Kulana Malama
Inspection history, citations, penalties and survey trends for this long-term care facility in Ewa Beach, Hawaii.
- Location
- 91-1360 Karayan Street, Ewa Beach, Hawaii 96706
- CMS Provider Number
- 125057
- Inspections on file
- 16
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Kulana Malama during CMS and state inspections, most recent first.
A resident experienced two unplanned tracheostomy decannulations during care, both of which were managed without distress or complications. Although the incidents were reported in facility incident reports, there was no corresponding documentation in the EHR by nursing or respiratory staff, contrary to facility policy requiring such documentation for changes in condition.
A resident with a history of traumatic brain injury and complex medical needs experienced a fall, after which nursing staff failed to perform and document complete neurological assessments, did not recognize or respond promptly to significant changes in condition, and delayed notifying the physician and transferring the resident for higher-level care. Staff lacked training, competency validation, and access to necessary equipment for neurological checks, and facility policies were insufficiently specific regarding post-fall assessment requirements.
A resident with cognitive impairment, quadriplegia, and nonverbal status following a traumatic brain injury did not have a care plan that included specific interventions for staff to communicate with him using his established nonverbal methods, such as blinking and eye tracking. The care plan lacked documentation of these communication techniques, resulting in the absence of consistent guidance for staff.
A resident who was fully dependent on staff for all ADLs and nonverbal, with quadriplegia and contractures, fell from bed when a CNA left at least one bed rail down, the bed unlocked, and the room poorly lit while moving to the other side of the bed during perineal care. This failure to follow the facility's fall prevention policy directly led to the resident's fall.
A resident with a complex medical history, including TBI, hydrocephalus with shunt, tracheostomy, and quadriplegia, experienced a fall and subsequent decline in condition. Nursing staff were unable to reach the assigned physician for over four hours despite multiple attempts, and did not transport the resident to the ER in a timely manner. The physician was eventually reached and instructed staff to send the resident to the ER, resulting in a delayed transfer.
A resident who was fully dependent on staff for care experienced a preventable fall due to staff not securing safety rails and not following the required two-person assist protocol. The facility did not complete a thorough incident report or root cause analysis, failed to ensure timely physician response and emergency transfer, and did not review these events in its QAPI program. Nursing staff lacked competency in post-fall assessment and documentation, and leadership did not investigate or act on staff concerns, resulting in missed opportunities to identify and address systemic care issues.
A resident in a persistent vegetative state did not receive auditory stimulation, such as music or television, as outlined in their care plan. Despite family requests and care plan interventions for sensory activities, observations showed the resident in a quiet room without stimulation. The Recreation Coordinator noted that dependent residents should have a television on, but this was not consistently done, as confirmed by a nurse who turned on the TV only after being questioned.
A facility failed to ensure a clean environment for a resident when the mesh netting inside her crib became soiled during care and was not promptly cleaned or changed. The resident, who frequently placed her legs against the mesh, had a large liquid bowel movement that soiled the mesh, which was observed over several days. This increased the potential for exposure to an unsanitary environment, as confirmed by a nurse during an interview and record review.
A facility failed to properly document and communicate necessary information during the discharge of a resident with complex medical needs. The physician's discharge summary was insufficient, and there were no documented discharge orders. The RN confirmed verbal communication with the caregiver but did not complete the required discharge instruction form, violating facility policy.
A facility failed to ensure a safe environment for a resident by not conducting a safety assessment after installing a crib canopy. The resident, a 2-year-old with complex medical needs, experienced an unwitnessed fall from her crib. Although a canopy was added as a safety measure, the facility did not evaluate its potential hazards or its impact on the resident's development, as confirmed by staff interviews.
A resident was given insulin despite a blood glucose level below the physician-ordered hold parameter, leading to a critical drop in blood glucose later that day. The error was identified and reported by facility staff, and the resident's physician adjusted the insulin dosage.
The facility failed to provide routine dental care for two residents, with one resident's last dental consult in 2020 and another in 2021, despite care plans requiring regular dental visits. Observations showed poor oral hygiene, and there was no documentation of recent dental exams.
A facility failed to accurately document a medication order for a resident, leading to a discrepancy in the narcotic medication record. The record incorrectly stated a dosage of 8 ml of Lacosamide oral solution via J-Tube twice a day, while the correct dosage was 12 ml as verified by the RN with the electronic medical record and MAR. The RN acknowledged the error and noted that the narcotic form should have been updated.
The facility failed to ensure proper infection control practices, as observed in two incidents. An RN did not perform hand hygiene between glove changes after administering medication via a gastrostomy tube, contrary to facility policy. Additionally, a DCS member was seen with a face mask improperly worn under the chin while providing care, exposing their mouth and nose. These actions were confirmed by interviews with facility staff, highlighting lapses in infection prevention protocols.
