Oahu Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1808 South Beretania Street, Honolulu, Hawaii 96826
- CMS Provider Number
- 125042
- Inspections on file
- 19
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Oahu Care Facility during CMS and state inspections, most recent first.
A resident with dementia and a history of exit-seeking behavior eloped from the facility after her Wanderguard bracelet failed to trigger the elevator alarm. Staff had last seen her in the dining room, but she left undetected and was later found by a member of the public with injuries from a fall. The device malfunction was confirmed after the incident, and the resident required hospital treatment for abrasions and skin tears.
Three residents with pressure ulcers did not receive consistent repositioning every two hours as required by their care plans and facility policy. Documentation of repositioning was missing or incomplete for multiple days, despite staff awareness of the requirement. The DON confirmed that repositioning tasks were not always triggered upon admission, and review of the facility's policy showed that documentation standards were not met.
The facility did not complete Baseline Care Plans within the required timeframe for three residents, failed to include a Stage 2 pressure ulcer in one care plan, and did not provide written summaries of the plans to two residents or their representatives, as confirmed by staff interviews and record reviews.
A resident with a history of falls and cognitive impairment was admitted following a subdural hematoma. Despite clear risk factors and multiple documented falls after admission, the care plan did not address fall risk until several days after the first in-facility fall. The omission of timely fall risk interventions in the care plan was confirmed by the DON and was not in accordance with facility policy.
The facility failed to maintain proper food safety and sanitation practices. Expired test strips were used to test sanitizer strength in the kitchen, a rack holding clean meal lids had rust-colored debris, and opened beverages in the nourishment refrigerator were not labeled with opened-on dates.
The facility failed to implement proper infection control measures for residents on isolation, as staff did not consistently wear required PPE when entering rooms of COVID-19 positive residents. Observations showed a Physical Therapist Assistant entering a room without a gown, face shield, or eye protection. Additionally, PPE and waste disposal practices were inadequate, with PPE containers and biohazard trash cans placed outside rooms due to space constraints, contrary to facility policy.
A facility failed to inform a resident of the risks and benefits of psychotropic drugs and did not obtain consent for their use. The resident, with anxiety disorder, dementia, and major depressive disorder, was prescribed mirtazapine and duloxetine. The DON could not locate the necessary consents, even after checking paper files, as the resident was on these medications before the facility's transition to EHR.
A resident capable of independent movement was improperly restrained by positioning wedges placed under the mattress and fitted sheet, restricting movement. Staff confirmed the wedges were not used for medical treatment but functioned as restraints. Despite the resident's high fall risk, no bed alarm was implemented, and care plans did not document the use of wedges.
The facility failed to provide written notification of the bed hold policy to two residents transferred to a hospital. One resident was transferred for acute lower GI bleeding, and the other for fractures after a fall. In both cases, the Social Worker Designee confirmed that the bed hold policy was not communicated in writing, contrary to facility policy.
A facility failed to use interpreter services for a Korean-speaking resident, leading to an inaccurate cognitive assessment and an elopement incident. Despite the care plan's directive to use alternative communication tools, staff attempted to communicate in English, resulting in ineffective interactions and an incomplete BIMS test. The resident, unable to understand English, demonstrated cognitive awareness by eloping from the facility, highlighting the need for proper communication support.
The facility failed to develop discharge plans for two residents admitted for short-term rehabilitation, as required by their policy. One resident, admitted for knee care, and another for a chronic leg wound, both lacked documented discharge plans with measurable objectives and timeframes in their EHRs. This deficiency was confirmed during a review with the DON.
A resident with limited English proficiency was not provided with necessary interpreter services, despite the facility having Korean-speaking staff and an administrator who speaks Korean. The care plan indicated the need for an interpreter, but services were not utilized since admission, leading to potential risk for the resident.
A resident with cognitive impairments eloped from a facility after accessing unattended scissors and cutting off her Wander guard. The facility failed to maintain a hazard-free environment and provide adequate supervision, as scissors were found in a resident-accessible area. The resident's cognitive abilities were underestimated, and her care plan was not updated following the elopement.
The facility failed to maintain accurate records for controlled medications, as a dose of morphine sulfate was administered without the administering nurse's signature on the log. This discrepancy was confirmed by an RN during an inspection, highlighting a breach in the facility's policy requiring immediate documentation of administered controlled substances.
The facility failed to properly store a resident's prescribed ointment and did not label ophthalmic drops with expiration dates for two residents. A CNA was found retrieving ointments from a resident's bedside table, which should have been locked in the treatment cart. Additionally, an inspection revealed that ophthalmic drops were not labeled with the date opened or expiration date, contrary to facility policy.
