Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Azalealand Nursing Home during CMS and state inspections, most recent first.
Improper food storage and an unsanitary ice machine were identified in the kitchen. Multiple open food items were found without dates, labels, or expiration dates, including meats, baked goods, vegetables, noodles, rice, and cheese, and the CDM and DS confirmed the items were not properly labeled. The ice machine also had a dirty substance on both the inside and outside.
Failure to Maintain Privacy During Care and Transfer: Two residents were observed without adequate privacy during care. One resident with dementia and a right femur fracture was transferred with a Hoyer lift while the room door was open, exposing the resident below the waist. Another resident, who required substantial assistance with toileting, was receiving incontinent care with the blinds open and the privacy curtain not fully closed, leaving the resident uncovered and visible to others outside and entering the room. Staff acknowledged forgetting to close the door, blinds, and curtain and identified the situations as dignity issues.
Unauthorized medications were found at the bedside of four residents without orders or documented self-administration assessments. One resident with severe cognitive impairment had lubricant eye drops and ipratropium bromide nasal spray on the bedside table, while three other residents with varying cognitive status had lubricant or prescribed eye drops at the bedside. The DON and ADON confirmed none of the residents were authorized to self-administer meds, and the DON stated the items appeared to be OTC products brought in by family.
The facility failed to comply with food safety standards, as the Food Service Director served food without a beard restraint, contrary to FDA guidelines. Additionally, food items in the nourishment refrigerator were not labeled or dated, violating the facility's policy. Staff interviews confirmed the expectation for labeling and dating, but this was not consistently practiced.
The facility failed to conduct background checks for three LPNs, as required by their abuse policy, due to a misunderstanding of the rules. The HR Director and Administrator believed that if an LPN's license was in good standing, no additional checks were needed. This oversight potentially placed 70 residents at risk of abuse, neglect, and exploitation.
A facility failed to evaluate the competencies of a Wound Care RN in infection control, observed during wound care for a resident. The RN placed clean dressings on the bed without a barrier, did not wash hands or change gloves between treating wounds, and provided a snack without handwashing. The RN was unaware of proper procedures, and the facility lacked a policy on nurse competencies, with no documentation of competency evaluations.
The facility failed to lock and secure two of five treatment and medication carts when unattended, as required by their policy. Observations revealed unlocked carts containing medications and biologicals, with staff confirming the carts should have been secured. Interviews with staff, including an RN, LPNs, the DON, and the Administrator, highlighted the importance of locking carts to prevent unauthorized access and ensure resident safety.
A facility failed to implement enhanced barrier precautions and proper infection control during wound care for a resident with multiple wounds. The Wound Care RN did not follow procedures for changing gloves and washing hands between treating different wounds, nor did she use a barrier for clean supplies. Despite active orders for EBP, the RN did not adhere to these precautions, increasing the risk of cross-contamination. Interviews revealed a lack of awareness and training among staff regarding infection control practices.
Improper Food Storage and Unsanitary Ice Machine
Penalty
Summary
Food items were found improperly stored in the kitchen and dry pantry, with multiple open foods not dated or labeled, including fish sticks, chicken breast, diced ham, hush puppies, hamburger patties, onion rings, pound cake, a slice of cake, sliced tomatoes, grits, cream of wheat, unidentifiable frostbitten meat, and shredded cheese. In the dry pantry closet, two packs of spaghetti noodles wrapped in saran wrap, two open bags of macaroni noodles, an open bag of wide noodles, and an opened bag of rice were found with no expiration date. The facility policy stated that food should be stored in a manner designed to prevent contamination and keep it safe, wholesome, and appetizing. During the same kitchen observation, the ice machine was found to have a dirty substance on both the outside and inside. The CDM observed and confirmed that the listed food items were not dated or labeled and that the ice machine was dirty inside and outside. The DS also confirmed that the items should have been labeled and dated with open and expiration dates.
