Aloha Nursing & Rehab Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Kaneohe, Hawaii.
- Location
- 45-545 Kamehameha Highway, Kaneohe, Hawaii 96744
- CMS Provider Number
- 125038
- Inspections on file
- 22
- Latest survey
- August 1, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Aloha Nursing & Rehab Centre during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently monitor and document dishwasher sanitizing temperatures, with multiple missed checks over several days. Additionally, open food items in the freezer were not labeled, and expired food remained in the refrigerator. Staff and the Dietary Manager confirmed these lapses, which were contrary to facility policy requiring regular temperature checks and proper food labeling and disposal.
A resident who required assistance with eating was helped by a CNA who stood rather than sat, spent only five minutes assisting, and did not encourage the resident to eat more, contrary to facility policy. Both the CNA and an RN confirmed that staff should sit and allow ample time for meals to maintain resident dignity and comfort.
A resident was not included in care plan decision-making upon admission, and no baseline care plan was documented or discussed with the resident or family within the required 48-hour period. The DON confirmed the care plan discussion and documentation were delayed by nearly two weeks, contrary to facility policy.
A resident with contractures and anoxic brain damage did not receive required range of motion interventions due to missing equipment, staff uncertainty about care procedures, and inaccurate documentation. The care plan called for a knee splint, positioning device, and heel boots, but these were not consistently available or applied, and staff documented use of equipment that was not present.
A resident with Alzheimer's/dementia and a history of multiple falls experienced repeated incidents, including one with injury, due to the facility's failure to implement and update fall prevention interventions. The resident's room was kept closed and located far from the nurses' station, limiting supervision, and the care plan was not revised to address contributing factors or include routine visual checks as required by facility policy.
A resident with a history of cerebral infarction and hemiplegia, identified as at risk for fluid and nutritional imbalance, was not provided with a water pitcher at the bedside on multiple occasions. Both a CNA and the DON confirmed that the resident should have had access to water, and facility policy required bedside water pitchers for hydration.
Two residents with severe cognitive impairment and PTSD did not have trauma-informed care assessments completed, as required by facility policy. Staff confirmed there was no process or screening tool in place to identify trauma history or triggers, and no documentation of such assessments was found in the electronic health record.
Surveyors found that medications and wound care supplies were left unlabeled and unsecured, including a medication cup with cream and a tongue depressor at a resident's bedside, and wound care solutions in a nightstand and on a bedside table. Nurses confirmed these items should have been labeled and locked away. Additional issues included unsecured crushed medications on a cart, eye drops missing required open/discard dates, and expired glucometer control solutions not discarded as required.
A resident receiving hospice care did not have a current certification of terminal illness or the latest IDG Comprehensive Assessment in their medical record or hospice binder. The DON confirmed these documents were missing and not available when requested by surveyors.
Staff failed to follow infection prevention protocols, including not hanging a resident's urinary catheter bag properly, not using required N95 masks and PPE when exiting a COVID-positive resident's room, and not performing glove changes or hand hygiene during wound care for a resident with a stage IV sacral ulcer. These actions were observed and confirmed by staff interviews and facility policy reviews.
The facility did not timely update care plans for four residents, resulting in care plans that failed to reflect current physician orders, family requests, and changes in resident conditions such as new fall interventions, wound care needs, and feeding requirements. The DON confirmed that care plans were not revised to match current interventions and orders.
A resident with multiple chronic conditions and a history of aspiration pneumonia experienced a significant change in condition after being fed by a private caregiver. Although the resident had an AHCD and a POA, there was no POLST or clear advance planning in the care plan to guide staff during emergencies. Nursing staff delayed consulting the physician and transferring the resident to the hospital, as they sought direction from the POA and physician, resulting in a delay in care.
The facility failed to inform two residents of the risks and benefits of psychotropic medications, as there was no documentation in their EHRs regarding informed consent or education about the medications. This deficiency was confirmed by the DON during record reviews, putting residents at risk for more than minimal harm.
The facility failed to store food safely and maintain a sanitary cooking area, with nourishment refrigerators on two floors and a pantry refrigerator in the main kitchen found at unsafe temperatures. Perishable foods were not labeled with disposal dates, and improper storage practices were observed, including an open package of cheese without a label and a dusty fan facing the cook station. Maintenance staff noted frequent refrigerator openings as a cause for warm temperatures, but electronic logs were unavailable for review.
The facility's assessment failed to document the staffing resources necessary to meet the needs of its residents. Although the assessment included details about the resident population and acuity levels, it did not specify the required staffing levels. During a review, the Administrator and DON confirmed this omission, highlighting a deficiency in the facility's assessment process.
The facility failed to ensure the right of three residents to formulate an Advanced Health Care Directive (AHCD). One resident, admitted after hospitalization, had no AHCD documented, and there was no follow-up with the spouse who was initially asked for it. Another resident, returning from the hospital, lacked an AHCD, with no care plan meeting held to address this. A third resident, with intact cognition, also had no AHCD, as the Social Services Manager assumed the Public Guardian handled it, leading to no discussion. These oversights indicate a failure in the facility's processes to ensure residents' rights regarding AHCDs.
A facility failed to transmit a resident's MDS data to CMS within the required 14-day period. The MDS Coordinator confirmed the delay during a record review, and the DON and Administrator verified that the assessment completion date exceeded the allowed timeframe, indicating the MDS was not completed and transmitted as required.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a PICC line lacked a care plan for its management, another with a history of skin cancer had a growth on his forearm not addressed in his care plan, and a third resident on blood thinners did not have a plan for monitoring side effects. These oversights were confirmed by the DON and placed residents at risk for a decline in their quality of life.
A facility failed to revise a resident's care plan after their return from a hospital stay. The resident was discharged to a hospital and returned to the facility, but no care plan meeting was scheduled or conducted. The Social Services Manager confirmed the oversight, and the MDS had not been submitted to trigger the scheduling of a care plan meeting. This was confirmed by the DON and Administrator.
A resident with a history of falls and moderate cognitive impairment was discharged from a facility without a safe discharge plan. Despite multiple falls and a high risk for further incidents, the care plan was inadequately updated, and the family was not informed about the appeal process for the discharge decision. The facility failed to ensure 24-hour supervision was arranged, leading to an unsafe discharge.
A facility failed to prevent urinary tract infections for a resident with a urinary catheter. The resident was observed with catheter tubing dragging on the floor while being assisted in a wheelchair, exposing them to potential contaminants. The Infection Preventionist confirmed that the tubing and collection bag should not contact the floor, as per facility policy.
A resident with severely impaired cognition was left unattended with medications on a bedside table, posing a potential safety risk. A nurse marked the Medication Administration Record as administered before observing the resident take the medication. The Director of Nursing confirmed the nurse's actions were inappropriate.
The facility failed to maintain accurate records of controlled drugs, as observed during a medication cart check. A nurse forgot to sign the Verification of Controlled Substance Count document after counting medications with the outgoing nurse, which is required by facility policy. The DON confirmed that both nurses should verify the count and sign off together.
The facility did not act on a pharmacist's recommendations during a monthly Medication Regimen Review for a resident receiving an atypical antipsychotic. The review suggested conducting a lipid panel, LFT, and A1C test, but these were not completed as the physician did not review the MRR. The facility's policy requires staff to act on all recommendations, which was not followed.
