Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Care Center - Honolulu, Llc during CMS and state inspections, most recent first.
Failure to fully cover urinary drainage and leg bags: A resident using a urinary drainage bag and later a urinary leg bag was observed with the bag only partially covered or not covered by a privacy/dignity bag while out of the room and in the dining area. The resident stated concern that the bag should always be covered and that the exposed leg bag made the resident uncomfortable because it was visible to others. RN and DON both confirmed that urinary bags should always be fully covered with privacy or dignity bags.
A resident with a catheter was observed with the catheter bag and tubing exposed outside the privacy bag and resting directly on the floor, and the resident moved the wheelchair over the bag. An RN later confirmed that catheter bag and tubing should not be in direct contact with the floor.
A pill cutter in the station 1C med cart was observed with large amounts of white and brown sediments inside it during survey. An RN administering meds from the cart confirmed the contamination and stated it was from not cleaning the cutter, adding that it should be cleaned after each use.
Failure to Provide Ordered AROM Program: A resident with weakness, pain, and a history of falls did not receive the ordered AROM restorative program 6 times a week as care planned. Record review showed some weeks with fewer than the required interventions, with treatments sometimes refused and sometimes not offered. The MDSC confirmed the frequency was not met and that refusals were not being addressed in the RNA program.
Failure to Provide Ordered AROM Program: A resident admitted with weakness, pain, and a history of falls was ordered AROM exercises 6 times a week to maintain mobility and strength. Documentation showed repeated missed sessions, refusals, and days marked not applicable or not done, and the MDS coordinator, RNA, and DON confirmed the program was not consistently carried out. Staff reported that staffing shortages, other assigned duties, and lack of time prevented them from completing the ROM program, revisiting the resident, or providing ongoing encouragement when the resident refused.
Staff failed to consistently use required PPE, perform hand hygiene, and ensure proper environmental controls when caring for residents on transmission-based and enhanced barrier precautions. Multiple instances were observed where staff entered or exited rooms of residents with communicable diseases, including COVID-19, without appropriate PPE, did not perform hand hygiene after glove removal, and disposed of contaminated PPE outside designated areas. Additional lapses included improper handling of urinary catheters and call lights, and inconsistent availability of PPE and disposal receptacles, all contributing to inadequate infection control.
Surveyors found that call devices were frequently placed out of reach for several residents with physical limitations, including those with blindness, fractures, and muscle weakness. Observations showed call lights wrapped around bed rails, on the ground, or on shelves, making them inaccessible. Staff interviews confirmed that call devices were not always secured or positioned to prevent them from falling or becoming unreachable, contrary to facility policy.
A resident with limited ROM did not receive consistent restorative nursing aide services, including splint application and exercises, due to insufficient RNA staffing. Staff reported that RNA personnel were often reassigned to CNA duties, leaving gaps in restorative care. The resident confirmed she was not receiving her prescribed exercises and stretches.
A medication cart's EHR was left open and unattended in the hallway, displaying a resident's medication list. An RN acknowledged forgetting to lock the EHR, resulting in unprotected personal health information.
A resident receiving oxygen therapy was not accurately assessed upon admission, as their O2 therapy was omitted from the MDS documentation. This led to the absence of O2 therapy in the care plan, lack of review of physician orders, and failure to monitor or label O2 tubing, as confirmed by MDS staff interviews.
A resident admitted with a right leg injury did not receive a copy of the baseline care plan (BCP) within 48 hours of admission. The resident reported not being informed about the plan of care, and review of the electronic health record confirmed the absence of documentation showing the BCP was provided. The DON stated that a care plan discussion took place during a welcome meeting, but there was no evidence that the resident received a copy of the care plan.
The facility did not develop or implement comprehensive, person-centered care plans for three residents with specialized needs, including oxygen therapy, hemodialysis, and catheter care. For these residents, care plans lacked required details such as interventions for O2 therapy, assessment of dialysis access sites, and catheter care, despite existing physician orders and facility policies. Staff confirmed these omissions during interviews and record reviews.
A resident with worsening moisture-associated skin damage (MASD) and a fungal infection on the sacrum and buttocks did not have their care plan updated to include antifungal treatment after the condition was identified. The facility also failed to obtain a physician's order for the necessary intervention.
Two residents did not have their individual activity preferences and special needs accommodated, as required by their assessments and the facility's policy. One resident, who was cognitively intact, was not offered in-room activities or provided with options matching her preferences, while another blind resident's care plan did not include or consistently implement activities suitable for her condition.
Two residents did not receive care according to physician orders and care plans: one resident with constipation did not receive prescribed as-needed bowel medications after multiple days without a bowel movement, and another resident with worsening MASD and a fungal infection did not receive timely antifungal treatment or care plan updates, despite documented progression of the condition.
A resident with hemiplegia and hemiparesis did not consistently receive prescribed passive and active ROM exercises or have splints applied as ordered. Observations and interviews confirmed that restorative nursing aide services were missed on multiple days, and the resident was repeatedly seen without required splints, despite physician orders and care plan instructions.
A resident was pushed in a wheelchair without leg rests by therapy staff, requiring the resident to hold her feet up during transport over a significant distance. Staff indicated the leg rests were left in the resident's room due to time constraints, and the wheelchair lacked a holder for the leg rests. The Director of Rehab confirmed that staff are trained to use leg rests during transport.
Two residents requiring O2 therapy and nebulizer treatments did not receive care consistent with professional standards. One resident’s assessment and care plan failed to include O2 therapy, and both residents had O2 and nebulizer tubing that was not properly labeled or changed as required. Physician orders for O2 therapy lacked necessary details such as flow rate and delivery method, and staff could not explain discrepancies in tubing labeling. These deficiencies in documentation and equipment management placed the residents at risk for respiratory complications.
A resident who returned from hemodialysis had their fistula pressure dressing left on overnight, exceeding the recommended two-hour removal window. Staff interviews revealed uncertainty about the required timing for dressing removal, and the care plan lacked specific interventions for assessing fistula function. Facility policy required monitoring the access site but did not ensure timely removal of the dressing, resulting in a deficiency in dialysis care.
