Liliha Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1814 Liliha Street, Honolulu, Hawaii 96817
- CMS Provider Number
- 125041
- Inspections on file
- 25
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Liliha Healthcare Center during CMS and state inspections, most recent first.
The facility did not maintain required documentation for resident grievances, with all sampled grievances lacking evidence of investigation, follow-up, or written decisions as outlined in facility policy. Multiple concerns reported by residents and a family member, including issues with staffing, personal belongings, and care, were not properly tracked or resolved in writing, and it was unclear if the complainants were satisfied with the outcomes. The Administrator confirmed that documentation was not kept up to date due to a vacant Social Services Director position.
The facility did not have a consistent process or documentation system in place to ensure that residents at risk for pressure ulcers, including those with severe mobility limitations and incontinence, were regularly repositioned as required by their care plans. Nursing documentation was sporadic, CNA documentation was absent, and staff interviews confirmed a lack of clarity and standardized procedures for repositioning, resulting in residents remaining in the same position for extended periods.
The facility did not conduct a comprehensive investigation into an alleged staff-to-resident abuse incident, as required by its policy. Only the accused CNA was interviewed, while other staff present, roommates, and other residents were not interviewed or assessed for signs of abuse. The Administrator confirmed the investigation was limited in scope.
Two residents with complex medical needs did not have their care plans updated to include physician-ordered interventions for skin protection, resulting in staff lacking critical information to address their conditions. One resident's care plan omitted the use of GERI sleeves for fragile skin despite open wounds and an active order, while another's care plan failed to include a Prevalon Boot for ankle protection, which was also not in use at the time of observation.
A resident with multiple comorbidities and a recent COVID diagnosis did not have all required vital signs consistently monitored and recorded by nursing staff, despite physician orders. Documentation showed repeated omissions of pulse, respiratory rate, and pulse oximetry over several days, even after family concerns about the resident's declining condition were raised. The Unit Manager confirmed that the monitoring was incomplete and did not meet the expected standard of care.
The facility did not have a registered nurse serving as DON, as required, after the previous DON left. The Administrator confirmed the vacancy and stated that other staff were covering some DON duties while the facility searched for a replacement. Facility assessment documents listed a DON as part of the required nursing staff, but the position remained unfilled.
The facility did not have a DON present on the Quality Assessment and Assurance Committee, as required, due to the position being vacant for several months. Other staff covered some DON duties, but QAPI meeting minutes confirmed the absence of a DON, resulting in noncompliance with committee membership requirements.
Surveyors found that cooked white rice stored in the kitchen refrigerator was not labeled with the required preparation or discard date, and unopened bottles of sauce in dry storage were missing best-by-date labels due to missing caps. Dietary staff confirmed the labeling omissions and removed the affected sauce bottles from storage.
A resident reported feeling disrespected and undignified when staff frequently spoke in their native language, which the resident did not understand, leading to the perception that staff were talking about them. Facility policy requires residents to be informed of their rights in a language they understand and to be treated with dignity and respect.
A CNA wrapped a resident's hands tightly with the lower portion of the resident's gown to complete incontinence care after the resident resisted by pushing down with her hands. This action was taken for staff convenience and not for medical treatment, contrary to facility policy prohibiting physical restraints for such purposes.
A resident with a history of wandering and exit-seeking behavior, as well as multiple medical and cognitive conditions, was not provided with consistent or one-on-one supervision despite repeated elopement attempts. Staff were unclear about who was responsible for monitoring the resident, and after following a visitor out the main entrance, the resident left the facility and walked unsafely in the community before being returned by staff and the administrator.
The facility did not ensure that cloth napkins provided with meal trays were clean, as evidenced by observations of stained and soiled napkins and acknowledgment by the Dietary Manager. This failure was identified through family interviews, direct observation, and review of facility policy.
Three staff members, including a RN and two CNAs, completed CPR training that did not include hands-on practice or in-person skills assessment, as confirmed by documentation and staff interviews. The facility administrator acknowledged the absence of a written policy for CPR training requirements, and one staff member confirmed the lack of hands-on training.
A medication cart was found left unlocked and unattended in a hallway, with staff passing by before an RN returned to secure it. Both the RN and the unit manager confirmed that medication carts should be locked when unattended, in accordance with facility policy requiring all drugs and biologicals to be stored in locked compartments.
