Avalon Care Center - Honolulu, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1930 Kamehameha Iv Rd, Honolulu, Hawaii 96819
- CMS Provider Number
- 125020
- Inspections on file
- 21
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avalon Care Center - Honolulu, Llc during CMS and state inspections, most recent first.
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 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.
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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