A resident with CHF and a vegetarian diet preference was repeatedly served meals containing meat, despite having communicated his dietary needs to the facility staff. The Executive Director acknowledged the error, attributing it to a mistake by kitchen staff. The resident's care plan noted his dietary preferences and nutritional risks, which were not accommodated as per the facility's policy on Resident Rights.
A facility failed to follow infection prevention and control measures for a resident with a PICC line receiving IV antibiotics. A nurse did not wear the required gown, placed clean supplies next to a urinal without a barrier, and did not perform hand hygiene between glove changes. The Infection Preventionist confirmed these actions violated the facility's policies for high-contact care and infection control.
Failure to Monitor Dishwasher Sanitization and Properly Label and Discard Food Items
Penalty
Summary
Surveyors observed that the facility failed to consistently monitor and document dishwasher sanitizing temperatures, as required by policy. Specifically, there were multiple missing temperature checks for various meal periods over several days in July. Kitchen staff acknowledged forgetting to check and record the temperatures, and confirmed that these checks are required three times daily after each meal to ensure proper sanitization of dishes and utensils. The Dietary Manager also confirmed that logs were not reviewed for missing entries due to staff shortages and being assigned to other duties. Additionally, the facility did not properly label or discard food items according to established guidelines. Inspectors found open food items in the freezer without labels indicating when they were first used, and several items in the refrigerator that were past their use-by dates. Staff admitted to forgetting to check and discard expired food, and to label opened items with the appropriate dates. Facility policies require that food be labeled with open and discard dates, and that items be discarded by their use-by dates to prevent serving spoiled food.
Failure to Maintain Dignity and Proper Assistance During Mealtime
Penalty
Summary
A certified nurse aide (CNA) was observed assisting a resident who required help with eating. The resident was in bed waiting for assistance with lunch, and the CNA provided help while standing, rather than sitting as required by facility policy. The CNA fed the resident four to five spoonfuls of food and sips of juice, spending only five minutes on the task before removing the lunch tray. There was no effort made to encourage the resident to eat more, despite the resident's known need for encouragement and assistance during meals. Interviews with the CNA and a registered nurse (RN) confirmed that the facility's policy requires staff to sit while assisting residents with meals to promote comfort and dignity, and to allow residents sufficient time to eat without feeling rushed. The facility's Feeding Impaired Residents policy specifically instructs staff to allow residents plenty of time to eat, not to rush them, and to continue assisting until the resident has finished or had enough food. The observed actions did not align with these requirements, resulting in a failure to maintain the resident's dignity and right to self-determination during mealtime.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to discuss and complete a baseline care plan (BCP) within 48 hours of admission for one resident. Upon interview, the resident reported not being included in care plan decision-making at the time of admission. Record review confirmed that no BCP was found in the electronic health record and there was no documentation that the BCP was discussed with the resident or their family within the required 48-hour timeframe. The Director of Nursing acknowledged that the care plan discussion and documentation were delayed by 13 days after admission and confirmed that no earlier documentation existed. Review of the facility's policy indicated that a BCP should be developed and verified by a supervising nurse within 48 hours of admission.
Failure to Provide and Document Required Range of Motion Interventions
Penalty
Summary
A resident with anoxic brain damage and contractures of the bilateral lower extremities was not provided with the appropriate treatment and equipment to prevent further decline in range of motion. The resident's care plan required the use of a left knee splint, a lower extremity positioning device, and heel boots. However, during observations and interviews, it was found that the left knee splint had been missing for several weeks, and staff were unable to locate it. The positioning cushion was also not immediately available, and only one heel boot could be found. Staff members were unsure about the correct application of the devices and whether two heel boots were required. Additionally, the shift report sheet did not consistently list all required equipment, and some staff were unfamiliar with the resident's care needs due to infrequent assignment. Documentation in the electronic health record indicated that the left knee splint was applied on multiple dates, even though it was missing during that time. The resident care coordinator confirmed that the splint was not available and that staff should not have documented its application. Furthermore, the lower extremity positioning device and heel boots were not included in the electronic documentation system for staff to sign off, leading to incomplete and inaccurate records of care. These failures resulted in the resident not receiving the necessary interventions to maintain or improve range of motion, as outlined in the care plan.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent avoidable falls for a resident with Alzheimer's/dementia and a history of multiple falls. The resident experienced five falls over a two-month period, with one incident resulting in an arm injury. Observations revealed that the resident's room was located far from the nurses' station and the door was kept completely closed, limiting staff supervision. Despite care plan revisions, interventions such as encouraging the resident to leave the door open for increased supervision were not consistently implemented, as staff confirmed they always kept the door closed, honoring the resident's preference. Record reviews indicated that after the most recent fall, staff performed neuro-checks, but the care plan was not updated to address contributing factors or to include routine visual checks. The Director of Nursing confirmed that the facility did not assess the causes of the falls or update the care plan to reduce the risk of further incidents. Facility policy requires timely assessment and increased monitoring following a fall, but these measures were not fully carried out for this resident.
Failure to Provide Bedside Water Pitcher for At-Risk Resident
Penalty
Summary
Staff failed to provide adequate hydration for a resident identified as being at risk for fluid and nutritional imbalance. On two separate observations, no water pitcher was found at the resident's bedside, despite the resident being able to pour water independently. A CNA confirmed that the resident should have a water pitcher available, and the Director of Nursing also acknowledged that the resident should have been provided with one. The resident's medical record indicated diagnoses including cerebral infarction and hemiplegia/hemiparesis, and the care plan specifically noted the need to monitor daily fluid intake and encourage fluids throughout the day. Facility policy required that additional fluids be routinely available via bedside water pitchers, but this was not followed for the resident in question.
Failure to Identify and Assess Resident Trauma Histories
Penalty
Summary
The facility failed to implement a protocol to identify past trauma experienced by residents, specifically for two residents with severe cognitive impairment and diagnoses including dementia and post-traumatic stress disorder (PTSD). Record reviews for both residents revealed that no trauma-informed care (TIC) assessments were present in their files, despite one resident's family member reporting a significant history of trauma related to military service and PTSD. Interviews with facility staff confirmed that there was no process or screening tool in place to assess trauma history or triggers for residents admitted with PTSD. A review of the facility's own policy indicated that trauma screening should be part of the comprehensive assessment, but staff acknowledged that this was not being done. The electronic health record system did not contain TIC assessment information for the residents' initial admissions, and no documentation of such assessments was provided. As a result, the facility did not identify trauma triggers for these residents, which was a direct violation of their stated policies and procedures.
Failure to Properly Store and Label Medications and Biologicals
Penalty
Summary
Surveyors observed multiple instances where medications and biologicals were not stored or labeled according to professional standards. In one case, a medication cup containing a white cream and tongue depressor was left unattended at the bedside of a resident, and the nurse confirmed it should have been discarded and not left out. Additionally, an unlabeled bottle of Dakin's solution and an unlabeled tube of Hydrogel, both used for wound care, were found in the resident's nightstand and later on the bedside table. The nurse and DON confirmed these items should have been labeled with the resident's information and stored in a locked treatment cart, regardless of the supplier. Further observations included a medication cup with crushed medications left on a medication cart while the nurse was away, which was not secured as required. Eye drops for three residents were found on a medication cart without the required 'opened on' and 'discard by' dates. Additionally, expired glucometer control solutions were found in the medication cart, with the nurse confirming they should have been discarded. These findings demonstrate a failure to follow facility policy and professional standards for the storage and labeling of medications and biologicals.