Surveyors identified failures in narcotic log documentation and reconciliation, including a nurse not signing out administered and wasted doses of Oxycodone, and improper handling of discontinued and expired medications such as Ferrous Gluconate and Methocarbamol. Staff interviews confirmed that these actions did not follow facility policy, affecting the safe administration and accountability of medications.
A resident's monthly medication regimen review included pharmacist recommendations for not crushing aspirin and for monitoring high-risk medications, but the facility did not update physician orders or document the required monitoring. The DON stated that monitoring was standard practice but not documented, and review of another resident showed nursing staff were not monitoring for opioid-related constipation.
A nurse failed to inform a resident about a laxative mixed in her water after she refused another laxative, and did not remain with the resident until all medications were consumed. Additionally, the nurse documented inconsistent blood pressure readings and could not provide evidence that the required blood pressure was taken before administering antihypertensive medications. These actions resulted in a medication error rate above 5%.
A medication cart was found left unlocked and unattended outside a resident's room, with no staff present. An RN confirmed that the cart should have been locked when not in use and acknowledged being educated on this requirement.
The facility failed to ensure proper infection control practices, including the use of PPE and hand hygiene, as well as the handling of medical equipment and supplies. Staff did not consistently follow transmission-based precautions for a resident with shingles, and used medical items were improperly stored or discarded.
The facility failed to ensure that three residents had the required physician's documentation stating they lacked the capacity to make their own healthcare decisions before allowing surrogates to act on their behalf. This deficiency was identified through record reviews and staff interviews, revealing gaps in compliance with state law and facility policy.
The facility failed to provide timely written notification of transfer or discharge to four residents or their representatives, as required by policy. The administrator admitted to not knowing the 30-day notification requirement, and no documentation was kept to confirm that notifications were sent.
The facility failed to provide written notification of the bed hold policy to three residents and their representatives during hospital transfers. Documentation was missing in the EHR, and the Administrator's check mark system did not clearly indicate that the policy was sent.
The facility failed to adequately manage pain for three residents due to incomplete pain evaluations, resulting in ineffective care plans. One resident experienced significant pain without timely medication, another had an incomplete pain evaluation lacking details on pain type and alleviation methods, and a third had several sections of her pain evaluation left blank. The DON confirmed these deficiencies and acknowledged their impact on resident care.
The facility failed to maintain resident dignity during meal assistance. The DON referred to a resident as a 'feeder' and directed staff to serve this resident last. A CNA referred to another resident as a 'feeder' while the resident was choking. Additionally, a CNA assisted a resident with his meal while standing and using her personal phone, contrary to facility policies.
A resident reported never receiving quarterly account statements or a statement upon request for her personal funds managed by the facility. The BOM confirmed the lack of a tracking system to ensure statements were provided, and the resident received her first statement only after the surveyor's inquiry.
The facility failed to maintain a clean and sanitary environment, as evidenced by black residue on the ceiling and vent outside of residents' rooms. Despite cleaning logs indicating the area was cleaned, the residue remained, and staff confirmed the issue might be mold from the air conditioning system.
The facility failed to ensure accurate documentation of a resident's discharge status. A resident discharged to home with home health services was incorrectly documented as discharged to a Short-Term General Hospital. This error was confirmed by the MDS Director during an interview.
The facility failed to develop and implement a person-centered Comprehensive Care Plan (CP) for a resident with contractures in the left hand. The ordered treatment of placing rolled gauze or a towel under the resident's fingers was not included in the CP, leading to inadequate care. The Director of Nursing acknowledged that the facility's practice of using generalized statements in the CP was not person-centered and did not meet the facility's policy.
A resident with multiple health issues developed diabetes while at the facility and was hospitalized due to diabetic shock. Despite being readmitted with a new diagnosis of type 2 diabetes, the care plan was not updated to include treatment and care for this condition, as confirmed by the Director of Nursing.
A resident experienced significant discomfort due to constipation for over five days because the facility failed to properly assess, document, and manage her bowel movements. Despite physician orders and the resident's requests, the prescribed interventions were not effectively administered.
A resident with contractures in both hands did not receive the ordered care of placing rolled gauze or a towel in his left hand every shift. Multiple staff members were unaware or inconsistent in implementing this order, leading to a deficiency in the resident's care.
A resident with hemiplegia, hemiparesis, and dysphagia was given the wrong meal and experienced a coughing episode while a CNA was distracted by her personal phone. The CNA failed to verify the meal ticket, and the facility's protocols for meal distribution and staff conduct were not followed.
The facility failed to ensure staff competency in narcotic log documentation and reconciliation. An RN did not sign out a Tramadol tablet at the appropriate time, despite having administered it earlier. Both the Unit Manager and the DON confirmed that narcotics should be signed out when pulled.
The facility failed to ensure all medications were labeled in accordance with professional standards. An albuterol inhaler was found without a name or date, despite being opened and used. The RN confirmed the inhaler had been used but could not explain the lack of proper labeling. The ADON confirmed that the inhaler and its box should have been labeled with at least the resident's name and the date it was opened.
The facility failed to ensure accurate documentation of a resident's medical record. Despite physician orders to place rolled gauze or a towel in the resident's left hand every shift, observations showed the treatment was not provided. Staff interviews confirmed the treatment was not consistently done, although it was marked as completed in the Treatment Administration Record (TAR).
A resident's bed control cord was found to be frayed in multiple places, posing a risk of electrocution. The resident had placed the control in her dresser drawer and was unable to answer questions about it. A Unit Manager RN confirmed the unsafe condition.
Failure to fully cover urinary drainage and leg bags
Penalty
Summary
The facility failed to ensure the resident's right to a dignified existence for 1 of 2 residents sampled for dignity, involving a resident who used a urinary drainage bag and later a urinary leg bag. During an observation, the resident was seen self-propelling to the dining area from Physical Therapy with a urinary drainage bag hanging under the wheelchair and only about one-third of the bag covered by a privacy/dignity bag. When asked about it, the resident stated concern that the drainage bag was not fully covered and said the bag should always be covered; the resident then tried to adjust the privacy bag but was unable to fully resolve the issue. During a later observation in the dining room, the resident had a urinary leg bag securely attached to the right leg and stated that the RN had changed the urinary bag to a leg bag and instructed that it be changed every time the resident left the room. The resident said the leg bag did not have a privacy bag covering it, that the resident preferred to wear short pants, and that the exposed leg bag made the resident uncomfortable because it was visible to others outside the room. RN11 and the DON both stated that urinary bags should always be fully covered with privacy or dignity bags, and the DON said the facility was in the process of ordering new urinary leg bags with dignity or privacy bags. The facility policy stated that the resident has a right to be treated with respect and dignity.
