Nuuanu Hale
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 2900 Pali Highway, Honolulu, Hawaii 96817
- CMS Provider Number
- 125024
- Inspections on file
- 19
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Nuuanu Hale during CMS and state inspections, most recent first.
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 significant functional decline was discharged home without adequate assessment of caregiver availability or capacity, despite therapy recommendations for 24-hour supervision and maximum assistance. The primary caregiver was unable to provide necessary care, and attempts at caregiver training were unsuccessful. The home health agency declined services due to an unsafe environment, and required post-discharge follow-up was not documented.
The facility failed to maintain sanitary conditions in two shower rooms, with black substance observed on the caulking. A CNA identified it as mold, while housekeepers were unsure of its nature and had tried scrubbing it off. The Maintenance Director later removed the substance, initially claiming it was black caulking, then dirt, and acknowledged it should have been addressed sooner.
A facility failed to document that written notice of transfer or discharge was provided to a resident and their representative, and that a copy was sent to the Long-Term Care Ombudsman. A resident was sent to the Emergency Department and admitted to the hospital, but there was no documentation that the discharge/transfer forms were sent to the necessary parties. The Social Services Director confirmed the lack of documentation and was unable to provide a fax confirmation notice.
The facility failed to develop and implement comprehensive care plans for several residents, including those with language barriers, pressure ulcers, and limited range of motion. This lack of care planning led to potential risks in residents' quality of life and well-being. The Director of Nursing confirmed the absence of documentation and a system for tracking care services.
The facility failed to update comprehensive care plans for four residents, leading to unaddressed needs such as meal assistance, range of motion exercises, oxygen therapy preferences, and pressure ulcer management. These deficiencies were confirmed by staff interviews and record reviews.
A long-term care facility failed to maintain an effective infection prevention and control program. Observations included a dirty pill cutter, improper hand hygiene by staff, and inadequate use of personal protective equipment. Clean medical supplies were placed on unclean surfaces, and a lancet was improperly discarded. Additionally, a urinary catheter bag was found on the floor, contrary to facility policy. These deficiencies put residents, staff, and visitors at risk of infection.
A facility failed to support a resident's bathing preferences and address his pruritic skin condition. The resident, with multiple health issues, reported that daily showers alleviated his itching, but was only allowed to shower twice a week. Staff interviews revealed a lack of documentation regarding his preferences and skin issues, and a CNA noted the resident's desire for more frequent showers.
A facility failed to provide written notification of the bed-hold policy to a resident's representative within 24 hours of an emergency hospital transfer. Although oral notification was given, the written section on the bed-hold agreement was incomplete, and there was no documentation confirming the mailing of the agreement. This oversight affects the resident's right to return and continuity of care.
Errors were found in the MDS Quarterly Assessments for two residents. One resident's active diagnosis of a contracture was omitted, and another resident's pressure ulcers were not documented upon return from the hospital. The DON and MDS Coordinator confirmed these omissions.
The facility failed to provide necessary communication support for three residents with limited English proficiency, leading to a deficiency in care. Despite being identified as needing language assistance, these residents were not provided with communication tools or interpreter services, and their care plans did not address their language needs. This oversight affected their ability to communicate effectively with staff, as confirmed by the Director of Nursing.
A facility failed to provide a resident-centered activities program for a visually impaired resident, who was unable to participate in preferred activities due to the lack of appropriate visual aids. The resident's care plans did not include specific interventions for his visual deficit, and the Activities Director confirmed that care plans typically contained only one generalized intervention. This oversight placed the resident at risk of a decline in psychosocial well-being.
A facility failed to implement an effective hydration program for a resident with chronic conditions, leading to inadequate fluid intake and potential dehydration. The resident's care plans identified risks but lacked specific interventions, and his fluid intake was not monitored. Another resident with a pruritic skin condition was not adequately addressed in his care plan, leading to frequent itching and bleeding lesions. Facility staff confirmed the lack of appropriate interventions and monitoring for both residents.
A resident with a stage 4 pressure ulcer did not receive necessary repositioning every two hours, as required by facility guidelines. Despite the resident's cognitive awareness and requests for assistance, staff failed to provide adequate support, and documentation of refusals and repositioning was lacking in the electronic health record.
