Hale Ola Kino By Arcadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Hon, Hawaii.
- Location
- 1314 Kalakaua Ave Second Floor, Hon, Hawaii 96826
- CMS Provider Number
- 125069
- Inspections on file
- 12
- Latest survey
- February 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hale Ola Kino By Arcadia during CMS and state inspections, most recent first.
A resident's personal property, a bottle of TUMS, was removed from his room without proper communication or consent, leading to distress. The TUMS were later found in the medication cart, and staff confirmed there was no physician's order for them. The facility failed to notify and educate the resident about the removal, and this communication was not documented in the electronic health record.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident with severe malnutrition did not have a dietary care plan, while another with congestive heart failure did not have their potassium levels monitored as required. These oversights were confirmed during interviews and record reviews.
A resident with a left foot contracture did not receive appropriate treatment as the facility failed to apply a prescribed splint consistently. Despite physician orders for the splint to be worn daily from 12:00 PM to 4:00 PM, observations showed it was often not in use. Staff interviews revealed a lack of awareness regarding the splint schedule, leading to non-compliance with the care plan.
A resident with chronic pain syndrome experienced ineffective pain management at the facility. Despite receiving oxycodone, the resident's pain level remained high, and there was no follow-up action documented to address the continued severe pain. Interviews with nursing staff indicated that a pain level of 7 should be considered ineffective, yet the charge nurse was not notified, and no further interventions were documented.
The facility failed to adhere to prescribed resident menus, affecting three residents. A resident on a controlled carbohydrate diet received incorrect portions of mashed potatoes during meals, while another resident on a similar diet initially received an incorrect portion, which was later corrected. Additionally, a resident on fluid restriction due to hyponatremia was served an excessive amount of soup, which was also corrected after review.
The facility failed to discard opened food items by their use-by date, as observed during a survey of the main kitchen. A container of olives in the walk-in refrigerator had an unclear label, and the Dietary Manager confirmed the dates should be written clearly. The cook confirmed the use-by date as 2/15 and stated she would discard the olives. The facility's policy is to discard opened food items seven days after opening.
The facility failed to ensure staff competency in safe transfers and perineal care for two residents. One resident was at risk due to inadequate training for safe transfers, while another resident experienced improper perineal care, including the use of dry cloths, failure to change gloves, and lack of hand hygiene.
The facility failed to provide fresh water to a resident despite multiple requests, leading to dehydration, and did not consistently offer alternate meal options when residents found their meals unappetizing. Observations and interviews revealed that staff did not follow the facility's hydration management policy, and residents expressed dissatisfaction with the food quality and availability of alternate menu items.
The facility failed to store food in accordance with professional standards, as several cardboard boxes of food were found resting on metal trays on the floor of the walk-in refrigerator/freezer. The Dietary Supervisor confirmed the food should be stored off the floor, and the Head Chef was unsure why the items were initially on the floor. The facility's Food Handling Policy requires food to be stored six inches above the floor.
A resident and his family reported an unsafe transfer and poor positioning in bed, but the facility failed to document or resolve the grievance. The resident, with a history of convulsions and hemiplegia, felt scared and unsafe during the transfer performed by an inexperienced CNA. Despite reporting the incident, the complaint was not properly recorded or addressed, leading to a decreased quality of life for the resident.
A resident's care plan for pain management was not followed, leading to ineffective pain control. The care plan was generalized, and interventions such as administering acetaminophen and documenting pain levels were not implemented. The DON and MDS Nurse confirmed that pain assessments were based on observations rather than direct questioning.
A resident with a history of constipation experienced abdominal discomfort and difficulty defecating due to the facility's failure to adequately monitor, care plan, and manage the condition. Despite an admitting diagnosis of constipation, the resident was not started on routine medication until later, and the care plan was not updated. The DON stated there was no bowel protocol, and inconsistencies in medication administration were noted.