Failure to Maintain Privacy During Care and Transfer
Penalty
Summary
The facility failed to ensure resident privacy during incontinent care and transfer for two residents. One resident had diagnoses including dementia and a right femur fracture, and the Quarterly MDS documented a BIMS score of 9 with dependence for ADLs and transfers requiring a mechanical device. During observation, two CNAs were transferring the resident to a shower bed with a Hoyer lift while the room door was wide open, leaving the resident’s body exposed from the waist down and visible to others. Both CNAs stated they forgot to close the door and confirmed the lift and shower bed could fit in the room with the door closed; they also acknowledged this was a dignity issue. The second resident had diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, cognitive communication deficit, and a cardiac pacemaker. The Quarterly MDS documented a BIMS score of 15 and substantial to maximal assistance needed for toileting, with dependence for most ADLs. During incontinent care, the window blinds were open and the privacy curtain did not fully encircle the bed, leaving the resident uncovered below the waist and visible to people entering the room and to the public outside through the window facing the street and walkway. The resident stated staff never closed the blinds and that her preference was for staff to ensure privacy by closing the window; the CNA confirmed forgetting to close the blinds and to fully close the privacy curtain.
Unauthorized Medications Left at Bedside
Penalty
Summary
The facility failed to ensure that four sampled residents did not have unauthorized and unsecured medications at the bedside. Review of the facility policy on medication storage stated that medications and biologicals are to be stored safely, securely, and properly, and that only licensed nursing personnel, pharmacy personnel, or other lawfully authorized staff may access medication supplies. The policy also stated that medication rooms, carts, and medication supplies are to be locked when not attended by authorized persons. R53 had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease and an MDS BIMS score of 6, indicating severe cognitive impairment. Review of the record showed no active orders for eye drops or nasal sprays and no physician order authorizing self-administration of medications, and there was no evidence that a self-administration assessment had been completed. During observation, lubricant eye drops and ipratropium bromide nasal spray were seen on the bedside table in R53's room, and the DON and CMA both confirmed the medications were there. The DON stated she was unsure whether R53 had been assessed or had an order to self-administer medications, and the ADON later confirmed that R53 did not have such an order or assessment. R37, R38, and R59 also had medications at the bedside without authorization to self-administer. R37 had a BIMS score of 12, an active order for Refresh Tears eye drops, no order authorizing self-administration, and no documented self-administration assessment; lubricant eye drops were observed on the bedside table. R38 had diagnoses including Parkinson's disease and moderate dementia, a BIMS score of 13, no active eye drop order, no self-administration order, and no assessment; lubricant eye drops were observed on the bedside table. R59 had diagnoses including type 2 diabetes mellitus with neuropathy and cognitive communication deficit, a BIMS score of 13, an active order for artificial tears, no self-administration order, and no assessment; lubricant eye drops were observed on the bedside table. The DON confirmed that none of these residents were authorized to self-administer medications and stated that the medications appeared to be over-the-counter products brought in by family.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to ensure compliance with food safety standards as outlined in the FDA Food Code 2022 and its own policies. The Food Service Director (FSD) was observed serving food without wearing a beard restraint, despite having facial hair, which is against the FDA guidelines that require food employees to wear hair restraints to prevent hair from contacting food. The FSD admitted to not requiring staff to wear beard restraints unless the beard was full and long, and the facility lacked a specific policy addressing the use of beard restraints. The Administrator acknowledged the availability of beard restraints and the regulatory requirement for their use, but the facility's policy did not specify this requirement. Additionally, the facility did not adhere to its policy regarding the labeling and dating of resident food items stored in the nourishment refrigerator. Observations revealed that several food items in the nourishment refrigerator were neither labeled nor dated, contrary to the facility's policy that mandates all food items be labeled with content and date. Interviews with staff, including a CNA, LPN, Dietary Manager, and the Administrator, confirmed that the expectation was for all food items to be labeled and dated, yet this was not consistently practiced. These deficiencies in food safety practices had the potential to affect all residents receiving meals from the dietary department.
