Life Care Center Of Kona
Inspection history, citations, penalties and survey trends for this long-term care facility in Kailua Kona, Hawaii.
- Location
- 78-6957 Kamehameha Iii Road, Kailua Kona, Hawaii 96740
- CMS Provider Number
- 125052
- Inspections on file
- 17
- Latest survey
- January 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of Kona during CMS and state inspections, most recent first.
The facility did not conduct annual performance reviews for CNAs, necessary for identifying weaknesses and providing education. The DON admitted the reviews were pending, affecting 13 CNAs with outdated reviews and 16 CNAs overdue for their next review. This oversight risks residents not receiving quality care.
The facility failed to monitor and document refrigerator/freezer temperatures and dishwasher disinfectant levels, risking foodborne illnesses. Logs showed missing entries despite policies requiring twice-daily temperature checks and thrice-daily dishwasher checks. Staff interviews confirmed non-compliance with these safety protocols.
The facility failed to ensure residents' dignity by not promptly responding to call lights, affecting four residents. One resident's call light was on for over 20 minutes without staff attending, despite several staff members passing by. Another resident, admitted for rehabilitation, reported waiting up to an hour for assistance, resulting in urinating in bed. A third resident experienced similar delays, with multiple staff, including the DON and Administrator, ignoring the call light. These incidents highlight insufficient staffing, particularly during weekends and nights.
The facility failed to protect residents from abuse, as evidenced by incidents involving two residents. One resident reported being run over and verbally abused by another resident, while another resident reported being physically and verbally abused by a staff member. The facility's response was inadequate, with a lack of timely investigation and recognition of the seriousness of the incidents. Additionally, 33% of the staff were not current with their abuse training, indicating systemic issues in the facility's approach to preventing and addressing abuse.
The facility failed to provide proper written notification of transfer or discharge to two residents or their representatives. One resident was transferred to a hospital for gastrointestinal bleeding without documented notification, and another resident experienced multiple hospitalizations without proper notification for one of the transfers. The facility administrator was unable to locate the necessary documentation for these notifications.
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to a hospital. This deficiency was identified for three residents transferred for various medical reasons, with no documentation found in their EHRs or paper charts. The facility's policy requires notification upon admission and transfer, or within 24 hours in emergencies, but the administrator could not locate any such notifications, indicating a systemic issue.
The facility failed to develop comprehensive care plans for two residents. One resident, using continuous oxygen, lacked a care plan for this intervention, confirmed by the administrator. Another resident, prescribed Norco for pain, had no non-pharmacological interventions in their care plan, as confirmed by the administrator and DON.
A resident with limited mobility and legal blindness was left unsupervised outside a facility, unable to return inside or notify staff for assistance. The hospitality aide left the resident outside after lunch, intending for her to be brought in by 4 PM, but the resident was forgotten until surveyors intervened. The facility lacked a signaling device for residents outside to communicate with staff inside.
A discrepancy was found in the count of Oxycodone HCl tablets during a medication cart inspection. An LPN reported administering the medication to a resident for pain but failed to update the controlled medication reconciliation sheet and the MAR. The facility's policy requires documentation of each dose administered.
The facility failed to maintain accurate EHR documentation for two residents. One resident's AHCD was signed by the wrong individual, and another resident's physician consistently documented incorrect age, allergy information, and code status over three years. The physician acknowledged these errors, citing software interface issues.
A facility failed to implement infection control measures for a resident on Enhanced Barrier Precautions. Staff did not wear gowns or perform hand hygiene between glove changes while changing the resident's dressing and assisting with transfers. The infection preventionist confirmed these actions were against facility policy, which requires gowns for high-contact activities and hand hygiene after removing PPE.
A facility failed to offer a pneumococcal vaccine to a resident, as revealed by a review of the EHR, which showed no record of the vaccine being administered or declined. The Infection Preventionist and Administrator confirmed the oversight, acknowledging the absence of documentation and the need to contact the family for consent. This failure was contrary to the facility's policy requiring pneumococcal immunization offers to all residents unless contraindicated.
The facility failed to report allegations of abuse involving two residents to the administrator and/or state agency within the required timeframe. One resident reported being run over and verbally abused by another resident, but the incident was initially classified as an accident. Another resident reported physical and verbal abuse by a staff member, but it was treated as a customer service issue. These failures highlight deficiencies in handling abuse reports, potentially affecting all residents.
