Hale Malamalama
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 6163 Summer Street, Honolulu, Hawaii 96821
- CMS Provider Number
- 125050
- Inspections on file
- 15
- Latest survey
- January 31, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hale Malamalama during CMS and state inspections, most recent first.
A resident with multiple medical conditions and impaired mobility was subjected to unsympathetic comments and willful neglect by a CNA, who refused to provide necessary toileting assistance and made inappropriate remarks. The resident reported being treated roughly during transfers and developed a lump on her head, leading to emotional distress and fear. Staff interviews confirmed the CNA's neglect and verbal abuse, resulting in the resident's mental anguish.
The facility did not promptly report two separate allegations of abuse and neglect involving two residents to OHCA as required. In one instance, a resident reported being physically mistreated by two CNAs, resulting in injury, but the Administrator was not notified immediately and the incident was not reported to OHCA. In another case, despite being informed of a neglect allegation and an APS investigation, the facility failed to investigate or notify OHCA. Facility policies require prompt reporting of such incidents to state agencies.
Two residents experienced failures in abuse and neglect investigations, including incomplete documentation, lack of immediate removal of alleged perpetrators, and insufficient review of care records. One resident reported mistreatment and was not assisted with toileting, while another did not receive timely incontinence care, with the facility failing to conduct thorough internal investigations in both cases.
A resident with multiple medical conditions experienced a decline in mobility, requiring increased assistance for transfers and toileting. Despite documentation of her need for two-person assist and later a Hoyer lift, the care plan was not updated in a timely manner to reflect these changes, potentially leaving staff unaware of her current care needs.
Two residents with significant incontinence needs did not receive incontinence care or documentation every two hours as required by their care plans and facility policy. Staff failed to consistently check and document incontinence episodes, with some intervals between checks extending well beyond the expected timeframe. Both CNA and DON interviews confirmed the policy and acknowledged the lapses in care and documentation.
The facility did not establish an annual Performance Improvement Project (PIP) to address high-risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) policy. Despite quarterly meetings to discuss facility issues, the QAPI binders lacked documentation of an official PIP, potentially impacting all residents' wellbeing.
The facility failed to maintain a homelike environment, with issues such as improperly stored and maintained oxygen equipment in a resident's room, noisy staff disrupting sleep, and a cold dining room. Despite resident council efforts and staff reminders, these problems persisted, affecting residents' comfort and rights.
Housekeeping staff at a facility were observed using a quat sanitizing spray directly on dining tables while residents were seated, despite the chemical's potential to cause skin and eye irritation. The housekeeping supervisor demonstrated a safer method of spraying under a cloth, but staff were not consistently following this practice, risking resident exposure. The MSDS for the chemical confirmed its harmful effects, and the long-term care ombudsman had advised against such practices.
A facility failed to maintain resident dignity during meal assistance. A CNA was observed sitting on a resident's bed while assisting with feeding due to a shortage of stools, while another CNA stood while assisting another resident. The DON confirmed that CNAs should sit at eye level with residents during feeding, and the facility's policy emphasizes respect and dignity for residents.
A resident experienced a fall resulting in multiple injuries and was sent to the emergency room. Despite the incident, the resident's care plan was not updated or revised to reflect the fall and necessary changes in care. This oversight was confirmed by the DON during an interview.
The facility failed to ensure proper storage of medications, as a medication cart was found unattended and unlocked in the dining room. Two staff members walked past the cart while accompanying a resident, and an RN was administering medications to a resident at the time. The DON confirmed that the cart should have been locked when unattended, in accordance with the facility's policy on medication storage.
Failure to Protect Resident from Verbal Abuse and Neglect of Toileting Needs
Penalty
Summary
A resident with a complex medical history, including cancer, diabetes, hypertension, heart disease, atrial fibrillation, repeated falls, weakness, ascites, a Stage 2 coccyx pressure ulcer, and vision impairment, was admitted for skilled nursing care. The resident was alert, oriented, and able to communicate in English, with a BIMS score indicating intact cognition. She required assistance for transfers and toileting due to impaired mobility and was considered a fall risk. The resident reported to the social worker that she had been mistreated by staff during evening and night shifts, specifically describing an incident where two CNAs were rough with her during a transfer from the bedside commode, resulting in a lump on the back of her head. She delayed reporting the incident due to fear of retaliation and appeared anxious when discussing the event. The social worker confirmed the presence of a lump and reported the incident to the DON. Staff interviews and documentation revealed that the resident frequently requested assistance with toileting, which was met with frustration and unsympathetic comments from CNA2. RN2 observed CNA2 refusing to assist the resident to the commode despite her pleas and making inappropriate remarks, such as blaming the resident for potentially making her sick. RN1 also noted an incident where CNA2 raised her voice at the resident during an argument about toileting needs. CNA2 admitted to telling the resident to use her diaper instead of assisting her to the commode, citing the resident's frequent requests and difficulty standing. These actions and inactions resulted in the resident not receiving necessary toileting assistance on multiple occasions. The facility's investigation substantiated verbal abuse based on eyewitness accounts of the argument but did not substantiate the physical abuse allegation due to lack of witnesses or a specific event causing the injury. The investigation report lacked details regarding the verbal comments and neglect of toileting assistance. The resident experienced mental anguish and emotional harm as a result of these willful acts, as evidenced by her expressed fear, anxiety, and desire to leave the facility. Observations and staff interviews confirmed the resident's distress and the failure to protect her from abuse and neglect.
