Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Azalea Health Center By Harborview during CMS and state inspections, most recent first.
Resident Council complaints were not followed up or documented as resolved. Meeting minutes showed no documented follow-up to resident concerns, and residents stated they were unaware of any outcomes. The Activities Director said she recorded notes but did not document grievances, the Social Services Director said she had not received grievances from the council, and the Administrator stated residents should be notified of the outcome.
Surveyors observed an unattended, unlocked medication cart with a medication bottle and a cup containing two loose pills left on top, with no nursing staff nearby, contrary to facility policy requiring medications to be under direct observation or locked during a med pass. An LPN reported leaving the medications on the cart while taking a resident to their room to check insulin, and both the DON and the Administrator confirmed that medications should not be left unattended and that once medications are removed, they are expected to be administered immediately.
Failure to notify after resident fall: A resident with severe cognitive impairment and extensive ADL needs had an unwitnessed fall, but the RP said she was never informed. The DON confirmed the fall occurred and staff interviews showed confusion about documentation and reporting, while the Administrator stated the physician, family, and Administrator should be notified after a fall.
A resident admitted with schizophrenia and major depressive disorder did not receive the required PASARR level 2 screening. The facility policy stated it coordinates PASARR assessments for individuals with mental disorders, intellectual disabilities, or related conditions. The Social Services Director said the resident may have been overlooked and did not realize the resident had schizophrenia, while the DON stated residents with MH issues are expected to receive the medication and services they require. The Administrator stated that a PASARR level 2 is required based on that diagnosis.
A facility failed to provide needed ADL care, including bathing and grooming, for multiple residents. One resident with severe cognitive impairment, CVA-related weakness, and dependence for personal hygiene had facial hair left on her face despite stating she wanted it removed daily. Another resident reported receiving only four baths since admission, and the shower log lacked documentation that scheduled showers were completed. Staff interviews showed awareness that ADL care should be provided, but the records and observations did not support that the residents received the bathing and grooming assistance identified in their care plans.
Failure to provide appropriate foot care occurred when staff did not obtain a podiatry appointment for a resident who was diabetic, cognitively intact, and dependent on staff for most ADLs. The resident said she asked to see the podiatrist for toenail trimming, but no one followed up, and surveyors observed thick, long toenails. A CNA reported notifying nursing and SSD, and the appointment/supply clerk confirmed speaking with the resident about scheduling podiatry, but the resident had never been seen by a podiatrist since admission.
The facility did not maintain the required eight consecutive hours of RN coverage each day, as evidenced by multiple days without an RN on duty. Both the staffing scheduler and DON were unaware of the specific requirements for RN coverage and were uncertain about whether the DON could be counted toward these hours.
Staff did not adhere to hand hygiene protocols during medication administration and resident care, with LPNs failing to perform hand hygiene between residents and CNAs not following Enhanced Barrier Precautions, including not wearing gowns or performing hand hygiene when assisting a resident with incontinence and pressure ulcers.
The facility failed to submit PASRR Level II for four residents after new mental illness diagnoses were added, as required by policy. Residents with diagnoses such as depression, PTSD, and bipolar disorder did not receive the necessary Level II reviews, despite exhibiting behavioral symptoms. The oversight was confirmed by facility staff, including the Regional Nurse Consultant and the new Social Services Director, who was unaware of the residents' PASRR status.
The facility failed to provide adequate ADL care for three residents, leading to unmet needs and diminished quality of life. A resident with severe cognitive impairment had not received a shower in a month due to transport issues, while another with moderate impairment was observed with unkempt hair and dirty fingernails. A third resident, requiring moderate assistance, reported not being offered showering help, with observations confirming the lack of hygiene care.
A facility failed to maintain a medication error rate below five percent, resulting in a 37.04 percent error rate for a resident. Medications scheduled for 9:00 am were administered late at 10:43 am, and one medication was unavailable. The DON and RN confirmed the deviation from the facility's policy, which requires medications to be given within one hour of the scheduled time.