The facility failed to provide appropriate care for three residents with limited ROM, leading to a risk of decline. A resident with a left-hand contracture did not have his splint applied or monitored, and there were no physician orders or care plan interventions. Another resident with quadriplegia did not receive necessary interventions to prevent worsening of his condition, and the facility lacked a Restorative Nursing Assistant program. A third resident with hemiplegia was observed with hand rolls not assessed or recommended by therapy, and there was no documentation of ROM exercises being performed.
A resident with a history of hemiplegia and hypoxemia was found with her oxygen face mask not properly positioned and the tubing disconnected from the concentrator, despite physician orders for continuous oxygen. The resident preferred to manage her own oxygen, but the RN confirmed the tubing should have been connected. This oversight placed the resident at risk for respiratory distress.
A facility failed to implement a physician-ordered gradual dose reduction for a resident's antidepressant medication. Despite a recommendation from the Consultant Pharmacist and the physician's directive to reduce the Citalopram dosage from 10mg to 5mg daily, the order was not executed. The Director of Nursing confirmed the oversight, highlighting a lapse in the facility's medication management and monitoring procedures.
A facility failed to ensure proper medication management, leading to potential medication errors. A resident's Carvedilol order was incorrectly labeled, and an expired Lantus insulin pen was found during an inspection. These issues highlight lapses in medication storage, labeling, and administration practices.
A resident, admitted for short-term rehabilitation, eloped from the facility due to an unsecured sliding door in the staff lounge leading to the courtyard. The resident, assessed as not at risk for elopement, was found across the street. Staff interviews revealed that the sliding door was typically left open during the day, with only a screen door closed, which lacked a latch. The facility's policy on elopement was not followed, as the courtyard was not a safe area for unsupervised residents.
A resident with multiple medical conditions, including blindness, was allowed to self-transfer to a floor mattress without proper evaluation of environmental hazards. The facility did not monitor the safety or effectiveness of this intervention, resulting in the resident sustaining multiple injuries. The resident was found tangled in cords and unable to use the call light, highlighting a lack of adequate supervision and safety measures.
A resident, dependent on staff for toileting, was found naked and tangled in cords on the floor, calling for help. The resident was left without a clean brief, exposed to their roommate, and in an unsafe environment. Staff failed to follow the care plan for frequent checks, and the call light was non-functional, leaving the resident at risk of infection and undignified conditions.
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 Ensure Safe Discharge Planning and Assessment of Caregiver Support
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who experienced a significant decline in functional status during their stay. Prior to admission, the resident was moderately independent with some assistance from a significant other, but at discharge, required maximum assistance for most activities of daily living, including transfers, toileting, bathing, and mobility. Despite recommendations from therapy staff for 24-hour care and maximum assistance, there was no evidence that the discharge plan adequately addressed the resident's need for continuous supervision or that the availability, capacity, and capability of the home caregiver were assessed. Interviews and record reviews revealed that the resident's significant other, who was identified as the primary caregiver, was herself disabled and unable to provide the necessary level of care. Attempts to involve the caregiver in training were unsuccessful, and there was no documentation that alternative discharge options were discussed or considered to ensure the resident's safety. The discharge planning notes lacked evidence of a comprehensive assessment of the home environment or the support system available to the resident. A referral was made to a home health agency for therapy and aide services, but the agency declined to admit the resident due to an unsafe home environment. Additionally, the facility's policy required a follow-up phone call after discharge to assess the resident's status and adjustment, but there was no evidence that this follow-up occurred. The lack of a thorough discharge plan and failure to ensure appropriate post-discharge support placed the resident at high risk for readmission and harm.
Failure to Maintain Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a sanitary and clean environment in two of the four shower rooms observed, which could potentially affect all residents. During a walkthrough of the 2nd floor [NAME] Wing shower room, a black substance was noted on the caulking of the shower stall. Similarly, the Ewa Wing shower room had a black substance on the caulking. A Certified Nurses Aid (CNA) identified the substance as mold but was unsure of the housekeeping procedures for cleaning it. Housekeepers acknowledged the presence of the black substance but were unaware of its nature and had attempted to remove it by scrubbing. The Maintenance Director (MD) later removed the black substance after it was brought to the attention of the housekeeping staff. Initially, the MD claimed the substance was black caulking applied by a previous maintenance worker, but upon further questioning, he stated it was dirt. The MD confirmed using tools to scrape the caulking and applied grout, acknowledging that the issue should have been addressed sooner.
