Kalakaua Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1723 Kalakaua Avenue, Honolulu, Hawaii 96826
- CMS Provider Number
- 125066
- Inspections on file
- 17
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kalakaua Gardens during CMS and state inspections, most recent first.
The facility failed to follow its Legionnaires' Disease infection prevention and control program by limiting pH and chlorine testing of potable water to a single first-floor sink instead of performing required monthly testing in multiple sinks/showers on every floor. Surveyors confirmed through logs that only first-floor pH and chlorine levels were monitored, although water temperatures were checked daily on all floors. A decorative water fountain at the facility entrance was not being tested annually for Legionella as required, despite acknowledgment by Maintenance, the Infection Nurse, and the Director of Facilities that such testing and broader water monitoring should have occurred. Policy review also showed requirements for daily cleaning and disinfecting of decorative water features, Legionella culture testing of those features, and monthly ice machine maintenance, which were not being fully carried out.
A resident experienced two falls due to inadequate supervision in the bathroom. Initially, the resident was left unattended, resulting in a fall and fractures. Despite recommendations to prevent future falls, the care plan was not updated, leading to a second fall with head injuries. The DON confirmed the care plan was not revised, acknowledging the second fall could have been avoided.
The facility was found to have deficiencies in food handling and storage practices. Boxes of food were improperly stored on the floor, and a container of tuna salad was used beyond the facility's policy limit. Additionally, staff were observed not wearing required hair restraints in the kitchen. These issues indicate non-compliance with professional standards for food safety.
A resident with multiple diagnoses, including hemiplegia and dysphagia, was found with an open wound on the right buttock due to a lack of a person-centered care plan. The care plan required two-person assistance for peri-care, but a CNA was observed providing care alone. The comprehensive care plan did not address the resident's functional abilities or include interventions to prevent skin integrity issues. The DON confirmed the care plan's deficiencies.
A resident experienced two falls in the bathroom due to the facility's failure to update their care plan with necessary interventions after a significant change in condition. Despite recommendations to accompany the resident to the restroom, they were left unattended, resulting in injuries including a head laceration and fractures.
The facility failed to ensure that QC solutions used for glucose meter testing were not expired. During an inspection, a pouch with a glucose meter, test strips, and two QC solutions was found, with the solutions being past their use-by date. An RN confirmed that QC testing is done daily and that the expired solutions were used, as indicated by the QC log. The DON provided documentation stating that control solutions should be discarded 90 days after opening or upon expiration.
The facility failed to follow up on an out-of-range temperature recording for a medication refrigerator, risking the effectiveness of stored medications. The Director of Nursing acknowledged the oversight, suggesting the recording might have been an error. Facility policy requires proper storage and temperature monitoring, which was not adhered to in this instance.
A facility failed to maintain complete and accurate medical records for a resident admitted for hospice care. The baseline care plan was dated four days after admission and lacked the name of the staff member and completion date. Interviews revealed delays and discrepancies in documentation, potentially affecting all residents.
A resident with a complex medical history experienced a decline in condition due to nursing staff's failure to recognize and report changes in consciousness, administer oxygen timely, and notify the physician about held blood pressure medication. The resident was transferred to the hospital with sepsis and fluid overload and later passed away. Interviews revealed inconsistencies in notifying physicians about changes in residents' conditions.
A facility failed to involve a resident's representative in decisions regarding an advance health care directive (AHCD). The resident, with cognitive deficits due to dementia, was documented as agreeing to a full code status, despite being incompetent to make such a decision. A conflicting DNR order was also present. The facility's policy requires staff to verify and document the resident's wishes, involving the representative if necessary, but the resident's representatives were not notified or involved in the process.
A facility failed to include a resident's representative in the care planning process and did not have the resident's physician attend IDT meetings. The resident, admitted for therapy after a stroke, was confused and unable to understand the meeting content. Although a baseline care plan was reviewed with family members, there was no documentation of their invitation to the IDT meeting, and the physician's absence was noted.
A resident's care plan was not updated to include new diagnoses and treatments, such as dehydration, UTI, IV fluids, antibiotics, and a PICC line, following a stroke. Facility staff confirmed that the care plan should have been revised by the nurse who received the new orders or initiated the therapy, highlighting a lapse in protocol.
A facility failed to ensure a resident received a required face-to-face physician visit within 30 days of admission. The resident, admitted for therapy after a stroke, did not have an in-person evaluation, as confirmed by staff and the physician. Instead, telemedicine or phone consultations were used, inaccurately documented as face-to-face encounters. The resident was later transferred to a hospital and expired. Nursing notes suggested the physician's presence, but lacked corresponding documentation.