A resident reported being handled roughly and verbally mistreated by a staff member during a transfer. Despite the resident's distress and potential for harm, the DON classified the incident as a customer service issue and did not conduct a thorough investigation. The incident was initially reported to an RN, who spent significant time deescalating the resident, but no investigation was initiated until weeks later.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for their Certified Nurse Aides (CNAs), which is necessary to identify any weaknesses and provide in-service education to address them. This deficiency was identified during an interview and record review. The Director of Nursing (DON) admitted that the performance reviews were not completed, as they were still pending on her desk. The facility has 24 CNAs, with 13 of them having outdated performance reviews, some dating back to May 2021. Additionally, 16 CNAs were overdue for their next review, which was due in May or June 2024. This lack of timely performance evaluations puts all residents at risk of not receiving quality care from CNAs who have not had their weaknesses identified and addressed through education.
Failure to Monitor Food Safety and Sanitation Logs
Penalty
Summary
The facility failed to adequately monitor and document the temperature of the refrigerator and freezer, as well as the disinfectant level of the dishwasher, which are essential for ensuring food safety and preventing foodborne illnesses. During an inspection, it was observed that the Refrigerator/Freezer Temperature Log was missing entries for several dates, despite staff being required to record temperatures twice daily. The Dietary Aide confirmed that the dishwasher was used three times a day, yet the Low Temperature Dish Machine Log also had numerous missing entries, indicating a failure to consistently check and log the temperature and disinfectant levels as required. Interviews with staff, including the Nutrition Coordinator, confirmed that the logs were not completed as per the facility's policies. The facility's policy on Food Safety mandates that temperatures be recorded at least twice daily, and any issues should be reported immediately. Similarly, the Sanitation and Maintenance policy requires the dishwasher's temperature and sanitizer levels to be recorded three times daily. The lack of adherence to these policies placed all residents at risk for potential foodborne illnesses due to improper food storage and inadequate dish sanitation.
Failure to Respond to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure residents' dignity by not promptly responding to call lights, affecting four residents. One resident's call light was observed to be on for over 20 minutes without any staff attending to it, despite several staff members, including a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), passing by without checking on the resident. The resident, who has moderate cognitive impairment and requires substantial assistance for daily activities, was left unattended, highlighting a staffing issue during lunch breaks and weekends. Another resident, admitted for short-term rehabilitation after knee surgery, reported waiting 45 minutes to an hour for staff to respond to her call light. This delay resulted in the resident urinating in bed due to the inability to hold herself, causing humiliation and concern about the impact on her rehabilitation progress. The resident expressed that longer wait times were more common during weekends and night shifts, indicating a pattern of insufficient staffing during these periods. A third resident, with intact cognition but dependent on staff for various daily activities, was observed with an activated call light for over 25 minutes, with multiple staff members, including the Director of Nursing and the Administrator, passing by without acknowledging the resident. The resident expressed frustration over the frequent long waits and the feeling of being ignored. Another resident also reported similar experiences of long wait times and lack of communication from staff, especially during weekends and nights, raising concerns about safety and the adequacy of staffing levels.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving two residents, R8 and R5. R8 reported that another resident, R23, ran over her feet twice with his wheelchair and verbally abused her by cursing. Despite R8 informing two staff members, the Activities Director and the Social Worker, the incident was not investigated as abuse but was instead reported as an accident. The facility administrator was unaware of the abuse allegations until much later, and no immediate investigation was conducted, which is a violation of the residents' rights to be free from abuse. In another incident, R5 reported being physically and verbally abused by a staff member, referred to as the Alleged Perpetrator (AP). R5 stated that AP handled her roughly during a transfer, yelled in her ear, and made derogatory comments about her being fussy, which affected her emotionally. The facility's response was inadequate, as the Director of Nursing (DON) did not interview R5 to understand her perspective and dismissed the incident as a customer service issue rather than potential verbal abuse. The DON's failure to recognize the seriousness of the situation and to conduct a thorough investigation contributed to the deficiency. The facility's policy on abuse prevention and response was not effectively implemented, as evidenced by the lack of timely reporting and investigation of the incidents. Additionally, a review of staff training records revealed that 33% of the staff were not current with their abuse training, further indicating systemic issues in the facility's approach to preventing and addressing abuse. These deficiencies put residents at risk for more than minimal harm and highlight the need for improved staff training and adherence to abuse prevention protocols.
Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
The facility failed to provide proper written notification of transfer or discharge to two residents or their representatives, which is a requirement for ensuring residents and their families are informed of their rights and the reasons for such actions. In the case of Resident 1, who was admitted to the facility and later transferred to an acute care hospital for gastrointestinal bleeding, there was no documentation found in the Electronic Health Record (EHR) indicating that a written notification of the transfer was provided to the resident or their representative. The facility administrator was unable to locate any document to show that the notification was sent. Similarly, for Resident 8, who had multiple hospitalizations, the facility failed to provide written notification of transfer for one of the hospitalizations. Resident 8 was discharged from the facility and sent to the emergency room for shortness of breath and later returned to the facility. Another instance involved the resident being found unresponsive and transferred to the hospital ICU. While the administrator was able to provide a copy of the discharge/transfer notice for one of the transfers, they could not find the notification form for the other transfer. This lack of documentation indicates a failure in the facility's process for notifying residents or their representatives of transfers or discharges.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to an acute care hospital, as required by its own policy. This deficiency was identified through interviews and record reviews for three residents who were transferred to hospitals. Resident 1 was transferred for gastrointestinal bleeding, Resident 30 for an abscess to his AV fistula, and Resident 8 for shortness of breath and later for being found unresponsive. In each case, there was no documentation in the Electronic Health Records (EHR) or paper charts indicating that the residents or their representatives received the required written notification of the bed hold policy. The facility's policy mandates that the bed hold policy should be provided upon admission and upon transfer to a hospital, or within 24 hours in cases of emergency transfer. Despite this, the administrator was unable to locate any written notifications for the residents in question, indicating a systemic failure to adhere to the policy. This oversight has the potential to affect all residents at the facility who are discharged to an acute care hospital, as they may not be informed of their rights and the facility's policies regarding bed holds and reserve bed payments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, which was identified during a survey. One resident, who was admitted with a diagnosis of acute respiratory failure with hypercapnia, was observed using continuous oxygen via nasal cannula at 2 liters per minute. Despite having a physician's order for this medical intervention, the resident did not have a care plan in place for the continuous oxygen use. This oversight was confirmed during a review of the resident's electronic health record and an interview with the facility's administrator. Another resident had a physician's order for an opioid pain medication, Norco, to be administered as needed for pain relief. However, the resident's care plan did not include non-pharmacological interventions for pain management, which should have been part of the comprehensive care plan. This deficiency was confirmed during an interview with the facility's administrator and the director of nursing. The lack of a comprehensive care plan for these residents could potentially affect all residents at the facility if not addressed.
Inadequate Supervision of Resident Outside Facility
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R52, who was found outside the facility in her wheelchair, unable to return inside on her own. On the evening of 09/23/24, surveyors observed R52 sitting outside the facility with her back to the door, calling for help to return inside. The resident, who has a history of hemiplegia and hemiparesis following a stroke, difficulty walking, and legal blindness, was unable to move herself in her wheelchair or notify staff of her need for assistance. The facility lacked any signaling device outside to communicate with staff inside, leaving R52 without a means to request help. Interviews conducted on 09/24/24 revealed that the hospitality aide had taken R52 outside after lunch and was supposed to return her inside by 4 PM for dinner. However, the aide finished her shift at 3 PM and informed a nurse of R52's request to return inside at 4 PM. Despite this, R52 was left outside until surveyors intervened. R52 reported that this was not the first time she had been forgotten outside, indicating a pattern of inadequate supervision. The administrator confirmed the lack of a signaling device and acknowledged the resident's inability to notify staff when left outside alone.
Controlled Drug Discrepancy Found During Medication Cart Inspection
Penalty
Summary
The facility failed to maintain an accurate account of controlled drugs, specifically Oxycodone HCl Oral Tablet 5 MG, for a resident. During an inspection of a medication cart with an LPN, a discrepancy was found between the controlled medication reconciliation sheet, which documented 38 tablets, and the actual count of 37 pills in the locked compartment. The resident's Medication Administration Record (MAR) did not show documentation of the medication being administered. The LPN reported that the resident was given Oxycodone HCl 5 mg earlier for pain but failed to update the reconciliation sheet and MAR accordingly. The facility's policy requires controlled substances to be signed out from the descending count sheet and documented on the MAR for each dose administered.
