Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azalea Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to follow care plans for two residents. One resident with severe cognitive impairment and a 2-person bed mobility assist requirement fell out of bed and sustained a femoral neck fracture when only one CNA provided care. Another totally dependent resident had a care plan directing tube feeds to be held around Dilantin administration, but an RN did not hold the medication as required and stated she did not realize the parameter applied.
Failure to Provide Two-Person Assist During Bed Mobility: A resident with severe cognitive impairment, Parkinson’s disease, and dependence on staff for self-care and mobility required a two-person assist for bed mobility. While a CNA was providing care alone and turning the resident in bed, the resident rolled out of bed, complained of pain, and was sent to the ER, where imaging showed a femoral neck fracture/right hip fracture.
The facility failed to keep air vents free of dust and grime in five resident rooms on Hall B. Surveyors observed dirty vents in multiple rooms, and the Maintenance Director confirmed the filters were dirty and had last been cleaned in August, while the ESD stated the facility had no policy for cleaning or maintaining air filters or AC units. The Administrator confirmed the dirty filter and said it should be cleaned immediately when dirty.
A resident with vascular dementia and severe cognitive impairment had unauthorized OTC medications left on a nightstand, and the record did not include a self-administration assessment. Staff confirmed the resident was confused and not assessed for self-administration, while the DON stated the IDT had not assessed any residents for self-administration and was unaware of the medications in the room.
Expired lubricating jelly and diclofenac sodium topical gel were found on one med cart, and unopened Rocklanta eye drops that required refrigeration were found on another cart without being refrigerated. Staff, including a CMA, LPN, RN, ADON, DON, and pharmacy consultant, acknowledged the storage problems and confirmed the items were expired or needed refrigeration before use.
Care Plan Not Followed for ADL Assistance and Medication Parameters
Penalty
Summary
The facility failed to ensure the care plan was followed for two residents related to ADL care and medication parameters. For one resident, the record showed a diagnosis history including a right femur fracture, Parkinson’s disease, dementia, COPD, and schizoaffective disorder. The quarterly MDS indicated severe cognitive impairment with a BIMS score of 4 and dependence on staff for self-care and mobility, requiring 2-person assistance. The care plan identified the resident as a fall risk and included 2-person assist with bed mobility, but on 12/13/2024 CNA EE provided ADL care alone, and the resident fell out of bed and sustained a sub-capital fracture of the femoral neck. The DON confirmed the resident was a 2-person assist for bed mobility and that the CNA was the only staff providing care. For the second resident, the MDS showed a BIMS score of 00 and total dependence for ADL care. The care plan identified a risk for phenytoin toxicity and included the intervention to hold g-tube feeding one hour before and one hour after Dilantin administration. The record showed the resident’s tube feeds were to be held around phenytoin administration, but RN FF stated she did not hold the medication as required and did not realize the medication needed to be held. She also stated she only reviews care plans when there is a change in condition. The MDS coordinator and DON stated that medication parameters are included in the care plan and that nurses have access to review them.
Failure to Provide Two-Person Assist During Bed Mobility
Penalty
Summary
The facility failed to provide care by two staff members for one of two residents reviewed for falls. Resident R78 had diagnoses including a right femur fracture, Parkinson’s disease, severe dementia, COPD, and schizoaffective disorder. The Quarterly MDS assessment showed a BIMS score of 4, indicating severe cognitive impairment, and Section GG showed the resident was dependent on staff for self-care and mobility and required two persons. The facility policy titled Falls Management stated that upon admission or readmission, the nurse will complete the Falls Risk Assessment, address risk factors on the plan of care, and implement appropriate interventions as identified. On 12/13/2024, while CNA EE was providing patient care and changing the resident’s brief and bed, the resident rolled out of bed onto the floor. CNA EE stated she was the only CNA providing care even though the resident required a two-person assist for bed mobility. The resident complained of right knee pain, was sent to the emergency room, and the hospital X-ray showed a subcapital fracture of the femoral neck, identified in the report as a right hip fracture. The DON confirmed the resident was a two-person assist for bed mobility and that the fall occurred when CNA EE provided care without assistance from another staff member.
Dirty Air Vents in Resident Rooms
Penalty
Summary
The facility failed to ensure vents were free from dust and grime buildup in five resident rooms on Hall B, affecting the resident environment in those rooms. Surveyors observed on 9/9/2025 that the air vents in each of the five rooms were covered in dust buildup at different times throughout the day. During interviews on 9/10/2025, the Maintenance Director stated he was responsible for cleaning the filters and confirmed the filters were dirty, possibly last cleaned in August 2025. He later said the filters were last cleaned on 8/13/2025 and that cleaning them takes days because he removes them outside, applies a purple cleaning solution, and hoses them off, working one hall at a time. The Environmental Services Director confirmed the air filters were dirty and stated the cleaning was tracked in Telles' maintenance system, but also said the facility did not have a policy for cleaning or maintaining air filters or air conditioning units. The Administrator confirmed the observed air filter in one room was dirty and stated that when filters are dirty, they should be cleaned immediately.
Unauthorized Medications Found at Resident Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that one sampled resident, who had diagnoses including vascular dementia, paroxysmal atrial fibrillation, hypertension, and chronic obstructive pulmonary disease, did not have unauthorized, unsecured medications at bedside. The resident’s quarterly MDS assessment showed a BIMS score of five, indicating severe cognitive impairment, and the clinical record did not contain a completed assessment to determine whether the resident was capable of self-administering medications. The facility policy titled Pharmacy Services stated that self-administration is permitted only when the interdisciplinary team determines it is safe and the resident can accurately self-administer medications. During an observation of the resident’s room, staff found a bottle of antacid tablets and a small tube of sterile lubricant eye ointment on the nightstand. A CMA reported being unaware of the medications in the room and stated the resident had periods of confusion that would make her incapable of self-administering medications without supervision. An LPN later confirmed the medications were in the room, removed them, and stated the resident had not been assessed for self-administration and was very confused. The DON reported that the IDT had not assessed any residents to self-administer medications and was unaware of the medications in the resident’s room.
Improper Storage of Expired and Refrigerated Medications
Penalty
Summary
Medications, biologicals, and supplies were not stored properly in two medication carts, including items that were expired or required refrigeration. On B hall medication cart, a CMA observed lubricated jelly dated [DATE] and diclofenac sodium topical gel 1% that had expired in [DATE]. The CMA acknowledged that both items were expired and stated the lubricated jelly should have been discarded. An LPN also admitted the diclofenac sodium topical gel 1% had expired and stated the lubricated gel expired in [DATE]. Staff interviews indicated that cart management was a shared responsibility, with night shift ultimately responsible for managing the medication cart, and that medication carts were expected to be clean, labeled, and have medications discarded timely. On A hall medication cart, an RN observed unopened Rocklanta eye drops that required refrigeration before use, with labeling on the box stating to refrigerate before use. The RN stated she was unsure how long the box had been in the cart and admitted the eye drops were not refrigerated and should have been. The ADON confirmed the eye drops were unopened and required refrigeration, and the DON, facility regional nurse, and pharmacy consultant all stated that Rocklanta eye drops are to be refrigerated until opened.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Metter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Nursing Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Orchard Health And Rehabilitation | 6.1 mi | ★★★★★ | 0 | 0 |
| Twin City Trails Of Journey Llc | 13.7 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - Swainsboro | 14.9 mi | ★★★★★ | 6 | 0 |
| Westwood Healthcare And Rehabilitation | 16 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.