Catheter Bag and Tubing Left in Contact With Floor
Penalty
Summary
Appropriate catheter care was not provided for Resident R144, who was observed seated in a wheelchair in the entrance of the resident's assigned room with the catheter bag outside of the privacy bag. Approximately the bottom third of the catheter bag and the tubing were resting directly on the floor, and the resident moved the wheelchair and ran over the exposed catheter bag. When the situation was brought to RN15's attention, RN15 secured the catheter bag and tubing off the floor. RN15 confirmed that appropriate treatment and care of the catheter bag and tubing was to ensure it was not in direct contact with the floor.
Contaminated Pill Cutter Found in Medication Cart
Penalty
Summary
The facility failed to provide a safe and sanitary environment when a pill cutter in the station 1C medication cart was found with large amounts of white and brown sediments inside the cutter. On 06/03/26 at 08:10 AM, surveyors checked the top drawer of the medication cart and observed the contaminated pill cutter in 1 of 3 medication carts reviewed. RN6, who was administering medications from the cart at the time, confirmed seeing the white and brown sediments and stated that it was from not cleaning it. RN6 also stated that the cutter should be cleaned after each use.
Failure to Provide Ordered AROM Program
Penalty
Summary
The facility failed to implement the person-centered care plan for one resident who was admitted with diagnoses including weakness, pain, and a history of falling. The resident was identified as a fall risk and had mobility issues related to weakness. The care plan, initiated on 02/20/26, directed the RNA restorative program to encourage active range of motion (AROM) exercises to both upper extremities using 3-pound dowel weights for 10 repetitions times 3 sets, 6 times a week as tolerated. Record review of the resident’s AROM program from 02/20/26 through 05/20/26 showed that the resident received at most four interventions in some weeks, with some treatments refused and others not offered. During observation on 05/21/26, the resident was sitting on a rollator in the activities room and did not participate in a balloon toss activity; when asked why, the resident shook her head and motioned that she could not lift her arms. Interviews with the MDSC, who was responsible for the RNA program, confirmed that the resident was supposed to receive AROM 6 times a week and did not receive that frequency. The MDSC also stated that refusals were not being addressed and were being left to nursing staff because the RNAs were short-staffed and pulled to other duties.
Failure to Provide Ordered AROM Program
Penalty
Summary
The facility failed to implement the active range of motion (AROM) program for one resident who was admitted with weakness, pain, and a history of falling. The resident was identified as a fall risk and had mobility issues related to weakness. The care plan, initiated on 02/20/26, directed the restorative nurse aide (RNA) to encourage bilateral upper extremity ROM exercises using 3-pound dowel weights for 10 repetitions and 3 sets, 6 times a week as tolerated. Review of the resident’s AROM documentation showed that the ordered 6-times-a-week program was not consistently provided. Across multiple weeks, the record reflected days with no AROM intervention, days marked as resident refused, days marked as not applicable, and some days marked with an X. The MDS coordinator, who was also responsible for the restorative nursing program, confirmed that the resident should have been receiving AROM exercises 6 times a week and stated that NA meant the activity was not done. The coordinator also explained that Tuesdays were not used for AROM because the RNAs focused on resident weights. Interviews with the MDS coordinator, RNA, and DON confirmed that staffing shortages affected the restorative program and that RNAs were pulled to other duties, limiting their ability to complete ROM activities, revisit residents, or provide education and encouragement when residents refused. The RNA stated the resident often refused because she was tired and sleepy after breakfast and wanted the activity later, but staff did not have time to circle back. The DON confirmed that refusals should have been addressed and that the resident should have been revisited and encouraged to participate.
Failure to Implement and Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement and maintain appropriate infection prevention and control practices, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE), hand hygiene, and environmental controls. Staff were observed entering and exiting rooms of residents on transmission-based precautions, including those with confirmed COVID-19, without donning the required PPE such as gowns, gloves, N95 masks, and face shields. In one instance, a certified nurse aide exited a quarantined resident's room wearing only a surgical mask, despite the resident being COVID-positive and facility policy requiring full PPE. Another staff member was observed delivering a meal tray and assisting a resident on Contact Precautions without wearing gloves or a gown, and was unable to articulate the difference between Contact Precautions and Enhanced Barrier Precautions. Hand hygiene practices were not consistently followed. A registered nurse was observed removing soiled gloves, obtaining new gloves, and donning them without performing hand hygiene in between, despite facility policy requiring hand hygiene after glove removal. Additionally, staff did not always change gloves or perform hand hygiene between different care tasks, such as repositioning a resident and then assisting with feeding. Environmental controls were also lacking, as PPE and disposal receptacles were not consistently available inside or outside rooms where required, leading staff to cross hallways in contaminated PPE to dispose of it, or to retrieve clean gloves from outside the room, increasing the risk of cross-contamination. Other infection control lapses included improper handling of indwelling urinary catheters, with catheter bags observed resting on the floor without a barrier, and staff confirming this was not in accordance with infection control standards. Call lights were returned to residents' beds without cleaning after being on the floor, and privacy bags for catheters were allowed to touch the ground. Interviews with staff and the infection preventionist revealed inconsistent understanding and application of PPE protocols, as well as logistical issues with PPE and trash receptacle placement, further contributing to the deficient practices.