Inaccurate EHR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Electronic Health Records (EHR) for two residents, leading to potential risks in their care. For one resident, the Advanced Health Care Directive (AHCD) was improperly signed by the agent designated to make healthcare decisions, rather than the resident himself. This error was confirmed by the facility's administrator upon review. Such a mistake could lead to issues in decision-making processes if the AHCD is needed for the resident's care. In another case, a resident's physician consistently documented incorrect information over a span of three years. The resident's age was not updated, and the physician's notes inaccurately listed the resident as having no known allergies, despite the EHR indicating an allergy to Clindamycin. Additionally, the resident's code status was incorrectly documented as Full Code, while the EHR and a signed POLST indicated the resident was Do Not Resuscitate (DNR) with Comfort Measures. The physician acknowledged these errors, attributing them to a lack of interface between the software used for practitioner notes and the facility's EHR system.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident on Enhanced Barrier Precautions (EBP). During an observation, a registered nurse care manager and a certified nursing assistant were seen changing the dressing on a resident's open wounds without wearing gowns, as required by the EBP guidelines. Additionally, the care manager did not perform hand hygiene between glove changes while attending to the resident's wounds and assisting with dressing and transferring the resident to a wheelchair. The infection preventionist confirmed that the staff should have worn gowns during these activities and emphasized that hand hygiene should be performed after removing gloves. The facility's policies on Enhanced Barrier Precautions and hand hygiene were reviewed, indicating that gowns should be worn for high-contact activities and hand hygiene should be performed after removing personal protective equipment. These lapses in protocol placed residents at risk for the potential spread of infections and communicable diseases.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a pneumococcal vaccine was offered to one of the five residents in the sample, identified as Resident 1. This oversight was discovered during a review of the Electronic Health Record (EHR), which showed no record of the pneumococcal vaccine being administered to the resident. Additionally, there was no documentation of the resident declining the vaccine. During an interview and record review with the Infection Preventionist, it was confirmed that there were no records or scanned documents in the EHR indicating that the vaccine was offered or declined. The Administrator later confirmed that the resident had not been offered the vaccine and stated that they would contact the family representative to obtain consent. The facility's policy, titled 'Influenza Vaccine & Pneumococcal Vaccine Policy for Residents,' mandates that each resident should be offered pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. The failure to offer the vaccine to Resident 1 was a deviation from this policy, placing the resident at risk for acquiring, transmitting, and developing possible complications from pneumococcal disease.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the facility administrator and/or state agency within the required two-hour timeframe. In the case of one resident, she reported that another resident had run over her feet with a wheelchair and verbally abused her. Despite notifying two staff members, the facility administrator was not informed, and the incident was initially classified as an accident rather than abuse. The state agency was only notified two days later, after the surveyor's inquiry. Another resident reported an incident where a staff member allegedly caused her physical pain during a transfer and verbally abused her. The resident informed a registered nurse and the social service director about the incident, but it was not identified as potential abuse. The director of nursing treated the situation as a customer service issue, despite the resident's distress and the staff member's admission of inappropriate comments. The incident was not reported to the state agency until weeks later, after a subsequent complaint by the resident. These failures to report and properly classify incidents as potential abuse could affect all residents in the facility. The facility's inaction in promptly addressing and reporting these allegations highlights a significant deficiency in their handling of abuse reports, potentially compromising resident safety and well-being.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident involving a resident who reported being handled roughly and verbally mistreated by a staff member during a transfer. The resident, identified as R5, reported that the staff member, referred to as the Alleged Perpetrator (AP), was rough with her gait belt, yelled in her ear, and made derogatory comments about her. Despite the resident's distress and the potential for physical, verbal, and psychosocial harm, the Director of Nursing (DON) classified the incident as a customer service issue rather than potential abuse. The DON only interviewed the AP and did not conduct a comprehensive investigation, failing to interview the resident or recognize the incident's potential for abuse. The incident was initially reported to a Registered Nurse (RN32), who spent significant time deescalating the resident due to her upset state. The resident later informed the Social Service Director (SSD1) of feeling abused, but no investigation was initiated until weeks later. The DON admitted to being aware of the resident's distress and the AP's admission of making inappropriate comments but maintained the classification of the incident as a customer service issue. This lack of a thorough investigation and failure to identify the potential for abuse put residents at risk for more than minimal harm.
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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