Azalea Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Azalea Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF656Sep 11, 2025

  Based on record review, staff interviews, and review of the facility policy titled Patient's Plan of Care, the facility failed to ensure the care plan was followed for two (R) (R78 and R31) of 37 residents related to Activities of Daily Living Care for R78 and R31 related to medication parameters. Harm was identified to have occurred on 12/13/2024 when Certified Nursing Assistant (CNA) EE was providing ADL care alone, resulting in R78 falling out of bed and sustaining a sub-capital fracture of the femoral neck.Findings included:1. […]

• Actual harm, isolatedF689Sep 11, 2025

  Based on record review, staff interviews, and review of policy titled Falls Management, the facility failed to provide care by two staff members for one of two residents (R) (R78) reviewed for falls. Harm was identified on 12/13/2024 when resident R78 fell from bed during care, resulting in a right hip fracture.Findings included: A review of the facility policy dated 12/29/2023 titled Falls Management revealed upon admission/readmission, the nurse will complete the Falls Risk Assessment and address the risk factors related to the patient on the plan of care and implement appropriate interventions as identified.A review of the medical record for R78 revealed the resident was initially admitted to the facility on [DATE] with the following diagnosis's not limited to fracture of unspecified… […]

• No harm, potential for more than minimal, patternF584Sep 11, 2025

  Based on observations and staff interviews, the facility failed to ensure vents were free from dust and grime buildup in five resident rooms on one of two halls (Hall B).Findings included:An observation on 9/9/2025 at 12:04 pm revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 11:32 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 11:11 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 10:16 am observed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 10:43 am revealed that the air vent was covered in dust buildup in Hall B in… […]

• No harm, potential for more than minimal, isolatedF554Sep 11, 2025

  Based on observations, staff interviews, record review, and review of the facility's policy titled Pharmacy Services, the facility failed to ensure one of 37 sampled residents (R) (R40) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility. Findings included:A review of the facility policy titled Pharmacy Services: dated 12/31/2024 revealed that the facility will facilitate a process for safe self -administration of medications by patients when appropriate each patient who desires to self administer medication is permitted to do so if the nursing center's interdisciplinary team has determined that the practice would be safe for the patient and other… […]

• No harm, potential for more than minimal, isolatedF759Sep 11, 2025

  Based on observations, staff interviews, record review, and a review of the facility policies titled Medication Administration-General and Insulin Administration, the facility failed to ensure a medication error rate of less than five percent for three of five residents (R) (R39, R14, and R31). There were three errors from 47 opportunities observed for a medication error rate of 6.38 percent. Findings included:A review of the Medication Administration-General policy revealed that medications are administered as prescribed, in accordance with good nursing principles. […]