A resident with a sacral wound had her dressing removed and wound assessed by a PA before her incontinence was cleaned and before a clean brief was placed. The CNA cleaned the area only after the wound assessment. Staff interviews confirmed that incontinence should be addressed before wound care to maintain infection control.
The facility failed to develop and implement individualized care plans for three residents, leading to a risk of decline in their quality of life. One resident's mobility needs were not addressed, another's care plan lacked frequency for Hemi-Walker use, and a third resident's required assistance for movement was not specified. MDS staff confirmed that care plans were generalized and not individualized.
The facility failed to maintain a comfortable environment by not keeping the wallpaper in the 1st-floor hallway in good repair. Observations showed wallpaper lifting, curling, and missing patches, along with watermarks and unkept areas where pictures had been removed.
The facility failed to treat two residents with respect and dignity. One resident reported that staff would respond to the call bell but not return for several hours, making them feel ignored. Another resident, who required substantial assistance for movement due to extensive edema, reported that staff would take a long time to return, causing increased pain. The lack of timely assistance did not provide care in a dignified manner.
The facility failed to ensure that two residents were informed of their right to develop an advance health care directive (AHCD), were aided in doing so, and were periodically reassessed in their decision-making capacity. No AHCDs were found in the electronic health records, and repeated requests to the Social Services Director and the administrator yielded no documentation showing that the residents had been offered information on formulating an AHCD upon admission or during their stay.
A resident with left-sided hemiplegia and hemiparesis following a stroke was observed multiple times with her head bent uncomfortably to the right, without any supportive devices to assist in proper positioning. The care plan lacked interventions for proper body mechanics, and the Unit Manager was unaware of any ordered orthotic devices. This deficiency hindered the resident from reaching her highest practicable well-being and has the potential to affect all residents with ROM deficits.
A resident with a high risk for falls was observed ambulating with oversized slippers, which were not identified as a safety hazard by the facility. The resident's care plan mentioned the need for proper footwear but did not specify the importance of proper fit, and no assessment had been made regarding the oversized slippers.
A resident with multiple diagnoses, including Alzheimer's and a nearly healed pressure ulcer, continued to receive a routine fentanyl patch without thorough pain assessments. The nurse administered routine acetaminophen for the resident's pain complaint without evaluating the pain's source or using as-needed analgesics. Communication barriers and lack of documentation contributed to the deficiency, confirmed by the unit manager and director of nursing.
The facility failed to provide routine dental services for its residents, as evidenced by a resident who had not received any dental visits since admission. The Unit Manager confirmed that the facility dentist had not been providing services since COVID-19, and residents with dental emergencies were sent out to the dentist's office. This is contrary to the facility's Dental Services policy, which mandates annual inspections and various dental procedures.
Failure to Document and Resolve Resident Grievances per Policy
Penalty
Summary
The facility failed to maintain proper documentation of resident grievances as required by its own policy and federal regulations. Six sampled grievances were reviewed, and none met the documentation requirements for recording the grievance decision. The facility's policy designates the Administrator as the Grievance Official and outlines responsibilities for tracking, investigating, and issuing written decisions regarding grievances, as well as maintaining a grievance log for three years. However, the facility did not follow these procedures, and the required documentation was incomplete or missing for all reviewed grievances. Specific examples include incomplete Concern Forms for multiple grievances reported by two residents and a family member. For instance, one resident reported issues such as mold and water damage, insufficient CNA staffing during night shifts, and missing personal items. The forms lacked documentation of immediate actions taken, investigation, follow-up, or resolution, and did not indicate whether the resident was satisfied with the outcome. Another family member reported concerns about resident care, therapy communication, and food quality, but the forms again lacked documentation of satisfaction, follow-up, or final resolution. During interviews, the Administrator confirmed that the facility did not have a Social Services Director at the time and acknowledged that grievance documentation and the grievance log were not kept up to date. The Administrator stated that some follow-up actions were taken, such as referring maintenance issues and reviewing staffing schedules, but these actions were not documented as required. As a result, it was unclear what actions had been taken in response to grievances and whether residents or their representatives were satisfied with the outcomes.