Failure to Document Transfer/Discharge Notification
Penalty
Summary
The facility failed to provide documentation that written notice of transfer or discharge was given to a resident and their representative, and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This deficiency was identified for one of five resident samples. Specifically, a resident was sent to the Emergency Department and admitted to the hospital. During a record review, it was found that while discharge/transfer forms were completed, there was no documentation indicating that these forms were sent to the resident's representative or the Long-Term Care Ombudsman. The Social Services Director confirmed that there was no documentation of the written discharge/transfer notification being sent and was unable to provide a fax confirmation notice.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for eight residents, leading to potential risks in their quality of life and well-being. For one resident, the facility did not include an active diagnosis of muscle contracture in the Minimum Data Set (MDS) Quarterly Assessment and failed to address the resident's limited range of motion needs. Another resident returned from hospitalization with pressure ulcers on both heels, but the facility did not update the MDS Quarterly Assessment or create a care plan for treatment and monitoring of these ulcers. Additionally, the facility did not develop communication and language barrier care plans for residents whose primary language was not English, despite identifying this need upon admission. The facility also neglected to create care plans for residents at risk of dehydration and those with ongoing skin conditions. One resident with a left-hand contracture did not have a care plan to address their limited range of motion needs. Another resident with hemiplegia and hemiparesis following a stroke had no documentation of range of motion exercises being performed, despite the care plan indicating the need for monitoring and therapy. The Director of Nursing confirmed the lack of documentation and stated that there was no system in place for Certified Nurse Aides to document passive range of motion services, nor was there evidence of physician orders or care planning for the use of hand rolls.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive person-centered care plans were reviewed and revised by the interdisciplinary team for four residents. For one resident, there was a significant change in their ability to feed themselves, requiring assistance with meals, which was not updated in their care plan. The Unit Manager confirmed that the care plan should have been updated to reflect this change. Another resident's care plan did not include the physical therapy recommendations for passive range of motion exercises, despite the resident's refusal to participate in physical therapy sessions. The Director of Nursing confirmed that the care plan should have included the physical therapy department's recommendations for passive range of motion exercises. Additionally, a resident's care plan did not reflect their preference for continuous oxygen use for comfort, nor did it document their ability to independently manage their oxygen mask. The facility's policy required that oxygen therapy interventions be included in the care plan. Furthermore, a resident with a stage 4 pressure ulcer did not have their care plan updated to include person-centered interventions for turning and positioning, despite their inability to reposition themselves effectively. The facility's policy required that interventions for pressure injury prevention and management be documented in the care plan.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. A pill cutter used for multiple residents was found with white and brown sediments, indicating it was not cleaned between uses. This was confirmed by a registered nurse who acknowledged the need for cleaning the cutter after each use. Additionally, a certified nurse assistant did not perform hand hygiene after removing dirty gloves before assisting a resident with her meal, which was against the expected practice as confirmed by the Director of Nursing. Further deficiencies were observed during wound care and other resident interactions. A registered nurse placed clean medical supplies on a dirty bedside table and failed to perform hand hygiene between glove changes while attending to a resident's pressure ulcer. The nurse admitted to not having recent training on hand hygiene, although the Director of Nursing confirmed that training is provided during orientation and annually. Another incident involved a nurse not wearing appropriate personal protective equipment while providing care to a resident under Enhanced Barrier Precautions, and failing to sanitize hands between glove changes. Additional issues included improper disposal of a lancet, which was left on a resident's bed instead of being discarded in a sharps container, posing a risk of blood-borne pathogen transmission. A urinary catheter bag was also observed on the floor, contrary to the facility's policy that requires it to be off the floor to prevent contamination. These practices collectively put residents, staff, and visitors at risk of infection and highlight significant lapses in the facility's infection control measures.
Failure to Support Resident's Bathing Preferences and Address Skin Condition
Penalty
Summary
The facility failed to identify and support the bathing schedule preference of a resident, leading to unmet needs and hindering the resident's well-being. The resident, a cognitively intact male with multiple health conditions including heart failure, high blood pressure, diabetes, and end-stage renal disease, was admitted for long-term care. Despite having an ongoing pruritic skin condition, the facility did not adequately address the resident's itching. Observations revealed the resident scratching his arm, with visible scratches and dried blood, and he reported that showering alleviated his itching. However, the resident was only allowed to shower twice a week, contrary to his preference for daily showers. Interviews with staff revealed a lack of documentation regarding the resident's shower preferences and skin issues in his care plan. The Unit Manager confirmed that the resident was on a twice-weekly shower schedule, and there was no documentation of an assessment of his shower frequency preference. A Certified Nurse Aide familiar with the resident's care stated that she would shower him daily when she worked in his area, acknowledging his preference for more frequent showers. This deficiency in supporting the resident's self-determination and addressing his skin condition was identified through observation, interview, and record review.