Failure to Implement Legionella Water Management and Monitoring Protocols
Penalty
Summary
The facility failed to implement its infection prevention and control measures for Legionnaires' Disease as outlined in its own Water Management Program and related policies. During an observation and interview with Maintenance, surveyors observed water testing being conducted only on a first-floor bathroom sink for pH, chlorine level, and temperature using a test strip and thermometer. Review of the Monthly Potable Water Log from late August 2024 through late November 2025 showed that pH, chlorine, and temperature monitoring was documented only for the first floor, even though the facility policy required testing pH in five sinks/showers per floor on a monthly basis. The Water Temperature Log did show daily temperature checks on all floors, but pH and chlorine testing were not performed or documented for upper floors. When questioned, Maintenance acknowledged that all floors should have been tested, monitored, and documented for pH and chlorine levels. Further observations and interviews revealed additional failures related to Legionella control. During a tour of the decorative water fountain at the front of the facility, Maintenance reported that the water pump had been turned off two days earlier and confirmed that the fountain water should be tested for Legionella annually per the facility’s Water Management Program, but this testing was not being done as required. In a subsequent interview, the Infection Nurse and Director of Facilities both confirmed that testing and monitoring for pH, chlorine, and water temperature should have been conducted on all floors, and that the decorative water fountain, where Legionella and other opportunistic waterborne pathogens can grow and spread, should have been tested. Review of the facility’s policy "Infection Prevention & Control Legionnaires' Disease" showed requirements for monthly pH monitoring in five sinks/showers per floor, annual Legionella testing of potable water, daily cleaning and disinfecting of decorative water features, Legionella culture testing of decorative water features by Maintenance, and monthly ice machine cleaning, all of which were not being fully implemented as observed and documented by surveyors.
Failure to Update Care Plan Leads to Repeated Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent a second fall for a resident, resulting in physical injuries. Initially, the resident was left unattended in the bathroom by a CNA, leading to a fall where the resident hit her head against the wall and sustained a right superior and inferior ramus fracture, along with skin tears. The facility's Fall Scene Investigation Tool identified the root cause as the resident's loss of balance while getting off the toilet, with a recommendation that the resident should not be left unattended in the bathroom. Despite these recommendations, the resident's comprehensive care plan was not updated to include these interventions. Consequently, the resident experienced a second fall when left unattended again, resulting in a head injury requiring sutures, a skin tear, and multiple bruises. The Director of Nursing confirmed that the care plan was not revised to prevent a similar fall, acknowledging that the second fall could have been avoided if the resident had not been left unattended.
Food Handling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food handling and storage, as observed during a survey. During an initial tour of the kitchen, six boxes of various food items were found on the floor of the dry storage area, and five boxes were on the floor of the walk-in freezer. The Dietary Director (DD) confirmed that these items should not have been on the floor and attributed the issue to a recent delivery. Additionally, a large metal pan with partially covered cooked noodles was stored in the refrigerator, which the DD explained was due to the noodles being hot when placed inside. Furthermore, a container of tuna salad dated 01/08/25 was found in the refrigerator, and a Dietary Aide (DA2) intended to use it for sandwiches, despite the facility's policy stating that such items should be used within four days. The survey also noted that the DD and a Dietary Aide (DA1) were not wearing required hair restraints while in the kitchen area. The DD acknowledged this oversight and immediately took corrective action by obtaining a hairnet. These observations indicate a lack of compliance with the facility's policies and procedures regarding food storage, handling, and personal hygiene, potentially affecting the safety and quality of food served to residents, visitors, and staff.
Deficient Care Plan Implementation for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was person-centered and implemented for a resident, leading to a risk of more than minimal harm. During an observation, a resident was found lying in bed with a wedge partially under their right hip, and an open wound was observed on the right buttock. The Certified Nurse Aide (CNA) providing care was unaware of the wound and mentioned that a wedge was being used to offload the resident's weight. The resident's family member confirmed that the resident did not have an open wound upon admission. A review of the resident's electronic health record revealed that the resident was admitted with diagnoses including hemiplegia, hemiparesis, pneumonitis, dysphagia, and atrial fibrillation. The baseline care plan required two-person assistance for peri-care, but the CNA was observed providing care alone. The comprehensive care plan did not include the resident's functional abilities or the necessary staff assistance. It documented potential skin integrity issues but lacked interventions to prevent the worsening of the open area or the development of pressure ulcers. An assessment noted Moisture Associated Skin Damage (MASD) on the intergluteal cleft, which was in-house acquired. The Director of Nursing confirmed that the care plan was not person-centered and did not include the resident's functional abilities, which should have been addressed.