Failure to Timely Report Allegations of Abuse and Neglect to State Authorities
Penalty
Summary
The facility failed to promptly report two separate allegations of abuse and neglect involving residents to the Office of Healthcare Assurance (OHCA) as required by regulation and facility policy. In the first case, a resident reported to the social worker that two certified nursing assistants (CNAs) had physically mistreated her by roughly handling her and throwing her onto the bed, resulting in a lump on the back of her head. The social worker immediately notified the Director of Nursing (DON), who confirmed the injury, but the Administrator was not informed until two days later. The incident and subsequent investigation findings were not reported to OHCA within the required timeframe, and the social worker confirmed that the case was under investigation by Adult Protective Services (APS) but had not been communicated to the Administrator or OHCA. In the second case, OHCA received an anonymous report alleging that caregivers neglected another resident by failing to provide necessary care when the resident was soiled and needed a diaper change. Although APS notified the facility that an investigation was being opened and the facility was aware of concerns regarding the resident's care and CNA assignments, the facility did not investigate the neglect allegation or notify OHCA. Review of facility policies confirmed that the Administrator or designee is responsible for promptly notifying OHCA and other agencies of all alleged or suspected cases of abuse, neglect, or mistreatment, as well as providing written reports of investigation findings and corrective actions.
Failure to Investigate and Protect Residents Following Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect involving two residents. In the first case, a female resident with multiple complex medical conditions, including hypertension, heart failure, diabetes, and mobility issues, reported mistreatment by staff, including being thrown onto her bed and sustaining a lump on the back of her head. The investigation documentation was incomplete, lacking specific details such as times, dates, and comprehensive interviews with all relevant staff and other residents cared for by the accused staff. Additionally, the facility did not immediately remove the alleged perpetrators from resident contact upon identification, as required by policy, and there was a delay in notifying the administrator and state authorities. Staff statements collected during the investigation revealed that one CNA had displayed inappropriate behaviors and had refused to assist the resident with toileting on multiple occasions, which was corroborated by eyewitness accounts. Despite these findings, the facility did not fully document interviews or collect written statements from all involved staff. The investigation was marked as unsubstantiated for physical abuse due to lack of witnesses, but verbal abuse was substantiated. However, the facility did not take immediate protective actions as outlined in their own policies, and the internal investigation process was not thoroughly documented or executed. In the second case, another resident with significant physical and cognitive limitations, who was dependent on staff for all care needs, was involved in an incident where staff failed to provide timely incontinence care. The facility was notified by Adult Protective Services (APS) of a neglect case, but did not conduct an internal investigation into the care provided, instead viewing the issue as a resolved staff assignment conflict. Review of care documentation showed that the resident was not checked for incontinence for over seven hours, contrary to the required two-hour checks, and there was no evidence that the facility reviewed or addressed this lapse in care. The facility's failure to investigate and address these issues resulted in unaddressed quality of care and potential neglect.
Failure to Timely Update Care Plan for Resident with Declining Mobility
Penalty
Summary
The facility failed to timely update the care plan for a female resident who was admitted for skilled nursing services with multiple complex medical conditions, including hypertension, heart failure, gastric cancer, and muscle weakness. Initially, the resident required one-person assistance for toileting and transfers. However, as her condition declined, documentation in the medical record indicated an increased need for assistance, including two-person assist and eventually the use of a Hoyer lift for transfers. Despite these documented changes in her functional status and care needs, the care plan was not revised in a timely manner to reflect the increased level of assistance required. Nursing and social services notes documented the resident's progressive decline, including increased weakness, inability to ambulate, and the need for 2-3 staff members for transfers. The active care plan continued to state that only one staff member was needed for toileting and transfers, with the last revision not reflecting the resident's current needs. This failure to update the care plan in accordance with the resident's changing condition resulted in the potential for staff to be unaware of the appropriate level of assistance required, as directly stated in the report.
Failure to Provide Timely Incontinence Care and Documentation
Penalty
Summary
The facility failed to provide incontinence care and adhere to standards of practice for two residents who required such care. Both residents had care plans specifying that disposable briefs should be checked every two hours and as needed, with perineal care provided after each incontinence episode. However, documentation revealed that staff did not consistently check or document incontinence care at the required intervals. Multiple instances were noted where checks occurred several hours apart, far exceeding the two-hour standard outlined in both the residents' care plans and facility policy. One resident was a female with dementia, impaired mobility, and high risk for pressure sores, who was chairfast and required moderate to maximum assistance for repositioning. Her care plan required frequent incontinence checks and perineal care, but CNA documentation showed significant gaps, with some checks occurring up to ten hours apart. The second resident, who was dependent on staff due to hemiplegia and other serious medical conditions, also had a care plan requiring two-hour checks and cleaning after each episode. Documentation for this resident similarly showed missed checks and long intervals between care episodes. Interviews with staff, including a CNA and the DON, confirmed awareness of the policy requiring two-hour checks and documentation, but acknowledged that these expectations were not consistently met. The DON reviewed the documentation and confirmed the gaps, attributing them to staff being busy but agreeing that the standard was not upheld. The facility's own policy reinforced the need for two-hour checks, which was not followed in practice for these residents.