Failure to Implement and Document Resident Repositioning for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement and document a consistent process for repositioning residents at risk for pressure ulcers. Three residents with significant mobility impairments and incontinence, who required assistance for bed mobility, did not have evidence of being repositioned according to their care plans. The care plans for these residents specified turning and repositioning per a rounding schedule, but there was no established schedule or documentation process for staff to follow. Record reviews showed sporadic and infrequent documentation of turning and repositioning in nursing progress notes, with large gaps between entries and no detailed information about the positions used or the frequency of repositioning. Certified Nurse Assistant (CNA) documentation was absent, and interviews revealed that CNAs were unclear about the rounding schedule and lacked a standardized method to record repositioning tasks. Observations confirmed that residents remained in the same position for extended periods during the survey. Interviews with staff, including a CNA and a Unit Manager, confirmed the absence of a formal process for documenting repositioning. The Unit Manager acknowledged that only nurses were documenting turning and positioning in progress notes, and that CNAs did not have a system in place to record these interventions. This lack of a structured process and documentation increased the risk of pressure ulcer development among residents requiring frequent repositioning.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of staff-to-resident abuse involving one resident. On the date of the alleged incident, the facility's staff schedule showed that four CNAs, including the alleged perpetrator, and two RNs were present on the unit. However, the investigation packet only included information obtained from the accused CNA. There was no documentation that other staff members working at the time, the resident's roommates, or other residents on the unit were interviewed. Additionally, there was no evidence that non-interviewable residents were assessed for signs and symptoms of abuse. During an interview, the Administrator confirmed that the investigation focused solely on the resident who made the allegation and did not include interviews with other potential witnesses or assessments of other residents. This approach was inconsistent with the facility's own policy, which requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegations, as well as providing complete and thorough documentation of the investigation.
Failure to Timely Update Care Plans with Physician-Ordered Interventions
Penalty
Summary
The facility failed to make timely revisions to the comprehensive care plans for two residents, resulting in staff not having all necessary information to address the residents' needs. For one resident, who had a history of chronic obstructive pulmonary disease, stroke, dysphasia, dementia, diabetes, and anemia, and was incontinent with a feeding tube, provider orders indicated the use of GERI sleeves on both arms to protect fragile skin. Despite documentation of open wounds on her arms due to scratching and an order for protective sleeves, the care plan was not updated to include this intervention. For another resident with Parkinson's disease, provider orders required the use of a Prevalon Boot on the right ankle/foot to prevent skin breakdown due to foot rotation causing pressure on the ankle. The care plan did not reflect this intervention, and during observation, the resident was found not wearing the boot, with a small area of redness noted on the ankle. The nurse confirmed the omission in the care plan and subsequently applied the boot. These omissions in care plan updates were identified through observation, interview, and medical record review.
Failure to Consistently Monitor and Record Vital Signs for Resident with COVID
Penalty
Summary
Nursing staff failed to consistently monitor and record all required vital signs for a female long-term resident diagnosed with COVID infection, despite physician orders to do so every shift. The resident, who had advanced dementia, breast cancer, Type 2 diabetes, major depressive disorder, hypertension, and dysphasia, was placed in isolation after her COVID diagnosis. Review of her medical records revealed that from the date of diagnosis through her transfer to the hospital, vital signs such as pulse, respiratory rate, and pulse oximetry were frequently omitted, with multiple days showing no documentation of these parameters. This incomplete monitoring occurred even after the resident's family expressed concern about her condition and changes in her level of consciousness. Progress notes indicated that after the family raised concerns, nursing staff administered a nebulizer treatment and documented some lung assessments, but did not perform a full set of vital signs or a thorough nursing assessment as would be standard practice. The Unit Manager confirmed during an interview that the expectation was for complete vital sign monitoring twice daily, and acknowledged that the records did not meet this standard. The lack of consistent and complete vital sign monitoring represented a failure to provide the standard of nursing care as required by the resident's condition and physician orders.
Failure to Designate a Registered Nurse as Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse as the Director of Nursing (DON) as required. During a staff interview, the Administrator confirmed that there was no DON currently in place and that the facility was in the process of searching for one. The Administrator also stated that the previous DON had left several months prior, and that other staff members were temporarily covering some of the DON's duties and responsibilities. Review of the facility assessment indicated that the facility's stated resources included a DON among the nursing staff, but this position was vacant at the time of the survey.