Failure to Prevent Elopement Due to Faulty Wanderguard Device and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, unsteady gait, and prior exit-seeking behavior eloped from the facility. The resident had been admitted following a hospital stay for an unwitnessed fall and was assessed as high risk for elopement. A Wanderguard bracelet was placed as a safety measure, and the resident was under supervision, with staff aware of her location in the dining room prior to the incident. However, the resident was able to leave the dining room undetected and exited the facility without staff noticing. The Wanderguard bracelet, which was intended to prevent such incidents, was found to be faulty after the event. Although staff had checked the device earlier in the day and found it to be working, it failed to trigger the elevator alarm when the resident exited. The malfunction was confirmed by both facility staff and an external technician after the incident. The resident was found several blocks away by a member of the public and was taken to the emergency department, where she was treated for multiple abrasions and skin tears resulting from a fall that occurred while she was outside the facility. The facility's policy required regular assessment and monitoring of the Wanderguard device, as well as supervision of residents at risk for elopement. Despite these measures, the failure of the Wanderguard system and lack of direct supervision at the time allowed the resident to leave the premises and sustain injuries.
Failure to Provide and Document Repositioning for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care by not ensuring that residents with existing pressure ulcers were repositioned as required by their care plans and facility policy. Three residents with pressure ulcers were not consistently turned or repositioned every two hours, and there was a lack of documentation to support that this standard of care was provided. For example, one resident was admitted with a sacral Stage 2 pressure ulcer that was not identified on her baseline care plan, and there was no documentation of repositioning until several days after admission. Another resident with an unstageable coccyx wound requiring substantial assistance had no documentation of repositioning every two hours as directed in the care plan. A third resident with multiple pressure ulcers also lacked documentation of regular repositioning, with records showing that documentation only began several days after admission. Interviews with CNAs confirmed that while they were aware of the need to reposition residents every two hours and document this in the electronic record, there were gaps in documentation, and some days had no entries for repositioning. The Director of Nursing acknowledged the importance of regular repositioning and confirmed that tasks for repositioning were not triggered for some residents upon admission. Review of the facility's repositioning policy further indicated that the required documentation and care practices were not followed, as staff failed to record the position, caregiver, and other required details in the residents' medical records.
Failure to Timely Develop and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to meet regulatory requirements for Baseline Care Plans (BCP) for three residents. For one resident, the BCP was not developed within 48 hours of admission, and for another, the BCP was left blank and not completed until after the required timeframe. Additionally, there was no documentation that two residents were provided with summaries of their BCPs, as required by facility policy. Interviews with the Director of Nursing (DON) and Nursing Supervisor (NS) confirmed that the BCPs were not completed on time and that the summaries were not provided to the residents or their representatives. One resident was admitted for short-term rehabilitation following hospitalization for repeated falls and was noted to have a Stage 2 sacral pressure ulcer on admission. The BCP for this resident did not identify the pressure ulcer, despite hospital discharge instructions including care for the injury. The BCP also lacked signatures from the resident or representative and no evidence was found that a copy was provided. The facility's policy requires BCPs to be developed within 48 hours of admission, to address immediate health and safety needs, and for written summaries to be provided and documented, but these steps were not followed.
Failure to Timely Address Fall Risk in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan (CCP) that addressed a resident's safety needs in a timely manner. The resident, who had a history of falls and was admitted with a subdural hematoma due to a fall at home, was noted on admission to be cognitively impaired, disoriented, and at risk for falls. Despite these risk factors, the baseline care plan did not assess functional ability and goals, and the high risk for falls was not included in the CCP upon admission. The care plan addressing fall risk was only initiated three days after the resident experienced a fall in the facility. During the resident's stay, multiple falls were documented in the nursing notes, including incidents where the resident was found on the floor, confused, and experiencing pain or minor injuries. Interviews confirmed that the high fall risk should have been included in the care plan from admission, in accordance with the facility's policy, which requires staff to identify and implement interventions for residents at risk of falls based on previous evaluations and current data. The failure to timely address the resident's fall risk in the care plan constituted the deficiency.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in their kitchen and nourishment areas. During an observation, it was found that the kitchen staff used expired Hydrion test strips to test the strength of the sanitizer solution in the three-compartment sink. The Food Service Worker confirmed the test strips were expired and replaced them with new ones, which tested the water within the acceptable range. Additionally, a rack holding clean meal lids near the stove was observed to have rust-colored debris, which was confirmed by the Dietary Manager. Furthermore, in the nourishment refrigerator on the second floor, opened beverages such as orange juice, prune juice, and cranberry juice were found without the required opened-on dates, as confirmed by the Nursing Supervisor.