Failure to Maintain Current Hospice Documentation
Penalty
Summary
The facility failed to maintain current and complete hospice documentation for one resident receiving hospice services. Specifically, the resident's electronic health record and hospice binder did not contain an up-to-date certification of terminal illness or the most recent Interdisciplinary Group (IDG) Comprehensive Assessment. During record review, it was found that these essential documents were missing from both the hospice binder and the EHR. The Director of Nursing confirmed the absence of these documents and was unable to locate them when initially asked, later acknowledging that the facility did not have the required documentation available at the time of the survey.
Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control measures as evidenced by multiple observed deficiencies. One resident with a suprapubic catheter was found with their urinary drainage bag resting on the ground near the bed, contrary to facility protocol and staff acknowledgment that the bag should be hanging. The resident denied moving the bedside table, and the nurse confirmed the bag should not be on the floor. This lapse was documented through direct observation and staff interviews. Additionally, a certified nurse aide exited the room of a COVID-positive resident wearing only a regular mask instead of the required N95 respirator, despite facility policy and posted signage specifying the need for N95 masks and full PPE for transmission-based precautions. Furthermore, a registered nurse performed wound care on a resident with a stage IV sacral ulcer and ongoing IV antibiotic therapy without changing gloves or performing hand hygiene after cleaning feces and before applying new dressings. The nurse later acknowledged the lapse, and both the infection preventionist and unit manager confirmed that proper glove changes and hand hygiene are required between tasks to prevent infection. Facility policies reviewed also supported these requirements.
Failure to Timely Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to make timely and appropriate revisions to the comprehensive person-centered care plans for four out of six sampled residents. For one resident admitted for pneumonia due to Coronavirus, the care plan was not updated to reflect the family's request for daily clothing changes and for the resident to be up for all meals, nor did it include the resident's need for 1:1 feeding assistance and one-person assist for activities of daily living and transfers, despite these needs being documented in progress notes and addressed verbally with staff. Another resident with metabolic encephalopathy, hypoxic respiratory failure, and other chronic conditions had a care plan that did not accurately reflect the physician's emergency oxygen order. Similarly, a third resident with a history of respiratory failure and multiple falls had a care plan that was not revised after three falls to include the use of floor mats or other new interventions, even though these were implemented and documented elsewhere in the record. A fourth resident with Parkinson's disease, severe dysphagia, and a history of aspiration pneumonia had a care plan that did not reflect current physician orders for oxygen administration, the presence of a Stage 3 pressure injury, or the use of preventive heel boots. Additionally, the care plan did not accurately reflect the resident's current dietary orders and feeding needs, as it was not updated after changes in the resident's nutritional status and interventions. The Director of Nursing confirmed that the care plans had not been revised to reflect current orders and interventions.
Failure to Plan for Predictable Condition Decline and Timely Physician Consultation
Penalty
Summary
The facility failed to adequately identify and plan for a predictable decline in a resident's condition that would require timely health care decision-making and guidance for direct care staff. The resident, an elderly male with multiple chronic conditions including Parkinson's disease, dementia, severe dysphagia, and congestive heart failure, experienced repeated hospitalizations for aspiration pneumonia and ultimately died following a significant change in condition. Although the resident had an Advanced Health Care Directive (AHCD) and a designated Power of Attorney (POA), there was no Provider Order for Life-Sustaining Treatment (POLST) in place, and the care plan did not address specific scenarios or provide clear guidance for staff in the event of a rapid decline. On the day of the incident, the resident was fed by a private caregiver and later developed unstable vital signs, including low blood pressure and oxygen saturation. Nursing staff responded by administering a nebulizer treatment and increasing oxygen support, but there was a delay in consulting the physician about the change in condition. The POA was notified and ultimately made the decision to transfer the resident to the hospital, but the process was delayed as staff sought direction from both the POA and the physician. Documentation and interviews revealed that while the POA was actively involved and wished to be notified of any changes, there was no advance planning or interdisciplinary team discussion to guide staff on how to respond to such predictable emergencies. Facility policies required staff to notify physicians of changes in condition and to arrange for emergency care as needed, but these steps were not followed promptly in this case. The lack of a POLST and absence of clear, advance guidance in the care plan contributed to confusion and delay in the resident's transfer to a higher level of care. The deficiency was identified based on interviews, record reviews, and policy analysis, which showed that the facility did not ensure staff had the necessary information and planning to act decisively in a foreseeable situation.
Failure to Inform Residents of Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents were informed in advance of the risks and benefits of psychotropic medication therapy, affecting two residents. For one resident, there was no documentation in the Electronic Health Record (EHR) regarding the use of Lexapro and Ativan, nor any record of education about the risks versus benefits of these medications. This was confirmed during a review with the Director of Nursing (DON). Similarly, another resident's EHR lacked documentation of informed consent or education about the risks and benefits of Citalopram and Ativan. The DON confirmed the absence of this information during a concurrent interview and record review. As a result, residents receiving these medications were at risk for more than minimal harm due to the lack of informed consent.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe manner and maintain a sanitary cooking area, as observed during a survey. Two nourishment refrigerators on the first and second floors were found with internal temperatures above the required 41 degrees, with readings of 49.5 and 51 degrees, respectively. Additionally, a pantry refrigerator in the main kitchen had an internal temperature of 43 degrees. Perishable foods in these refrigerators were at unsafe temperatures, posing a risk for foodborne illness. Opened foods in the pantry, dry storage, and cooking areas were not labeled with disposal dates, further contributing to the deficiency. During the survey, an open package of shredded mozzarella cheese without a label or date was found in the pantry refrigerator, which lacked an internal thermometer. The external digital temperature reading was 48 degrees, while the internal thermometer read 43 degrees. In the dry storage room, an open box of biscuit mix with an unsealed plastic bag was observed. Near the cook station, a container of barbecue sauce was improperly stored, and a fan with heavy dust was facing the food preparation area. The maintenance staff indicated that the refrigerators were new and frequently opened, which they believed contributed to the warm temperatures. However, the electronic temperature logs were not available for review, and the facility's food safety policy was not adhered to, as refrigerators must maintain temperatures at or below 41 degrees, and all foods must be labeled and dated before storage.
Facility Assessment Lacks Staffing Documentation
Penalty
Summary
The facility failed to include the necessary staffing resources in their facility-wide assessment, which is crucial for meeting the needs of their resident population. The facility is licensed for 141 beds with an average daily census of 95 residents. Although the assessment documented the resident population and acuity levels, it lacked documentation of the staffing levels required to meet these needs. During an interview and record review with the Administrator and the Director of Nursing (DON), it was revealed that staffing levels are determined based on census and acuity. However, upon reviewing the facility assessment, both the Administrator and DON confirmed that the required staffing levels were not documented, indicating a deficiency in the facility's assessment process.