Failure to Ensure Call Devices Were Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call devices were consistently placed within reach and accessible for six sampled residents, all of whom had intact cognitive function but varying physical limitations. Observations revealed that call devices were often wrapped around bed rails, placed on the ground, or positioned on shelves, making them inaccessible to residents who were in bed. In several instances, residents were unable to locate or reach their call devices when asked to demonstrate their use, and staff confirmed that the devices were not always within reach. Specific examples included a resident with legal blindness and Parkinson's disease who repeatedly had her call device placed out of reach, either wrapped around the bed rail or positioned on the bed's edge. Another resident with a spinal fracture and muscle weakness was unable to locate his call device, which was placed at the top of a pillow and out of reach. Additional residents were observed with call devices on the ground, behind their backs, or on shelves, and staff interviews confirmed that the devices were not always secured or positioned to prevent them from falling or becoming inaccessible. The facility's own policy required that the call system be accessible to residents while in bed, but multiple observations and staff interviews demonstrated that this standard was not consistently met. The failure to ensure call devices were within reach prevented residents from independently calling for assistance and did not accommodate their needs and preferences as required.
Insufficient Staffing for Restorative Nursing Services
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide restorative services for a resident with limited range of motion (ROM). On observation, the resident was found eating breakfast in bed with her left arm folded and fisted on her chest, without her prescribed splint. Staff confirmed that the resident should have been wearing her splint daily, but there was no restorative nurse aide (RNA) available that day. The resident also reported that she had not been receiving her exercises and stretches, which she wished to continue. Interviews with facility staff revealed that the RNA program was understaffed, with only one RNA available on most days instead of the required two, and sometimes none due to staff absences or reassignments to CNA duties. Staff trained to provide RNA services reported they were unable to perform these duties when assigned as CNAs due to workload. Review of staffing records confirmed gaps in RNA coverage, and the Director of Nursing acknowledged that RNA staff were reassigned to CNA roles when CNA staffing was insufficient, resulting in no RNA coverage for residents requiring restorative services.
EHR Left Open, Exposing Resident Medication Information
Penalty
Summary
A deficiency occurred when the electronic health record (EHR) on a medication cart was left open and unattended in the hallway, displaying a resident's list of medications. This was observed during a morning survey, and the information was visible and not protected. When interviewed, the registered nurse responsible acknowledged forgetting to close the EHR and stated that it should be locked every time staff walk away.
Failure to Accurately Assess and Document Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a comprehensive assessment accurately reflected a resident's status, specifically omitting oxygen (O2) therapy from the admission Minimum Data Set (MDS) for one resident. The resident was receiving O2 therapy at the time of admission, but this was not documented in Section O of the MDS. As a result, the resident's O2 therapy was not included in the care plan, physician orders for O2 were not reviewed, and the O2 tubing was not properly monitored or labeled. Interviews with MDS staff confirmed that O2 therapy should have been documented in the MDS and acknowledged the omission.
Failure to Provide Baseline Care Plan Copy to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan (BCP) to a resident within 48 hours of admission, as required. The resident, who had been admitted with a right leg injury and was receiving physical and occupational therapy, reported that the facility did not discuss his plan of care with him and that he did not receive a copy of his care plan. Review of the electronic health record confirmed that there was no documentation showing the BCP was given to the resident. Although the Director of Nursing indicated that a care plan discussion occurred during a welcome meeting with the Interdisciplinary Team, there was no evidence in the chart that the resident was provided with a copy of the care plan.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for three residents with specific clinical needs. One resident receiving oxygen therapy did not have a care plan addressing O2 therapy, including the type of delivery system, parameters, delivery method, or monitoring requirements, despite facility policy requiring these elements. The resident's O2 tubing was also not labeled with the date it was last replaced, and physician orders lacked necessary details. Both the MDS Director and DON confirmed the absence of a care plan for this resident's oxygen therapy. Another resident undergoing hemodialysis had a care plan that omitted interventions for assessing the dialysis access site for thrill and bruit, even though these checks were being performed and documented per physician orders. The DON confirmed that the care plan should have included these interventions. A third resident with an indwelling catheter for urinary retention did not have a care plan addressing catheter care, goals, or interventions, despite documentation of urinary retention and physician orders for catheterization. The DON verified that catheter care should have been included in the resident's care plan.
Failure to Update Care Plan for MASD and Fungal Infection
Penalty
Summary
The facility failed to update the care plan for Resident 136 to include a new intervention for treating moisture-associated skin damage (MASD) with an antifungal after the condition was identified. Despite recognizing that the resident had developed a fungal infection and MASD on the sacrum and buttocks, which had worsened since admission, the facility did not obtain a physician's order for an antifungal treatment or revise the resident's care plan accordingly. This deficiency was identified through interviews and record reviews, and it involved one of four residents sampled for non-pressure skin conditions.
Failure to Individualize and Implement Resident Activity Preferences
Penalty
Summary
The facility failed to care plan and implement individualized activity preferences and accommodate special needs for two residents. One resident, a cognitively intact female, reported that no one offered her activities in her room and expressed feelings of boredom and distress. Although group activities were canceled due to Covid, the facility posted that one-on-one in-room activities would be provided. However, the resident's care plan did not include interventions for one-on-one activities, nor did it reflect her stated preferences for keeping up with the news, participating in religious activities, or going outside for fresh air, as documented in her Minimum Data Set (MDS). The recreation director confirmed these omissions and stated that activity preferences were not reviewed or documented as required. Another resident, also cognitively intact and blind, had a care plan that did not list specific activities to accommodate her blindness, such as sensory stimulation, hand massage, trivia, or music, despite these being provided occasionally. Documentation showed that activities appropriate for her condition were infrequently implemented, and some activities, such as cards or board games, were not suitable given her blindness. The facility's policy required activity programs to be designed to meet each resident's assessed needs and interests, coordinated with their comprehensive assessment, functional ability, and preferences, which was not followed in these cases.
Failure to Follow Physician Orders for Bowel Regimen and Skin Condition Management
Penalty
Summary
The facility failed to provide resident-centered care and services for two residents, resulting in deficiencies related to the management of constipation and skin conditions. One resident with a diagnosis of constipation had a physician-ordered bowel regimen that included scheduled and as-needed medications. Despite documentation in the care plan and electronic health record (EHR) that the resident did not have bowel movements for multiple periods exceeding three days, the as-needed medications were not administered as ordered. The Director of Nursing confirmed that the EHR system should have alerted staff to administer the as-needed medication, but this did not occur, and the medication administration record showed the medications were not given on the required days. Another resident with moisture-associated skin damage (MASD) and a fungal infection to the sacrum and bilateral buttocks experienced a worsening of her condition over several days. The initial treatment order for MASD was discontinued, and from the time the treatment ended until several days later, there were no new physician orders or care plan updates to address the fungal infection. Skin assessments documented that the MASD had increased in size and severity, but no antifungal treatment was initiated during this period. The care plan was not updated to reflect the need for antifungal treatment until after the issue was identified during a surveyor interview with the Director of Nursing. Both deficiencies were identified through record review and interviews, which confirmed that the facility did not follow physician orders or update care plans in response to changes in residents' conditions. The lack of timely intervention and adherence to prescribed regimens placed the residents at risk for further complications related to constipation and skin breakdown.