Failure to Provide Written Bed-Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to a resident's representative within 24 hours following an emergency transfer to the hospital. Resident 69 was sent to the Emergency Department and admitted to the hospital. A review of the records revealed that while oral notification was given, the section for written notification on the bed-hold agreement was not completed. The Social Services Director confirmed that the bed-hold agreement was mailed to the resident's representative, but there was no documentation in the progress notes to confirm this action. This oversight does not ensure the resident's right to have a place to return and does not provide continuity of care.
Errors in MDS Quarterly Assessments for Two Residents
Penalty
Summary
Errors were identified in the Minimum Data Set (MDS) Quarterly Assessments for two residents in the facility. For one resident, an error was found in Section I, Active Diagnoses, where the resident had a documented contracture of the left upper arm that was not included in the MDS assessment. The resident was observed with a contracture in his left hand, and the Director of Nursing confirmed that this diagnosis should have been included in the MDS assessment. For another resident, an error was found in Section M, Skin Conditions. This resident was admitted to the hospital with pressure ulcers on both heels and was discharged with the same condition. However, upon returning to the facility, the skin assessments did not document these pressure ulcers, and they were not included in the MDS Quarterly Review. The Minimum Data Set Coordinator confirmed that the pressure ulcers should have been documented in the resident's MDS assessment.
Failure to Provide Communication Support for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate communication support for residents with limited English proficiency, leading to a deficiency in care. Three residents, identified as needing language assistance, were not provided with necessary communication tools or interpreter services. Resident 37, who speaks Chuukese, was observed without any communication aids at his bedside, and his care plan did not address his language needs. Despite his brother occasionally translating for him, the facility did not implement any formal communication strategies. Similarly, Resident 24, a Korean speaker, was not provided with communication tools or aids, and her care plan lacked any interventions for her language barrier. The MDS Coordinator acknowledged that such needs should be addressed in the care plan, but no actions were taken to include interpreter services or other communication aids for her. Resident 55, who speaks Cantonese, was also not provided with interpreter services despite being identified as needing them. The staff did not use interpreter services during interactions, and his care plan did not include any language assistance interventions. The Director of Nursing confirmed that the resident should have had a care plan for an interpreter, but this was not implemented, resulting in a deficiency in meeting the residents' communication needs.
Failure to Address Visual Impairment in Activities Program
Penalty
Summary
The facility failed to provide an ongoing resident-centered activities program that addressed the needs of a visually impaired resident. The resident, a male admitted for long-term care, was identified as having a visual deficit, specifically being able to see large print but not regular print. Despite this, the facility did not implement activities that the resident could perform, such as providing reading glasses, which he did not bring with him from home. The resident expressed enjoyment in word search puzzles but was unable to participate due to the lack of appropriate visual aids. The resident's Comprehensive Care Plan acknowledged his visual impairment but did not include specific interventions to address it, beyond monitoring for changes in vision. The Activities Care Plan also failed to identify the visual deficit and only included a generalized intervention for all residents. The Activities Director, who was no longer in the position, acknowledged the oversight and confirmed that the care plans typically contained only one generalized intervention. This lack of individualized planning placed the resident at risk of a decline in psychosocial well-being.