Failure to Document Unplanned Tracheostomy Decannulations in EHR
Penalty
Summary
The facility failed to ensure proper documentation in the electronic health record (EHR) for two unplanned decannulations of a resident's tracheostomy tube. On two separate occasions, the resident experienced unplanned decannulations while being cared for by certified nurse aides, with both incidents being witnessed and reported in facility incident reports. In both cases, the tracheostomy tube was reinserted without difficulty, and the resident did not show signs of distress or decreased oxygen saturation. However, a review of the resident's EHR revealed that there were no progress notes written by a nurse or respiratory therapist regarding these unplanned decannulations, despite the facility's policy requiring nursing staff to document care provided and changes in the resident's condition in the medical record. Interviews with staff, including the respiratory therapist and the director of nursing (DON), confirmed that the expectation was for the nurse who responded to the incident to document the event in the EHR. The respiratory therapist involved in the incident stated he did not believe it was expected of him to chart the change in the EHR. The DON confirmed that the nurse should have documented the incident. The facility's documentation policy, provided by the DON, specifies that nursing staff are required to document care and changes in the resident's condition in the medical record, including through progress notes.
Failure to Ensure Nursing Staff Competency in Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide safe and appropriate care for residents with complex medical needs, particularly those with neurological impairments. Multiple licensed staff did not demonstrate competency in performing and documenting neurological assessments, identifying medical emergencies requiring timely intervention, or using critical thinking to determine the need for thorough assessments after a fall with potential head or neck injury. Documentation revealed that after a resident with a history of traumatic brain injury, craniectomy, and quadriplegia sustained a fall, staff did not complete full neurological assessments, including level of consciousness and pupillary response, as required by facility policy and standard care protocols. The resident, who had a baseline of neurological impairment and communicated by blinking, experienced a fall from bed while being changed by a CNA. Initial and subsequent nursing documentation focused primarily on vital signs, with incomplete or missing neurological assessment data. Staff failed to consistently document or perform assessments of the resident's level of consciousness and pupil response, and did not recognize or act upon significant changes in the resident's condition in a timely manner. There was a delay in notifying the physician and transferring the resident to a higher level of care, despite clear evidence of altered mental status and neurological decline. Interviews and record reviews indicated that staff were unclear about the components and frequency of neurological assessments, lacked access to necessary equipment such as penlights, and had not received adequate training or competency validation in these areas. The facility's policies lacked specificity regarding post-fall neurological assessments, and there was no evidence of structured training or competency checks for staff involved in the resident's care. The deficiency was determined to be immediate jeopardy due to the involvement of multiple staff and the serious nature of the failures.
Failure to Develop Comprehensive Communication Care Plan for Nonverbal Resident
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident with significant cognitive impairment and nonverbal status following a traumatic brain injury. The resident, who was quadriplegic, had a tracheostomy and a PEG tube, was unable to communicate verbally and relied on nonverbal cues such as blinking, laughing, and tracking with his eyes to interact with staff. Medical records and staff interviews confirmed that the resident used specific blinking patterns to indicate 'yes' or 'no' responses, and also responded with laughter and eye movements. Despite this, the resident's care plan did not include detailed interventions or instructions for staff on how to communicate with him using these established nonverbal methods. The care plan only generally addressed altered communication and cognition, with interventions limited to assessing pain using a specific pain scale. There was no documentation in the care plan about the resident's unique communication methods, such as blinking or tracking with his eyes, nor was there information about his baseline behaviors like laughing or smiling. This omission meant that staff did not have consistent, documented guidance on how to effectively communicate with the resident.
Failure to Secure Bed Rails Results in Resident Fall
Penalty
Summary
A resident with quadriplegia, contractures, and a history of traumatic brain injury, who was completely dependent on staff for all activities of daily living and nonverbal, experienced a fall from bed. The incident occurred when a CNA was changing the resident's diaper and turned the resident onto his right side. The CNA then moved to the opposite side of the bed, leaving at least one bed/safety rail down, the bed unlocked, and the room poorly lit. As a result, the resident fell from the bed while the CNA was on the other side. Facility records and staff interviews confirmed that the side rail on the side closest to the window, where the resident fell, was lowered at the time of the incident. The facility's fall prevention policy required that side rails be kept in the raised position when a resident is in bed. The DON confirmed that the fall was avoidable and that the CNA did not ensure the safety rails were secure and in place before leaving the resident's side, directly leading to the accident.