Failure to Provide Consistent ROM and Splint Care
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for a resident with hemiplegia and hemiparesis following a cerebral infarction, as well as neuralgia and neuritis. The resident was observed multiple times with her left arm folded and fisted on her chest without the prescribed splint in place. Interviews with the resident's representative and the resident herself indicated that the facility had not been assisting with the required exercises and stretches for her left knee, arm, and hand as ordered. Documentation review revealed that the resident did not receive restorative nursing aide (RNA) services for several days, with only one instance of service provided during the sampled period. Physician orders and the care plan specified a program of passive and active ROM exercises and the use of splints for the resident's left hand, elbow, and knee, with detailed instructions on frequency and duration. However, records showed inconsistent application of these interventions, and staff interviews confirmed that RNA services were not consistently provided, sometimes due to RNA staff being reassigned to CNA duties. The lack of consistent implementation of the prescribed ROM and splint program resulted in the resident not receiving the necessary care to maintain or prevent a decline in ROM.
Resident Transported Without Wheelchair Leg Rests
Penalty
Summary
A deficiency occurred when a resident was transported in a wheelchair without leg rests in place, which was observed by surveyors. The resident was pushed by a Physical Therapy Assistant and an Occupational Therapy Assistant from the end of the hall to her room, a distance totaling 146 feet, while holding her feet up due to the absence of leg rests. When questioned, the staff stated that they were pressed for time and that the leg rests were in the resident's room. The wheelchair used did not have a holder for the leg rests, and staff confirmed that such holders could be ordered and installed on facility-owned wheelchairs. Further interviews revealed that staff typically retrieve the leg rests from the resident's room after therapy sessions, and that some residents may have difficulty keeping their feet elevated, especially those with cognitive or physical limitations. The Director of Rehab confirmed that staff are trained to ensure leg rests are in place when transporting residents in wheelchairs, and acknowledged that the leg rests should have been used during the transport.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care consistent with professional standards for two residents who required oxygen (O2) therapy and nebulizer treatments. One resident was admitted with diagnoses including cough, allergic rhinitis, and asthma, and had a hospital discharge summary indicating possible reactive airway disease or chronic obstructive pulmonary disease. Despite this, the resident’s comprehensive assessment did not reflect the use of O2 therapy, and the care plan did not include O2 therapy as an intervention. Observations revealed that the resident’s O2 and nebulizer tubing were not labeled with the date of last replacement, and the resident reported that the tubing had not been changed since admission. The O2 concentrator was observed in use at a flow rate of 2.5 LPM, but the physician’s orders lacked specific parameters such as flow rate, duration, and delivery method. The Medication Administration Record (MAR) showed O2 was administered at bedtime, but there was no documentation for supplemental O2 use during the day, and the DON confirmed the order did not specify duration and that tubing should be labeled and changed weekly. A second resident was observed sleeping with an oxygen concentrator and nasal cannula, but the oxygen tubing and sterile saline tubing were not labeled with the date of initiation. On a subsequent observation, the tubing had an orange sticker with a backdated change date. The DON was unable to explain why staff would backdate the tubing label, but confirmed that tubing is supposed to be changed every Saturday. These findings indicate that the facility did not consistently follow protocols for labeling and changing respiratory equipment. Interviews with staff, including the MDS Director and DON, confirmed that the assessments, care plans, and physician orders were incomplete or inaccurate regarding O2 therapy. The lack of proper documentation, labeling, and adherence to physician order requirements for respiratory care placed both residents at risk for respiratory complications, as the facility did not ensure that respiratory care was provided in accordance with professional standards.
Failure to Timely Remove Dialysis Fistula Dressing
Penalty
Summary
A deficiency occurred when a resident who required hemodialysis returned to the facility with a pressure dressing on their right upper arm fistula, which was not removed within the recommended two hours after dialysis treatment. The resident reported that staff typically removed the dressing when they had time, and that staff did not routinely check for the thrill and bruit, which are indicators of proper fistula function. The resident stated that they often removed the dressing themselves. Observation confirmed that the dressing remained in place the morning after dialysis, well beyond the recommended timeframe. Record review showed that the resident's care plan included monitoring for signs of infection at the access site but did not specify assessment for thrill and bruit. The Treatment Administration Records indicated that fistula checks were documented every shift. Interviews with nursing staff and the DON revealed uncertainty about the specific timing for dressing removal, and the facility's policy required monitoring and documentation of the access site but did not ensure timely removal of the pressure dressing. Confirmation from a dialysis charge nurse established that the standard practice is to remove the dressing two hours post-treatment to prevent complications.
Deficient Narcotic Documentation and Medication Disposition
Penalty
Summary
The facility failed to maintain accurate narcotic log documentation and reconciliation for two of four medication carts observed. In one instance, a blister pack of Oxycodone for a resident was found to have 22 pills remaining, while the Controlled Drug Record indicated there should have been 24. A registered nurse admitted to administering one pill without signing it out and also to wasting a tablet without documenting the waste. The nurse explained that narcotics are typically signed out after administration, which is inconsistent with facility policy requiring immediate documentation upon removal from storage. The Director of Nursing confirmed that the correct process is to document narcotics at the time of preparation, not after administration. Additionally, the facility did not ensure the timely removal and proper disposition of discontinued or expired medications. During inspection, an expired box of Ferrous Gluconate and a discontinued blister pack of Methocarbamol for a discharged resident were found in a medication cart. Staff confirmed that the expired medication should have been disposed of and that the discontinued medication should have been removed from the cart at the time of discontinuation. These lapses in medication management practices were confirmed through staff interviews and record reviews.