Inadequate Infection Control Measures for Residents on Isolation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for residents on isolation, specifically those on transmission-based precautions (TBP). Observations revealed that staff did not consistently wear the required personal protective equipment (PPE) when entering rooms of residents who tested positive for COVID-19. For instance, a Physical Therapist Assistant was seen entering a resident's room without a gown, face shield, or eye protection, despite the room being marked for Special Droplet/Contact Precautions. The Director of Nursing confirmed that all staff were expected to wear a gown, gloves, mask, and eye protection when entering such rooms, as per the facility's policy. Additionally, the facility's handling of PPE and waste disposal was inadequate. PPE containers and biohazard trash cans were placed outside the rooms of residents who tested positive for COVID-19 due to space constraints inside the rooms. This practice was justified by the facility's administrator, citing advice from an Infection Control Consultant. However, the facility did not implement alternative solutions such as over-the-door PPE caddies and trash bag holders, which were discussed but not observed during the survey. The facility's policy required that PPE be donned upon entry and discarded in a dedicated container before leaving the resident room, which was not consistently followed.
Failure to Obtain Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform a resident of the risks and benefits associated with the use of psychotropic drugs and did not obtain the necessary consent for one of the five residents sampled for unnecessary medications. The resident in question was an elderly individual with diagnoses including anxiety disorder, dementia, and major depressive disorder, and was prescribed mirtazapine and duloxetine, both antidepressants. Upon review of the resident's Electronic Health Records (EHR), it was found that documentation of consent for these medications, including education on their risks and benefits, was missing. The Director of Nursing (DON) was asked to provide the consents for the use of these antidepressants, but he was unable to locate them, even after checking the paper files, as the resident had been on these medications before the facility transitioned to the EHR system. This deficiency placed the resident at risk for more than minimal harm due to the lack of informed consent.
Improper Use of Positioning Wedges as Restraints
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints used for staff convenience rather than medical necessity. Observations revealed that positioning wedges were placed under the mattress and fitted sheet of a resident's bed, creating a concave shape that restricted the resident's ability to move freely. The resident, who was capable of moving independently, confirmed that the wedges hindered his movement and that he could not remove them. Interviews with staff corroborated that the wedges were not used for repositioning or treating a medical condition, but rather functioned as a restraint. The resident was identified as a high fall risk, having recently fallen out of bed, yet no bed alarm was implemented as a precautionary measure. The resident's care plans for skin integrity and high fall risk did not include the use of wedges, indicating a lack of appropriate documentation and planning. The facility's policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident, which was applicable in this case. This deficiency placed residents with the ability to move independently at risk of harm.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for two residents who were transferred to an acute care hospital. The first resident, a [AGE] year-old, was admitted to the facility and later transferred to a hospital for acute lower gastrointestinal bleeding. The electronic health record (EHR) did not contain documentation that the resident's representative was provided with a written notification of the bed hold policy. The Social Worker Designee (SWD) confirmed that the policy was communicated via phone call but not in writing, which is against the facility's policy requiring a written agreement within 24 hours of discharge. The second resident was transferred to a hospital for pain related to fractures of the right hip and shoulder after an unwitnessed fall. Upon review, it was found that neither the resident nor the resident's representative was notified of the bed hold policy at the time of transfer. The SWD confirmed this oversight. This deficiency in communication has the potential to affect all residents transferred to an acute care hospital, as it could lead to miscommunication regarding the bed hold policy.
Failure to Implement Interpreter Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a Korean-speaking resident, identified as R56, by not utilizing interpreter services as documented in the resident's care plan. During an observation, staff attempted to communicate with R56 in English, despite the resident's inability to understand the language, as noted in the resident's Electronic Health Record (EHR). The care plan specified the need for alternative communication tools, such as interpreter services, which were not used during the Brief Interview for Mental Status (BIMS) assessment, resulting in an inaccurate score of 99, indicating the test could not be completed. Interviews with the MDS Coordinator and a Registered Nurse revealed that interpreter services had never been used for BIMS testing, and the resident's cognitive abilities were not accurately assessed due to the language barrier. The resident, who was minimally able to communicate with English-speaking staff, demonstrated cognitive awareness by eloping from the facility after observing staff behavior and disabling the Wander guard system. The RN confirmed that the resident's behaviors and elopement attempt could have been mitigated if interpreter services had been implemented to address the resident's needs and explain her circumstances.