The facility failed to ensure resident safety, resulting in a resident sustaining a wound from exposed wooden parallel bars in the Therapy Room and another resident experiencing unsafe transfer practices due to an untrained CNA. The facility did not follow its policy on safe lifting and movement of residents, leading to hazardous conditions.
A resident admitted for rehabilitation after a lumbar fracture reported not receiving pain medication regularly, only upon request. Observations and interviews revealed that nursing staff did not consistently assess or document the resident's pain levels, and the care plan for pain management was not followed, leading to increased pain for the resident.
The facility failed to adequately assess and identify past traumas experienced by a resident, leading to a deficiency in trauma-informed care. The resident reported experiencing post-traumatic stress from terrifying hallucinations prior to her hospitalization and subsequent transfer. Despite her distress, no staff member had spoken to her about traumatic events since her admission. The facility's trauma-informed care assessment was insufficient, and the resident's triggers were not identified or addressed, placing her at increased risk of re-traumatization.
Failure to Communicate Removal of Resident's Personal Property
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not properly communicating about the removal of his personal property. The resident, identified as R4, reported that a friend had brought him a bottle of TUMS, which he placed in his drawer. However, the TUMS disappeared from his room without his knowledge or consent. R4 expressed distress and considered calling the police, as he felt his personal property was taken without explanation. A search of his room confirmed that the TUMS were missing. Further investigation revealed that the TUMS were found in the medication cart, labeled with R4's room and bed number. The nursing staff, including an RN and an LPN, confirmed that R4 did not have a physician's order for TUMS, indicating it was his personal property. The RN acknowledged that if a resident brings an over-the-counter medication, the nursing staff should be informed, and the resident should be notified and educated about why the medication cannot be kept in their room. However, this communication was not documented in R4's electronic health record, highlighting a lapse in the facility's protocol for handling residents' personal items and communication regarding their rights.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. One resident, admitted with severe protein-calorie malnutrition, experienced a significant weight loss of 5.35% within a month. Despite the dietician's awareness of the resident's poor intake and food preferences, a dietary care plan was not developed. The resident's care plan lacked a dietary section, which was confirmed by the dietician during an interview and record review. Another resident, with a history of congestive heart failure and edema, had an order for diuretic medication but did not have their potassium levels monitored as required by their care plan. The Director of Nursing confirmed that the monitoring of potassium levels was not implemented, despite being listed in the resident's plan of care. This oversight was identified during a concurrent interview and record review, highlighting a failure to adhere to the facility's policy on comprehensive assessments and care delivery.
Failure to Apply Splint as Ordered for Resident with Foot Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment for a left foot contracture. The resident, who was admitted with diagnoses including dementia, hemarthrosis to the right knee, hemiplegia and hemiparesis following a cerebral infarction, and osteoarthritis, had a care plan that included the use of a splint for the left foot. Physician orders specified that the splint should be applied for four hours daily, from 12:00 PM to 4:00 PM. However, observations revealed that the splint was not consistently applied as ordered. On multiple occasions, the splint was found on a chair or the floor, and the resident was observed without the splint during the prescribed times. Interviews with facility staff, including a CNA and an LPN, indicated a lack of awareness and adherence to the prescribed schedule for the splint application. The CNA was unaware of the specific times the splint should be worn, and the LPN confirmed that the medication nurse was responsible for applying and removing the splint. Despite the resident not refusing the splint, it was not consistently applied, putting the resident at risk of further decrease in range of motion. This deficiency highlights a failure in the facility's processes to ensure compliance with physician orders and proper care for residents with mobility limitations.