Failure to Revise Care Plan Leads to Resident Harm
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan with person-centered interventions following a significant change in condition assessment. This deficiency resulted in the resident being physically harmed on two occasions. Initially, the resident was left unattended in the bathroom by a CNA, leading to a fall from the toilet. The resident sustained a head injury and fractures as a result of this incident. Despite the facility's Fall Scene Investigation Tool identifying the need for the resident to be accompanied to the restroom and not left unattended, these recommendations were not incorporated into the resident's care plan. Subsequently, the resident experienced a second fall in the bathroom under similar circumstances, where they were again left unattended. This fall resulted in a head laceration requiring sutures, as well as additional bruises and skin tears. The Director of Nursing confirmed that the care plan was not updated to prevent such incidents, acknowledging that the second fall could have been avoided if the resident had not been left unattended.
Expired QC Solutions Used for Glucose Meter Testing
Penalty
Summary
The facility failed to ensure that the supplies used for Quality Control (QC) testing of the blood glucose meter were not expired or beyond their discard date. During an inspection of a medication cart, a pouch containing a glucose meter, test strips, and two QC solutions was found. The QC solutions had a green sticker indicating an open date and a use-by date, which had already passed. Registered Nurse (RN)12 confirmed that QC testing is performed daily by the night shift nurse and acknowledged that the QC solutions were beyond their stated use-by date and would be discarded. Upon reviewing the QC log, RN12 confirmed that the staff had used the expired QC solutions, as the lot number matched the log. The Director of Nursing (DON) provided a document stating that unused control solutions should be discarded 90 days after first opening or after the expiration date.
Failure to Follow Up on Out-of-Range Temperature in Medication Refrigerator
Penalty
Summary
The facility failed to follow up on an out-of-range temperature recording for a medication refrigerator, which was observed during a survey. On the specified date, several medications were stored under temperature control, and the temperature log for the refrigerator showed an out-of-range recording that was neither followed up on nor reported. This oversight was acknowledged by the Director of Nursing (DON) during a staff interview, who suggested that the out-of-range temperature might have been recorded in error. The facility's policy on the storage of medications requires that medications and biologicals be stored properly, following manufacturers' or provider pharmacy recommendations, to maintain their integrity and ensure safe, effective drug administration. The policy also mandates that medications requiring refrigeration be kept within a specific temperature range, with a temperature log maintained to verify compliance. Despite these requirements, the facility did not adhere to its policy, as evidenced by the lack of follow-up on the out-of-range temperature recording, posing a risk to the effectiveness of the stored medications.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident admitted for hospice care. The resident's baseline care plan, which is a critical component of their medical record, was found to be incomplete and inaccurately documented. Specifically, the baseline care plan was dated four days after the resident's admission, and it lacked the name of the staff member who completed it and the date of completion. This discrepancy was identified during a review of the resident's Electronic Health Record (EHR), where it was noted that the baseline care plan was scanned into the EHR four days post-admission, contrary to the facility's practice of completing it on the day of admission. Interviews with the Medical Records Specialist and a Registered Nurse revealed further issues with the documentation process. The Medical Records Specialist confirmed that the baseline care plan was scanned into the EHR after her return to work, indicating a delay in documentation. The Registered Nurse, who admitted the resident, was unable to provide documentation confirming that the baseline care plan was completed within 48 hours of admission. This lack of documentation and adherence to professional standards in maintaining medical records has the potential to affect all residents admitted to the facility.
Nursing Staff Competency Deficiencies Lead to Resident Harm
Penalty
Summary
The facility nursing staff failed to demonstrate the necessary competencies to meet the needs of a resident, leading to a critical situation. The staff did not identify a change in the resident's level of consciousness, failed to report the trend of high blood pressure medication being held due to low blood pressure, administered medication twice when it should have been held, and did not administer oxygen timely or notify the physician when the resident's oxygen level remained below the required threshold. These deficiencies resulted in the resident's changing condition not being recognized and reported to the physician, preventing timely interventions. The resident, a female with a complex medical history including hyperlipidemia, chronic kidney disease, atrial fibrillation, and dementia, was admitted to the facility for short-term rehabilitation following a stroke. During her stay, the resident experienced a decline in her condition, including lethargy and low oxygen saturation levels, which were not adequately addressed by the nursing staff. The resident's medication administration records showed that her blood pressure medication was held multiple times due to low readings, yet the physician was not consistently notified of these occurrences. Additionally, the resident's oxygen saturation levels were not monitored as frequently as required, and oxygen was not administered promptly when levels dropped below the target. Interviews with nursing staff revealed inconsistencies in the practice of notifying physicians about changes in residents' conditions, such as low blood pressure or changes in consciousness. The Assistant Director of Nursing acknowledged the lack of a clear policy for notifying physicians when blood pressure medication is held. The resident's condition deteriorated, leading to her transfer to the hospital, where she was diagnosed with sepsis and fluid overload and subsequently passed away. The failure to recognize and act on the resident's changing condition highlights significant deficiencies in the facility's nursing care practices.