Lack of DON Participation in QAA Committee Meetings
Penalty
Summary
The facility failed to meet the requirement for the Quality Assessment and Assurance (QAA) Committee to include the Director of Nursing (DON) as a member and to have the DON participate in quarterly meetings. During a staff interview, the Administrator confirmed that there was no DON currently employed at the facility, as the previous DON had left several months prior. Other staff members were temporarily covering some of the DON's responsibilities, but the QAPI meeting minutes for the past two months showed no DON present. A review of the facility's assessment indicated that the DON is considered an essential part of the nursing services team, which is responsible for providing 24-hour nursing care. Despite this, the absence of a DON from the QAA Committee and related QAPI activities was documented, as the facility was still in the process of recruiting for the position. This lack of DON participation resulted in noncompliance with regulatory requirements for the QAA Committee's composition and function.
Failure to Properly Label and Date Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly label cooked and stored food in the kitchen, specifically noting a container of cooked white rice in a refrigerator that lacked a label identifying the food item, preparation date, or discard date. The dietary staff member confirmed the rice was prepared that morning and acknowledged that a label with the current date and discard date should have been created. Additionally, in the dry food storage room, multiple unopened bottles of Browning and Seasoning Sauce were found, with two bottles missing the yellow cap that displays the best-by-date. The dietary staff member was unable to determine why these bottles lacked caps and subsequently removed them from storage. Review of the facility's food safety policy confirmed requirements for labeling, dating, and monitoring refrigerated food, including leftovers, to ensure proper use or disposal.
Resident Dignity Compromised by Staff Communication Practices
Penalty
Summary
A deficiency was identified when a resident reported feeling that their right to a dignified existence was violated due to staff members frequently speaking in their native language, which was not English, in the resident's presence. The resident expressed feeling that staff were talking about them, leading to discomfort and a perceived lack of respect and dignity. Review of the facility's policy confirmed that residents are to be informed of their rights in a language they understand and are entitled to a dignified existence, self-determination, and communication. The incident involved one resident and was based on direct resident interview and policy review.
Resident Restrained During Personal Care for Staff Convenience
Penalty
Summary
A Certified Nurse Aide (CNA) wrapped a resident's hands with the lower portion of the resident's gown during personal care after the resident resisted care by pushing down with her hands. This action was taken so the CNA could finish changing the resident's incontinence brief. The CNA confirmed during an interview that the hand wrapping was tight and was done for the purpose of completing care. The facility's policy states that residents have the right to be free from any physical restraint imposed for staff convenience and not required to treat medical symptoms. The incident was identified during a Facility Reported Incident (FRI) investigation and confirmed through interviews and record review.
Failure to Provide Adequate Supervision for Elopement Risk Resident
Penalty
Summary
A deficiency occurred when a resident identified as an elopement risk was not provided with adequate supervision, resulting in the resident leaving the facility without authorization. The resident had a history of medical and cognitive conditions, including pyogenic arthritis, muscle weakness, difficulty walking, anxiety, depression, and a cognitive communication deficit. Upon admission, the resident expressed a desire to go home and was noted to wander the hallways but was generally redirectable. On the day of the incident, the resident attempted to elope multiple times, expressing the intent to leave and return home. Despite these behaviors, supervision was inconsistent. The Social Services Director observed the resident in the lobby but was not specifically assigned to provide one-on-one supervision. The receptionist was asked to monitor the resident but was unable to do so continuously due to other duties. After the first elopement attempt, one-on-one supervision was not implemented, and staff were unclear about who was responsible for monitoring the resident. The Central Supply Coordinator spoke with the resident but was not officially tasked with supervision. Multiple staff interviews confirmed that close supervision was not consistently provided, and there was confusion regarding who was responsible for monitoring the resident after the initial elopement attempt. The resident ultimately exited the facility by following a visitor out the main entrance and proceeded to walk up a busy street, crossing without regard for safety. The Social Services Director and transport driver attempted to intervene, but the resident continued to walk unsafely in the community until the administrator was notified and able to redirect the resident back to the facility. Facility policy required adequate supervision for residents at risk of elopement, but this was not effectively implemented in this case.
Failure to Provide Clean Cloth Napkins with Meal Trays
Penalty
Summary
The facility failed to maintain a clean environment as evidenced by multiple observations and interviews regarding stained and soiled cloth napkins provided with meal trays. During a family interview, concerns were raised about numerous stains and spots on the cloth napkins accompanying meal trays. Subsequent observation of breakfast trays confirmed the presence of several napkins with spot and smudge stains. The Dietary Manager, upon review of the stored cloth napkins, acknowledged that several napkins had spots and stains as described. Review of the facility's policy indicated that maintaining a sanitary environment includes keeping resident care equipment, such as items used in daily living activities, clean and properly stored.