Failure to Ensure Residents' Right to Formulate AHCD
Penalty
Summary
The facility failed to ensure the residents' right to formulate an Advanced Health Care Directive (AHCD) for three residents. Resident 151, an elderly male admitted after hospitalization for metabolic encephalopathy, had no AHCD documented in his Electronic Health Record (EHR) or Care Plan. Despite the spouse being asked for a copy of the AHCD at admission, there was no follow-up to obtain it. Similarly, Resident 87, who returned from the hospital, did not have an AHCD on file, and there was no documentation of discussions about formulating one. The Social Services Manager confirmed that no care plan meeting had been held to address this since the resident's return. Resident 97, an elderly male with intact cognition, also lacked documentation of an AHCD in his EHR. The Social Services Manager assumed the resident's Public Guardian handled the AHCD, leading to no discussion with the resident or guardian. The deficiency was identified when a list of residents without AHCDs was provided to the Administrator, prompting a belated inquiry about the AHCD status. These oversights highlight a failure in the facility's processes to ensure residents' rights to formulate or update their AHCDs.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to electronically transmit and complete the Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within the required 14-day timeframe for a resident. The deficiency was identified during an interview and record review of the resident's Electronic Health Record with the MDS Coordinator. The review revealed a late warning for the submission of the admission MDS, as the resident had returned from the hospital and the MDS had not been submitted. The MDS Coordinator confirmed the delay. Further interviews with the Director of Nursing and the Administrator confirmed that the MDS 3.0 Final Validation Report documented the assessment completion date was more than 14 days after the Assessment Reference Date, indicating the MDS should have been completed and transmitted by the specified date but was not.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident 250, admitted for short-term rehabilitation and long-term IV antibiotics, had a Peripherally Inserted Central Catheter (PICC) line, but no care plan was developed for its management. This oversight was confirmed by the Director of Nursing (DON), who acknowledged that the interdisciplinary team should have created a care plan upon the resident's admission. Similarly, Resident 52, who had a history of squamous cell carcinoma, had a raised growth on his left forearm, but this condition was not included in his care plan. Despite documentation in the progress notes, the care plan lacked specific interventions to address this skin condition, as confirmed by the DON. Resident 300, with a medical history of congestive heart failure and long-term use of anticoagulants, did not have a care plan for monitoring the side effects of blood thinners. The DON confirmed the absence of such a plan, which should have been in place to monitor for adverse effects like bleeding and hemorrhage. The facility's policy on anticoagulants required that the resident's plan of care alert staff to monitor for these risks, but this was not implemented for Resident 300. These deficiencies placed the residents at risk for a decline in their quality of life and prevented them from attaining their highest practicable well-being.
Failure to Revise Care Plan Post-Hospitalization
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for a resident, identified as R87, after their return from a hospital stay. R87 was discharged to a hospital on June 28, 2024, and returned to the facility on July 17, 2024. However, as of August 7, 2024, R87 had not had a care plan meeting since their return. The Social Services Manager confirmed that R87 was not scheduled for a care plan meeting, and the Minimum Data Set (MDS) had not been submitted to trigger the scheduling of such a meeting. This was further corroborated during a record review and interview with the Director of Nursing and the Administrator, who confirmed the absence of a care plan meeting for R87 since their return from the hospital.
Failure to Ensure Resident Safety and Develop Adequate Discharge Plan
Penalty
Summary
The facility failed to ensure a resident, identified as R150, was free from accidents during her stay and did not develop a safe discharge plan. R150, who had undergone surgery for a malignant brain neoplasm, experienced multiple falls while in the facility. Despite being at high risk for falls, as indicated by a Morse Fall Scale score of 80, the facility did not adequately update her care plan after each fall. The care plan only included a single revision to assist with routine toileting, and no comprehensive discharge plan was developed to ensure her safety upon leaving the facility. R150's family expressed concerns about her safety at home due to the lack of supervision during the day, as both family members worked and children attended school. The facility's Social Services Assistant (SSA2) informed the family that R150 needed to be discharged and provided minimal assistance with Medicaid paperwork, without offering guidance on how to complete it. The family was not informed about the appeal process for the discharge decision, which they later learned about from a long-term care ombudsman. Despite a conference involving various staff members, including physical and occupational therapists, the discharge plan did not adequately address R150's needs, and the family was threatened with adult protective services if they did not take her home. The facility's Director of Nursing (DON) was unaware of the multiple falls R150 experienced, indicating a lack of communication and documentation. The Social Services Manager (SSM) confirmed that R150 was covered under an employer health plan and did not receive a Notice of Medicare Non-Coverage or information about the appeal process. The facility did not assist in enrolling R150 in Medicare, which could have provided additional services. The discharge recommendations from the physical therapist included 24-hour supervision, which was not feasible for the family, highlighting the facility's failure to ensure a safe discharge plan for R150.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Handling
Penalty
Summary
The facility failed to provide appropriate services to prevent urinary tract infections for a resident with a urinary catheter. During an observation, the resident was seen in a wheelchair with the catheter tubing dragging on the floor as they were being assisted from the elevator to the dining area. This practice exposed the resident to potential contaminants that could lead to urinary tract infections. The resident had a suprapubic catheter, which had been changed during a recent doctor's visit. An interview with the Infection Preventionist confirmed that the catheter tubing and collection bag should not come into contact with the floor, as per the facility's urinary catheter policy.
Failure to Ensure Resident Safety During Medication Administration
Penalty
Summary
The facility failed to ensure that staff implemented specific competencies necessary for resident safety, as evidenced by an incident involving a resident with severely impaired cognition. The resident, who scored a seven on the Brief Interview for Mental Status, was observed alone in their room with ten medication tablets on a bedside table and no staff present. When questioned, the resident could not recall if they had taken any of the medications. This situation posed a potential risk to the resident's safety due to their cognitive impairment and the lack of supervision. Further investigation revealed that a registered nurse had marked the medication as administered in the Medication Administration Record before actually observing the resident take the medication. The nurse confirmed that the resident was left unattended and should not have been. Upon reconciling the medication, it was determined that the resident had taken two specific medications. The Director of Nursing confirmed that the nurse should not have marked the MAR prior to administering the medications and should not have left the resident unattended with the medications.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and reconciled, which increases the risk for diversion of residents' medications. During a medication cart check, it was observed that the Verification of Controlled Substance Count document for the day shift on 08/08/24 was missing the signature of the oncoming nurse. Registered Nurse (RN)7 acknowledged forgetting to sign his name after counting the medications with the outgoing night shift nurse, which is the correct process. The Director of Nursing (DON) confirmed that both outgoing and incoming nurses should verify the controlled medication count together and sign off on the cart to complete the handoff. The facility's policy requires narcotics to be verified at the beginning and end of each shift with licensed staff signatures on the Verification of Controlled Substance Count Record.
Failure to Act on Pharmacist's Recommendations in MRR
Penalty
Summary
The facility failed to review and act upon a pharmacist's recommendation during a monthly Medication Regimen Review (MRR) for one of the sampled residents, identified as R79. The MRR, dated 05/31/24, included a recommendation for R79, who was receiving an atypical antipsychotic, to undergo a lipid panel, liver function test (LFT), and A1C test. However, a review of R79's Electronic Health Record (EHR) revealed that these lab results were not present, indicating that the recommended tests were not conducted. An interview with the Director of Nursing (DON) confirmed that the MRR was not reviewed by the physician, and as a result, the necessary lab work was not completed. The facility's policy on Medication Regimen Review, revised on 04/01/24, mandates that staff act upon all recommendations according to procedures for addressing medication regimen review irregularities, which was not adhered to in this case.
Failure to Accommodate Vegetarian Diet Preference
Penalty
Summary
The facility failed to accommodate the dietary preferences of a resident, identified as a vegetarian, which led to the resident being served meals containing meat on multiple occasions. The resident, a male with a history of congestive heart failure (CHF) and at risk for nutritional imbalance, reported that despite having communicated his vegetarian preference to the dietician and cook, he was served spaghetti with meat sauce and beef stew. This was confirmed by a physical therapist who observed beef stew on the resident's lunch tray. The Executive Director of the kitchen acknowledged awareness of the resident's vegetarian preference but attributed the incident to a mistake by kitchen staff. The resident's care plan in the Electronic Health Record (EHR) highlighted his vegetarian preference and nutritional risks. The facility's policy on Resident Rights mandates respect and dignity for residents, including making reasonable accommodations for individual needs and preferences, which was not adhered to in this case.
Infection Control Deficiency in IV Antibiotic Administration
Penalty
Summary
The facility failed to implement its infection prevention and control measures while providing care for a resident with a Peripherally Inserted Central Catheter (PICC) line for intravenous (IV) antibiotics. During an observation, a registered nurse (RN) did not wear the required personal protective equipment (PPE), specifically a gown, when administering IV antibiotics to the resident, who was on Enhanced Barrier Precaution (EBP). The RN also placed clean supplies, such as an IV antibiotic bag and prefilled normal saline syringes, on the resident's bedside table next to a urinal without using a barrier, which is against the facility's infection control policy. Additionally, the RN did not perform hand hygiene between glove changes while administering the IV medication, which is a requirement according to the facility's infection control policy. An interview with the Infection Preventionist (IP) confirmed that administering IV medication to a resident with a PICC line is considered high-contact care, necessitating the use of a gown, and that hand hygiene should be performed between glove changes. The IP also stated that clean supplies should be placed on a clean surface with a barrier, not next to a urinal.
Latest citations in Hawaii
A resident with multiple chronic conditions and documented wandering and exit-seeking behaviors repeatedly expressed a desire to go home and was frequently observed near exit doors, yet her care plan did not address elopement risk despite an elopement risk score above the facility’s threshold. She was taken outside and left alone by an activity aide and later observed alone in an unauthorized outdoor area, and subsequently eloped twice through the unsecured main entrance, being found in the parking lot on both occasions only after another resident alerted staff. The main entrance lacked alarms or automatic locking, there was no reception area to monitor egress, behavior monitoring records did not reflect increased supervision after the incidents, and documentation often indicated no behaviors despite prior notes of exit-seeking.
The facility failed to provide adequate supervision and fall prevention for multiple high‑risk residents, resulting in unwitnessed falls and serious injuries. One resident with a history of repeated unwitnessed falls and documented weakness fell in the bathroom while adjusting clothing and using a FWW, sustaining head abrasions and hematomas; he was discovered by housekeeping staff after calling for help, and an RN later stated he needed more supervision. Another resident with dysphagia, prior falls, and declining mobility attempted to stand from a newly issued wheelchair while a CNA was behind a closed curtain assisting another resident, fell forward onto her face, and suffered a scalp laceration, facial contusions, and facial fractures. A third resident with prior falls and on sedating, hypotension‑associated psychotropic and antidepressant medications was placed in a dining area but left unsupervised when nursing staff were called away; she attempted to ambulate to the bathroom without her walker, fell, and sustained a right hip fracture. Her care plan had not been updated to reflect her current need for consistent walker use, and staff did not fully follow existing interventions regarding walker availability and use.
A resident with debility, legal blindness, CHF, DM, medication side effects, and a history of falls had a care plan identifying fall risk and requiring standby assist with ambulation. Despite this, staff left the resident unsupervised while the RN walked away and the CNA was busy with another resident, and the resident attempted to ambulate without a walker, leading to an unwitnessed fall and hip fracture. The care plan had not been fully updated to reflect the need for consistent walker use, and staff did not fully follow existing interventions related to walker availability and use.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
Staff failed to timely report a large, dark bruise of unknown origin on a resident’s left hip and thigh. A CNA first observed the bruise during a night shift but did not notify the nurse on duty and only relayed the information to an incoming CNA. Later, a CNA, an RNA, and an RN observed and discussed the bruise during care, and the RN assessed it but assumed it had already been reported and did not document an initial entry or initiate required notifications. The RNA later noted another large bruise and informed an LPN. Despite multiple staff being aware of the injury, the DON, Administrator, physician, resident representative, and State Agency were not notified within the required 2-hour timeframe specified in the facility’s abuse and injury-of-unknown-source reporting policy.
Nursing staff failed to perform and document timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. A CNA first observed the bruise and did not report it to a nurse, only relaying it to another CNA, and when an RN later assessed the bruise, the RN assumed it had already been reported and did not complete an initial assessment entry. An LPN subsequently noted the large purplish bruise, found no prior documentation, and initiated an event, while weekly skin assessments by an RN repeatedly documented no new skin impairments and omitted the bruise. Nursing notes recorded that the bruise was visible and then fading over time, but lacked complete assessment details such as size, shape, and full description, and the incorrect event form was used, resulting in incomplete documentation of the injury.
A resident with multiple comorbidities, including ESRD on dialysis, developed urinary retention during a rehab stay and was discharged home with an indwelling Foley catheter and a mechanical lift. The resident’s son, designated as caregiver, had previously assisted her at home but had not managed a urinary catheter before. Nursing documentation at discharge noted follow-up with a PCP and home health and described the transfer to the son’s car, but recorded education/training as not applicable and contained no evidence of Foley catheter care teaching. During interviews, staff indicated that a vendor trains caregivers on the mechanical lift but could not confirm any nursing education on catheter care, and the Administrator acknowledged nursing’s responsibility to assess, provide, and document caregiver training and capacity, which was not done in this case.
A resident with a history of stroke, encephalopathy, gait abnormalities, incontinence, and insulin-dependent Type 2 DM was discharged home alone with only a private hire caregiver for two hours per day, despite provider orders for 24-hour care and therapy recommendations for 24/7 or extensive caregiver support. Interdisciplinary documentation inaccurately indicated the resident had family and a wife as primary caregiver, and there was no evidence that the facility discussed with the resident his limitations, the risks of minimal supervision, or that the provider was informed of the reduced supervision at discharge. The discharge MDS documented full continence despite multiple recorded episodes of incontinence, and the facility did not verify or document that the resident could self-inject insulin or that a qualified caregiver was trained to do so. Additionally, an ordered stool culture for persistent diarrhea was not completed due to improper specimen handling, and there was no documentation that the provider, PMD, or resident was notified that the test was not performed.
Surveyors found that the facility failed to include ordered O2 therapy in a resident’s care plan despite physician orders for continuous O2 via NC with parameters for use and weaning, and the ADON confirmed this omission. In a separate case, a resident with BLE edema and cellulitis was repeatedly observed in bed with exposed legs and no heel protectors in place, even though there were physician orders for bilateral heel protectors and a care plan directive to offload the heels while in bed; nursing staff acknowledged the heel protectors should have been reapplied after PT and a shower.
Two residents were not adequately protected from accidents when one sustained a skin tear during Hoyer lift transfers despite known fragile skin and prior family complaints about staff moving too quickly, and another, identified as high fall risk due to dementia and prior lumbar fractures, was left unsupervised in a hallway in a w/c for a meal after the CNA watching her went to assist another resident, resulting in a fall discovered by a visitor.
Failure to Supervise and Implement Elopement Interventions for an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision and interventions to prevent accidents, resulting in two elopement incidents involving Resident 36. The resident was an adult female with multiple medical diagnoses including DMII, adjustment disorder with mixed anxiety and depressed mood, hypertension, chronic kidney disease, hypothyroidism, and obstructive sleep apnea. Review of the electronic health record showed numerous progress notes from October 2025 through January 18, 2026 documenting that the resident frequently verbalized wanting to go home, made frequent phone calls to family, asked staff and other residents to take her home, wandered in the facility, and displayed exit-seeking behavior, including ambulating near the facility entrance and exit doors. Despite these documented behaviors, there was no care plan addressing her wandering and exit-seeking prior to the first elopement on January 19, 2026. On January 19, 2026, the resident eloped through the main exit doors at approximately 6:10 PM. Earlier that day, around 4:00 PM, an activity aide had taken her for a stroll outside and left her alone sitting at a table outside, and later that same day the DON and a Resident Care Manager observed her sitting alone at the resident smoking tent, where she was not allowed to be. The facility’s Elopement Risk Evaluation had been completed on October 16, 2025 with a score of 0 and again on October 28, 2025 with a score of 2, which met the facility’s threshold for being at risk for elopement (score of 1 or greater). However, the Administrator stated that although they review changes in score to determine needed interventions, no interventions regarding the resident’s elopement risk were implemented prior to the January 19 incident. The DON confirmed that the resident had exit-seeking behaviors prior to the first elopement and that she was functionally at supervision level and able to ambulate with a front-wheeled walker. A second elopement occurred on January 28, 2026 at 4:10 PM, nine days after the first incident. For both elopements, the resident was found in the parking lot near the first handicap stall, and staff were not aware she had left the building until another resident notified them. During the survey entrance on March 11, 2026 at 6:45 AM, the surveyor observed that the main entrance doors were unlocked, lacked an alarm or automatic locking mechanism, and opened into a large open area with no reception or receiving area, with no indication that the door could secure automatically to prevent elopement. Review of Behavior Monitoring and Interventions Reports from January 1 to February 28, 2026 showed documentation only once per shift and did not reflect increased monitoring after the two elopements; most entries were marked “No Behaviors Observed,” which was inconsistent with the exit-seeking episodes documented in the progress notes. The facility could not provide documentation of increased monitoring after the first elopement, and at the time of the Administrator’s interview there was still another resident identified as an elopement risk.
Failure to Provide Adequate Supervision and Fall Prevention for High‑Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an environment free from accident hazards and to provide supervision based on individual residents’ assessed needs. One resident with a history of multiple unwitnessed falls was observed with a bandage on his head and later with visible bruising and abrasions after an unwitnessed bathroom fall. His care plan documented several prior falls, including unwitnessed falls with head pain, bruising, and sliding out of bed while reaching for a urinal. On the date of the most recent fall, he was found on the bathroom floor on his right side with his pants and underwear around his thighs, reporting that he had been attempting to adjust his clothing while walking with a front‑wheeled walker. He sustained multiple abrasions and hematomas to the top and sides of his head, reported 8/10 head pain and nausea, and required transfer to the ER. Nursing staff reported that a housekeeper, not direct care staff, discovered him after hearing him call for help, and the RN stated that the resident needed more supervision, especially given increased weakness since his prior fall. Another resident with dysphagia, a history of falling, and generalized muscle weakness experienced a fall with major injury after attempting to stand from a newly issued wheelchair. She reported that she stood up and did not expect the wheelchair to be so high, lost her balance, and fell forward onto her face while the CNA was in the same room but behind a closed curtain assisting another resident. The resident sustained an approximately two‑inch actively bleeding scalp laceration, facial contusions, and later ER documentation confirmed a closed fracture of the left maxillary sinus, a closed fracture of the left orbital floor, a scalp laceration, and a closed head injury. The MDS showed that, prior to this fall, she had already demonstrated decline in eight of ten mobility areas, and she later returned from the hospital with 8 staples in her scalp and extensive bruising and swelling to the left eye, scalp, and ear. The resident and her family member expressed that the fall should not have happened and attributed it to short staffing. A third resident with a documented fall history and on medications including quetiapine and mirtazapine, both of which have side effects of drowsiness, dizziness, and orthostatic hypotension, sustained an unwitnessed fall resulting in a right hip fracture. She was found on the floor on her right side without shoes, socks, or her walker, and stated she had been trying to go to the bathroom. The care plan had not been updated to fully reflect her current needs for consistent walker use, and staff did not fully adhere to existing interventions regarding walker availability and use at the time of the incident. Nursing staff interviews indicated that this resident required line‑of‑sight supervision and “eyes on her” because she would suddenly stand without warning and was unsteady, yet at the time of the fall she had been placed in the dining area in front of the nurse’s station and was left unsupervised when the RN and CNA were called away. Kitchen staff later found her on the floor, and she reported being on the floor for about 15 minutes before help arrived. She was diagnosed with a right hip fracture, underwent surgery, was admitted to the ICU for hypotension, and subsequently died; the unwitnessed fall with hip fracture was determined to be a contributing event that exacerbated her overall medical decline, though not the primary cause of death.
Failure to Implement Standby Assist and Walker Use Care Plan Resulting in Fall Injury
Penalty
Summary
The facility failed to implement a person-centered intervention for standby assistance with ambulation as outlined in the comprehensive care plan for one resident, resulting in an unwitnessed fall with major injury. The resident had multiple risk factors for falls, including debility, legal blindness, congestive heart failure, diabetes mellitus, medication side effects, and a history of prior falls. The care plan, revised on 01/23/2026, identified the resident as at risk for falls and included an intervention for standby assist with ambulation, updated on 01/22/2026, with a goal that the resident would be free of falls through the review date of 03/25/26. Prior to the incident, the resident had experienced two falls in the facility, one witnessed fall onto the buttocks while fixing clothing by a mirror and one guided fall after losing balance while walking. On 02/06/26, the resident sustained an unwitnessed fall in building 1 on the B unit while attempting unsupervised ambulation without her walker, resulting in a right hip fracture and transfer to the ER for evaluation and surgery. Interviews with nursing staff confirmed that the resident was known to suddenly stand without warning, was unsteady, and required someone present when walking, and that she needed continuous visual supervision due to her fall risk. At the time of the fall, the RN reported having to walk away and the CNA was occupied with another resident, leaving no one available to assist the resident to get up. The final investigation summary noted that the care plan had not been updated to fully reflect the resident’s current needs for consistent walker use and that staff did not fully adhere to existing care plan interventions regarding the availability and use of the walker at the time of the incident.
Inadequate Infection Control in Catheter Care, Water Management, and Waste Handling
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, particularly related to urinary catheter care, use of personal protective equipment (PPE), implementation of a water management plan for Legionella, and timely trash disposal. For one resident with an indwelling urinary catheter, the surveyor observed the catheter bag on the floor inside a gray bin with the catheter tubing extending out of the bin and in direct contact with the floor. The tubing showed visible discoloration and white sediment. The resident later reported itchiness outside the vagina and leaking from the catheter. A registered nurse acknowledged awareness of the sediment, stated the catheter was changed monthly, and indicated she planned to contact the physician for more frequent changes. She also stated the tubing could be irrigated with saline and confirmed that catheter tubing should not be on the floor for infection control reasons. The Infection Preventionist (IP), when shown a photograph of the tubing on the floor with sediment, confirmed the tubing should have been changed and that tubing should not be on the floor due to infection risk. Another resident, a male with a history of stroke and benign prostatic hyperplasia requiring an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP) with orders for catheter care every shift and as needed. During observation, his catheter tubing was seen lying directly on the floor when the bed was in the lowest position. The nurse present acknowledged that the tubing should not be on the floor and adjusted the bed and tubing placement. In a separate observation, a CNA performed catheter care for this resident, including emptying the catheter bag and cleaning the lower catheter tubing and the floor area near the bag, while only wearing gloves and no gown, despite a noticeable urine-like odor at the bedside. The IP confirmed that the resident was on EBP due to having a Foley catheter and stated staff should wear PPE, including a gown, when performing catheter care such as emptying the collection bag in case of splashes. The CNA acknowledged she was supposed to wear PPE for catheter care and indicated PPE was stored down the hall on a wall shelf, not immediately near or outside the resident’s room, despite the facility’s EBP policy stating gowns and gloves should be made available immediately near or outside the room for high-contact care activities such as urinary catheter care. The facility also failed to effectively implement its water management plan for Legionella prevention and control. The written plan described a central hot water system with recirculation, specified hot water storage tank setpoints at or above 140°F and distribution temperatures above 124°F, and listed monitoring procedures including monthly hot water temperature checks by maintenance, as well as verification and validation steps such as reviewing monitoring logs, infection surveillance data, and water testing results. However, the Maintenance Director reported there were no storage or water heater tanks with water temperatures greater than 140°F, and only one month of temperature logs was available, showing resident room and water heater temperatures between 105°F and 115°F, which did not align with the Legionella prevention temperature guidelines referenced from CDC. The IP, newly in the role, stated she was not familiar with the water management plan, that collaboration with maintenance was non-existent, and that no control measures, weekly flushing of shower heads and faucets, or monthly temperature monitoring were being done. Additionally, the facility did not ensure prompt disposal of trash, resulting in trash bags being piled outside the trash bin and on an exterior stairwell landing. Surveyors observed multiple trash bags outside the facility next to the trash bin and on the stairwell landing, blocking access to the staircase. Housekeeping staff reported that trash from the second floor was placed in the bin about every hour but sometimes had to wait for the maintenance worker, who had the only key to open the bin. Another housekeeper stated she left heavy trash bags by the bin twice a day because she could not lift them into the bin and relied on the maintenance worker to place them inside, noting she had notified him about trash needing to be placed in the bin about an hour earlier. The maintenance worker stated he had been told by aides to hold off putting trash in the bin but did not know why. The Maintenance Director later confirmed that housekeepers should be putting trash in the bin more frequently and acknowledged that trash pile-up can lead to unsanitary conditions affecting the facility and neighborhood. Overall, these observations and interviews show that the facility did not maintain catheter tubing off the floor or address visibly soiled tubing, did not consistently use required PPE for residents on EBP during high-contact catheter care, did not implement or monitor its Legionella water management plan as written, and did not ensure timely placement of trash into secured bins, resulting in accumulated trash in exterior areas.
Failure to Timely Report Injury of Unknown Source Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source that resulted in serious bodily injury for one resident. Staff first observed a large, dark bruise on the resident’s left hip and thigh around midnight during a night shift, but the CNA who discovered it did not notify the night shift nurse, stating she was busy and forgot, and instead only told an incoming day shift CNA. The day shift CNA later informed the RN on duty while assisting with the resident’s care. The RN assessed the bruise, describing it as purple and located on the posterior left thigh; the resident did not recall how it occurred and denied pain or discomfort. The RN assumed the bruise had already been reported to licensed staff on the prior shift and did not make an initial entry or initiate required notifications. Subsequently, the restorative nurse aide (RNA) and another CNA observed the large bruise in the lower hip area while assisting with a shower and confirmed with each other that the on-duty RN had been informed. The next day, the RNA observed another large bruise on the resident’s thigh and reported it to an LPN. Despite multiple staff being aware of the bruising over more than one shift, the DON, Administrator, physician, resident representative, and State Agency were not notified until several days after the bruise was first seen. This sequence of inaction and miscommunication occurred despite the facility’s abuse policy requiring that allegations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source that result in serious bodily injury be reported immediately, but no later than two hours after the allegation is made, with immediate notification of the Administrator or designee to initiate reporting to state agencies.
Failure to Perform and Document Complete Skin Assessment for Large Hip/Thigh Bruise
Penalty
Summary
The facility failed to ensure licensed nursing staff demonstrated appropriate competencies and skills to perform timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. Staff first observed the bruise on 07/30/25, but no initial assessment was conducted at that time. A CNA working the night shift observed the bruise and did not report it to the Charge Nurse, instead only telling the incoming day shift CNA the next day. The day shift CNA then informed an RN, who assessed the bruise as purple in color on the posterior left thigh, with the resident unable to recall how it occurred and denying pain or discomfort. The RN assumed the bruise had already been reported to licensed staff and did not complete an initial assessment entry. On 08/01/25, an LPN observed the large purplish bruise extending from the resident’s lower hip to the thigh, found no prior assessment or event note documenting the bruise, and then created an event and notified the DON. An X-ray ordered by the physician showed soft tissue swelling without acute fracture, dislocation, or bony lesions. Despite the presence of the bruise, weekly skin assessments completed by the RN on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 did not document the bruise on the left hip and thigh. These assessments repeatedly documented that there were no new onset skin impairments and described only dry scattered scabs to the bilateral shins treated with Medihoney gel. Nursing notes associated with the event report initiated on 08/01/25 documented that the bruise on the left hip and thigh was visible and then fading over multiple subsequent dates, with color changes from purple to yellow. However, these notes did not include a complete skin assessment or detailed documentation of the bruise’s progression, such as size, shape, initial appearance, or date of resolution. During interviews, the IP and Administrator confirmed that the RN’s weekly skin assessments should have included the bruise, that staff should perform a full skin assessment and initiate an RMC Injury/Integumentary Alteration event when a new skin issue is identified, and that the event report used by the LPN was not the correct form and did not capture a complete assessment. The report also cross-referenced F609, noting that the injury of unknown source resulting in serious bodily injury was not reported to the Administrator within two hours of discovery, as it was first observed on 07/30/25 but not reported until 08/01/25.
Failure to Assess and Educate Caregiver on Foley Catheter Care Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate discharge plan and caregiver education for a resident who was discharged home with an indwelling urinary catheter. The resident, an older female admitted for short-term rehabilitation after an acute hospitalization, had multiple medical conditions including diabetes, spinal stenosis, chronic back pain, muscle weakness, gait and mobility abnormalities, and end-stage renal disease requiring dialysis. While in the facility, she developed urinary retention and required an indwelling urinary catheter, which remained in place at the time of discharge home with her son as the designated caregiver. The nursing progress note documented that the resident was discharged home with her son, to be followed by her primary care provider and home health services, and that staff assisted with transfer to the son’s car. The note also indicated “Education/Training Response as indicated: n/a,” and there was no documentation that the caregiver received education on Foley catheter care. Following a report of concern to the Office of Health Care Assurance that the resident did not have needed resources after discharge and that the caregiver could not safely manage the urinary catheter, surveyors reviewed records and interviewed staff. The Social Services Assistant, after consulting the Social Worker, reported that a vendor provides caregiver training on the mechanical lift when delivering the equipment to the home, but the Social Worker did not know if nursing had provided catheter care education. It was acknowledged that although the son had cared for the resident prior to hospitalization, she did not have a urinary catheter at home before this admission. In an interview, the Administrator confirmed that nursing was responsible for assessing caregiver training needs, providing and documenting the training, and documenting that the caregiver was willing, capable, and had the capacity to provide the required care. The facility was unable to provide evidence that such assessment and education on Foley catheter care were completed or documented for this caregiver.
