Ann Pearl Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Kaneohe, Hawaii.
- Location
- 45-181 Waikalua Road, Kaneohe, Hawaii 96744
- CMS Provider Number
- 125048
- Inspections on file
- 22
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Ann Pearl Nursing Facility during CMS and state inspections, most recent first.
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.
A resident with severe cognitive impairment and dependent care needs alleged abuse, but the facility delayed notifying leadership and initiating an investigation, resulting in a failure to promptly protect the resident and begin required safety checks and staff interviews.
A resident who sustained a fall was not promptly evaluated for worsening symptoms, including swelling and decreased strength in the right wrist and hand. Although the on-call provider had instructed staff to report any changes, staff failed to notify the provider when these changes occurred. An x-ray was not ordered until two days later, revealing acute displaced fractures. Both the provider and DON confirmed that earlier notification and intervention should have occurred.
A resident made a serious allegation of sexual abuse, but the nurse on duty did not report the incident immediately as required, resulting in a delay of more than two days before the Administrator, DON, and authorities were notified. This failure to follow reporting protocols led to a delay in initiating safety measures and an abuse investigation.
A facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. Errors included failure to administer medications, improper preparation, and incorrect documentation. One resident did not receive Amlodipine due to stock issues, another received improperly prepared Omeprazole, and a laxative was not administered as scheduled. Additionally, a resident was given a stool softener without being informed, and another did not receive Acetaminophen, which was incorrectly marked as refused.
A facility failed to create a trauma-informed care plan for a resident with PTSD, resulting in staff not having adequate information to address the resident's trauma triggers and specific needs.
A resident with schizophrenia and dementia had a care plan for wandering and exit-seeking behaviors, but it was not updated after the resident left the facility seeking money for cigarettes. The DON confirmed that the care plan should have been revised to address the root cause of the elopement.
A facility failed to ensure a resident with limited ROM received appropriate treatment to maintain her condition. Despite orders for daily application of splints and PROM exercises, observations and records showed inconsistent application. Interviews with staff revealed discrepancies in documentation and treatment application, placing the resident at risk of decline.
The facility failed to prevent accident hazards and ensure resident safety. A wet floor was left unattended, and a blind resident had access to cigarettes and a lighter, contrary to policy. Additionally, a resident with epilepsy lacked proper seizure pads on one side of his bed rail, despite being on seizure precautions.
A facility failed to adhere to a physician's order for oxygen therapy for a resident during a meal. A CNA was observed replacing the resident's oxygen mask with a nasal cannula, despite the physician's order specifying oxygen via face mask for shortness of breath or low oxygen saturation. The RN confirmed there was no order to switch to a nasal cannula, indicating a deviation from the prescribed care plan.
A facility failed to provide trauma-informed care for a resident with PTSD, as her trauma triggers were not identified, and no care plan was developed to address her needs. Despite the facility's policy requiring trauma screening, the resident's care plan lacked interventions for her sleep disturbances caused by loud noises and staff conversations. This oversight placed the resident at risk of re-traumatization.
A facility failed to ensure a physician addressed a pharmacist's recommendations for a resident's psychotropic medication regimen. The resident, with dementia and behavioral disturbances, was prescribed lorazepam as needed. The pharmacist recommended a specific stop date and clinical rationale for continuing the medication past 14 days, but the physician's response was inadequate. The DON acknowledged the oversight, which placed the resident at risk of complications.
A resident on contact precautions for MRSA infection received wound care from the DON and an RCM, during which the RCM failed to perform hand hygiene between glove changes. This breach in infection control occurred when the RCM donned new gloves without sanitizing her hands after running out of dressing supplies.
A resident with mild cognitive impairment and hearing aids, whose primary language was Korean, did not receive adequate care due to a language barrier. The facility lacked effective communication processes, resulting in staff being unable to understand and meet the resident's needs. Despite efforts to calm her, including using a geri chair and 1:1 supervision, the staff could not communicate effectively, leading to the resident's agitation and attempts at self-harm.
A facility failed to develop a comprehensive care plan for a resident with significant hearing impairment. Despite documentation of her hearing issues and primary language being Korean, the care plan did not address her hearing needs. This oversight was evident when the resident was transferred to the Emergency Department for psychiatric evaluation, where communication barriers were noted due to her hearing impairment and lack of hearing aids.