Staff Lacked Proper Hands-On CPR Training
Penalty
Summary
Three staff members, including a registered nurse and two certified nurse aides, were found to have completed CPR training through an online course that did not include hands-on practice or an in-person skills assessment. Documentation reviewed confirmed that the training lacked these essential components, which are required for proper basic life support (BLS) competency according to accepted professional guidelines. During interviews, the facility administrator acknowledged there was no written policy outlining CPR training requirements. The administrator also stated that, after consulting with the Infection Preventionist, it was clarified that BLS is required for licensed nurses. One of the staff members confirmed that her CPR training did not include any hands-on or in-person skills assessment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the second-floor hallway was observed left unlocked and unattended, with two staff members passing by the cart before a registered nurse returned and secured it. The registered nurse confirmed that the cart should have been locked when unattended. The unit manager also confirmed that unattended medication carts are required to be locked and secured. Review of the facility's policy on medication storage, revised on 06/01/23, documented that all drugs and biologicals must be stored in locked compartments, including medication carts, cabinets, drawers, refrigerators, and medication rooms.
Wound Care Performed Prior to Incontinence Cleaning
Penalty
Summary
During wound care rounds, a resident was observed with a bowel movement on her buttocks, which extended to the bottom edge of her sacral dressing. The physician assistant removed the dressing and assessed the wound before the resident's incontinence was cleaned and before a clean brief was placed under her. The certified nurse aide cleaned the bowel movement only after the wound assessment was completed. Interviews with the infection preventionist, unit manager, and certified nurse aide confirmed that the resident should have been cleaned of incontinence prior to any wound care or assessment to maintain infection control standards.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility did not ensure the development and implementation of comprehensive person-centered care plans for three residents, leading to a risk of decline in their quality of life. For one resident, despite identifying positioning and mobility needs, the facility failed to develop a care plan to address these needs effectively. Another resident expressed a desire to mobilize more with a Hemi-Walker, but the care plan lacked the frequency of occurrence for this intervention. The MDS staff confirmed that the care plans were generalized and not individualized, which contributed to the deficiency. Additionally, a third resident required substantial assistance for movement due to extensive edema in both lower and upper extremities. The care plans in place for this resident did not specify the required amount of assistance needed for various movements, such as moving from lying to sitting and vice versa. The MDS staff member verified that the care plans were generalized and not individualized, failing to address the specific needs of the resident. These deficiencies highlight the facility's failure to develop and implement individualized care plans, placing residents at risk for a decline in their quality of life.
Failure to Maintain Environment in Good Repair
Penalty
Summary
The facility failed to provide a comfortable environment for residents, staff, and the public by not maintaining the environment in good repair. Observations made from January 23, 2024, to January 26, 2024, revealed that the wallpaper on the upper half of the walls in the hallway of the 1st floor was lifting off in several areas and curling over. Outside of room [ROOM NUMBER], a patch of wallpaper approximately 12 x 18 inches was missing, appearing to have been torn off. On the opposite wall, a picture had been removed, leaving an area significantly lighter in color than the rest of the wallpaper, giving an unkept appearance. Additionally, watermarks were apparent on several areas of the wallpapered hallway on the 1st floor unit. These conditions contributed to an environment that was unkept and not conducive to a homelike atmosphere.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to treat two residents, R9 and R139, with respect and dignity. Resident R68 reported that staff would respond to the call bell and promise to return but would not come back for several hours, making the resident feel ignored. Similarly, R9 stated that staff would acknowledge the call bell but take several hours to return, ignore requests to speak to the doctor, and speak to each other in a language other than English, making the resident feel as if they were being talked about. The facility's policy on Resident Rights emphasizes the importance of a dignified existence, self-determination, and communication, which was not upheld in these instances. Resident R139, who required substantial assistance for movement due to extensive edema of both lower and upper extremities, reported that staff would acknowledge the call bell and state they would return soon but would often take a long time, sometimes up to 40 minutes. This delay in assistance caused increased pain for R139, who was tearful during the interview while relaying this information. The lack of timely assistance did not provide care for these residents in a dignified manner, as required by the facility's policy on Resident Rights.
