Azalea Health Center By Harborview

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on staff interviews, record reviews, and review of the facility's job description titled Registered Nurse (RN), the facility failed to ensure the services of an RN for at least eight consecutive hours a day was maintained. The facility's census was 87 residents. Findings include: Review of the facility's job description titled Registered Nurse (RN), revised October 2020, revealed the Primary Purpose of this Position section stated, The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state. Review of the staffing schedule and time punch cards revealed six days with no RN coverage: 10/16/2025, 10/18/2025, 10/19/2025, 10/20/2025, 10/27/2025, and 11/7/2025. During an interview on 10/30/2025 at 2:06 pm, the Staffing Scheduler stated she was unaware that an RN had to be on staff for eight consecutive hours every day, and thought that because the Director of Nursing (DON) was in the building, that would suffice. During an interview on 11/10/2025 at 10:14 am, the DON stated that when no RN's name was written on the staffing schedule, or there was no time punch card entry, it meant there was no RN on shift.

During an interview on 11/10/2025 at 10:58 am, the DON stated she was unsure who could be counted as

the RN on shift and that she thought she could count herself. She stated that she was unaware that the census played a role in the DON being counted in the required eight consecutive RN hours.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Azalea Health Center by Harborview

1600 Anthony Road Augusta, GA 30904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, staff interviews, record reviews, and review of the facility's policies titled Hand Hygiene and Enhanced Barrier, the facility failed to ensure staff complied with standards of practice regarding proper hand hygiene during medication pass. In addition, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during resident care. This deficient practice had the potential to place the 87 residents residing in the facility at risk of increased exposure to infection due to cross-contamination. Findings include:Review of the facility's policy titled Hand Hygiene, revised 3/1/2025, revealed the Policy section stated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The Policy Explanation and Compliance Guidelines section included . 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The Hand Hygiene Table included that hand hygiene should be performed between resident contacts, before applying and after removing personal protective equipment PPE including gloves, before preparing or handling medications, and before and after handling clean or soiled dressings, linens.Review of the facility's policy titled Enhanced Barrier Precautions, revised 3/1/2025, revealed the Policy section stated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The Policy Explanation and Compliance Guidelines section included 1. Prompt recognition of need: All staff received training on enhanced barrier precautions upon hire and at least annually, and are expected to comply with all designated precautions. 1.

During an observation on 10/29/2025 at 8:55 am of medication pass, Licensed Practical Nurse (LPN) BB was observed administering medication and failing to perform hand hygiene between residents. In an interview, LPN BB confirmed she did not perform hand hygiene between residents and stated she should have.During an observation of medication pass on 10/29/2025 at 9:22 am, LPN DD was observed administering medications to three residents without performing hand hygiene between the residents. LPN DD confirmed she did not perform hand hygiene and stated she should have.2. During an observation on 10/29/2025 at 9:03 am, Certified Nurse Aides (CNA) EE and FF were observed in a room labeled with an Enhanced Barrier Precaution sign, assisting the resident who was in bed, and not performing hand hygiene

before putting on gloves or after removing them. CNAs EE and FF were not wearing a gown. In concurrent interviews, CNA EE stated that the resident they assisted was incontinent and had pressure ulcers. Both CNAs stated they provided bed mobility to the resident without wearing a gown and did not realize there were EBP signs posted on the room door. CNAs EE and FF confirmed they did not perform hand hygiene

before putting on or taking off gloves during the resident care.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet