The Ching Villas
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 2230 Liliha Street, Honolulu, Hawaii 96817
- CMS Provider Number
- 125064
- Inspections on file
- 24
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at The Ching Villas during CMS and state inspections, most recent first.
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.
The facility did not notify the physician when two residents experienced a change in condition that required oxygen administration. In both cases, nursing staff provided oxygen for shortness of breath and documented the intervention, but failed to inform the provider as required by facility policy and physician orders. The DON confirmed that these incidents met the criteria for a significant change in condition and that provider notification should have occurred.
Three residents experienced deficiencies in medical record documentation, including misfiled nursing notes, inconsistent and incomplete records of oxygen administration, and an inaccurate discharge notice that did not reflect a resident's true condition. Facility leadership confirmed missing assessments and documentation errors, and the facility's own policy for thorough and accurate records was not followed.
A resident admitted for post-stroke rehabilitation had a PIV catheter in place for several days without a physician's order, and staff used a hospital weight as the admission baseline instead of obtaining a new weight on the facility scale. Significant discrepancies in weights were not verified or reported, and required neurological assessments were not documented after the resident was found unresponsive. These failures resulted in a lack of appropriate treatment and care according to orders and resident needs.
A resident was administered Lisinopril despite a documented systolic blood pressure below the ordered threshold, in violation of the physician's order. The facility did not identify or report this medication error to the DON or Administrator as required by policy.
A resident's belongings were collected and bagged by CNAs after hospital transfer, and a family member later discovered a visibly soiled bed pad/brief with urine and feces among the items. Staff interviews and video review confirmed the soiled item was included in the belongings given to the family.
The facility failed to honor the preferences of three residents regarding therapy schedules and outdoor activities, compromising their right to self-determination. A resident preferred morning therapy sessions due to energy levels but was not scheduled accordingly, while another resident was frustrated by the lack of advance notice for therapy times. Additionally, a resident expressed a desire to go outside for fresh air, but the facility did not assist him, leaving him confined to his room. These issues indicate a systemic problem in accommodating resident choices.
The facility failed to maintain the ice and water equipment in a sanitary condition, as observed with a buildup of brown sediment on the dispenser used daily for resident hydration. The Registered Dietician acknowledged the need for regular cleaning, but no maintenance log was kept to verify the cleaning schedule. The Maintenance Associate and Facilities Coordinator agreed that the brown sediment was unusual and should be avoided.
A resident reported feeling disrespected and bullied by a traveling nurse who repeatedly woke her for non-urgent matters and ignored her instructions on wound care. The grievance noted issues with the nurse's bedside manner, but staff education did not address these concerns.
A facility failed to ensure privacy for a resident who was left exposed by a CNA and did not protect the confidentiality of another resident's electronic health record, which was left open and unattended on a laptop. Staff interviews confirmed the expectation to protect residents' privacy and confidentiality.
A resident was transferred to the hospital due to a change in condition, but the facility failed to provide a completed Interact Nursing Home to Hospital Transfer Form. Despite the emergency nature of the situation, the form was not filled out or sent, as confirmed by the Resident Care Manager. The responsible RN did not complete the form, although other documents were sent and a report was given to the hospital ER nurse. Training on the form was part of new hire orientation, but the RN's participation in ongoing training was not verified.
The facility failed to implement comprehensive care plans for two residents, potentially diminishing their quality of life. One resident, admitted for subacute rehab, had no documentation of bleeding at an access site or physician notification. Another resident, admitted post-stroke, had no interventions documented for pain management despite having a care plan addressing acute pain.
A resident admitted for wound care and therapy was not involved in the development of his care plan, despite having no cognitive impairment. The resident was unaware of his care plan and duration of stay, and no documentation of an interdisciplinary team meeting was found. The Social Service Manager admitted the possibility that the meeting did not occur as planned.
The facility failed to provide resident-centered care, resulting in frequent hospitalizations for a resident with complex needs, inadequate scheduling of physical therapy for another resident, and improper insulin management for a third resident. These deficiencies highlight issues in addressing residents' medical and personal preferences, leading to potential risks and avoidable declines.
A facility failed to change an enteral feeding bag within the required 24-hour period for a resident with a history of digestive surgery, risking preventable complications. An LPN initiated tube feeding using a bag labeled with a date indicating it was past the discard time, contrary to facility policy. Upon noticing the error, the LPN stopped the pump and sought a new setup.
A resident with RSV and complex medical conditions was observed with a nasal cannula incorrectly placed and the oxygen meter off, despite a physician's order for oxygen administration. The DON confirmed the incorrect placement, and a nurse's note indicated a room air challenge was unsuccessful, necessitating the re-initiation of oxygen.
A resident with severe cognitive impairment and a history of stroke and diabetes experienced inadequate pain management, affecting her participation in physical therapy and family visits. Despite having a care plan that included Gabapentin, Lidocaine patches, and Tramadol, the resident's pain was not effectively managed, as evidenced by inconsistent medication administration and high pain levels.
A facility failed to provide dialysis care consistent with professional standards for a resident, leading to a deficiency. The resident experienced bleeding from her hemodialysis access site after a session, requiring an ace wrap. However, there was no documentation in the EHR or dialysis communication form about the bleeding or dressing application. The facility's policy requires monitoring and notifying the provider if bleeding persists, but there was no record of such actions being taken.
The facility failed to dispose of expired medications and ensure accurate reconciliation of controlled medications. A nurse administered an expired inhaler medication to a resident, and another medication cart's narcotic count sheet was unsigned for two shifts, indicating a lack of proper documentation and adherence to facility policy.
The facility failed to store and label medications properly, with expired medications found in storage and unsecured medication carts observed. An open vial of Tubersol was also found without proper labeling. Staff acknowledged these oversights.
The facility failed to ensure proper infection control measures, as a CNA did not wear PPE or perform hand hygiene when delivering a lunch tray to a resident on contact precautions, and an RN did not perform hand hygiene between glove changes during a dressing change for a resident with a stage 4 pressure ulcer. The facility's policies require PPE use and hand hygiene, which were not followed in these instances.
A resident with a history of Parkinson's disease, diabetes, and orthostatic hypotension did not receive consistent monitoring of orthostatic blood pressures and pulse as ordered by the physician. Despite the requirement for daily checks, the facility documented these vital signs only 11 times over 34 days, with several instances lacking explanations for missed recordings. The DON confirmed that licensed staff were responsible for these checks, and the physician noted the inconsistency in monitoring, which was crucial for managing the resident's condition.
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.
Failure to Notify Physician of Change in Condition Requiring Oxygen Administration
Penalty
Summary
The facility failed to notify the physician of a change in condition for two residents who required administration of oxygen. In the first case, a male resident with a history of stroke, dysphagia, and mild cognitive impairment experienced shortness of breath with oxygen saturation dropping to 87-89%. Nursing staff administered oxygen as ordered, but there was no documentation that the provider was notified of this change in condition, nor was there documentation of how long the resident required oxygen. The Director of Nursing confirmed that this met the criteria for a condition change and that the provider should have been notified. In the second case, another resident complained of shortness of breath and was administered oxygen, resulting in improved oxygen saturation. The event was recorded in the facility's communication book, but not in the resident's electronic medical record, and there was no documentation of notification to the on-call physician, despite a physician's order requiring notification if oxygen was applied or increased. The facility's policy requires notification of the attending physician for significant changes in a resident's condition or when medical treatment is altered. These failures were confirmed through interviews and record reviews.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation of oxygen administration, misfiled nursing notes, and inaccurate discharge information. For one resident, the electronic medical record contained a nursing progress note that was intended for a different resident, and this error was not identified prior to the survey. Additionally, the documentation of oxygen administration for two residents was inconsistent and incomplete across multiple record-keeping systems, including nursing notes, vitals reports, and respiratory administration records. There were missing assessments, discrepancies in the timing and documentation of oxygen use, and a lack of clarity regarding when oxygen was administered or discontinued. Interviews with facility leadership confirmed that the records did not provide sufficient information to determine the accurate use of PRN oxygen and that required assessments were missing. For another resident, a complaint of shortness of breath and subsequent oxygen administration was documented in a unit communication book but was not entered into the resident's official nursing progress notes. The nursing notes for that day did not reflect the resident's complaint or the intervention provided, and the DON confirmed that this documentation should have been included in the progress notes. This omission resulted in an incomplete medical record for the resident. A third resident received a Notice of Discharge that inaccurately stated her health had improved sufficiently to no longer require facility services, despite therapy and assessment records indicating a decline in her condition and ongoing need for skilled nursing care. Interviews with the social worker and administrator revealed that the discharge notice did not accurately reflect the resident's true condition, and the administrator acknowledged marking the form incorrectly. The facility's own documentation policy requires that records be timely, accurate, objective, thorough, and complete, but these standards were not met in the cases reviewed.
Failure to Provide Appropriate Care and Documentation for Post-Stroke Resident
Penalty
Summary
Nursing staff failed to provide the standard of quality care to a male resident admitted for rehabilitation following a stroke. The resident, who had dysphagia, expressive aphasia, mild cognitive impairment, and was dependent on staff for all activities of daily living, had a peripheral intravenous (PIV) catheter in place for three days without a physician's order. Documentation showed that the PIV was eventually pulled out by the resident, resulting in bleeding, but there was no evidence of an order for the PIV at any time during his stay. Additionally, staff used the resident's hospital weight as his baseline admission weight instead of obtaining a weight on the facility's scale, as required by facility policy. Subsequent weights showed significant discrepancies, with no repeat weights performed to confirm accuracy and no documentation that nursing staff or the provider were notified of the large weight loss. Furthermore, licensed staff did not document a neurological assessment or monitoring as required after the resident was found unresponsive to verbal stimuli and unable to be awakened. There was no evidence of reassessment or documentation of the resident's neurological status during the shift, despite the facility's stroke program and staff education on the importance of neurological monitoring. These actions and omissions resulted in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Identify and Report Medication Error
Penalty
Summary
The facility failed to identify and report a medication error as required by its policy. A resident with an order for Lisinopril 2.5 mg, to be administered orally in the evening and held if the systolic blood pressure (SBP) was less than 120 mm Hg, received the medication despite having an SBP of 113 mm Hg documented on the Medication Administration Record. The medication order was not followed, and the error was not detected or reported to the Administrator or Director of Nursing (DON) for review and appropriate action. During an interview and concurrent review of the resident's records with the DON, it was confirmed that the medication should have been held and that the facility had not previously identified or reported the error.
Soiled Bed Pad/Brief Included in Resident's Discharge Belongings
Penalty
Summary
The facility failed to ensure the safe handling and disposal of a soiled bed pad/brief for one resident. After the resident was transferred to the hospital, staff collected and bagged the resident's belongings, which were then placed at the nursing station for pickup by a family member. Upon receiving the belongings, the family member discovered a soiled bed pad/brief, visibly contaminated with urine and feces, inside a clear bag labeled with the resident's name and room number. Photographic evidence confirmed the presence of the soiled item among the resident's personal effects. Interviews with the certified nurse aides involved in packing the belongings revealed that while they recognized the bags as the resident's, neither could recall specifically packing the clear bag containing the soiled item. One aide confirmed packing the blue bags but not the clear ones, while the other could not recall which bags they packed but denied knowingly including soiled items. Video surveillance confirmed that the clear bag with the soiled bed pad/brief was handed off to the family member as part of the resident's belongings. The administrator and surveyors reviewed the evidence and confirmed the deficiency.
Failure to Honor Resident Preferences in Therapy Scheduling and Outdoor Activities
Penalty
Summary
The facility failed to honor the preferences of three residents regarding their therapy schedules and outdoor activities, which compromised their right to self-determination. Resident 60, a female admitted for wound care and therapy, expressed a preference for morning therapy sessions due to her energy levels. Despite notifying the therapy team of her preference, no schedule was created, and she was often approached for therapy in the afternoon without prior notice. This lack of scheduling was confirmed by the Director of Rehabilitation, who acknowledged the oversight. Similarly, Resident 79, a male admitted for similar reasons, expressed frustration over not being informed of therapy times in advance, which was corroborated by a Resident Care Manager who noted frequent complaints about this issue. Additionally, Resident 21, a male admitted for wound care and therapy, expressed a desire to go outside for fresh air, a preference documented in his care plan. However, he reported that the facility had not assisted him in going outside, leaving him confined to his room. These failures to accommodate resident preferences were observed through interviews and record reviews, indicating a systemic issue in the facility's approach to honoring resident choices, potentially affecting all residents.
Unsanitary Ice and Water Equipment
Penalty
Summary
The facility failed to maintain the ice and water equipment in a clean and sanitary condition, as observed during an inspection of the resident nourishment room on the 4th floor. A buildup of hardened brown sediment was found around the bottom edge of the plastic chute dispensing water and ice. This equipment is used daily to provide hydration to residents, and the unsanitary condition poses a risk of pathogen exposure. The Registered Dietician present during the inspection acknowledged that the dispenser should be cleaned regularly but could not identify the brown buildup or confirm its acceptability. Interviews with the Maintenance Associate and Facilities Coordinator revealed that the ice and water dispenser is cleaned weekly, with the last cleaning reportedly occurring three days prior to the inspection. However, no maintenance log was kept to verify this cleaning schedule. Both the Maintenance Associate and Facilities Coordinator agreed that while calcium deposits are typically white, the brown sediment observed was unusual and should be avoided. The lack of proper documentation and the presence of brown sediment indicate a failure in maintaining the equipment according to professional standards for food service safety.
Resident Rights and Dignity Deficiency
Penalty
Summary
The facility failed to protect and promote the rights of a resident, identified as R60, by not ensuring she was treated with respect and dignity. R60, a female resident admitted for wound care, antibiotic, and rehabilitative therapy, was found to have no cognitive impairment based on her Minimum Data Set Admission Assessment. During an interview, R60 reported an incident involving a traveling nurse, RN2, who repeatedly woke her for non-urgent matters and did not listen to her instructions regarding her dressing change. R60 felt bullied and disrespected by RN2's behavior. The issue was brought to the attention of the Resident Care Manager, RCM4, who acknowledged the complaint and completed a grievance form. The grievance noted R60's dissatisfaction with RN2's wound care approach and bedside manner. However, the staff education provided in response to the complaint did not address the issues of bedside manner, resident approach, or cultural competency, which were central to R60's concerns.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to ensure privacy for Resident 274, as observed on December 12, 2024. A Certified Nurse Aide (CNA) was seen assisting the resident from the bathroom to her bed without providing adequate coverage, leaving the resident exposed in a top that ended above her hips and an adult incontinence brief. Despite noticing the presence of a State Agency observer, the CNA did not take measures to protect the resident's privacy, such as offering a towel or gown, or closing a door or privacy curtain. Interviews with another CNA and the Resident Care Manager confirmed that staff are expected to protect residents' privacy by providing cover-ups or using privacy curtains. Additionally, the facility failed to protect the confidentiality of Resident 113's electronic health record. On December 12, 2024, a medication cart on the 5th floor was found unattended with a laptop displaying the resident's health information. The Registered Nurse responsible for the cart acknowledged that the laptop should not have been left open and unattended, thereby compromising the confidentiality of the resident's medical records.
Failure to Complete Transfer Form for Hospitalized Resident
Penalty
Summary
The facility failed to provide a completed Interact Nursing Home to Hospital Transfer Form for a resident, identified as R107, who was transferred to the hospital due to a change in condition. R107 experienced shortness of breath and low oxygen saturation levels, prompting an emergency transfer to the hospital. Despite the emergency nature of the situation, the facility's protocol required the completion and transmission of the transfer form, which was not done. The Resident Care Manager confirmed that the form was not filled out and acknowledged that it should have been sent with the resident to the hospital. Interviews with the staff revealed that the Registered Nurse responsible for the transfer, RN25, did not complete the form, although she sent other documents and gave a report to the hospital ER nurse. The nurse educator and resident care manager indicated that training on the form is part of new hire orientation and ongoing huddles, but RN25's name was not found on the huddle rosters. The facility's documents stated that in emergency situations, the form could be faxed later, but this was not done. The failure to complete and send the transfer form was identified as a deficiency in the facility's process for transferring residents to the hospital.
Deficient Care Plans for Two Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, which potentially diminishes their quality of life. The first resident, a female admitted for subacute rehab services following a decline in ADLs and functional mobility, had a care plan that included monitoring for bleeding at an access site. However, there was no documentation of bleeding or that it was reported to a physician, indicating a lapse in care. The second resident, a female admitted for rehab services after a stroke, had a care plan addressing acute pain related to the stroke and left-sided weakness. Despite this, there were no interventions documented for managing the resident's pain, highlighting a deficiency in addressing her medical needs.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to involve a resident, identified as R79, in the development of his comprehensive care plan. R79, a male admitted for wound care, antibiotic, and rehabilitative therapy, was found to have no cognitive impairment with a BIMS score of 15. Despite this, R79 reported not being invited to or participating in any care planning meetings, leaving him uncertain about his current plan of care and the duration of his stay. A review of his electronic health record revealed no documentation of an interdisciplinary team (IDT) discussion since his admission. Further investigation revealed that the Resident Care Manager (RCM4) acknowledged that IDT meetings are typically held on admission and quarterly, with documentation expected in a progress note by Social Services. However, no such documentation was found, and the Social Service Manager (SSM) confirmed that the IDT discussion should have been documented. The SSM could not explain the absence of the progress note and admitted the possibility that the IDT meeting did not occur as planned. This lack of documentation and potential failure to hold the meeting resulted in the deficiency.
