Kuakini Geriatric Care, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 347 North Kuakini Street, Honolulu, Hawaii 96817
- CMS Provider Number
- 125026
- Inspections on file
- 16
- Latest survey
- January 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kuakini Geriatric Care, Inc during CMS and state inspections, most recent first.
The facility failed to ensure proper sanitization of dishware and silverware, as the dishwasher's final rinse temperature was below the required 180 degrees Fahrenheit. Despite logs showing compliance on previous days, the surveyor observed a lapse in practice, with staff unaware of the correct temperature requirements. The facility's policy was not followed, posing a risk of foodborne illness due to improper sanitization.
A facility failed to inform a resident's representative about the risks and benefits of psychotropic medications, resulting in a lack of documented consent. The resident, with severely impaired cognition, was prescribed Trazodone, Seroquel, and Zoloft without the representative's informed consent. Staff interviews confirmed the absence of documentation, as the responsible employee was on leave, leading to potential harm for residents receiving these medications.
The facility failed to implement comprehensive care plans for two residents. One resident with COPD did not have their continuous oxygen use included in their care plan, despite a physician's order. Another resident with a UTI caused by ESBL did not have enhanced barrier precautions in place as required by their care plan. These deficiencies were confirmed by facility staff.
A resident with a history of constipation did not receive prescribed laxatives as ordered, leading to missed doses of Lactulose when the resident did not have a bowel movement for two days. Despite the resident's acknowledgment of constipation and taking stool softeners, the facility failed to administer the medication as per the treatment plan, with no documentation of refusal.
The facility failed to maintain cleanliness of enteral feeding equipment for three residents, leading to unsanitary conditions with dried formula residue on feeding pumps and poles. Staff were unclear about cleaning responsibilities, contributing to the deficiency.
The facility failed to label oxygen tubing for three residents, risking respiratory infections. A resident with COPD used a nasal cannula without a date label, contrary to policy. Another resident with a tracheostomy had unlabeled tubing, and a third resident on droplet precautions had an oxygen meter initially off and unlabeled tubing. The DON confirmed the need for weekly changes and labeling, highlighting a systemic issue in respiratory care management.
The facility failed to implement infection control measures for three residents. A resident on contact isolation lacked proper signage, and another on enhanced barrier precautions did not have a PPE cart or signage. Additionally, a CNA delivered a meal to a resident on droplet precautions without appropriate PPE. These deficiencies were confirmed by the DON and staff, indicating lapses in infection prevention protocols.
The facility failed to notify physicians of abuse allegations involving three residents. One resident reported rough handling by a CNA, another experienced care without communication, and a third was witnessed being abused by a CNA. In each case, the physicians were not informed, contrary to facility policy.
The facility failed to protect residents from physical abuse by staff, involving incidents where a resident was pushed during a shower, another was undressed without consent, and a third was stomped on the foot. These incidents involved contract and night shift CNAs, with one resident expressing fear of retaliation. The facility's policy requires immediate protective actions, but the report does not specify if these were implemented.
The facility failed to report abuse allegations to the state agency within the required timeframe. In two incidents, reports were delayed by two and three days, respectively. One involved a resident who reported a night shift CNA providing care without explanation, and another involved a resident with Alzheimer's who was reportedly abused by a CNA. The facility's policy mandates timely reporting, which was not followed.
The facility experienced staffing deficiencies on two occasions during the second shift, leading to incidents of improper delegation and staff-to-resident abuse. On one occasion, an RN delegated medication administration to a CNA, which is outside the CNA's scope of practice. On another occasion, a CNA reportedly stomped on a resident's foot, who has Alzheimer's and was on 1:1 monitoring. The staffing levels were below the required matrix, contributing to these incidents.
An RN improperly delegated medication administration to a CNA, which is outside the CNA's scope of practice. The CNA was instructed to give a resident her bedtime medication, which the resident refused, questioning the CNA's role. The RN admitted to the delegation due to discomfort with the resident and lack of available staff.
A facility failed to accurately document medication administration for a resident. RN3 asked CNA5 to offer medication to the resident, R40, due to feeling uncomfortable after a prior incident. Despite R40 refusing the medication, RN3 documented in the MAR that R40 had taken Tylenol and Melatonin. RN3 did not seek help from another nurse or the Shift Coordinator.