The facility failed to maintain a clean, homelike, and safe environment in one of its units, with observations revealing cluttered living areas, exposed sheet rock, chipped sink ledges, and hard-to-open bathroom doors. Privacy curtains had brown spots, and walls had black marks and peeling wallpaper. The laundry room had missing and water-stained ceiling tiles, and a ventilation unit was improperly wrapped. These conditions were confirmed by the Administrator and Environmental Services Manager.
A facility failed to protect residents' medications from misappropriation during administration. An RN, unable to find a resident's prescribed metoprolol ER 50 mg, obtained two 25 mg tablets from another nurse, who took them from a different resident's supply. The DON confirmed that the correct procedure was not followed, breaching the facility's medication administration policy.
A resident with hypertension did not receive timely medication due to unavailability in the medication cart and lack of a backup pharmacy provider. The facility's policy on timely medication acquisition was not followed, and the DON confirmed awareness of the issue with medication reordering.
A resident with hypertension did not receive their prescribed diltiazem ER 120 mg at the scheduled time due to unavailability. The medication, which should have been administered within one hour of the 9:00 am schedule, was given after 4:00 pm. This delay was confirmed by the RN, LPN, and DON, who acknowledged the medication was not available and administered outside the required timeframe.
Resident Council Complaints Not Followed Up
Penalty
Summary
The facility failed to follow up on complaints expressed by residents during Resident Council meetings. Review of the facility’s Resident and Family Grievances policy showed that the Grievance Official is responsible for overseeing grievances through conclusion, leading investigations as needed, and keeping the resident apprised of progress toward resolution. The Resident Council policy stated that a Resident Council Response Form would be used to track issues and their resolution, and that the department related to the concern would be responsible for addressing the item(s) of concern. Review of Resident Council meeting minutes from September 2025 through April 2026 revealed no documented follow-up to the residents’ complaints discussed in the meetings. During an interview, members of the Residents Council stated they were not aware of any follow-up on complaints discussed during the meetings. The Activities Director stated she documented notes on the forms but was unaware of what the minutes meant, and said that if complaints or grievances were filed, she would take them to the social worker, who would follow up; she also stated she had not documented grievances. The Social Services Director stated she had not received grievances from the Resident Council meetings. The Administrator stated she expected Resident Council follow-up to be captured correctly and that residents should be notified of the outcome.
Unattended and Unsecured Medication Cart with Accessible Medications
Penalty
Summary
Surveyors identified a deficiency related to medication security when one of three medication carts was found unattended and unlocked, with a medication bottle and a medication cup containing two loose pills left on top of the cart. The facility’s Medication Storage policy, revised on 03/01/2025, requires that during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area or cart. During an observation on 04/20/2026 at 2:27 PM, there was no nursing staff in proximity to the cart or in the hallway while the medications remained accessible. In an interview at the same time, an LPN stated that medications should not be left out on the medication cart and explained that he had taken the resident back to the room to check insulin, leaving the medications on the cart. In separate interviews, the DON and the Administrator both confirmed that medications should not be left unattended on the medication cart and that the expectation is that once medications are taken out, they should be given to the resident, indicating that the observed practice did not meet the facility’s standard of practice. The deficient practice had the potential to allow residents and/or visitors unauthorized access to medications, as documented in the report.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure that the responsible party was notified of a resident’s fall. Resident 101 was admitted with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis and unspecified dementia with severe cognitive impairment, as shown by a BIMS score of 99 on the quarterly MDS. The resident also required extensive assistance with ADLs, including one/two or more-person assistance. The resident’s responsible party stated she was never informed of the fall. The DON stated the resident had an unwitnessed fall on 02/11/2026 and that the fall should have been documented in the progress notes, including who was called. An LPN stated she recalled the resident had a fall but it did not occur on her shift and she was not sure who was documented as being called. The unit manager stated he did not know the procedure for completing an exception report, and the Administrator stated that when a resident has a fall, the physician, family, and Administrator should be notified.
