This failure had the potential to impact 74 of 74 residents who received oral nutrition.

Inspectors wroteBased on observations, staff interviews and review of manufacturer's instructions, the facility failed to: 1) store the hand-held plastic scoops outside of 2 of 3 dry food bins holding flour and sugar 2) wash dishes in hot water and sanitize dishes in the facility's three-compartment sink per Food and Drug Administration Food Code recommendations in a quaternary sanitizing solution of at least 50-parts per million (ppm) and maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer and maintain a clean and sanitized kitchen area for food preparation. These practices had the potential to affect 74 of 74 residents' food quality and kitchen sanitation safety.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure the area surrounding dumpsters remained free of garbage and debris and to close and/or replace all missing doors to the dumpsters that contained waste for 1 of 2 dumpsters reviewed. These failures had the potential to attract pests and rodents.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide effective leadership and implement effective systems to ensure the facility was able to obtain 60-gallon, 30-gallon, and 10-gallon plastic can garbage liners, toilet tissue, paper towels, and 30 ml. plastic medication cups to meet residents' needs. This failure result affected 74 of 74 residents reviewed for Administration.

Inspectors wroteBased on record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to maintain implemented procedures and monitor interventions the committee put in place following a Focused Infection Control survey and complaint investigation completed on 06/23/23, a recertification survey and complaint investigation completed on 12/09/22, a Focused Infection Control survey and complaint investigation completed on 06/03/22, a recertification survey and complaint investigation completed on 09/23/21, and a revisit survey and complaint investigation completed on 04/28/21. This was for 5 deficiencies cited in the areas of Quality of Care (684), Nutrition/Hydration Status Maintenance (692), Labeling and Storing Drugs & Biologicals (761), Sufficient Dietary Support Personnel (802), and Food Procurement, Store, Prepare, and Serve (812). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services (Resident #18 and Resident #66) and failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (form 10123) prior to discharge from Medicare Part A skilled services (Resident #324) for 3 of 3 residents reviewed for beneficiary protection review.

Inspectors wroteBased on observations, record review, staff, Registered Dietician, and Nurse Practitioner interviews the facility failed to obtain physician ordered weights for 7 of 7 residents (Resident #274,#5, #31, #24,#47, #48, #26 ) and provide a nutritional supplement for 1 of 1 resident (Resident #274) reviewed for nutrition.

Inspectors wroteBased on record review and interviews with the staff, Administrator and Regional Nursing Consultant, the facility failed to prevent the Director of Nursing (DON) from having a resident care assignment including working on the medication cart with a facility census of greater than 60 residents for 7 of 7 days reviewed.

Inspectors wroteBased on observations, record review, staff, Registered Dietician, and Nurse Practitioner interviews the facility failed to provide physician ordered low concentrated sweets therapeutic diets to 2 of 2 diabetic residents (Resident #34 and Resident #48) reviewed for nutrition.

Inspectors wroteBased on resident, staff and Registered Dietician interviews, the facility failed to provide packed meals for a dialysis resident who left the facility at 6:30 AM and did not return until lunchtime three days a week for 1 of 1 resident reviewed, Resident #279. This deficiency had the potential to affect all five residents residing at the facility who received hemodialysis.

Inspectors wroteBased on record review, staff and Nurse Practitioner interviews the facility failed to administer a topical antibiotic ointment prescribed for treatment to the nasal area following a dermatology procedure and to administer antibiotic ophthalmic drops according to the physicians order for 2 of 2 residents (Resident #48, and Resident #43) reviewed for quality of care.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement the treatment protocol for a newly acquired nephrostomy tube (a catheter surgically placed through the back and into the kidney to drain urine that is blocked). The treatment included monitoring the insertion site for signs and symptoms of infection, providing daily dressing changes to the insertion site, monitoring and recording urine output, and monitoring the tube for kinks or obstruction. This resulted in the nephrostomy tube and insertion site not being monitored for 8 days following hospitalization. There was no negative outcome. This occurred for 1 of 1 resident ( Resident #5) reviewed for catheter care.

Inspectors wroteBased on record review, observation, and staff, Registered Dietician and Nurse Practitioner interviews, the facility failed to follow a physician order for the method of administration of the enteral feeding (nutrition taken through a tube directly into the stomach) and the calculated amount of water flush. 2) Implement the enteral feeding tube policy upon admission resulting in the residents gastrostomy tube not being flushed every six hours when not in use with 30 milliliters of water for 4 days following admission. This occurred for 2 of 2 residents (Resident #26, and Resident #274) reviewed for management of enteral feeding tubes.

Inspectors wroteBased on observation, and staff, Corporate Nursing Consultant and Administrator interviews the facility failed to: store an opened bottle of lorazepam in the locked box of the medication refrigerator and label a bottle of lispro insulin with an opened date for 1 of 1 medication storage rooms observed for medication storage (Hibiscus Pharmacy Room). 1. An observation of the Hibiscus Pharmacy Room (Medication Storage Room on 100 hall) with Nurse #12 in attendance revealed the nurse unlocked the room. In the Pharmacy Room there was a refrigerator which was unlocked. An unlocked box was observed in the refrigerator. The box contained two 30 milliliter bottles of lorazepam concentrate 2 milligrams per milliliter labeled for Resident # 53. One of the bottles was sealed. The other bottle was opened with liquid observed in the bottle. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to post accurate nurse staffing information for 15 of 84 days for daily nursing posted staffing data reviewed. This included nursing and unlicensed nursing staff.

Inspectors wroteBased on record review and staff interviews the facility failed to complete discharge Minimum Data Set (MDS) assessments for 3 of 3 residents reviewed for discharge. (Resident #63, Resident #13, and Resident #52).

Inspectors wroteBased on staff interviews and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 24 residents reviewed for MDS accuracy (Resident #38 and Resident #323).