Failure to Develop Discharge Plans for Short-Term Rehab Residents
Penalty
Summary
The facility failed to develop a discharge plan for two residents, leading to a deficiency in ensuring safe and appropriate discharge processes. Resident 61, a [AGE] year-old individual admitted for short-term rehabilitation for knee care, did not have a discharge plan documented in their comprehensive care plan. Despite the resident's indication of being at the facility for short-term rehabilitation, the electronic health record (EHR) lacked measurable objectives and timeframes necessary for a safe discharge, putting the resident at risk of premature discharge and potential readmission. Similarly, Resident 219, a [AGE] year-old admitted for short-term rehabilitation following hospitalization for a chronic right leg wound, also lacked a documented discharge plan in their EHR. The resident expressed a desire to return home once able to walk a short distance, yet their care plan did not include the necessary discharge goals or timeframes. During a review with the Director of Nursing (DON), it was confirmed that both residents' comprehensive care plans were missing the required discharge plans, contrary to the facility's policy expectations.
Failure to Provide Interpreter Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R122, was provided with appropriate communication services, specifically interpreter services, despite the resident's limited English proficiency. During the survey, it was discovered that the resident's primary language is Korean, and her ability to speak English is very limited. The care plan for R122, which was initiated and revised while surveyors were onsite, indicated that the resident requires an interpreter for communication. However, interviews and record reviews revealed that interpreter services were not offered or used for R122 since her admission, except when family and friends were available. Interviews with staff, including a registered nurse and admissions staff, indicated a lack of consistent use of interpreter services. The registered nurse was unsure if interpreter services were being used, while the admissions staff confirmed that no staff interpreters were used during the admission process. Although the facility has Korean-speaking staff and the administrator speaks Korean, these resources were not utilized to facilitate communication with R122. This oversight placed non-English speaking residents at potential risk for more than minimal harm due to impaired communication.
Resident Elopement Due to Inadequate Supervision and Hazardous Environment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision, resulting in a resident's elopement. During an observation, a pair of metal scissors was found unattended in a resident-accessible area, contrary to the facility's policy that scissors should be stored in the treatment cart. This oversight allowed a resident to access scissors and elope from the facility without staff knowledge, posing a risk of more than minimal harm to residents. The resident involved, a woman with a history of hypotonic hyponatremia, encephalopathy, depression, suicidal ideations, hypertension, and dementia, used scissors from her manicure kit to cut off her Wander guard, enabling her to exit the building undetected. The resident's cognitive abilities were underestimated, as she had previously tested the Wander guard system and observed staff disarming it. Despite her inability to complete the BIMS test due to language barriers, staff confirmed her awareness and cognitive functioning. The incident highlighted a lapse in supervision and environmental safety, as well as a failure to update the resident's care plan post-elopement.
Controlled Medication Recordkeeping Deficiency
Penalty
Summary
The facility failed to ensure that records for controlled medications were maintained and accurate, which could potentially lead to the diversion of controlled substances. During an inspection of the medication cart on the second floor, a discrepancy was found in the controlled medication logs. Specifically, a dose of morphine sulfate, an opioid pain-relieving medication, was administered to a resident, but the log lacked the signature of the staff member who administered it. This incident occurred on 08/16/24 at 11:01 PM. Registered Nurse (RN)9 confirmed that the staff member should have signed the log immediately after administering the medication, as per the facility's policy on controlled substances. The policy clearly states that the licensed nurse administering the medication must immediately enter their signature on the accountability record.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store physician-prescribed topical ointment for a resident and did not ensure that medicated ophthalmic drops were properly labeled with an expiration date for two residents. In the first instance, a resident with bowel and bladder incontinence had prescribed ointments stored improperly in her bedside table. A CNA was observed retrieving medicine cups containing creams and ointments from the resident's bedside table, which were not supposed to be left there. A registered nurse admitted to placing the ointment in a medicine cup for another nurse who did not have access to the locked treatment cart, assuming the ointment would be applied to the resident. In the second instance, an inspection of the medication cart revealed that three bottles of ophthalmic drops for two residents were not labeled with the date they were opened or an expiration/discard by date. This made it impossible to confirm when the medicated ophthalmic drops were opened. The facility's policy requires that multi-dose vials be labeled to ensure product integrity, and nursing staff should document the date opened on multi-dose vials. The registered nurse confirmed that the bottles should have been labeled according to the facility's policy.
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.
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.
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 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 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 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 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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