Failure to Complete PASARR Level 2 Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that one resident reviewed for PASARR level two actually received a level two screening. The resident was admitted with diagnoses including schizophrenia, major depressive disorder, type 2 diabetes mellitus without complications, volvulus, acquired absence of other specified parts of the digestive tract, and diarrhea, unspecified. Review of the facility policy stated that the facility coordinates assessments with the PASARR program for individuals with a mental disorder, intellectual disability, or related condition. During interviews, the Social Services Director stated she did not know why the resident did not have a level 2 unless the resident was overlooked and said she did not realize the resident had a diagnosis of schizophrenia. The DON stated that when a resident has mental health issues, the expectation is that the resident would receive the medication and services they required. The Administrator stated that a PASARR level 2 is a must based on that diagnosis.
Failure to Provide Needed Bathing and Grooming Assistance
Penalty
Summary
The facility failed to provide needed ADL care, including bathing and grooming, for three sampled residents. One resident with severe cognitive impairment, hemiplegia and hemiparesis following cerebral infarction, weakness, dysphagia, and acute cystitis with hematuria was assessed as needing extensive assistance with ADLs and dependent assistance for personal hygiene. Her care plan directed staff to provide dependent bathing and personal hygiene assistance, yet observations showed facial hair on her face during multiple encounters, and she stated she did not want it there and wanted it removed daily. Staff interviews confirmed awareness that the resident had facial hair and that it should be removed, but the unit manager stated he did not know she wanted it done daily. A second resident reported that she had only had four baths since admission. Her care plan identified a need for assistance with bathing, grooming, and personal hygiene related to mobility impairment, ROM limitations, and self-care impairment. The shower schedule showed she was to receive showers three nights per week, but the record review found no documentation supporting that the showers were completed as scheduled and missing documentation on the bath sheets. Another resident also had a care plan for assistance with bathing, grooming, and personal hygiene, and the report noted that staff were aware residents should receive baths according to the bath schedule or when requested. Interviews with staff showed that a CNA knew to check the kardex for ADL care, the DON stated that patient care should always come first and ADLs should always be carried out, and the Administrator stated that ADL care should be done because it can affect dignity if it is not done. The facility also confirmed it was using agency CNA staff. The report documented that the resident who reported limited bathing said she sometimes went weeks without a bath, and the social worker stated she knew the resident had psychiatric problems and that the resident made both true and false allegations.
Failure to Arrange Podiatry Care for Resident With Thick Toenails
Penalty
Summary
Failure to provide appropriate foot care occurred when the facility did not obtain a podiatry appointment for R87, one of 36 sampled residents. The facility policy titled "Fingernails/Toenails, Care of" stated that staff should stop and report to the nurse supervisor if there is evidence of ingrown toenails, infection, pain, or if nails are too hard or thick to cut with ease. R87’s admission MDS showed a BIMS score of 15, indicating intact cognition, and Section GG documented that she was dependent on staff for most ADLs. R87 told surveyors that she had asked about seeing the podiatrist to have her nails clipped and said she was told staff would take care of it, but no one came to talk to her about it. She stated that she was diabetic and needed a podiatrist to trim her toenails. Surveyors observed thick and long toenails on her feet. A CNA stated she had informed a nurse when she identified a need for a resident to see a podiatrist and said she had also informed the SSD that R87 asked to see her about making a podiatry appointment. The appointment/supply clerk confirmed she had spoken with R87 about making an appointment to the podiatrist, but the resident had never been seen by a podiatrist since admission. The DON and Administrator stated their expectation was that residents needing specialized services receive those services without waiting.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours each day, as required. Review of staffing schedules and time punch cards revealed that there was no RN coverage on six specific days, despite a census of 87 residents. The job description for RNs indicated their role in providing skilled nursing care under physician direction. Interviews with the staffing scheduler and the Director of Nursing (DON) revealed a lack of awareness regarding the requirement for daily RN coverage, with both staff members expressing uncertainty about whether the DON could be counted toward the required RN hours and whether the facility census affected this requirement. The DON confirmed that on days with no RN listed on the schedule or time punch card, there was no RN on shift.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to comply with established infection prevention and control protocols, specifically regarding hand hygiene and Enhanced Barrier Precautions (EBP). During medication administration, two LPNs were observed not performing hand hygiene between residents, despite facility policy requiring hand hygiene before and after glove use, between resident contacts, and before handling medications. Both LPNs acknowledged not following the required hand hygiene procedures during their medication passes. Additionally, two CNAs were observed providing care to a resident in a room marked for EBP without performing hand hygiene before donning or after removing gloves, and without wearing the required gown. The CNAs assisted a resident who was incontinent and had pressure ulcers, and they were unaware of the EBP signage on the room door. Both confirmed they did not follow the hand hygiene protocol during the care provided.