A resident experienced a hip fracture during physical therapy, but the incident was not reported to the physician, leading to a delayed diagnosis and treatment. Despite the resident's complaints of severe pain and limited mobility, the facility did not investigate the incident, resulting in a 12-day delay in appropriate care.
The facility failed to maintain the dignity of a resident by not covering the urinary catheter bag, which was visible from the hallway. An LPN confirmed that the cover is meant to maintain dignity and should always be in place, as indicated in the resident's care plan.
A resident sustained a left hip fracture, and the facility failed to thoroughly investigate the injury. The resident reported an incident during physical therapy, but this information was not included in the investigation, leading to a delay in diagnosis and treatment. The facility was unaware of the resident's report, which contributed to the deficiency.
The facility failed to ensure controlled drug records were reconciled between shifts, as an RN was observed pre-signing the reconciliation sheet without performing the count with the off-going nurse. The DON confirmed this practice was against the facility's policy, which requires a joint count and documentation by two licensed clinicians.
The facility failed to label medications in accordance with professional standards. An LPN was observed preparing medications for a resident, and the inhaler box had no open and discard dates. The LPN confirmed that the inhaler should have been labeled, as per the facility's policy on medication storage.
The facility failed to implement infection control measures for a resident on enhanced barrier precautions (EBP). A CNA was observed emptying a urinary catheter collection bag without wearing a gown, contrary to the facility's policy. The Infection Preventionist confirmed the need for PPE in such situations.
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.
Delayed Response to Alleged Abuse and Investigation
Penalty
Summary
The facility failed to prevent potential abuse and ensure the immediate safety of a resident with severe cognitive impairment who alleged abuse. The resident, who was dependent for self-care and bed mobility and receiving hospice services, reported being raped in front of her husband. This allegation was documented as a late entry several days after the event, and there was no evidence that the facility's Administrator or DON were notified at the time of the allegation. The facility's policy required immediate protection of the alleged victim and prompt initiation of an investigation, but the notification to leadership and the start of the investigation were delayed by two days. As a result of this delay, the facility did not implement its procedures to ensure the safety of the alleged victim or other residents, nor did it begin the required Safe Survey forms or staff interviews until days after the initial report. Interviews with facility staff confirmed that the investigation and resident safety checks were not initiated until leadership was made aware, which was not in accordance with the facility's abuse and neglect policy.
Failure to Notify Physician of Worsening Injury After Resident Fall
Penalty
Summary
Facility staff failed to consult with a physician after a resident experienced a worsening injury following a fall. The resident was initially found on the floor complaining of right forearm pain, with full range of motion but weak movement due to pain. The on-call provider was notified at that time, but no new orders were received. The following day, staff documented pain, swelling, and decreased strength in the resident's right wrist and hand compared to the left, and this information was endorsed to the oncoming nurse with a note to obtain an x-ray order. Despite these changes in the resident's condition, including swelling and decreased strength, staff did not notify the on-call provider as instructed. It was not until two days after the fall that an x-ray was ordered, which revealed acute displaced fractures of the distal radial metaphysis and ulnar styloid. Both the on-call provider and the Director of Nursing confirmed that the provider should have been contacted when the swelling and strength discrepancy were first observed, and that an x-ray would have been ordered at that time.
Failure to Timely Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately, as required by both facility policy and federal regulations. A resident made a serious allegation of sexual abuse, which was witnessed by her husband and reported to the nurse on duty. Despite being aware of the seriousness of the allegation and having received prior education on reporting requirements, the nurse did not report the incident promptly, citing being busy and forgetting. Documentation shows that the incident occurred in the evening, but the Administrator and DON were not notified until two days later. The initial report to the State Agency and law enforcement was also delayed, being submitted more than two days after the alleged incident. Record review and staff interviews confirmed that the facility's policy required reporting of abuse allegations within two hours if the event involved abuse or resulted in serious bodily injury. However, the Administrator and DON both acknowledged that they were not notified immediately, and the required reports were not submitted within the specified timeframe. There was no documentation that the appropriate facility leadership was informed at the time of the allegation, and the delay in reporting resulted in a failure to implement immediate safety measures and timely investigation for the resident involved.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 16% error rate. This was evidenced by five medication errors observed out of 31 opportunities. The errors involved three residents who were placed at risk of negative outcomes due to these medication errors. The errors included failure to administer medications, improper medication preparation, and incorrect documentation of medication administration. One resident did not receive their prescribed Amlodipine due to it being out of stock, and the nurse failed to follow the protocol of checking the RX NOW system or contacting the pharmacy. Another resident was given a delayed-release Omeprazole capsule that was improperly opened and mixed with applesauce, contrary to the facility's guidelines. Additionally, a laxative was not administered as scheduled, and the nurse incorrectly documented it as given on time. Further errors included a resident being given a stool softener without being informed, despite refusing it, and another resident not receiving their scheduled Acetaminophen, which was incorrectly marked as refused before being offered. These actions and inactions by the nursing staff, particularly RN1, contributed to the medication errors and the facility's failure to adhere to safe medication administration practices.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a resident-centered trauma-informed care (TIC) plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). This deficiency was identified during an interview and record review, revealing that the facility staff lacked sufficient information to address the trauma triggers and specific needs of the resident.