Ineffective Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as R84, who was admitted with diagnoses including insomnia, surgical aftercare, and chronic pain syndrome. R84 reported experiencing constant pain in the left shoulder, with pain levels reducing only slightly from 9 to 7 on a 0-10 pain scale after receiving oxycodone. Despite the resident's reports of continued severe pain, the nursing staff did not follow up with additional interventions or medications to further alleviate the pain. The resident had requested an increase in oxycodone dosage, which was implemented, but the pain level remained at 7, indicating the medication was ineffective. The Medication Administration Record (MAR) showed instances where oxycodone was documented as ineffective, yet there was no follow-up action documented. Interviews with the LPN and RN revealed that a pain level of 7 should be considered ineffective, and the charge nurse should have been notified to inform the physician. However, there was no documentation of further actions taken to address the resident's pain on specific dates. The lack of documentation and follow-up on the resident's pain management plan contributed to the deficiency in providing appropriate care.
Failure to Follow Prescribed Resident Menus
Penalty
Summary
The facility failed to ensure that resident menus were followed as prescribed, which affected the nutritional management of three residents. Resident 10, who is on a controlled carbohydrate diet for weight control, was observed to receive a full portion of mashed potatoes instead of the prescribed half portion during both lunch and breakfast. This discrepancy was noted by the resident's representative and confirmed by staff during meal observations. Similarly, Resident 135, also on a controlled carbohydrate diet, was initially served a full scoop of mashed potatoes instead of the required half scoop during the lunch tray line, which was later corrected by the dining room server. Additionally, Resident 28, who is on a fluid restriction due to a history of hyponatremia, was served a full bowl of soup instead of the specified 60 mL portion. The dining room server initially served 120 mL of soup, which exceeded the resident's fluid restriction, but corrected the portion after reviewing the menu. The dietician confirmed the importance of adhering to these dietary restrictions to manage the residents' health conditions effectively.
Failure to Discard Food by Use-By Date
Penalty
Summary
The facility failed to ensure that opened food items were discarded by their use-by date, as observed during a survey of the main kitchen. During an initial tour, a surveyor observed a small metal container of olives in the walk-in refrigerator, covered with saran wrap and labeled with a date that was unclear. The label read 'TODAY'S DATE 2/8' and the use-by date was indistinguishable, appearing to be either 2/15 or 2/16. The Dietary Manager confirmed that the dates should be written clearly and acknowledged that the olives should have been discarded if the use-by date was indeed 2/15 or 2/16. The cook, who was responsible for preparing food, confirmed the use-by date as 2/15 and stated she would discard the olives. Further interviews revealed that the facility's policy is to discard opened food items seven days after opening. The Dietary Supervisor confirmed that the cook prepares and cooks food in the main kitchen and then brings it to the facility kitchenette. The failure to clearly label and discard food items by their use-by date has the potential to affect residents, visitors, and staff who consume meals prepared by the facility, placing them at risk for foodborne illness.
Staff Competency Deficiencies in Safe Transfers and Perineal Care
Penalty
Summary
The facility failed to ensure staff competency in safe transfers and perineal care for two residents. In the case of Resident 131, the facility did not provide adequate training for safe transfers, which placed the resident at risk for avoidable injuries. This was identified through interviews and record reviews, highlighting a significant gap in staff training and competency in handling transfers safely. For Resident 13, the deficiency was observed during perineal care performed by a Certified Nurse Aide (CNA). The CNA used dry cloths instead of moistened ones, failed to change gloves when moving from dirty to clean tasks, and did not perform hand hygiene between glove changes. This improper technique led to contamination and compromised the resident's hygiene. The Infection Preventionist confirmed that the CNA did not follow proper procedures, indicating a lack of adequate training and adherence to infection control protocols.
Failure to Provide Adequate Hydration and Alternate Meal Options
Penalty
Summary
The facility failed to implement a food and hydration program that recognizes and addresses the preferences of each resident. This is evidenced by the repeated failure to provide fresh water to Resident 132 despite her multiple requests. Observations on different days showed that Resident 132's water pitcher remained empty for extended periods, and staff members, including CNAs and LPNs, did not take responsibility to ensure she received water. The resident also reported experiencing dark and burning urine, indicating dehydration, and her care plan specifically mentioned the need to encourage fluids to prevent infection and manage pain. Despite this, the facility's hydration management policy was not followed, leading to the resident's continued lack of access to water throughout the day. Additionally, the facility failed to offer and provide alternate menu items when residents found their meal trays unappetizing. Resident 132 reported being denied an alternate meal option because she had not pre-ordered it, contrary to the facility's policy that alternate menu items should always be available. Other residents also expressed dissatisfaction with the food quality and the lack of alternate options during a resident council meeting. Interviews with the Dietary Supervisor, Registered Dietician, and Head Chef confirmed that residents should have access to alternate menu items, but this practice was not consistently implemented, leading to widespread dissatisfaction with the meals provided.