Failure to Submit PASRR Level II for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for four residents after new mental illness diagnoses were added. This deficiency was identified through observations, staff interviews, record reviews, and a review of the facility's policy on Resident Assessment-Coordination with PASARR Program. The policy mandates that any resident with a newly evident or possible serious mental disorder should be referred promptly for a Level II resident review. However, the facility did not adhere to this policy for the residents in question. Resident 5 was admitted with various diagnoses, including dementia and PTSD, and later had depression added as a diagnosis. Despite this, the resident's records showed no submission for a PASRR Level II. Similarly, Resident 2, who had multiple mental health diagnoses added over time, also did not have a PASRR Level II submitted. Both residents' records were reviewed by the Director of Operations and the MDS Director, who confirmed the oversight. The new Social Services Director, responsible for submitting PASRRs, was unaware of these residents' diagnoses and PASRR status due to being new in her role. Residents 14 and 294 also had significant mental health diagnoses, including bipolar disorder, but lacked a PASRR Level II submission. Resident 14 exhibited behavioral symptoms and was observed yelling for help, yet no Level II review was initiated. Similarly, Resident 294, with a diagnosis of bipolar disorder, showed behavioral symptoms but was not referred for a Level II review. The Regional Nurse Consultant confirmed that neither resident had a PASRR Level II applied for, indicating a systemic issue in the facility's process for managing PASRR requirements.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for three residents, leading to unmet needs and diminished quality of life. Resident 8, who has severe cognitive impairment and requires substantial assistance, had not received a shower in a month due to issues with shower bed transport. Observations revealed that the resident had visible facial hair and unkempt hair, and interviews with staff confirmed the lack of scheduled showers and personal hygiene care. Resident 84, with moderate cognitive impairment and dependence on staff for personal hygiene, was observed with visible facial hair and unkempt hair, as well as fingernails with a brown substance. Despite the care plan indicating the need for assistance with grooming and hygiene, the resident did not receive the necessary care, as evidenced by multiple observations over several days. Resident 294, who requires moderate assistance with personal hygiene, was observed with greasy, unkempt hair and dirty fingernails over several days. The resident reported not being offered assistance with showering, and observations confirmed the lack of hygiene care. The Director of Nursing acknowledged the expectation for staff to provide scheduled ADL care and document any refusals, which was not adhered to in these cases.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 37.04 percent error rate during the observation of medication administration for one resident. The facility's policy on medication administration, which includes ensuring the six rights of medication administration, was not adhered to. Specifically, medications that were scheduled to be administered at 9:00 am were given late at 10:43 am, and one medication, diltiazem ER 120 mg, was not available for administration. This deviation from the scheduled medication times was confirmed by the Director of Nursing (DON) and the Registered Nurse (RN) involved in the administration. The resident involved, identified as R17, had multiple diagnoses including essential hypertension, metabolic encephalopathy, tachycardia, and anxiety disorder. The resident's physician's orders included several medications to be administered once daily or every morning, all scheduled for 9:00 am. During the observation, it was noted that the medications were administered late, and the RN acknowledged the delay. The DON confirmed that the facility's expectation was for medications to be administered within one hour before or after the scheduled time, which was not met in this instance.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike, and safe environment in one of its units, specifically Unit 2. Observations revealed multiple deficiencies, including cluttered living areas with personal items stored on the floor and overbed tables, exposed sheet rock, chipped sink ledges, and hard-to-open bathroom doors. Privacy curtains were found to have brown spots, and walls had black marks and peeling wallpaper. Additionally, the space between beds was cluttered with wheelchairs, rollators, and clothing items, limiting residents' ability to transfer safely. Further observations in the laundry room revealed missing and water-stained ceiling tiles, a ventilation unit wrapped in aluminum foil-like material secured with duct tape, and insulation spilling out. These conditions were confirmed by the Administrator and the Environmental Services Manager during walking rounds. The facility's policy on maintaining a safe and homelike environment was not adhered to, as housekeeping and maintenance services failed to ensure a sanitary, orderly, and comfortable environment for the residents.