Failure to Involve Resident's Representative in Advance Directive Decisions
Penalty
Summary
The facility failed to provide information to a resident's representative about the right to formulate an advance health care directive (AHCD). The resident, who was admitted for short-term therapy following a stroke and had cognitive deficits due to dementia, was documented as having been provided with advanced directive information and agreed to a full code status. However, the resident was not competent to make such a decision, and her representative was not involved in the process. Additionally, there was a conflicting physician order for do not resuscitate (DNR) upon admission, which was not aligned with the documented full code status. The facility's policy on resident rights and advanced directives requires staff to verify and document the resident's wishes regarding advance directives, involving the resident's representative if necessary. Despite this, the interdisciplinary team meeting documentation showed that the resident's representatives were not invited or notified, and the resident, who could not understand the meeting content, was in attendance. The social services staff member involved could not recall the meeting, indicating a lack of adherence to the facility's policy and procedures for ensuring the resident's wishes were accurately communicated and documented.
Failure to Include Resident's Representative in Care Planning
Penalty
Summary
The facility failed to include a resident's representative in the development of a comprehensive care plan and did not have the resident's physician attend the interdisciplinary team (IDT) meetings. The resident, a female admitted for short-term physical and occupational therapy following a stroke, had a history of Alzheimer's, hypertension, atrial fibrillation, and other conditions. Upon admission, she was confused and oriented only to herself. Although a baseline care plan was developed and reviewed with the resident's family members on the day of admission, the IDT meeting held shortly after did not include the resident's representatives, and there was no documentation that they were invited or notified. The IDT meeting documentation indicated that the resident attended, but due to her confusion, she would not have been able to understand the meeting's content. The facility's social services staff acknowledged that the usual practice is to invite family members to a welcome meeting within a few days of admission, but there was no documentation to confirm that this occurred. Additionally, the resident's physician did not attend the IDT meetings, and the facility could not provide documentation of a subsequent meeting with the family member.
Failure to Update Care Plan with New Diagnoses and Treatments
Penalty
Summary
The facility failed to ensure the timely revision of a resident's care plan to include changes in therapy and new diagnoses, compromising the continuity of care and communication with the resident and family. The resident, an elderly female admitted for short-term physical and occupational therapy following a stroke, experienced several changes in her medical status during her stay. These changes included diagnoses of dehydration and a urinary tract infection (UTI), requiring treatments such as intravenous fluids and antibiotics, as well as the placement of a PICC line due to IV infiltration. Despite these significant changes, the resident's care plan was not updated to reflect the new diagnoses or the associated treatments. Interviews with facility staff, including the Assistant Director of Nursing and a Registered Nurse, confirmed that the care plan should have been revised by the nurse who received the new orders or initiated the therapy. The failure to update the care plan with the new diagnoses and treatments was acknowledged by the staff, indicating a lapse in the facility's protocol for maintaining accurate and current care plans.
Failure to Conduct Required Physician Face-to-Face Visit
Penalty
Summary
The facility failed to provide evidence that a resident received the required physician face-to-face initial comprehensive visit within 30 days of admission. The resident, an elderly female with a history of Alzheimer's, hypertension, atrial fibrillation, orthostatic hypotension, muscle weakness, and age-related physical debility, was admitted for short-term physical and occupational therapy following a stroke. Despite the requirement for a face-to-face evaluation, the physician did not conduct such a visit, as confirmed by interviews with nursing staff and the physician himself. The physician admitted to using telemedicine or phone consultations instead of in-person visits, which was not documented accurately in the progress notes. The resident was transferred to an acute care hospital for a change of condition and later expired. The progress notes for the resident's admission and transfer were in a template format, indicating a face-to-face encounter that did not occur. Nursing progress notes suggested the physician was present in the facility on certain dates, but there were no corresponding physician notes to confirm these visits. This discrepancy highlights the facility's failure to ensure that the resident's needs were met through proper physician evaluations, potentially affecting all new admissions.
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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