Deficiencies in Resident-Centered Care and Insulin Management
Penalty
Summary
The facility failed to provide resident-centered care and services in accordance with the goals to meet the physical, mental, and psychosocial needs of three residents. For one resident, the facility did not adequately address her complex physical needs, resulting in frequent hospitalizations. This resident, who was admitted with conditions such as diabetic ketoacidosis, acute hypoxic respiratory failure, and end-stage renal disease, experienced multiple transfers to acute care due to issues like hypoglycemia and infections. The facility's management of her insulin and dietary needs was insufficient, leading to severe hypoglycemic episodes and subsequent hospitalizations. Another resident's preferences for physical therapy scheduling were not honored, impacting her ability to manage pain effectively. The resident preferred morning sessions when her energy levels were higher, and pain management could be optimized with as-needed medication. However, the facility failed to schedule her therapy sessions accordingly, leading to difficulties in administering pain medication in a timely manner before therapy. Additionally, the facility did not clarify and correct ambiguous insulin orders for a third resident, which resulted in a hypoglycemic episode. The resident's insulin orders were incorrectly documented, and a hypoglycemic event was not properly recorded, lacking critical details such as the time of occurrence and interventions applied. This oversight placed the resident at risk for avoidable declines and injuries, highlighting a deficiency in the facility's documentation and medication management practices.
Failure to Change Enteral Feeding Bag Within 24 Hours
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident. The resident, an elderly individual admitted for surgical aftercare following digestive system surgery, had a medical history including diverticulosis and nontraumatic perforation of the intestine. The resident was prescribed enteral feeding four times a day. During an observation, an LPN initiated tube feeding for the resident and checked the feeding tube placement and residual presence. However, the feeding bag used was labeled with a date indicating it was past the 24-hour discard time, contrary to the facility's policy that requires changing the feeding bag and tubing every 24 hours. Upon realizing the oversight, the LPN stopped the pump and left to obtain a new setup. This deficiency in practice had the potential to put residents on enteral feeding at risk for preventable complications.
Oxygen Dispensation Error for Resident with RSV
Penalty
Summary
The facility failed to correctly dispense oxygen for a resident diagnosed with Respiratory Syncytial Virus (RSV) and placed in isolation on droplet/contact precautions. The resident, a male with complex medical conditions including Diabetes Mellitus and pneumonia, was observed wearing a nasal cannula with the oxygen monitor in the off position. The family member present confirmed the resident had tested positive for RSV and was started on antibiotics. The Resident Care Manager confirmed the physician's order for oxygen was 1-4 Liters per minute as needed, but the oxygen was not being administered correctly. Further observations revealed the nasal cannula was incorrectly placed on the side of the resident's face, and the oxygen meter remained off. The Director of Nursing confirmed the incorrect placement and noted that if the resident did not need oxygen, it should be removed and stored properly after a respiratory assessment. The physician's orders specified oxygen administration for shortness of breath or oxygen saturation less than 92%, with instructions to notify the medical doctor if oxygen was applied or increased. A nurse's progress note indicated a room air challenge was unsuccessful, with the resident presenting at 87% oxygen saturation, leading to the re-initiation of oxygen at 1 LPM.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to effectively manage the pain of a resident, identified as R228, which negatively impacted her quality of life and ability to participate in physical therapy and family visits. On multiple occasions, the resident experienced significant pain, as observed by her family member and noted by the surveyor. During an observation in the rehabilitation gym, the resident was in visible discomfort and had not received pain medication prior to her physical therapy session. The nurse administered Tramadol only after the session had begun, and the resident's pain was severe enough to cause a breakdown, leading her son to defer the therapy session. The resident's medication administration record indicated inconsistent administration of pain medication, with Tramadol documented as given on only two occasions in December, despite the resident frequently experiencing pain rated as high as 10 on a numeric scale. The resident's care plan included orders for Gabapentin, Lidocaine patches, and Tramadol for severe pain, but there was a lack of timely administration of these medications. The resident, who is severely cognitively impaired and primarily Cantonese-speaking, has a primary diagnosis of stroke and diabetes mellitus, further complicating her pain management needs.