Dishwasher Sanitization Deficiency
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to proper sanitization procedures for dishware and silverware, as observed during a survey. The deficiency was identified when the surveyor noted that the final rinse temperature of the dishwasher was at 172 degrees Fahrenheit, below the required 180 degrees Fahrenheit necessary for heat sanitization. Despite the facility's logs indicating compliance with temperature standards from previous days, the surveyor's observation revealed a lapse in practice. The Food Services Supervisor and Food Service Workers were unaware of the correct temperature requirements, and the dishwasher did not use a chemical sanitizer, relying solely on heat for sanitization. The facility's policy clearly stated that the final rinse temperature should be 180 degrees Fahrenheit or above, and any deviation should prompt immediate cessation of dishwashing procedures and notification of the Plant Operations department. However, this protocol was not followed, as evidenced by the continued unloading of dishes despite the substandard rinse temperature. This oversight posed a risk of foodborne illness to residents and staff, as the dishware and silverware were not properly sanitized according to professional standards and the U.S. Department of Health and Human Services guidelines.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's representative was informed in advance about the risks and benefits of proposed treatments, specifically the use of psychotropic medications. This deficiency was identified for one of the five residents sampled for unnecessary medications. The resident in question, identified as having severely impaired cognition with a BIMS score of 6, was dependent on staff for all care. The resident was prescribed Trazodone, Seroquel, and Zoloft for dementia behavior, agitation, and anxiety, respectively. However, there was no documentation in the resident's Electronic Health Record (EHR) or the facility's psychotropic medication consent binder indicating that the resident's designated health decision-maker, a family member, had been informed or had consented to the use of these medications. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed the absence of documented consent. The RN acknowledged that the consent process involved emailing the resident's family member, who was off-island, but the responsible employee was on leave, resulting in a lack of documentation. The DON also confirmed that there was no evidence of the family member being informed or consenting to the medication administration, nor was there documentation of the family member being educated on the risks and benefits of the medications. This oversight placed residents receiving psychotropic medications at risk for more than minimal harm.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For one resident with chronic obstructive pulmonary disease (COPD), the care plan did not include the continuous use of oxygen, despite a physician's order for supplemental oxygen to maintain oxygen saturation levels above 90%. This oversight was confirmed by both the Nursing Assessment Specialist and the Director of Nursing, who acknowledged that the resident's care plan should have included the oxygen use. Another resident, who was readmitted to the facility with a urinary tract infection caused by an antibiotic-resistant bacteria (ESBL), had a care plan that required enhanced barrier precautions (EBP) to prevent further infection. However, during an interview, a Certified Nurse Aide revealed that these precautions were not being followed, as there was no signage or personal protective equipment available outside the resident's room. The Director of Nursing confirmed that the care plan required these precautions, but they were not being implemented as intended.
Failure to Administer Laxatives as Ordered for Constipated Resident
Penalty
Summary
The facility failed to implement prescribed interventions for a resident, identified as R79, who was experiencing constipation. R79, an elderly resident admitted for long-term care, had a medical history that included dehydration, muscle weakness, and constipation. Despite having orders for laxatives such as Senna, Lactulose, and Bisacodyl Suppository to manage constipation, the facility did not administer Lactulose as ordered when R79 did not have a bowel movement for two consecutive days on multiple occasions in December 2024 and January 2025. During an interview, R79 mentioned experiencing constipation due to decreased activity and confirmed taking stool softeners, though she was unsure of the frequency. A review of the Medication Administration Record (MAR) revealed that Lactulose was not administered as required, and there was no documentation of refusal by R79. A registered nurse, RN6, acknowledged the oversight and confirmed that some doses were missed, indicating a failure to follow the prescribed treatment plan for R79's constipation.
Inadequate Cleaning of Enteral Feeding Equipment
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications of enteral feeding for three residents. Observations revealed that the equipment used for enteral feeding was not properly cleaned and maintained. For one resident, dried formula residue was observed on the feeding pump, base of the pole, and floor over two consecutive days, indicating a lack of sanitation. A Patient Care Coordinator acknowledged the unsanitary condition and the potential for attracting pests that could carry pathogens. Another resident's feeding pump and pole were also found to be soiled with dried formula. A registered nurse indicated that the night shift was responsible for cleaning the equipment, but the task was not specifically assigned to anyone. Additionally, a third resident's feeding pump was observed with a thickened layer of old formula, and a plastic tray below the pump had dried splatters of formula. The charge nurse confirmed that all staff were responsible for cleaning the equipment, but the lack of clear assignment led to the deficiency.
Failure to Label Oxygen Tubing in Respiratory Care
Penalty
Summary
The facility failed to properly label oxygen tubing when it was initiated for three residents, which placed them at risk of facility-acquired respiratory infections. Resident 89, who has a diagnosis of chronic obstructive pulmonary disease (COPD) and other respiratory conditions, was observed using a nasal cannula connected to wall oxygen without a date label on the tubing. The resident confirmed that the oxygen was on at 2 liters per minute continuously and stated that staff changed the nasal cannula when requested. The facility's policy requires nasal cannula changes weekly and as needed, with labeling to indicate the date of change. Resident 19, who requires oxygen therapy and tracheostomy care, was observed with a trachea collar connected to an aerosol bottle, but the tubing lacked a date label. The Director of Nursing (DON) confirmed that respiratory tubing should be changed weekly and labeled accordingly. The facility's policy specifies that the nebulizer, tracheostomy collar, and tubing setup should be changed daily and as needed. Resident 216, on droplet precautions for respiratory syncytial virus (RSV), was observed with a nasal cannula for oxygen delivery, but the oxygen meter was initially off, and the tubing was not labeled with a change date. A registered nurse confirmed that the oxygen was supposed to be set at 2 liters and acknowledged the absence of a label on the tubing. The facility's failure to label the oxygen tubing as per policy was consistent across multiple residents, indicating a systemic issue in respiratory care management.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control measures for three residents. Resident 23, who was on contact isolation due to Methicillin Resistant Staphylococcus Aureus, did not have the required signage outside their room to alert staff and visitors of the transmission-based precautions. This was confirmed by both the Patient Care Coordinator and the Director of Nursing, who acknowledged that signage should have been placed to prevent the spread of infections. Similarly, Resident 38, who had a history of ESBL and was on enhanced barrier precautions, did not have the necessary PPE cart or signage outside their room, as confirmed by a Certified Nurse Aide and the Director of Nursing. Additionally, a Certified Nurse Aide was observed delivering a meal to Resident 72, who was on droplet precautions due to testing positive for Respiratory Syncytial Virus, while only wearing a surgical mask. The Director of Nursing confirmed that the staff should have been wearing a face shield, gown, an approved mask, and gloves when entering the room. These lapses in infection control measures placed residents and staff at risk of preventable infections.
Failure to Notify Physicians of Abuse Allegations
Penalty
Summary
The facility failed to consult with physicians regarding allegations of abuse involving three residents. Resident 12 reported being roughly handled by a CNA during a shower, which made her afraid of potential retaliation. Despite the incident being reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), there was no documentation in the resident's electronic health record (EHR) indicating that the physician was notified. Similarly, Resident 26 reported an incident involving a night shift CNA who provided care without communication, but again, the physician was not informed. The physician stated that if notified, they would have requested an investigation and checked for harm. In another incident, Resident 33 was witnessed being abused by a CNA, who stomped on the resident's foot. The nursing supervisor was informed of the incident but did not ensure the physician was notified. The EHR review confirmed the lack of notification to the physician, and the physician later confirmed they were unaware of the incident. The facility's policy requires immediate notification of the physician and family in such cases, but this procedure was not followed, leading to a deficiency in the facility's handling of abuse allegations.
Failure to Protect Residents from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect residents from physical abuse by staff, as evidenced by multiple incidents involving three residents. One resident reported to her family that a staff member had pushed her head against the wall during a shower. The family informed the facility, and the resident confirmed the incident to the Registered Nurse (RN) and the Assistant Director of Nursing (ADON). The resident expressed fear of retaliation, although she was not physically hurt. The staff member involved was a contract worker, and her contract was subsequently canceled. Another resident reported feeling violated when she woke up to find herself undressed by a night shift Certified Nurse Assistant (CNA) without prior notification. The resident expressed discomfort with the staff member's actions, which were reported to the RN and subsequently to the ADON and Director of Nursing (DON). The incident was investigated, and it was determined that the night shift CNA had not communicated with the resident before providing care. A third incident involved a resident with Alzheimer's who was reportedly stomped on the foot by a CNA. The incident was witnessed by another CNA, who reported that the action appeared intentional. The resident was on a one-to-one monitoring plan due to restlessness and agitation. The CNA involved claimed the action was a response to the resident attempting to hit her with a walker. The facility's policy requires immediate action to protect residents from suspected abuse, but the report does not detail if this was followed in this case.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required two-hour timeframe after being reported to the Charge Nurse (CN), Nursing Supervisor (NS), or Assistant Director of Nursing (ADON) and Director of Nursing (DON). In two separate incidents involving residents, the facility delayed reporting to the state agency. For one resident, the incident was reported to the CN and subsequently to the state agency two days later. The resident had reported that a night shift CNA began providing care without informing her of the actions being taken. The Facility Reported Incident (FRI) was sent to the Office of Healthcare Assurance (OHCA) two days after the initial report. In another case, a resident with Alzheimer's and a history of agitation was reportedly abused by a CNA who stomped on the resident's foot. This incident was reported to the NS and DON, but the FRI was sent to the state agency almost three days later. The ADON confirmed that the CNA admitted to stepping on the resident's foot, describing it as a light touch, but it was believed to be intentional. The facility's policy requires notifying state officials within 24 hours or by shorter timeframes as per regulatory guidelines, which was not adhered to in these cases.
Staffing Deficiencies and Incidents in Skilled Nursing Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff on two occasions during the second shift on the skilled nursing unit, specifically on 02/07/24 and 07/05/24. On 02/07/24, the staffing matrix indicated that the unit should have had 2 RNs, 2 LPNs, and 4 or 5 CNAs for 37 residents. However, the actual staffing was 2.5 RNs, no LPNs, and 3.5 CNAs, resulting in a shortage of 1.5 LPNs and 0.5 to 1 CNA. This staffing deficiency led to an incident where an RN improperly delegated medication administration to a CNA, which is outside the CNA's scope of practice. The Associate Director of Nursing (ADON) confirmed that the facility does not teach nurses to delegate medication pass to CNAs, and a meeting was held with the involved staff to discuss their scope of practice. On 07/05/24, the unit had 31 residents and should have been staffed with 1 RN, 2 LPNs, and 4 or 5 CNAs according to the staffing matrix. However, the actual staffing was 2.5 RNs, no LPNs, and 4 CNAs, resulting in a shortage of 0.5 LPN and up to 1 CNA. During this shift, an incident of staff-to-resident abuse occurred when a CNA reportedly stomped on a resident's foot. The resident involved, who has Alzheimer's and a history of agitation, was on a 1:1 monitoring at the time. The CNA admitted to stepping on the resident's foot, describing it as a light touch, but it was suspected to be intentional due to the resident's behavior.
Improper Delegation of Medication Administration
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) and a Certified Nurse Aide (CNA) practiced within their professional scope of practice, which could potentially affect all residents. On February 7, 2024, an RN delegated the task of medication administration to a CNA, which is outside the CNA's scope of practice. The Associate Director of Nursing (ADON) confirmed that the Director of Nursing (DON) had informed him of this incident. The ADON and DON subsequently met with the involved staff, RN3 and CNA5, to discuss their professional boundaries and the facility's policies. The incident involved a resident, R40, who was demanding her bedtime medication. CNA5, who was not licensed to administer medication, was instructed by RN3 to give the medication to R40. CNA5 was aware that this was outside her scope of practice but proceeded to offer the medication, which R40 refused to take, questioning why a CNA was administering it instead of a nurse. RN3 admitted to delegating the task due to feeling uncomfortable with R40 after a previous incident and because the other nurse and Nursing Supervisor were busy. The facility's policy clearly states that only licensed individuals are permitted to administer medications.
Inaccurate Medication Documentation for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident, identified as R40. On the evening of 07/18/24, RN3, a registered nurse, admitted to asking CNA5, a certified nursing assistant, to offer medication to R40 because RN3 felt uncomfortable entering the resident's room after an incident the previous day where R40 yelled at her. RN3 did not seek assistance from another nurse or the Shift Coordinator, citing that the other nurse was busy. RN3 remained at the resident's door while CNA5 offered the medication, which R40 refused. However, a review of R40's Medication Administration Record (MAR) on 07/19/24 revealed that RN3 inaccurately documented that R40 had taken Tylenol 625 mg and Melatonin 3 mg by mouth at 2113, despite the resident's refusal.
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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