Federal inspectors documented the hand hygiene failures during an October 29 observation at Azalea Health Center by Harborview. At 8:55 am, they watched LPN BB administer medications to multiple residents without performing any hand hygiene between patient contacts. When confronted, the nurse admitted her mistake.
"She confirmed she did not perform hand hygiene between residents and stated she should have," inspectors wrote.
The violations weren't isolated to a single staff member. Just 27 minutes later, inspectors observed Licensed Practical Nurse DD committing identical infractions during her medication rounds. At 9:22 am, LPN DD administered medications to three separate residents without washing her hands between any of the encounters.
Like her colleague, LPN DD acknowledged the violation when questioned by inspectors, confirming she failed to perform required hand hygiene and admitting she should have followed proper protocols.
The facility's own policies, revised as recently as March 1, 2025, explicitly prohibit such practices. The Hand Hygiene policy states that all staff must perform proper hand hygiene procedures to prevent infection spread to other personnel, residents, and visitors. The policy specifically requires hand washing between resident contacts and before preparing or handling medications.
More troubling violations emerged when inspectors observed nursing assistants ignoring enhanced barrier precautions designed to prevent transmission of dangerous drug-resistant organisms.
At 9:03 am on the same day, Certified Nurse Aides EE and FF entered a room clearly marked with an Enhanced Barrier Precaution sign. The room housed a resident with incontinence and pressure ulcers - conditions that create high infection risks. Despite the posted warnings, both CNAs provided bed mobility assistance without wearing required gowns and failed to perform hand hygiene before putting on gloves or after removing them.
The nursing assistants' ignorance of basic safety protocols was striking. During interviews, both CNAs stated they didn't realize Enhanced Barrier Precaution signs were posted on the room door, despite walking directly past the warnings. They confirmed providing care to the vulnerable resident without proper protective equipment.
CNA EE acknowledged that the resident they assisted was incontinent and had pressure ulcers - medical conditions that significantly increase infection transmission risks. Both assistants admitted they provided bed mobility care without wearing gowns and failed to perform hand hygiene before donning or after removing gloves.
The facility's Enhanced Barrier Precautions policy, also revised March 1, requires staff to implement special protections to prevent transmission of multidrug-resistant organisms. The policy mandates that all staff receive training on enhanced barrier precautions upon hire and at least annually, with expectations for full compliance with designated precautions.
Federal inspectors determined these deficient practices placed all 87 residents at the facility at risk of increased infection exposure through cross-contamination. The violations occurred despite clear written policies requiring proper hand hygiene procedures.
The facility's Hand Hygiene policy explicitly states that glove use doesn't replace hand washing requirements. Staff must perform hand hygiene before putting on gloves and immediately after removing them. The policy's Hand Hygiene Table specifies that hand washing should occur between resident contacts, before and after removing personal protective equipment including gloves, and before handling medications.
For residents with compromised immune systems, chronic wounds, or other medical vulnerabilities common in nursing homes, such infection control failures can have serious consequences. Cross-contamination from inadequate hand hygiene can spread dangerous bacteria, viruses, and drug-resistant organisms throughout a facility.
The inspection findings reveal a systematic breakdown in basic infection prevention practices at Azalea Health Center. Multiple licensed nurses and certified nursing assistants violated fundamental safety protocols during routine care activities, suggesting inadequate supervision or training despite written policies requiring proper procedures.
The October 29 observations captured violations occurring within a 27-minute window, raising questions about how frequently such practices occur when inspectors aren't present. The staff members' ready admissions of wrongdoing indicate awareness of proper procedures, making their failures to follow protocols particularly concerning.
These infection control violations put elderly residents at unnecessary risk during routine medical care and personal assistance - activities that should provide healing and comfort rather than potential exposure to preventable infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Azalea Health Center By Harborview from 2025-11-17 including all violations, facility responses, and corrective action plans.
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