Failure to Document and Report Post-Dialysis Bleeding
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident, leading to a deficiency. The resident, who has a hemodialysis access site in her left arm, reported that the site sometimes continues to bleed after dialysis sessions, requiring her to apply pressure with a dressing. On one occasion, the resident had an ace wrap on her left upper arm due to bleeding from her arterio-venous fistula (AVF) after dialysis. Despite this, there was no documentation in the Electronic Health Record (EHR) or the dialysis communication form regarding the bleeding or the application of a dressing. The facility's policy for hemodialysis care requires monitoring of the access site for bleeding and notifying the provider if bleeding lasts longer than 30 minutes or is severe. However, there was no documentation that the bleeding was reported to the Medical Doctor (MD), and the nurse's notes did not mention any active bleeding or the application of a dressing. The Director of Nursing (DON) and Resident Care Manager (RCM) confirmed the lack of documentation in the EHR, indicating a failure to adhere to the facility's policy and procedure for hemodialysis care.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper disposal of medications for discharged residents and those past their discard date, as well as to implement a thorough process for accurate reconciliation and accounting of controlled medications. During an inspection of a medication cart on the fifth floor, a Registered Nurse (RN8) was found to have administered a dose of Wixela Inhub, an inhaler medication for asthma, to a resident despite the medication being past its discard date of 12/09/24. The nurse acknowledged the oversight and indicated she would discard the expired medication and obtain a new one. Additionally, an inspection of another medication cart on the third floor revealed that the Narcotic Count Sign In Sheet had not been signed by the off-going and oncoming nurses for two shifts. This lack of documentation was confirmed by another Registered Nurse (RN6), who stated that both nurses should initial the log to confirm that the narcotic count was conducted and correct. The facility's policy requires a physical inventory of all controlled substances at each shift change, which was not adhered to in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to professional standards, which is necessary to promote safe administration practices and decrease the risk of medication errors. During an inspection of the medication storage room on the 4th floor, a bottle of magnesium citrate and a bottle of Colace liquid were found with expiration dates that had already passed. The Resident Care Manager (RCM) acknowledged that these expired medications were missed during weekly checks and should have been discarded. Additionally, there were instances of unsecured medication carts. An unlocked medication cart was observed outside a room with no staff present, and the responsible nurse admitted to not locking it before leaving. Another unlocked cart was found on the 5th floor, and the nurse responsible for it acknowledged the oversight. Furthermore, an open vial of Tubersol in the 5th floor medication storage room was found without an open date or discard date, and the RCM confirmed it needed to be discarded due to the lack of labeling.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as observed in two separate incidents. In the first incident, a Certified Nurse Aide (CNA) delivered a lunch tray to a resident on contact precautions without wearing the required personal protective equipment (PPE), such as gloves and a gown, and did not perform hand hygiene after exiting the room. The CNA admitted to not seeing the precautionary signage due to being unfamiliar with the floor. The facility's policy on contact precautions clearly states that gloves and gowns should be worn when entering a room and hand hygiene should be performed immediately after removing gloves. In the second incident, a Registered Nurse (RN) failed to perform hand hygiene between glove changes while conducting a dressing change on a resident with a stage 4 pressure ulcer. The resident, who is totally dependent on staff for care, developed the ulcer at the facility, and it is being managed by an outside wound specialist and facility nurses. The Resident Care Manager confirmed that staff are expected to wash their hands or use hand sanitizer between glove changes, and this practice is reinforced during training and huddles.
Failure to Monitor Orthostatic Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that a resident received the necessary monitoring in accordance with nursing professional standards, the individualized care plan, and physician orders. The resident, who was admitted following surgery for a fractured left hip and had a medical history including advanced Parkinson's disease, diabetes, anemia, hypertension, and orthostatic hypotension, was supposed to have orthostatic blood pressures and pulse monitored daily. However, the nursing staff did not consistently complete these vital sign checks as ordered. The first set of orthostatic vitals was recorded a week after the order was written, and out of 34 days, orthostatic vitals were documented only 11 times. There were also instances where the pulse was not recorded, and several days where the vital signs were not taken without documented reasons. Interviews with the Director of Nursing and a Registered Nurse revealed that the facility's practice was for licensed staff to take orthostatic vitals, not Certified Nurse Assistants. The Director of Nursing confirmed that if vital signs were not done, there should be a documented reason. The physician who ordered the orthostatic vitals noted in a progress note that the nursing staff had not been consistently performing the checks, which was important for confirming hypotension and monitoring after medication adjustments. The lack of consistent monitoring resulted in insufficient data to manage the resident's condition effectively.
Latest citations in Hawaii
A resident with multiple chronic conditions and documented wandering and exit-seeking behaviors repeatedly expressed a desire to go home and was frequently observed near exit doors, yet her care plan did not address elopement risk despite an elopement risk score above the facility’s threshold. She was taken outside and left alone by an activity aide and later observed alone in an unauthorized outdoor area, and subsequently eloped twice through the unsecured main entrance, being found in the parking lot on both occasions only after another resident alerted staff. The main entrance lacked alarms or automatic locking, there was no reception area to monitor egress, behavior monitoring records did not reflect increased supervision after the incidents, and documentation often indicated no behaviors despite prior notes of exit-seeking.