Deficiencies in Hydration and Skin Care Management
Penalty
Summary
The facility failed to implement an effective hydration program for a resident with chronic congestive heart failure and other conditions, who was not on any fluid restrictions. Despite being on diuretics and an antidiabetic medication that could lead to volume depletion, the resident was not provided with adequate fluids, as evidenced by the absence of water pitchers or cups at his bedside during multiple observations. The resident's care plans identified an increased risk for dehydration but lacked specific interventions to ensure adequate fluid intake. The resident's fluid intake was consistently below the facility's standard, and there was no monitoring or logging of his fluid intake, nor was he placed on the Hydration List for residents with low fluid intake. Another resident with a pruritic skin condition was not adequately addressed in his care plan. Despite having a history of heart failure, high blood pressure, diabetes, and end-stage renal disease, the resident frequently experienced itching, particularly on his arms and back, which led to multiple tiny scratches and bleeding lesions. The resident reported that showers provided relief, but he was only allowed to shower twice a week. Although a lotion was prescribed for the itching, there was no documentation of its effectiveness, and the care plan did not include interventions for the pruritic condition. Interviews with facility staff, including the Director of Nursing and Unit Manager, confirmed the lack of appropriate interventions and monitoring for both residents. The facility's policy on hydration maintenance was not followed, and the care plans did not reflect the necessary interventions for the residents' conditions. The deficiencies in hydration and skin care have the potential to affect all residents at the facility.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment consistent with professional standards of practice to promote healing of a stage 4 pressure injury for a resident. The resident, who was cognitively intact and required substantial assistance for mobility, was not turned and repositioned every two hours as needed. Despite having a pressure injury on her coccyx, the resident reported that she had to ask staff for assistance with repositioning, and if she did not ask, they did not help. Observations confirmed that the resident attempted to reposition herself using her arm strength, but no pillows or wedges were used to assist her. The resident expressed discomfort with the hard foam wedge provided and requested pillows instead, but staff did not follow through with this request. The facility's guidelines required routine repositioning every two hours, but this was not documented in the resident's electronic health record. The Unit Manager and Infection Preventionist confirmed that refusals and repositioning were not documented, and staff should have educated the resident on the risks and benefits of treatment, as well as documented any refusals.
Failure to Provide Appropriate ROM Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for three residents with limited range of motion (ROM), leading to a risk of decline in their condition. Resident 27, who had a left-hand contracture following a stroke, did not have his hand splint applied or monitored. The splint was found buried under his belongings, and there were no physician orders or care plan interventions addressing its use. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that the splint should have been documented in the care plan or physician orders. Resident 20, diagnosed with quadriplegia and left-hand contracture, did not receive the necessary interventions to prevent worsening of his condition. The care plan lacked interventions for his contractures, and there were no physician orders for treatment. The Unit Manager stated that the resident sometimes refused care, and the DON confirmed the absence of a Restorative Nursing Assistant program due to staffing shortages, which impacted the provision of passive range of motion (PROM) exercises. Resident 56, with hemiplegia and contractures, was observed with hand rolls that were not assessed or recommended by therapy. The care plan mentioned monitoring for pain during ROM, but there was no documentation of ROM exercises being performed. The Physical Therapy Assistant and Occupational Therapy Assistant confirmed that no referrals were made for therapy assessment after the resident's discharge from physical therapy. The DON acknowledged the lack of documentation and confirmed that hand rolls should not have been used without proper assessment and physician orders.
Failure to Ensure Proper Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident's oxygen (O2) tubing was properly connected to the O2 concentrator, as required by professional standards of practice. This deficiency was observed in the case of a resident who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hyperlipidemia, hypertension, and hypoxemia. The resident had physician orders for continuous O2 at two liters per minute via face mask, with the option to titrate the flow to maintain oxygen saturation levels above 90%. However, during an observation, the resident's O2 face mask was found not covering her mouth or nose, and the tubing was disconnected from the concentrator, with the end of the tubing touching the floor, while the concentrator was running. During an interview with a registered nurse (RN), it was revealed that the resident preferred to manage her own O2 face mask and wanted the concentrator on continuously, although it was not deemed necessary by the RN. The RN confirmed that the tubing should have been connected to the concentrator. The facility's policy on oxygen administration, which was reviewed and revised in June 2023, states that oxygen is to be administered under physician orders and staff should monitor for complications and take precautions to prevent them. This oversight placed the resident at risk for respiratory distress due to not receiving the prescribed continuous oxygen therapy.