Delay in Emergency Physician Response and Resident Transfer
Penalty
Summary
The facility failed to ensure the availability of a physician for emergency care for one resident who experienced a fall and subsequent change in condition. The resident, a male with a history of traumatic brain injury, subdural hematoma, decompression craniotomy, post-traumatic hydrocephalus with a shunt, tracheostomy, PEG tube, and quadriplegia, fell from bed while being changed by a CNA. Following the fall, the resident exhibited a drop in oxygen saturation and became increasingly lethargic, eventually becoming unresponsive to painful stimuli and verbal questions. Despite these significant changes in condition, nursing staff were unable to reach the assigned physician for over four and a half hours, making multiple attempts to contact him directly and through the physician exchange service. During this period, staff did not transport the resident to the emergency room in a timely manner, despite the inability to reach the physician and the resident's deteriorating condition. The physician was eventually reached after more than four hours and instructed staff to send the resident to the ER, at which point 911 was called and the resident was transferred. Interviews with staff and the DON confirmed the delay in reaching the physician and uncertainty about the appropriate steps to take when the physician could not be contacted, especially as the physician was reportedly out of the country at the time.
Failure to Analyze and Address Quality Deficiencies After Resident Fall and Unplanned Hospitalizations
Penalty
Summary
The facility failed to systematically analyze and address quality deficiencies related to a resident's adverse events, including a fall and two unplanned hospitalizations for altered mental status. The resident was completely dependent on staff for all activities of daily living, including toileting, bed mobility, and transfers, and required a two-person assist and mechanical devices due to weight. Despite these needs, staff did not ensure safety rails were secure before leaving the resident unattended, resulting in a preventable fall. The incident report for the fall was incomplete, lacking documentation on whether the care plan was followed and if appropriate transfer techniques were used. The root cause analysis did not identify that incontinence care was provided by only one staff member instead of the required two, and there was no reminder to staff about the two-person assist requirement. The facility also failed to ensure 24-hour physician availability for emergency care, as the physician could not be reached for over four hours after the resident's fall and condition change. Staff did not transport the resident to the emergency room in a timely manner when unable to reach the physician. The Quality Assurance and Performance Improvement (QAPI) program did not review or identify delays in physician response or unplanned transfers, and did not address staff feedback regarding these issues. QAPI meeting minutes did not include any discussion of the resident's fall or related unplanned hospitalizations, and data elements related to rehospitalization and medical record audits were marked as compliant or not applicable, despite the events. Nursing staff demonstrated deficiencies in competency, including failure to perform and document neurological assessments, identify medical emergencies requiring timely transfer, notify providers of baseline condition changes, and conduct comprehensive assessments after the fall. Leadership received staff feedback about these deficiencies but did not investigate or develop action plans. The Director of Nursing was aware of the fall but did not personally investigate or review the medical record, and the administrator confirmed that unplanned discharges were not routinely reviewed for quality improvement opportunities. As a result, system and process issues were not identified or addressed to ensure nursing care met recognized standards of practice.
Failure to Provide Auditory Stimulation for Resident in Vegetative State
Penalty
Summary
The facility failed to enhance the quality of life for a resident who was in a persistent vegetative state by not providing auditory stimulation such as music or television. Observations over several days showed the resident in bed, either awake with eyes closed or sleeping, in a quiet room without any auditory stimulation. The resident's family member expressed concern about the lack of television or music, stating they had previously requested cartoons or similar programs to be played. Despite these requests, the facility did not consistently provide auditory stimulation. The Recreation Coordinator indicated that the presence of auditory stimulation depended on the resident's activity level, with more active residents having access to devices like iPads or cell phones. However, for dependent residents, a television should be on unless it is time to sleep. The resident's care plan included sensory stimulation activities, yet these were not implemented as observed. A Registered Nurse, when questioned, mentioned that activities would occur later in the day and subsequently turned on the television to a sports channel, highlighting a lack of consistent implementation of the care plan's interventions.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean environment for a resident, identified as R12, who was observed to have soiled mesh netting inside her crib. During care, the mesh netting came into contact with a soiled bedsheet after the resident had a large liquid bowel movement. Despite the resident's tendency to place her legs against the mesh, staff did not clean or change the soiled mesh immediately. Observations over several days confirmed the resident's continued contact with the soiled mesh, increasing the potential for exposure to an unsanitary environment. The deficiency was confirmed during an interview and record review with a registered nurse, who acknowledged the need for the mesh to be changed.