Failure to Revise Care Plan for Resident Elopement Risk
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R42, who was at risk for elopement. R42, a male resident with schizophrenia and dementia, was admitted to the facility and had a care plan created for wandering and exit-seeking behaviors on 07/10/24. However, after an incident on 10/11/24, where R42 walked out of the facility seeking money for cigarettes, the care plan was not updated to address the root cause of his elopement. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have been revised following the incident.
Inconsistent Application of Orthotic Devices and ROM Exercises
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a decline in ROM in her left hand and elbow. The resident, who is cognitively intact and has a history of left-sided weakness and paralysis following a stroke, was observed without her prescribed orthotic devices on multiple occasions. Despite physician orders for daily application of splints and passive range of motion (PROM) exercises, the resident's electronic health record did not reflect consistent application or offer of these treatments since a specific date. Interviews with facility staff revealed inconsistencies in the documentation and application of the resident's prescribed treatments. The Certified Nurse Aide responsible for the resident's care stated that she performed PROM and applied splints daily, yet the Point-of-Care responses indicated these treatments were documented for only half of the days in the past month. The Director of Nursing acknowledged that the expectation was for daily application of splints, as ordered, and the assessment data should reflect this. The failure to consistently apply the prescribed treatments placed the resident at risk of a decline in ROM and loss of function.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. In one instance, a wet floor was observed in the hallway and a resident's room, with staff walking around the area without taking action to clean it or place caution signs. The Director of Nursing confirmed that the wetness should have been addressed promptly. Additionally, a resident who was not on the facility's list of smokers was found with cigarettes and a lighter in his possession, despite being blind and requiring assistance to smoke safely. The facility's policy mandates that smoking materials be locked up and checked out by a nurse, which was not adhered to in this case. Another deficiency involved a resident with epilepsy who was observed without proper seizure pads on one side of his bed rail, despite being on seizure precautions. The Resident Care Manager confirmed that both sides of the bed should have been padded for the resident's safety. The facility's seizure management policy requires padding for side rails and the bed headboard, which was not fully implemented for this resident. These deficiencies indicate a failure to eliminate known hazards and ensure adequate supervision to prevent accidents.
Failure to Follow Physician-Ordered Oxygen Therapy During Meal
Penalty
Summary
The facility failed to provide the physician-ordered oxygen therapy during a meal for a resident who required oxygen support. On the morning of February 27, 2025, a Certified Nurse Aide (CNA) was observed removing the resident's oxygen mask and replacing it with a nasal cannula, with the oxygen flow rate set at five liters per minute via an oxygen concentrator. The CNA stated that she was informed by the nurse that the resident must always have oxygen on, and it was acceptable to switch from a face mask to a nasal cannula during meals. However, a review of the physician's orders indicated that the resident was prescribed oxygen at a rate of five to ten liters per minute via face mask for shortness of breath or if oxygen saturation fell below 90%, with instructions to notify the physician if oxygen was applied or increased. The Registered Nurse (RN) confirmed that there was no order to switch to a nasal cannula during meals, indicating a deviation from the prescribed care plan.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to adequately assess and identify past trauma experienced by a resident, leading to a deficiency in providing trauma-informed care. The resident, a female with a history of cerebral infarction, major depressive disorder, anxiety disorder, and PTSD, was admitted to the facility without a trauma-informed care (TIC) plan in place. Despite the facility's policy requiring a trauma screening upon admission and at regular intervals, the resident's trauma triggers were not identified, and no TIC care plan was developed to address her specific needs. Interviews and record reviews revealed that the resident experienced sleep disturbances due to loud noises and staff conversations, which were not addressed in her care plan. The Director of Nursing confirmed that the Social Services Director failed to conduct the required quarterly trauma screening, and the resident's care plan lacked interventions for her identified triggers. This oversight placed the resident at risk of re-traumatization and hindered her mental and psychosocial well-being.