Failure to Ensure Safe Discharge Planning and Follow-Up for a Resident Discharged Home Alone
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s transfer/discharge plan met his needs and preferences and that he was adequately prepared and supported for a safe discharge to the community. The resident was an older male admitted after a stroke for medical management and rehabilitation, with a history of encephalopathy, muscle weakness, gait and mobility abnormalities, Type 2 DM on insulin, chronic heel ulcers, and hypertension. While in the facility, he was incontinent of bladder and bowel and wore disposable briefs. Prior to the stroke, he lived alone with community supports including a care coordinator, meals on wheels, transportation, a life alert system, help from a neighbor with groceries, and a friend who cleaned his house. He did not have a power of attorney. During the stay, an interdisciplinary care conference note documented that the resident would be discharged “home with family,” that he lived alone but had community services and a health coordinator, and that he would return home with established services and home health PT/OT/nursing. The discharge planning section inaccurately indicated that he had family and identified a wife as the primary caregiver, and it documented an intervention to evaluate and discuss prognosis, limitations, risks, benefits, and needs for independence. However, the resident did not have a wife or family caregiver, and the private hire caregiver was arranged by the facility. There was no evidence that the facility discussed with the resident the prognosis for independent living with minimal supervision, his limitations, or that he fully understood the risks. There was also no evidence that the provider was aware that the final discharge arrangement would involve only minimal supervision rather than the ordered level of care. The resident’s discharge orders specified a need for 24-hour care and home health services including PT, OT, speech therapy, nursing, and medication management, and therapy documentation indicated he was not safe to be home alone and required increased assistance at home. PT and OT notes recommended 24/7 care or at least a caregiver for 20 hours per week, and the resident’s modified Barthel ADL score reflected moderate dependence. The discharge MDS showed he required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers and mobility, but it documented him as always continent despite nursing documentation of multiple episodes of urinary and bowel incontinence in the week prior to discharge. The social services assistant confirmed the resident had no family or full-time caregiver, knew there would be a lag before community services resumed, and arranged a private hire caregiver for only two hours per day without knowing the caregiver’s qualifications. She acknowledged that the resident needed to be checked on daily and that he required daily insulin injections, which she stated nursing was responsible to ensure could be safely managed, but the facility could not provide evidence that the resident was competent to self-inject insulin or that a capable caregiver was identified and trained. Additional documentation and interviews showed that the care coordinator had informed the social services assistant that the resident had no support at home and that community services such as meals on wheels would not resume immediately, and that home health evaluation and possible services would not start until several days after discharge. The social services assistant did not document her discharge planning communications with the care coordinator in the medical record at the time and later produced a retrospective typed note. The friend who cleaned the resident’s home reported that upon discharge he struggled to get out of a chair, walked slowly, had frequent accidents on the floor, and could not figure out how to set his insulin pen correctly. The PT and OT confirmed that the resident had memory issues, was not at his pre-stroke baseline, could not change his own brief, and still needed assistance and cues for toileting and hygiene. The DON stated that nursing was responsible to ensure the resident could self-inject insulin or that a trained caregiver was identified, and confirmed the facility lacked evidence of such competence or caregiver training. The deficiency also included a failure to ensure appropriate follow-up for an ordered diagnostic test prior to discharge. Nursing documentation showed the resident had persistent diarrhea and stomach upset, and a stool culture and O&P were ordered along with a probiotic. The laboratory later reported that the stool sample was received in a sterile container instead of stool media, was no longer stable for testing, and that the resident was no longer at the facility so recollection was not needed. There was no documentation that the provider, primary medical doctor, or resident was notified that the stool culture was not completed. The DON confirmed that the stool culture and sensitivity had not been done and that the provider should have been notified to ensure follow-up after discharge.
Failure to Care Plan O2 Therapy and Implement Heel Protector Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed all ordered treatments. For one resident receiving oxygen (O2) therapy, surveyors observed the resident on 1 L O2 via nasal cannula and later without O2, with no signs of respiratory distress. Record review showed a physician’s order for continuous O2 supplementation at 1–4 L/min via nasal cannula for shortness of breath or SpO2 < 90%, with an order to wean O2 as tolerated every shift. However, the resident’s care plan did not include any problems, goals, or interventions related to O2 therapy. The ADON confirmed that O2 therapy was not included in the care plan and acknowledged that the care plan is important as it directs the care provided. The facility’s Oxygen Administration policy stated that the resident’s care plan will identify the interventions of oxygen therapy based on assessment and orders. A second deficiency involved failure to implement the care plan intervention for bilateral heel protectors for a resident with bilateral lower extremity (BLE) edema and cellulitis. The resident was repeatedly observed in bed with BLE edema, redness, and dry, scaly skin, with BLE exposed and no socks or heel protectors applied, despite reporting pain at 8/10 and stating that pain medication and daily cream application provided relief. Record review showed a physician’s order for bilateral heel protectors and a care plan intervention to ensure heels are offloaded by floating heels while in bed. Nursing staff confirmed that heel protectors should have been reapplied after physical therapy and a shower to protect the resident from further skin breakdown. The facility’s Comprehensive Care Plan policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment.
Failure to Prevent Injury During Mechanical Transfer and Unsupervised Hallway Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries during transfers and while residents were out of bed. One resident with dementia, hemiplegia following a stroke, and fragile skin experienced recurrent skin tears associated with transfers using a Hoyer lift. Family members reported that staff needed to be more careful when using the lift because the resident’s skin tears easily and that problems with skin tears occurred during transfers. The resident was observed wearing Geri sleeves on both arms, and a nursing progress note documented a skin tear to the left elbow that occurred after transferring the resident back to bed. Family members had previously filed a grievance stating that a CNA was moving too fast during a transfer from bed to wheelchair, and that the CNA reported she was holding the Hoyer sling to help navigate the resident’s position during the transfer. The resident’s RN stated that CNAs follow an ADL schedule, that the resident receives showers four times per week, and that Geri sleeves are used as a preventive measure. The RN also stated that the resident often screams during Hoyer transfers and characterized this as the resident’s behavior. The DON reported that various considerations had been made for the resident at the family’s request, including an increased shower schedule and discussion about nail trimming, while confirming that the family declined staff trimming the resident’s nails. A second resident, an older female with dementia, debility, pain, and a history of lumbar fractures, was care planned as being at risk for falls, with an approach to observe her frequently and place her in a supervised area when out of bed. Despite this, she was placed in a hallway in a wheelchair for a meal and left unattended when the CNA who had been watching her went to assist another resident in a room. The charge nurse was in the Resident Care Manager’s office when a visitor alerted staff that the resident had fallen; the resident was found on the floor on her left side. The charge nurse later acknowledged that the resident was at high risk for falls due to dementia, should not have been left unsupervised, and that the CNA, a part-time staff member unfamiliar with the residents on that floor, should have called for help before leaving the hallway and losing sight of the resident and others.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