Deficiency in Discharge Documentation and Communication
Penalty
Summary
The facility failed to ensure proper communication and documentation at the time of discharge for a resident identified as R32. The resident, a male with a history of spastic diplegic cerebral palsy, epilepsy, acute respiratory failure, and a tracheostomy, was discharged voluntarily. However, the necessary discharge documentation was incomplete. The physician's discharge summary merely noted a 'stable course' without providing a detailed account of the resident's stay and treatment. Additionally, there were no documented discharge orders from the physician, and the discharge instructions form was not completed or documented in the Electronic Medical Record (EMR). The Registered Nurse (RN) responsible for the discharge confirmed that she verbally communicated the discharge checklist to the resident's caregiver but failed to document this discussion or complete the required discharge instruction form. The facility's policy mandates that all discharges require a physician's order and that the assigned nurse must complete and review the discharge instructions with the resident and responsible party, which was not adhered to in this case. This lack of documentation and communication represents a deficiency in the facility's discharge process.
Failure to Conduct Safety Assessment for Crib Canopy
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, resulting in a deficiency related to the safety of a resident's crib. A resident, a 2-year-old female with complex medical conditions including George's syndrome, paralysis of vocal cords and larynx, and chronic respiratory failure, experienced an unwitnessed fall from her crib. The incident occurred after staff had suctioned her tracheotomy and left the room, only to find her on the ground later with her GJ tube dislodged. Following this incident, the facility implemented a crib canopy as a safety intervention but did not conduct a safety assessment or evaluate the potential accident hazards associated with the new equipment. The lack of a safety assessment after the installation of the crib canopy was confirmed during interviews with facility staff, including a registered nurse and the administrator. The canopy, made of heavy-duty plastic, distorted the images on the television that the resident watched, which was not considered in terms of its impact on the resident's development. The facility's failure to assess the safety of the canopy and its effects on the resident's environment and development contributed to the deficiency identified in the report.
Insulin Administration Error Due to Ignored Hold Parameter
Penalty
Summary
The facility failed to ensure that a resident's insulin was withheld when their blood glucose level was below the physician-ordered threshold. Specifically, the resident was administered 55 units of Lantus Solostar insulin despite having a blood glucose level of 79 mg/dl, which was below the hold parameter of 80 mg/dl. This incident occurred during the morning medication round, and the error was identified later that day by the facility staff. The resident's blood glucose level was monitored throughout the day, and it was found to drop to a critical level of 69 mg/dl in the evening, necessitating intervention with glucose tablets. The error was reported to the charge nurse, the Director of Nursing, the resident's physician, and the resident's son. The physician subsequently adjusted the insulin dosage and maintained the same hold parameters.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure routine dental care for two residents, R10 and R5, as evidenced by outdated dental consults. R10's most recent dental consult was conducted in November 2020, despite having a care plan initiated in January 2020 that required yearly and as-needed dental consults. During a record review, it was found that there was no documentation of R10 being seen by a dentist in 2023, and the Assistant Director of Nursing was unable to confirm any recent dental visits. Similarly, R5's last documented dental consult was in November 2021, although the resident's care plan required dental examinations twice a year. Observations revealed that R5 had poor oral hygiene, with yellow and dirty teeth and white residue in the mouth. Despite the facility's claim that the dentist visits once a year, there was no documentation of a dental exam for R5 after 2021. The Unit Clerk was unable to provide evidence of a 2023 dental visit, as the dentist's office was closed at the time of inquiry.
Incorrect Documentation of Medication Dosage
Penalty
Summary
The facility failed to accurately document a medication order in the narcotic medication record for a resident, identified as R20, during a medication administration observation. The narcotic medication record incorrectly stated that Lacosamide oral solution 10 mg/ml should be administered at a dosage of 8 ml via J-Tube twice a day. However, upon verification with the electronic medical record and the medication administration record (MAR), it was confirmed that the correct dosage was 12 ml. The Registered Nurse (RN) 23 acknowledged the discrepancy and noted that the narcotic form should have been updated to reflect the correct dosage. The medication bottle had small labels indicating that the dosage had been changed in the medical record, but this update was not reflected in the narcotic medication record, leading to the deficiency.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented by staff, leading to deficiencies in infection prevention and control. On June 5, 2024, a Registered Nurse (RN) was observed administering medication to a resident via a gastrostomy tube. After completing the task, the RN removed her dirty gloves and donned a new pair without performing hand hygiene in between. When interviewed, the RN stated that she did not believe her hands were dirty, indicating a lack of adherence to the facility's hand hygiene policy, which requires hand hygiene immediately after glove removal. This was confirmed by the Assistant Director of Nursing, who acknowledged the requirement for hand hygiene between glove use. Additionally, on June 3, 2024, a Direct Care Staff (DCS) member was observed providing suctioning to a resident and then entering another resident's room with their face mask pulled down under the chin, exposing their mouth and nose. This was confirmed during an interview with the Infection Control Physician, who stated that staff should wear a face mask properly covering the mouth and nose while in a resident's room and during procedures like suctioning. These observations highlight lapses in the facility's infection control practices, specifically regarding hand hygiene and proper use of personal protective equipment (PPE).
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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