Failure to Address Pharmacist's Recommendations for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that medication regimen irregularities and recommendations were addressed by the physician for a resident sampled for unnecessary medications. The resident, a female with dementia and behavioral disturbances, was prescribed lorazepam as needed for anxiety. The pharmacist recommended providing a specific stop date or time period and a clinical rationale for continuing the psychotropic medication past 14 days. However, the physician's response did not align with the pharmacist's recommendation, as it lacked a specific stop date and clinical rationale. The Director of Nursing (DON) acknowledged that the physician's response was inappropriate and should have been addressed before the pharmacist repeated the recommendation the following month. The facility's policy requires that recommendations be acted upon within 30 days, but the process was not followed, leading to the deficiency. The failure to address the pharmacist's recommendation placed the resident at risk of avoidable complications related to the continued use of the psychotropic medication without proper justification.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident who was on Transmission Based Precautions due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. The resident, who had been admitted with multiple diagnoses including acute osteomyelitis, stage 4 pressure ulcer, and local infection of the skin, was observed receiving wound care from the Director of Nursing (DON) and a Resident Care Manager (RCM). During the procedure, the RCM did not perform hand hygiene between glove changes, which is a critical step in preventing the spread of infections. The incident occurred when the RCM ran out of dressing supplies and had to request more. After removing her gloves and discarding them, she donned a new pair without sanitizing her hands in between. This oversight was confirmed during an interview with the RCM, who acknowledged the lapse in protocol. The failure to perform hand hygiene between glove use during wound care for a resident on contact precautions represents a significant breach in infection control practices.
Language Barrier Leads to Inadequate Care
Penalty
Summary
The facility failed to provide a resident, whose primary language was Korean, with the right to equal access to quality care due to a lack of effective communication processes. The resident, who had mild cognitive impairment and used hearing aids, was admitted for short-term physical and occupational therapy. The staff were unable to communicate effectively with her, as they did not have access to interpreters or a reliable translation service. This communication barrier led to the staff being unable to understand and meet the resident's needs, which resulted in her becoming agitated and attempting self-harm. The nursing notes and interviews with staff revealed that the resident was restless and repeatedly attempted to leave the facility, expressing a desire to go home. Despite the staff's efforts to calm her, including the use of a geri chair and 1:1 supervision, they were unable to communicate effectively with her due to the language barrier. The staff resorted to using translation apps and attempting to contact the resident's daughter, but these efforts were insufficient. The facility's policy on Limited English Proficiency (LEP) was not effectively implemented, as staff were unaware of or unable to access the bilingual access line or other interpreter services. Interviews with various staff members, including nurses, the Resident Care Manager, and Social Services, highlighted the lack of a clear process for obtaining interpreter services. The staff relied on ad-hoc methods such as using Google Translate or contacting family members, which were not always effective. The facility's failure to provide adequate language assistance led to a situation where the resident's rights to communication and self-determination were compromised, ultimately affecting her quality of care and well-being.
Failure to Address Hearing Impairment in Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with significant hearing impairment. The resident, a Korean-speaking female with mild cognitive impairment, was admitted for short-term physical and occupational therapy. Despite documented evidence in progress notes indicating her hearing impairment and primary language, the care plan did not address her hearing needs. The baseline care plan inaccurately stated that her hearing was adequate and required no improvement, and the comprehensive care plan only noted her language barrier without addressing her hearing impairment. During her stay, the resident was transferred to the Emergency Department for psychiatric evaluation after attempting self-harm. The emergency department noted significant communication barriers due to her hearing impairment and lack of hearing aids. The facility's policy on comprehensive care plans emphasizes the need for person-centered care that includes measurable objectives and timeframes to meet residents' needs, but this was not reflected in the care plan for this resident.