Failure to Implement Physician-Ordered Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to manage and monitor the medication regimen for a resident by not implementing a physician-ordered gradual dose reduction (GDR) for an antidepressant. The Consultant Pharmacist recommended a review of the resident's Citalopram 10mg for an annual GDR or clinical contraindication. The resident's physician marked the option to attempt a dose reduction to 5mg daily and signed the Medication Regimen Review (MRR) form. However, upon reviewing the resident's September and October physician orders, no change in the Citalopram dosage was noted, and the resident continued to receive the original 10mg dosage. An interview with the Director of Nursing (DON) confirmed that the physician's notation on the MRR indicated a reduction to 5mg daily, and the date on the form was verified as 09/27/24. The DON stated that the facility receives MRRs monthly, and they are reviewed by the DON, Unit Manager, and clinical team. Despite this process, the order for the dose reduction was not carried out, indicating a lapse in the facility's medication management and monitoring procedures.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were stored, labeled, and administered according to professional standards, which could lead to medication errors affecting all residents. During a medication pass observation, it was found that a resident's Carvedilol 25mg order on the Medication Administration Record (MAR) was listed to be given twice a day, while the label on the medication blister pack indicated it should be given every 12 hours. The discrepancy was confirmed by a Registered Nurse (RN), who admitted that the blister pack with the incorrect label was being used instead of being discarded. This issue arose after the resident returned from a hospital stay, and the RN transcribed the order incorrectly. Additionally, during an inspection of the Right-Wing medication cart with the Director of Nursing (DON), an expired Lantus insulin pen was found for another resident. The insulin pen had been labeled with an open date and a discard date, which had already passed. The DON confirmed that the insulin pen was expired and should have been wasted. These findings indicate a failure in the facility's medication management practices, specifically in ensuring proper labeling and timely disposal of medications.
Resident Elopement Due to Unsecured Facility Door
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, resulting in an elopement incident. A resident, admitted for short-term rehabilitation after knee surgery and assessed as not at risk for elopement, was able to exit the facility without authorization. The resident was last seen in her bed and later found across the street. An investigation revealed that the resident's belongings were found in the courtyard area, suggesting she exited through the staff lounge, where a sliding door leading to the courtyard was left unlocked. Interviews with staff indicated that the sliding door in the staff lounge was typically left open during the day, with only a screen door closed, which did not have a latch to secure it. The facility's policy on elopement and wandering residents was not adhered to, as the courtyard was not considered a safe area for unsupervised residents. The Administrator and DON acknowledged that the courtyard was not safe for residents without supervision, especially when the floor was wet, and that the resident likely exited through the unsecured staff lounge door.
Failure to Ensure Safe Environment for Resident
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R8, who was allowed to self-transfer from a bed to a floor mattress. The facility did not evaluate or address potential environmental hazards associated with this intervention. As a result, R8 sustained multiple skin tears, bruising, and wounds on both lower legs. The facility did not monitor the effectiveness or safety of the floor mattress intervention, which contributed to the resident's injuries. R8 was admitted with multiple diagnoses, including dementia with behavioral disturbances, spinal stenosis, and blindness due to a ruptured eye. Despite having intact cognition, R8 was dependent on staff for toileting and transfers, requiring two or more staff and a Hoyer lift. The care plan allowed R8 to self-transfer to a floor mattress, with bedrails to assist in mobility, as per the resident's power of attorney's request. However, the facility did not assess the room or floor space for potential hazards, nor did it monitor R8's safety while on the floor mattress. During an observation, R8 was found naked on the floor, tangled in cords, and unable to use the call light due to blindness. The resident reported that the call light was intentionally placed out of reach. The facility's director of nursing confirmed that no assessments were conducted to ensure the safety of the floor mattress intervention, and there was no follow-up after R8 sustained injuries. The facility's failure to identify, evaluate, and monitor environmental hazards and the effectiveness of interventions led to the resident's avoidable accidents.
Resident Left in Undignified and Unsafe Conditions
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence, resulting in a deficiency. The resident, who is dependent on staff for toileting and transfers due to impairments in upper and lower extremities, was found naked and tangled in cords on the floor, calling out for help. The resident's cognitive status was intact, and they had a history of myocardial infarction, dementia with behavioral disturbances, and other medical conditions. The care plan included interventions for disrobing behavior and frequent checks when the resident was on the floor mattress, but these were not adequately followed. During the night shift, staff left the resident without a clean brief after removing a soiled one, leaving the resident exposed and in an unsafe environment. A registered nurse confirmed that the resident's environment was hazardous, with the resident tangled in cords and sustaining wounds from being on the floor. The privacy curtain was left open, exposing the resident to their roommate, and the call light was not functional for the resident, who is blind. Interviews with staff revealed that the resident was left without clothing or a brief for at least 30 minutes, and there was no documentation of frequent checks or assistance with toileting during the night shift. The director of nursing confirmed the lack of documentation and acknowledged the undignified situation observed by the surveyor. The resident was at risk of infection due to direct contact with the floor, and the facility's failure to provide a safe and dignified environment was evident.
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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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