Medication Misappropriation During Administration
Penalty
Summary
The facility failed to ensure that residents' medications were free from misappropriation during medication administration. During an observation, a Registered Nurse (RN) discovered that a resident's prescribed metoprolol extended-release 50 mg was not available on the medication cart. Instead of following the proper protocol to obtain the medication from the facility's backup dispensing system, the RN obtained two metoprolol ER 25 mg tablets from another nurse. This nurse, a Licensed Practical Nurse (LPN), admitted to taking the medication from another resident's medication pack, acknowledging that she knew it was against policy but acted without thinking. The Director of Nursing (DON) later confirmed that the correct procedure, if a medication is unavailable, is to retrieve it from the backup system or contact the pharmacy if it is not available there. The incident highlights a breach in the facility's medication administration policy, which mandates adherence to the six rights of medication administration, including ensuring the right drug and dosage for the right resident. This misappropriation of medication from one resident to another constitutes a failure to protect residents' belongings, specifically their medications, from wrongful use.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to ensure timely pharmaceutical services for a resident, identified as R17, who was observed for medication administration. R17 had physician orders for metoprolol ER 50 mg and diltiazem ER 120 mg to be administered in the morning for hypertension. During a medication administration observation, it was noted that these medications were not available in the medication cart. The facility's policy on pharmacy services, which mandates timely acquisition and administration of medications, was not adhered to. Further investigation revealed that the facility did not have a backup pharmacy provider, and the diltiazem ER 120 mg was not available on-site. The LPN stated that the pharmacy would be notified to arrange for the medication, but it would take at least an hour for delivery, missing the scheduled administration time. The DON acknowledged awareness of the issue with timely medication reordering and confirmed the failure to ensure R17's medications were available as ordered by the physician.
Significant Medication Error Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a medication administration review. The facility's policy required medications to be administered within one hour before or after the scheduled time. However, the resident's diltiazem ER 120 mg, prescribed for hypertension, was not available for administration at the scheduled 9:00 am time. The medication was eventually administered after 4:00 pm, significantly outside the allowed timeframe. This delay was confirmed by the RN and LPN involved, as well as the Director of Nursing, who acknowledged the medication was unavailable and not administered as required. The resident involved had a medical history that included essential hypertension, metabolic encephalopathy, tachycardia, and anxiety disorder. The deficiency was identified when the medication was not administered during the observed medication pass at 10:43 am, and the RN confirmed the unavailability of the medication. The LPN and DON both confirmed the medication should have been administered within the specified timeframe, and the delay was noted in the resident's progress notes, indicating the medication was given after the physician was informed of the situation.
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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 Augusta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Augusta Hills | 1 mi | ★★★★★ | 3 | 0 |
| Pruitthealth - Augusta | 1.4 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Creekside | 2.5 mi | ★★★★★ | 0 | 0 |
| Place At Martinez, The | 4.2 mi | ★★★★★ | 17 | 0 |
| Place At Deans Bridge, The | 4.2 mi | ★★★★★ | 0 | 0 |
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