Failure to Document and Implement Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to document the rationale for not implementing changes recommended by the pharmacist during a monthly medication regimen review for one resident. The pharmacist had recommended specific actions and high-risk medication monitoring for aspirin, diabetic agents, and opioid agents, including not crushing aspirin and monitoring for signs and symptoms of bleeding, hypoglycemia, hyperglycemia, constipation, delirium, over-sedation, changes in mental status, and reduced respirations. While the facility documented acceptance of the recommendation to not crush aspirin, this was not reflected in the physician orders, nor were the recommended monitoring parameters for diabetes and opioid medications included in the orders. During an interview, the DON stated that the facility's standard practice was not to crush aspirin unless it was chewable and to monitor for the relevant signs and symptoms for diabetic and opioid medications, but this monitoring was not documented. Additionally, a review of another resident's care revealed that nursing staff were not monitoring for constipation related to opioid use, further indicating a lack of adherence to recommended monitoring practices.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed out of 28 opportunities, resulting in a 7% error rate. During medication administration, a registered nurse (RN) was observed preparing and administering medications to a resident without properly informing her of all the medications being given. Specifically, the RN failed to disclose that a laxative (Clearlax) was mixed into the water provided to the resident, despite her refusal of another laxative (Senna-Plus) and her stated desire to avoid such medications. The resident was not made aware of the presence of the laxative in her water and only learned of it after questioning by the surveyor, at which point she expressed her wish to refuse it. Additionally, the RN did not remain with the resident until all medications were consumed, leaving the room before the resident had finished taking the medications. This practice was confirmed by both the RN and the Director of Nursing as not meeting facility expectations. Furthermore, there were discrepancies in the documentation and measurement of the resident's blood pressure prior to administering antihypertensive medications. The RN documented two different blood pressure readings for the same medication administration time, and there was no evidence that the RN had actually taken the resident's blood pressure that morning, as required by the medication parameters. Record review revealed that the resident frequently had blood pressure readings too low to meet the parameters for administration of one of her antihypertensive medications, highlighting the importance of accurate and timely blood pressure measurement. The combination of failure to inform the resident about her medications, improper medication administration practices, and inaccurate documentation contributed to the facility's medication error rate exceeding the acceptable threshold.
Unattended Unlocked Medication Cart
Penalty
Summary
A medication cart was observed left unlocked and unattended outside a resident's room, with no staff present in the immediate area. When questioned, the Infection Prevention RN confirmed that the cart should be locked whenever unattended. Shortly after, another RN returned to the cart and acknowledged that she had been educated to lock the cart before leaving it, and admitted it should have been locked. This incident involved one of four medication carts observed and was directly witnessed by surveyors during their inspection.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections. This was evidenced by staff not following transmission-based precautions (TBP) and standard precautions. Specifically, staff did not consistently wear the required personal protective equipment (PPE) when entering the room of a resident on Droplet and Contact Precautions for shingles. Multiple instances were observed where staff either forgot to wear a face shield or did not wear any PPE at all when entering the room. Additionally, staff were observed not performing hand hygiene between glove changes, and a crumpled gown was found in a drawer with new gowns, which should have been discarded. These actions were confirmed by interviews with the Infection Preventionist and other staff members, who acknowledged the lapses in protocol. Further deficiencies were noted in the handling of medical equipment and supplies. A resident with nephrostomy tubes had drainage bags placed on the ground instead of being hung from the bed, as required. Another resident had a used glove left on his bed by a therapist, which was confirmed by the manager of the physical and occupational therapy department. These observations indicate a failure to maintain proper infection control practices, potentially affecting all residents, healthcare personnel, and visitors in the facility.
Failure to Document Residents' Incapacity for Surrogate Decision-Making
Penalty
Summary
The facility failed to ensure that three residents, who had surrogate forms filled out, included the physician's documentation stating that the residents did not have the capacity to make their own healthcare decisions, as required by state law. For Resident 147, the electronic health record lacked a copy of the advanced healthcare directive, and the physician had not documented that the resident lacked capacity. Despite requests, the resident's son, who claimed to be the Power of Attorney, did not provide the necessary documentation. The administrator confirmed the absence of the physician's documentation for Resident 147's lack of capacity to make healthcare decisions. Similarly, Resident 67's medical records included a surrogate form but lacked the physician's documentation of the resident's incapacity to make healthcare decisions. The administrator acknowledged this deficiency and mentioned plans to implement a process in the future. For Resident 48, the electronic health record contained a surrogate form but did not include the primary physician's determination of the resident's incapacity. The Social Services Assistant was unaware if such documentation existed. The facility's policy and state law require the primary physician to document a resident's lack of capacity before a surrogate can make healthcare decisions, which was not adhered to in these cases.