The facility failed to provide adequate supervision and fall prevention for multiple high‑risk residents, resulting in unwitnessed falls and serious injuries. One resident with a history of repeated unwitnessed falls and documented weakness fell in the bathroom while adjusting clothing and using a FWW, sustaining head abrasions and hematomas; he was discovered by housekeeping staff after calling for help, and an RN later stated he needed more supervision. Another resident with dysphagia, prior falls, and declining mobility attempted to stand from a newly issued wheelchair while a CNA was behind a closed curtain assisting another resident, fell forward onto her face, and suffered a scalp laceration, facial contusions, and facial fractures. A third resident with prior falls and on sedating, hypotension‑associated psychotropic and antidepressant medications was placed in a dining area but left unsupervised when nursing staff were called away; she attempted to ambulate to the bathroom without her walker, fell, and sustained a right hip fracture. Her care plan had not been updated to reflect her current need for consistent walker use, and staff did not fully follow existing interventions regarding walker availability and use.
A resident with debility, legal blindness, CHF, DM, medication side effects, and a history of falls had a care plan identifying fall risk and requiring standby assist with ambulation. Despite this, staff left the resident unsupervised while the RN walked away and the CNA was busy with another resident, and the resident attempted to ambulate without a walker, leading to an unwitnessed fall and hip fracture. The care plan had not been fully updated to reflect the need for consistent walker use, and staff did not fully follow existing interventions related to walker availability and use.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
Staff failed to timely report a large, dark bruise of unknown origin on a resident’s left hip and thigh. A CNA first observed the bruise during a night shift but did not notify the nurse on duty and only relayed the information to an incoming CNA. Later, a CNA, an RNA, and an RN observed and discussed the bruise during care, and the RN assessed it but assumed it had already been reported and did not document an initial entry or initiate required notifications. The RNA later noted another large bruise and informed an LPN. Despite multiple staff being aware of the injury, the DON, Administrator, physician, resident representative, and State Agency were not notified within the required 2-hour timeframe specified in the facility’s abuse and injury-of-unknown-source reporting policy.
Nursing staff failed to perform and document timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. A CNA first observed the bruise and did not report it to a nurse, only relaying it to another CNA, and when an RN later assessed the bruise, the RN assumed it had already been reported and did not complete an initial assessment entry. An LPN subsequently noted the large purplish bruise, found no prior documentation, and initiated an event, while weekly skin assessments by an RN repeatedly documented no new skin impairments and omitted the bruise. Nursing notes recorded that the bruise was visible and then fading over time, but lacked complete assessment details such as size, shape, and full description, and the incorrect event form was used, resulting in incomplete documentation of the injury.
A resident with multiple comorbidities, including ESRD on dialysis, developed urinary retention during a rehab stay and was discharged home with an indwelling Foley catheter and a mechanical lift. The resident’s son, designated as caregiver, had previously assisted her at home but had not managed a urinary catheter before. Nursing documentation at discharge noted follow-up with a PCP and home health and described the transfer to the son’s car, but recorded education/training as not applicable and contained no evidence of Foley catheter care teaching. During interviews, staff indicated that a vendor trains caregivers on the mechanical lift but could not confirm any nursing education on catheter care, and the Administrator acknowledged nursing’s responsibility to assess, provide, and document caregiver training and capacity, which was not done in this case.
A resident with a history of stroke, encephalopathy, gait abnormalities, incontinence, and insulin-dependent Type 2 DM was discharged home alone with only a private hire caregiver for two hours per day, despite provider orders for 24-hour care and therapy recommendations for 24/7 or extensive caregiver support. Interdisciplinary documentation inaccurately indicated the resident had family and a wife as primary caregiver, and there was no evidence that the facility discussed with the resident his limitations, the risks of minimal supervision, or that the provider was informed of the reduced supervision at discharge. The discharge MDS documented full continence despite multiple recorded episodes of incontinence, and the facility did not verify or document that the resident could self-inject insulin or that a qualified caregiver was trained to do so. Additionally, an ordered stool culture for persistent diarrhea was not completed due to improper specimen handling, and there was no documentation that the provider, PMD, or resident was notified that the test was not performed.
Surveyors found that the facility failed to include ordered O2 therapy in a resident’s care plan despite physician orders for continuous O2 via NC with parameters for use and weaning, and the ADON confirmed this omission. In a separate case, a resident with BLE edema and cellulitis was repeatedly observed in bed with exposed legs and no heel protectors in place, even though there were physician orders for bilateral heel protectors and a care plan directive to offload the heels while in bed; nursing staff acknowledged the heel protectors should have been reapplied after PT and a shower.