Failure to Inform and Assist Residents with Advance Health Care Directives
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 33 and 55, were informed of their right to develop an advance health care directive (AHCD), were aided in doing so, and were periodically reassessed in their decision-making capacity. For Resident 33, admitted in August 2023, no AHCD was found in the electronic health record (EHR), and the Social Services Director (SSD) confirmed the absence of documentation indicating that the resident had been offered assistance in creating one. Similarly, for Resident 55, no AHCD was found in the EHR, and repeated requests to the SSD and the administrator yielded no documentation showing that the resident had been offered information on formulating an AHCD upon admission or during their stay. This deficiency places residents at risk of not having their healthcare wishes honored should they become incapacitated.
Failure to Provide Appropriate ROM Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment, equipment, and services to maintain or improve the range of motion (ROM) of her neck and head. The resident, a [AGE] year-old female with diagnoses including left-sided hemiplegia and hemiparesis following a stroke, was observed multiple times with her head bent heavily and uncomfortably to the right. Despite being completely dependent on staff for positioning, there were no interventions addressing proper body mechanics or positioning in her care plan. Observations over several days showed the resident in bed with her head misaligned, without any supportive devices like pillows, neck rolls, or braces to assist in positioning her head correctly. On one occasion, a wedge pillow under her right shoulder further exacerbated her discomfort, causing her to moan in her sleep. An interview with the Unit Manager (UM) revealed that the UM was unaware of any neck braces or orthotic devices ordered to assist in positioning the resident's head. The UM also confirmed that the resident appeared uncomfortable with her head misaligned with her shoulders and body. The lack of appropriate interventions and equipment to maintain or improve the resident's ROM led to the resident being hindered from reaching her highest practicable well-being. This deficiency has the potential to affect all residents at the facility with ROM deficits.
Failure to Address Oversized Footwear as a Fall Risk
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards, specifically regarding the use of oversized slippers. Resident 52, a [AGE] year-old female with a history of dementia, difficulty in walking, syncope, and restlessness, was observed ambulating with slippers that were too large for her feet. Despite being identified as a high risk for falls, the facility did not recognize the oversized slippers as a potential hazard until it was pointed out by the State Agency. The resident's electronic health record did not document any discussion about the risks versus benefits of using the oversized slippers for ambulation. During an interview, the Unit Manager confirmed that the oversized slippers were a safety hazard and that they were provided by the resident's family. The resident loved her slippers and refused to wear non-slip socks, always opting for the oversized slippers when walking. The Unit Manager also confirmed that the oversized slippers had not been previously identified as a safety hazard and were not included in the resident's care plan. The care plan did mention the need for proper well-maintained footwear but did not specify what proper footwear would entail, such as proper fit, which had not been assessed before.
Failure to Ensure Nurse Competency in Pain Assessment
Penalty
Summary
The facility failed to ensure nurse competency in pain assessment for a resident, leading to the continued use of a narcotic with a high risk of addiction and dependence. The resident, a [AGE] year-old female with diagnoses including Alzheimer's disease, muscle weakness, an almost healed sacral pressure ulcer, and severe protein-calorie malnutrition, was found to be on a routine fentanyl patch. During morning rounds, the resident complained of pain in her feet, but the nurse only administered routine acetaminophen without conducting a thorough pain assessment or using as-needed analgesics. The nurse was uncertain about the location, source, or character of the resident's pain and did not document any pain assessments in the electronic health record (EHR). The unit manager and director of nursing confirmed that there was no clear documentation of the resident's pain, and a more thorough pain assessment was needed to determine if the routine fentanyl order was still necessary. The resident's primary language is Cantonese, and communication barriers may have contributed to the inadequate pain assessment. The nurse did not assess the resident's feet or legs when she complained of pain and relied on routine medication without evaluating the effectiveness or necessity of the narcotic. The unit manager believed the fentanyl order was a carryover from when the resident was on hospice care for a pressure ulcer, which was almost healed. The director of nursing confirmed that nurses are expected to conduct thorough pain assessments when administering any pain medication, whether routine or as needed. This deficiency placed the resident at risk for avoidable addiction and dependence on fentanyl, as well as other adverse effects of the medication.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for its residents, as evidenced by the case of a female resident who had not received any routine dental visits since her admission. During an interview, the resident's family representative reported the lack of dental care. A review of the resident's electronic health record confirmed the absence of any dental visits or exams. The Unit Manager admitted that the facility dentist had not provided routine or emergency dental services since the onset of COVID-19, and residents with dental emergencies were sent out to the dentist's office. The facility's Dental Services policy mandates annual inspections and various dental procedures, which were not being followed.
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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