Lack of Annual Performance Improvement Project
Penalty
Summary
The facility failed to create an annual Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas identified through data collection and analysis. During an interview and document review with the facility Administrator, it was found that the Quality Assurance and Performance Improvement (QAPI) binders lacked documentation of an annual PIP. Although the QAPI committee met quarterly to discuss current facility issues and improvements, there was no official PIP in place. The facility's policy on QAPI indicated that PIPs should be implemented as per CMS protocol, but this was not adhered to, potentially affecting all residents' overall wellbeing.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike and comfortable environment for its residents, as evidenced by several observations and interviews. In one resident's room, an oxygen concentrator and tanks were stored despite the resident not currently receiving oxygen treatment. The equipment was not properly maintained, with an empty oxygen tank and a concentrator lacking a clear service date. Additionally, the room was cluttered with a wheelchair, footrests, and a cane, contributing to a disorderly appearance. The Director of Nursing (DON) confirmed that maintenance staff should be responsible for checking the equipment, but the maintenance supervisor was unavailable for comment. Further issues were identified in the dining room, where housekeeping staff were observed cleaning and mopping without caution signs while residents were present. The dining room was also reported to be too cold, a concern raised multiple times by residents in council meetings. Despite attempts to address the issue, such as placing a sign on the air conditioner to regulate temperature, the problem persisted, particularly during the evening shift. The Social Worker (SW) acknowledged ongoing complaints about the cold temperature and staff noise at night, which disrupted residents' sleep. Interviews with the SW and DON revealed that efforts to resolve these issues were insufficient. The SW noted that staff were reminded to be quiet at night, and the DON mentioned weekly huddles to address noise concerns. However, a specific staff member continued to disregard the air conditioning guidelines during the evening shift. The resident council's efforts to address these concerns were unsuccessful, indicating a failure to provide a comfortable and homelike environment for the residents.
Unsafe Use of Chemical Cleaners in Dining Area
Penalty
Summary
The facility failed to ensure that housekeeping services were provided in a safe manner, as observed by surveyors. During an observation in the dining room, two housekeeping workers were seen spraying a chemical cleaner directly onto dining tables while residents were seated at the tables with glasses of liquid and straws. The chemical used was identified as a quat sanitizing spray, which had a caution label indicating it was dangerous and should be kept out of reach of children. The housekeeping supervisor demonstrated a method of spraying the chemical under a cloth, but it was noted that staff were not consistently following this practice, potentially exposing residents to harmful chemicals. The Material Safety Data Sheet (MSDS) for the OASIS 146 Multi-quat Sanitizer indicated that the chemical causes eye and skin irritation and requires medical attention if inhaled or ingested. Despite this, the housekeeping supervisor admitted that the chemical could burn the skin and acknowledged that staff were instructed to spray under a cloth, but this was not being monitored effectively. The long-term care ombudsman had previously advised the facility not to spray chemicals while residents were eating, yet the practice continued, placing residents at risk for chemical exposure.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during meal assistance. An observation was conducted where a Certified Nurse Aid (CNA) was seen sitting on a resident's bed while assisting with feeding due to a shortage of stools. Another CNA was observed standing while assisting another resident with feeding, stating it was easier to do so. The Director of Nursing confirmed that CNAs should be sitting at eye level with residents during feeding assistance, and that standing or sitting on a resident's bed is not acceptable. The facility's policy on resident rights emphasizes the right to be treated with respect and dignity.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for one of the residents, identified as R18, after the resident experienced a fall with injury. The incident occurred on 07/19/24, when R18 fell and sustained multiple skin tears and abrasions, as well as a bump and redness on the side of the face. Following the fall, R18 was sent to the emergency room via ambulance. A review of R18's Electronic Health Record (EHR) confirmed the details of the fall and injuries. However, the care plan for R18 was not updated or revised to reflect the fall and the necessary changes in care. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan should have been revised after the incident.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in a locked compartment, as required by their policy. During an observation and interview conducted in the dining room, a medication cart was found unattended and unlocked. Two staff members were observed walking past the cart while accompanying a resident. A Registered Nurse (RN) was administering medications to a resident seated at the dining table, and when questioned about the unlocked cart, the RN acknowledged that it should have been locked since it was left unattended. The Director of Nursing (DON) confirmed during an interview that nurses are required to lock the medication cart when it is unattended. A review of the facility's policy on medication storage indicated that medications and biologicals must be stored safely, securely, and properly, with medication rooms, carts, and supplies locked or attended by authorized personnel.
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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