Improper Food Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a return visit to the kitchen. Several cardboard boxes of food were found resting on metal trays on the floor of the walk-in refrigerator/freezer on the B1 floor. The Dietary Supervisor (DS) confirmed that the food should be stored off the floor and instructed another kitchen staff to move the food. The Head Chef (HC) later confirmed that the items had been placed on shelves but was unsure why they were initially on the floor. The facility's Food Handling Policy requires food to be stored six inches above the floor.
Failure to Address and Document Resident Grievance
Penalty
Summary
The facility failed to properly address and document a grievance raised by a resident and his family representative regarding an unsafe transfer and poor positioning in bed. The resident, a male with a history of unspecified convulsions, left hemiplegia, and left hemiparesis following a stroke, reported that a certified nurse aide (CNA) performed a mechanical lift transfer without adequate preparation or explanation, causing the resident to feel scared and unsafe. The CNA was described as rough and inexperienced, and the transfer was deemed unsafe by both the resident and his family representative. Despite reporting the incident to the Director of Rehabilitation (DOR) and the Minimum Data Set Coordinator (MDSC), the complaint was not documented or resolved satisfactorily, leaving the resident and his family feeling ignored and blamed for the incident. The facility's grievance log showed no documentation of the complaint, and interviews with the DOR and MDSC confirmed that the incident was not properly recorded or addressed. The facility's policy on grievance management requires that all complaints be documented and investigated to ensure satisfaction and improve services, but this was not followed in this case. The failure to document and resolve the grievance resulted in a decreased quality of life for the resident and had the potential to affect all residents who voice concerns at the facility.
Failure to Implement Person-Centered Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident admitted for rehabilitation services after suffering a lumbar fracture. The care plan for the resident was generalized and did not include the resident's name. Additionally, the interventions for pain management outlined in the care plan were not followed. Specifically, the care plan included interventions such as assisting with repositioning for comfort and offering analgesics according to physician orders, but these were not implemented. The Medication Administration Record (MAR) and pain log revealed that acetaminophen was not documented as given over several days, and the pain level and non-pharmacological interventions were not recorded. During an interview, the Director of Nursing (DON) and MDS Nurse indicated that nurses typically rate the resident's pain based on their observations rather than asking the resident to rate their pain on a scale. This practice led to the failure to document and manage the resident's pain effectively. The resident's pain management was not adequately addressed, as evidenced by the lack of documentation and adherence to the care plan interventions.
Failure to Monitor and Manage Constipation
Penalty
Summary
The facility failed to adequately monitor, care plan, and manage an elevated risk of constipation for a resident, resulting in abdominal discomfort and difficulty defecating. The resident, a [AGE] year-old male with a history of unspecified convulsions, left hemiplegia, left hemiparesis following a stroke, and constipation, was admitted on [DATE]. Despite an admitting diagnosis of constipation, the resident was not started on a routine medication for constipation until 02/20/24, and the care plan was not updated to reflect this change. The resident's family representative reported that the resident experienced hard stools and difficulty defecating, and had requested a suppository but was told it was only for no bowel movements after three days. The nursing progress notes documented constipation on 02/06/24, with the last bowel movement on 02/01/24, but the resident did not receive appropriate medication until 02/20/24. Additionally, there were inconsistencies in the administration of as-needed medications for constipation, with Lactulose and Bisacodyl suppository being administered despite documented bowel movements on previous days. The Director of Nursing (DON) stated that the facility has no bowel protocol and that staff should follow the doctor's orders. However, the resident's comprehensive care plan did not specifically address the constipation problem identified on admission and was not revised when the routine medication was added or increased. The care plan only referenced as-needed medications and was included under an Alteration in Comfort care plan related to other conditions. This lack of a specific care plan and inconsistent medication administration contributed to the resident's ongoing constipation issues and discomfort.