Failure to Conduct Background Checks for LPNs
Penalty
Summary
The facility failed to consistently implement the screening component of their abuse policy, as evidenced by the lack of background checks for three Licensed Practical Nurses (LPNs) out of five licensed staff whose files were reviewed. The facility's policy, titled 'Abuse Neglect and Exploitation,' mandates background, reference, and credentials checks for potential employees, including licensed staff. However, the facility did not provide evidence of background checks for LPN 7, LPN 9, and LPN 10, who were exempt from the Georgia Crime Information Center/Criminal Background Check. This oversight had the potential to place the 70 residents at risk of abuse, neglect, and exploitation. Interviews with the Human Resources Director and the Administrator revealed a misunderstanding regarding the requirements for background checks. The HR Director stated that license checks were conducted yearly, and any issues would be reflected in the license status. She believed that since the Georgia Board of Nursing completed background checks for licensed nurses, additional checks were unnecessary if the license was in good standing. The Administrator confirmed this understanding, stating that the facility assumed no further criminal background checks were needed if the LPN's license was clear. Consequently, no criminal background checks were conducted for the LPNs in question.
Deficiency in Wound Care and Infection Control Competency
Penalty
Summary
The facility failed to evaluate the competencies of the Wound Care Registered Nurse (RN) in providing wound care and infection control, which was observed during wound care for a resident. The Wound Care RN entered the resident's room with clean dressings and medication, placing them directly on the resident's bed without a barrier. She did not wash her hands or put on a gown before applying gloves. During the wound care process, the Wound Care RN did not wash her hands or change gloves between removing and treating multiple wounds, and she left some wounds open to air while obtaining additional supplies. After completing the treatments, she provided a snack to the resident without washing her hands after removing her gloves. Interviews revealed that the Wound Care RN was unaware of the need to clean hands and change gloves between treating wounds and did not know to use a barrier for clean supplies. The RN had received training from an online wound care company, but neither the Infection Control Preventionist nor the Director of Nursing (DON) had observed her performing wound care. The DON confirmed the lack of a policy addressing nurse competencies and had no documentation of competency evaluations for the Wound Care RN. The Administrator also expected nurses to be competent in infection control during wound care.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that two of five treatment and medication carts were locked and secured when unattended by staff, as required by their policy titled 'Medication Storage in The Facility.' This policy mandates that medications and biologicals be stored safely and securely, accessible only to authorized personnel. During an observation, a treatment cart on the [NAME] Hall was found unlocked, containing various medications and biologicals. Interviews with staff, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), confirmed that the treatment cart should have been locked when not attended or within the staff's line of sight. However, the RN walked away without securing the cart. Further observations revealed an unlocked medication cart outside the nurses' station on Skidaway Hall, with no staff present in the area. An LPN acknowledged that he was trained to lock the cart to prevent unauthorized access to medications. Interviews with other LPNs and the Director of Nursing (DON) reiterated the importance of securing medication carts to prevent unauthorized access and ensure resident safety. The Administrator also confirmed the expectation that medication carts should be locked when not in use to prevent unauthorized access to medications.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and ensure proper infection control practices during wound care for a resident with multiple wounds. The Wound Care Registered Nurse (RN) did not follow the facility's Wound Care Procedure, which required treating each wound individually and changing gloves and washing hands between handling different wounds. During an observation, the RN placed clean dressings and medication directly on the resident's bed without a barrier, did not wash hands or change gloves between removing and treating wounds, and did not use a gown as required by EBP. The resident, identified as having severe cognitive impairment, had multiple wounds requiring specific treatments, including a wound vacuum and negative pressure dressing. Despite having active orders for EBP due to wounds on the right thigh and knee, the RN did not adhere to these precautions. The RN also failed to use a barrier for clean supplies and did not change gloves or wash hands between treating different wounds, increasing the risk of cross-contamination. Interviews with the RN and other staff revealed a lack of awareness and training regarding the necessity of using barriers and changing gloves between wound treatments. The Director of Nursing (DON) confirmed the expectation for EBP and proper infection control practices, including using barriers and changing gloves between wound care tasks. The RN's actions, or lack thereof, demonstrated a failure to follow established protocols, potentially increasing the risk of infection for the resident and others.
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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 Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Health & Rehab Ctr | 1.3 mi | ★★★★★ | 11 | 0 |
| Candler Skilled Nursing Unit | 1.6 mi | ★★★★★ | 3 | 0 |
| Thunderbolt Care Center Llc | 1.7 mi | — | 0 | 0 |
| Savannah Post Acute Llc | 3.6 mi | ★★★★★ | 2 | 0 |
| Pruitthealth - Savannah | 4.6 mi | ★★★★★ | 1 | 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.