Failure to Notify Physician of Incident Resulting in Hip Fracture
Penalty
Summary
The facility failed to ensure that a resident's physician was notified after an incident during physical therapy resulted in a left hip fracture. The resident, who had intact cognition, reported hearing a loud crack and experiencing sharp pain when the physical therapist pushed his left knee to his chest. Despite the resident's complaints of severe pain and inability to move his left knee, the incident was not communicated to the physician or the treatment team, leading to a delayed diagnosis and treatment of the fracture. The resident's electronic health record showed multiple progress notes documenting the resident's complaints of pain and limited mobility following the incident. However, the facility did not investigate the resident's report of the incident during physical therapy. The resident continued to experience severe pain and a decline in mobility, eventually leading to a hospital transfer for surgical repair of the fracture. Interviews with direct care staff and the nurse practitioner confirmed that the resident was a reliable source of information and that the incident was not reported to the physician. The nurse practitioner stated that if she had been informed of the incident, the course of treatment would have been different, including an immediate x-ray and cessation of physical therapy. The facility's failure to notify the physician and investigate the incident resulted in a delay of 12 days in diagnosing and treating the resident's hip fracture.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident (R101) by not covering the urinary catheter bag, which was visible from the hallway. R101, an elderly resident admitted for short-term rehabilitation and wound care, had an indwelling urinary catheter to prevent wounds in the groin area from getting wet. On the morning of 03/19/24, R101 was observed lying in bed with the catheter bag uncovered and visible from the hallway. An interview with an LPN confirmed that the cover for the catheter bag is meant to maintain the resident's dignity and should always be in place, as also indicated in R101's baseline care plan.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a thorough investigation of an injury of unknown origin for a resident who sustained a left hip fracture. The incident was reported to the nursing staff by the resident during physical therapy, where the resident heard a loud crack and felt sharp pain. However, this information was not included in the investigation report submitted to the state agency. The initial x-ray taken did not show any obvious fracture, but a subsequent x-ray revealed an avulsion fracture, indicating a traumatic injury had occurred. During an interview with the director of nursing (DON), resident care manager (RCM)1, and RCM2, it was confirmed that the facility was unaware of the resident's report of the incident during physical therapy. The facility's investigation did not consider this potential source of the injury, leading to a delay in the diagnosis and treatment of the resident's left hip fracture. The resident is considered a reliable source of information, and the failure to investigate the reported incident contributed to the deficiency.
Failure to Reconcile Controlled Drug Records Between Shifts
Penalty
Summary
The facility failed to ensure the controlled drug records were reconciled between shifts, as observed during a medication administration observation with a registered nurse (RN). The RN was seen initialing the controlled medication reconciliation count sheet for both the off-going and on-coming shifts without performing the count in the presence of the off-going nurse. The RN admitted to pre-signing the form for the on-coming shift, which could lead to errors in the reconciliation of controlled medications. During an interview with the Director of Nursing (DON), it was confirmed that the facility's procedure requires the off-going and on-coming shift nurses to count the controlled medications together and sign the reconciliation sheet in each other's presence. The facility's policy and procedure also mandate that a physical inventory of controlled medications be conducted by two licensed clinicians at each shift change and documented on an audit record. The failure to follow this procedure was confirmed by the DON.
Failure to Label Medications Properly
Penalty
Summary
The facility failed to label medications in accordance with acceptable professional standards. During a morning medication pass, an LPN was observed preparing medications for a resident, and it was noted that the inhaler box had no open and discard dates. In a subsequent interview and inspection of the medication cart, the LPN confirmed that the inhaler should have been labeled with these dates. The facility's policy on medication storage requires medications to be labeled with open and discard dates when opened, which was not followed in this instance.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control measures, specifically regarding the use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). On 03/19/24, a sign indicated that Resident 101 was on EBP due to an indwelling urinary catheter and open wounds in the groin area. However, Licensed Practical Nurse (LPN) 23 incorrectly stated that a gown was only needed for high-contact care activities and not for tasks such as giving oral medications or serving meals. This misunderstanding was evident when Certified Nurses' Aide (CNA) 53 was observed emptying the resident's urinary catheter collection bag without wearing a gown on the same day. On 03/21/24, the Infection Preventionist (IP) confirmed that CNA 53 should have been wearing a gown while performing this task. The facility's policy on Transmission-Based Precautions under Enhanced Barrier Precautions clearly states that staff should wear gowns and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs). The failure to adhere to these guidelines placed all residents at risk for the potential spread of infections and communicable diseases.
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.
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