Failure to Ensure Resident Safety in Therapy Room and During Transfers
Penalty
Summary
The facility failed to ensure residents were free from accident hazards in the Therapy Room and during transfers. Resident 23, a cognitively intact female with a history of convulsions, syncope, and muscle weakness, sustained a wound on her left forearm from an exposed end of the wooden parallel bars in the Therapy Room. The injury occurred when the resident slipped while using the bars, and the exposed end caused a skin tear. The injury report was completed by a nurse who was not present during the incident, and the exposed ends of the parallel bars remained unprotected even after the injury was reported and observed by staff. Resident 131, a male with left hemiplegia and hemiparesis following a stroke, experienced unsafe transfer practices. The resident and his family reported that a CNA attempted a mechanical lift transfer alone without explaining the process, causing the resident to feel scared and unsafe. The CNA was described as rough and inexperienced, and the transfer was not conducted according to the resident's assessed needs, which required 100% assistance or two or more helpers. The CNA had not completed the required training for safe transfers and had not been tested on the specific mechanical lifts used in the facility. The facility's policy on safe lifting and movement of residents was not followed, as nursing staff did not consult with rehabilitation staff before attempting the transfer. The DON confirmed that the CNA had not completed all required training, including the Transferring Safely component. The failure to ensure proper training and adherence to safety protocols led to unsafe conditions for residents in the Therapy Room and during transfers.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to recognize and evaluate when a resident experienced pain and did not manage the pain consistent with the comprehensive assessment, plan of care, and current professional standards of practice. The resident, a [AGE] year-old male admitted for rehabilitation services after a lumbar fracture, reported that he was not receiving pain medication regularly and only when he requested it. Observations revealed that nursing staff did not consistently ask the resident about his pain level, and the pain log did not document pain levels or non-pharmacological interventions. The resident's care plan included interventions for pain management, but these were not followed as prescribed, leading to increased pain for the resident. Interviews with the Director of Nursing (DON), MDS Nurse, and other staff indicated a lack of consistent practice in assessing and documenting pain levels. The DON stated that nurses document pain levels based on their observations rather than asking residents directly. The facility's pain management guidelines emphasize the importance of recognizing pain and using specific strategies for different levels and sources of pain, but these guidelines were not adhered to in the case of this resident. The failure to follow the care plan and professional standards resulted in inadequate pain management for the resident.
Failure to Adequately Assess and Identify Past Traumas
Penalty
Summary
The facility failed to adequately assess and identify past traumas experienced by a resident, leading to a deficiency in trauma-informed care. The resident, a cognitively intact female, reported experiencing post-traumatic stress from terrifying hallucinations prior to her hospitalization and subsequent transfer to the skilled nursing home. Despite her distress, the resident stated that no staff member had spoken to her about traumatic events in her life since her admission. The facility's trauma-informed care assessment, conducted by the Minimum Data Set Coordinator (MDSC), consisted of only two questions, and the resident's assessment had 'no' marked as the answer to the first question, which led to the second question not being asked. The MDSC admitted to not always reading all the examples given in the assessment questions, which may have contributed to the oversight. During interviews, the resident expressed that she was visibly upset and experienced physical symptoms of distress when recounting her traumatic experiences. She also reported that certain staff members and background noises triggered her anxiety, yet these triggers were not identified or addressed by the facility. The lack of a thorough trauma-informed care assessment and the failure to recognize and address the resident's triggers placed her at increased risk of re-traumatization and hindered her mental and psychosocial well-being.
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.
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.
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 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 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 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 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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