Failure to Provide Timely Written Notification of Transfer/Discharge
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to four sampled residents or their representatives. Resident 246 was notified of an upcoming discharge to home only 19 days before the planned date, and the facility did not notify the ombudsman until six days before the discharge. The administrator admitted to not knowing the requirement for a 30-day notification. Resident 48 was transferred to the hospital without any written notification provided to the resident or their representative. The social services aide and the administrator had conflicting understandings of who was responsible for issuing these notifications, and no documentation was kept to confirm that notifications were sent. Similarly, Resident 58 and Resident 40 were transferred to the hospital without any written notification provided to them or their representatives. The administrator could not provide documentation that notifications were sent and admitted that the facility did not keep copies of the written transfer/discharge forms. The facility's policy, dated July 2018, requires that residents and their representatives be notified in writing before any transfer or discharge, but this policy was not followed in these cases.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure written notification of the bed hold policy was provided to three residents and their representatives during transfers to the hospital. Resident 40 was transferred to the hospital for sepsis, but the Electronic Health Record (EHR) did not contain documentation that the bed hold policy was provided to the resident's representative. The Administrator was unable to provide documentation during an interview that the policy had been given to the representative. The facility's policy requires written information to be provided before or upon transfer, but this was not adhered to in this case. Resident 48 was transferred to the hospital with diagnoses of hyperglycemic state and failure to thrive, and there was no documentation in the EHR that the bed hold policy was provided. The Social Services Aide reported that they call family members instead of providing written notification. The Administrator mentioned a process involving check marks on a hospital tracking portal but admitted that no copies of the written notifications were kept. Similarly, Resident 58 was transferred to the hospital with acute metabolic encephalopathy, and there was no documentation in the EHR that the bed hold policy was provided. The Administrator again referred to the check mark system, which did not clearly indicate that the policy was sent.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to adequately prevent and manage pain for three residents, resulting in an inability to attain or maintain their highest practicable level of well-being. Resident 197, a female admitted for short-term rehabilitation, experienced significant pain that was not effectively managed. Her pain evaluation was incomplete, leading to an inadequate care plan. Despite having physician orders for pain medication, she was observed in pain multiple times, and her pain evaluation lacked critical follow-up questions, resulting in a low-risk pain assessment score that did not reflect her actual condition. The Director of Nursing confirmed the evaluation was incomplete and acknowledged the impact on the resident's care plan. Resident 146, who experienced right leg and hip pain, also had an incomplete pain evaluation. The evaluation did not document the type of pain or methods of alleviating it, which hindered the development of an effective pain management plan. The Director of Nursing confirmed the deficiencies in the pain evaluation and expressed that the nurse should have filled out the areas in question. Resident 13, who suffered from pain in her right leg, had several sections of her pain evaluation left blank, including her current pain level, factors that made the pain better or worse, and the effects of pain on her activities of daily living. The Director of Nursing confirmed the incomplete pain evaluation and stated she would address the issue with the nursing staff. These deficiencies in pain management evaluations prevented the residents from receiving appropriate and effective pain management care.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote care for residents in a manner that maintains and enhances their dignity. During a lunch observation, the Director of Nursing (DON) referred to a resident as a 'feeder' and directed a staff member to serve this resident's tray last. This incident occurred in the presence of the resident and other individuals in the dining room. Additionally, a Certified Nurse's Aide (CNA) referred to another resident as a 'feeder' while the resident was choking, indicating a lack of respect and dignity in addressing the resident's needs. The facility's Administrator confirmed that staff members should never refer to residents as 'feeders'. Another incident involved a CNA assisting a resident with his meal while standing and using her personal phone. The resident, who has medical diagnoses including hemiplegia, hemiparesis, and dysphagia, was not provided with the appropriate level of care and attention. The CNA acknowledged that she should have been sitting while assisting the resident. The Unit Manager and DON both confirmed that staff should not be on their personal phones while providing care and should be seated when assisting residents with meals. The facility's policies on resident rights and employee conduct were reviewed and found to support these standards of care.
Failure to Provide Quarterly and Requested Account Statements
Penalty
Summary
The facility failed to provide quarterly statements and statements upon request for a resident whose personal funds were managed by the facility. The resident, a [AGE] year-old female admitted on [DATE], reported during an interview that she had never received an account statement since her admission and had not received a statement despite requesting one. The Business Office Manager (BOM) confirmed that there was no recorded log or tracking system to ensure residents received their quarterly statements, and the current process involved placing printed statements on residents' bedside tables. The resident finally received her first account statement after the surveyor's inquiry.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by the presence of black residue on the ceiling and vent outside of residents' rooms. On 4/02/24, a surveyor observed the black residue, which was spread across the ceiling and walls outside of the residents' rooms. When questioned, a Heavy Cleaner (HC1) indicated that the residue might be mold from the air conditioning system and mentioned that vacuuming did not remove it. The Housekeeping Director (HD) was consulted and stated that the facility had contacted their corporate office in Utah for guidance, which attributed the issue to Hawaii's weather. The HD also mentioned that a cleaning solution containing hydrogen peroxide was being used to address the residue. However, the cleaning logs reviewed showed that the area had been marked as cleaned through March 2024, and the HD confirmed that staff are instructed to report areas that remain dirty after cleaning attempts. The facility's policy titled 'Resident Rights Safe, Clean and Comfortable Environment' dated 07/2018 was reviewed, which mandates housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior. Despite this policy, the presence of black residue on the ceiling and vent indicates a failure to adhere to these guidelines, potentially exposing residents to an increased risk of infection. The deficiency was identified through direct observation and staff interviews, highlighting a lapse in the facility's cleaning and maintenance procedures.
Inaccurate Discharge Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Discharge Assessment for Resident 94 accurately reflected the resident's discharge status. During a record review on 04/04/24, it was noted that Resident 94, who was admitted to the facility and discharged to home on 02/06/24, had an incorrect Minimum Data Set (MDS) Discharge Assessment. The assessment inaccurately documented the resident as being discharged to a Short-Term General Hospital instead of home with home health services. This error was confirmed during an interview with the MDS Director on 04/04/24, who acknowledged the incorrect documentation and transmission of the Discharge Assessment.
Failure to Implement Person-Centered Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to develop and implement a person-centered Comprehensive Care Plan (CP) for a resident with contractures in the left hand. The deficiency was identified through observation, interview, and record review. Specifically, the facility did not include the ordered treatment of placing rolled gauze or a towel under the resident's fingers in the CP. This omission meant that staff did not have the necessary information to adequately care for the resident's contractures, which is essential for ensuring the resident's highest potential of physical and psychosocial well-being. During an interview with the Director of Nursing (DON), it was revealed that the facility's practice was to document a generalized statement rather than specific treatments in the CP. The DON acknowledged that this approach was not person-centered and did not meet the facility's policy and procedure for Comprehensive Care Plans, which require the CP to be comprehensive and person-centered. The policy mandates that the CP should describe the resident's medical, nursing, physical, mental, and psychosocial needs and preferences, as well as how the facility will assist in meeting these needs and preferences.
Failure to Update Care Plan for New Diabetes Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's person-centered comprehensive Care Plan (CP) was reviewed and revised following a new diagnosis of diabetes. Resident 48, a male with multiple diagnoses including hemiplegia, hemiparesis, dysphagia, vascular dementia, hypertension, chronic kidney disease, and muscle weakness, was admitted to the facility on an unspecified date. During an interview, a family member reported that Resident 48 developed diabetes while living at the facility and was hospitalized due to diabetic shock. Despite being readmitted to the facility with a new diagnosis of type 2 diabetes, the CP was not updated to include treatment and care for this condition. The Director of Nursing (DON) confirmed that the CP for Resident 48 was not revised after the new diagnosis of diabetes, which should have been done. The resident's electronic health record indicated that he was transferred to the hospital with diagnoses of hyperglycemic state and failure to thrive and was readmitted to the facility with the new diagnosis. The failure to update the CP put Resident 48 at risk of a decline in his quality of life and potential serious harm due to complications from diabetes.
Failure to Manage Constipation
Penalty
Summary
The facility failed to effectively assess, identify, and manage constipation for a resident, resulting in the resident experiencing no bowel movements for more than five days and significant abdominal pain and discomfort. The resident, who was admitted for short-term rehabilitation following a fall and loss of consciousness, had a history of chronic pain and was on opioid medication, which is known to cause constipation. Despite the resident's verbalization of her constipation issues and her request for laxatives, the facility did not adequately document or follow up on her bowel movements, leading to prolonged discomfort and distress for the resident. Upon admission, the resident's last bowel movement was not properly assessed, and although there were physician orders to manage constipation, these were not effectively implemented. The resident's electronic health record showed no bowel movements from admission until five days later, and the prescribed interventions, such as polyethylene glycol and bisacodyl suppository, were either not administered or were ineffective. The Director of Nursing confirmed that there was a failure in monitoring and addressing the resident's constipation, which should have been identified and managed earlier given the resident's high risk due to opioid use and immobility.
Failure to Provide Proper Contracture Care
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Resident 25, who was admitted with diagnoses including dysphagia, anemia, unspecified dementia without behavioral disturbance, and contracture to both hands, was not provided with the ordered care of placing rolled gauze or a towel in his left hand every shift. This order was documented in the resident's Electronic Health Record and revised on 10/17/21. However, during multiple observations over several days, the resident was seen without the rolled gauze or towel in his left hand. Interviews with various staff members, including Restorative Aides, the Director of Rehab, Certified Nurse Aides, the MDS Director, and Licensed Practical Nurses, revealed inconsistencies and misunderstandings regarding who was responsible for implementing the order. The Restorative Aides reported they only performed passive range of motion exercises to the lower extremities and were unaware of the need for rolled gauze or a towel in the resident's hands. The Director of Rehab confirmed the necessity of the rolled gauze or towel to prevent contractures and further complications. Despite the order being in place, it was not consistently followed, leading to a deficiency in the resident's care.
Inadequate Supervision and Assistance During Meal Time
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for a resident with significant medical conditions. The resident, a male with hemiplegia, hemiparesis, and dysphagia, was observed by a Certified Nurse's Aide (CNA) who was distracted by her personal phone while assisting the resident with his breakfast. The resident was given a meal that did not match his dietary requirements, leading to a coughing episode. The meal ticket and food items on the tray were intended for another resident, and the CNA did not verify the meal ticket before assisting the resident. The Unit Manager confirmed that staff are trained to check meal tickets when distributing meals, and the Director of Nursing stated that staff should not use personal phones while providing care. The facility's Employee Handbook also specifies that personal calls or texts should only be made during breaks and in non-working areas. This incident highlights a lapse in following established protocols for meal distribution and staff conduct, which could negatively impact residents requiring assistance with feeding.
Failure in Narcotic Log Documentation and Reconciliation
Penalty
Summary
The facility failed to ensure staff competency in narcotic log documentation and reconciliation. During an inspection and reconciliation of the narcotic log on medication cart 2C, it was observed that a blister pack for a resident's Tramadol 50 mg had thirty-nine tablets remaining, while the narcotic log reflected a balance of forty tablets. The Registered Nurse (RN) involved signed out one tablet of Tramadol only after being prompted by the surveyor, despite having administered the medication earlier. The RN admitted to not signing out the medication at the appropriate time. Both the Unit Manager and the Director of Nursing confirmed that the expectation is for narcotics to be signed out when they are pulled, not after administration.
Failure to Properly Label Medications
Penalty
Summary
The facility failed to ensure all medications were labeled in accordance with professional standards. During an inspection of medication cart 2B, an albuterol inhaler was found pulled from the emergency kit without a name or date, despite being opened and used. The Registered Nurse confirmed the inhaler had been used but could not explain the lack of proper labeling. The Assistant Director of Nursing confirmed that the inhaler and its box should have been labeled with at least the resident's name and the date it was opened. A review of the facility's policy on Pharmacy Services Labeling and Storage of Drugs and Biologicals indicated that medications designed for multiple administrations should be labeled with the specific resident's name.
Failure to Accurately Document Medical Records
Penalty
Summary
The facility failed to ensure a resident's medical record was accurately documented. Specifically, the facility did not provide the proper care and treatment for a contracture in the resident's left hand as ordered. The physician's order required rolled gauze or a towel to be placed in the resident's left hand every shift, an order that was revised on 10/17/21. However, during multiple observations over several days, the resident was seen without the rolled gauze or towel in their left hand, despite the Treatment Administration Record (TAR) indicating that the treatment was administered on all shifts during the survey period. Interviews with staff, including a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN), revealed that the treatment had not been consistently provided. The CNA reported that the treatment had not been done lately, and the LPN confirmed that she had not seen the treatment performed since working on the unit. The Director of Nursing (DON) confirmed that the treatment was documented as completed in the TAR but acknowledged that staff reported not providing the treatment. The DON stated that the nursing staff should not mark the treatment as completed if it was not done and should mark it as refused if the resident refused the treatment. This discrepancy indicates that the medical record was not accurately recorded, and staff were not following the physician's order.
Unsafe Bed Control Cord
Penalty
Summary
The facility failed to maintain a resident's bed cord control in safe operating condition. During an observation, the bed control cord for a resident was found to be frayed in multiple places, posing a risk of electrocution to both the resident and staff. The resident, who was tired and unable to answer questions about the bed control, had placed the control in her dresser drawer at the bedside. A Unit Manager Registered Nurse later confirmed the unsafe condition of the bed control cord.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 172 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nuuanu Hale | 0.7 mi | ★★★★★ | 26 | 0 |
| Maluhia | 1.2 mi | ★★★★★ | 0 | 0 |
| Liliha Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Kuakini Geriatric Care, Inc | 1.7 mi | ★★★★★ | 0 | 0 |
| The Ching Villas | 1.7 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.