Two residents were not adequately protected from accidents when one sustained a skin tear during Hoyer lift transfers despite known fragile skin and prior family complaints about staff moving too quickly, and another, identified as high fall risk due to dementia and prior lumbar fractures, was left unsupervised in a hallway in a w/c for a meal after the CNA watching her went to assist another resident, resulting in a fall discovered by a visitor.
Failure to Supervise and Implement Elopement Interventions for an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision and interventions to prevent accidents, resulting in two elopement incidents involving Resident 36. The resident was an adult female with multiple medical diagnoses including DMII, adjustment disorder with mixed anxiety and depressed mood, hypertension, chronic kidney disease, hypothyroidism, and obstructive sleep apnea. Review of the electronic health record showed numerous progress notes from October 2025 through January 18, 2026 documenting that the resident frequently verbalized wanting to go home, made frequent phone calls to family, asked staff and other residents to take her home, wandered in the facility, and displayed exit-seeking behavior, including ambulating near the facility entrance and exit doors. Despite these documented behaviors, there was no care plan addressing her wandering and exit-seeking prior to the first elopement on January 19, 2026. On January 19, 2026, the resident eloped through the main exit doors at approximately 6:10 PM. Earlier that day, around 4:00 PM, an activity aide had taken her for a stroll outside and left her alone sitting at a table outside, and later that same day the DON and a Resident Care Manager observed her sitting alone at the resident smoking tent, where she was not allowed to be. The facility’s Elopement Risk Evaluation had been completed on October 16, 2025 with a score of 0 and again on October 28, 2025 with a score of 2, which met the facility’s threshold for being at risk for elopement (score of 1 or greater). However, the Administrator stated that although they review changes in score to determine needed interventions, no interventions regarding the resident’s elopement risk were implemented prior to the January 19 incident. The DON confirmed that the resident had exit-seeking behaviors prior to the first elopement and that she was functionally at supervision level and able to ambulate with a front-wheeled walker. A second elopement occurred on January 28, 2026 at 4:10 PM, nine days after the first incident. For both elopements, the resident was found in the parking lot near the first handicap stall, and staff were not aware she had left the building until another resident notified them. During the survey entrance on March 11, 2026 at 6:45 AM, the surveyor observed that the main entrance doors were unlocked, lacked an alarm or automatic locking mechanism, and opened into a large open area with no reception or receiving area, with no indication that the door could secure automatically to prevent elopement. Review of Behavior Monitoring and Interventions Reports from January 1 to February 28, 2026 showed documentation only once per shift and did not reflect increased monitoring after the two elopements; most entries were marked “No Behaviors Observed,” which was inconsistent with the exit-seeking episodes documented in the progress notes. The facility could not provide documentation of increased monitoring after the first elopement, and at the time of the Administrator’s interview there was still another resident identified as an elopement risk.
Failure to Provide Adequate Supervision and Fall Prevention for High‑Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an environment free from accident hazards and to provide supervision based on individual residents’ assessed needs. One resident with a history of multiple unwitnessed falls was observed with a bandage on his head and later with visible bruising and abrasions after an unwitnessed bathroom fall. His care plan documented several prior falls, including unwitnessed falls with head pain, bruising, and sliding out of bed while reaching for a urinal. On the date of the most recent fall, he was found on the bathroom floor on his right side with his pants and underwear around his thighs, reporting that he had been attempting to adjust his clothing while walking with a front‑wheeled walker. He sustained multiple abrasions and hematomas to the top and sides of his head, reported 8/10 head pain and nausea, and required transfer to the ER. Nursing staff reported that a housekeeper, not direct care staff, discovered him after hearing him call for help, and the RN stated that the resident needed more supervision, especially given increased weakness since his prior fall. Another resident with dysphagia, a history of falling, and generalized muscle weakness experienced a fall with major injury after attempting to stand from a newly issued wheelchair. She reported that she stood up and did not expect the wheelchair to be so high, lost her balance, and fell forward onto her face while the CNA was in the same room but behind a closed curtain assisting another resident. The resident sustained an approximately two‑inch actively bleeding scalp laceration, facial contusions, and later ER documentation confirmed a closed fracture of the left maxillary sinus, a closed fracture of the left orbital floor, a scalp laceration, and a closed head injury. The MDS showed that, prior to this fall, she had already demonstrated decline in eight of ten mobility areas, and she later returned from the hospital with 8 staples in her scalp and extensive bruising and swelling to the left eye, scalp, and ear. The resident and her family member expressed that the fall should not have happened and attributed it to short staffing. A third resident with a documented fall history and on medications including quetiapine and mirtazapine, both of which have side effects of drowsiness, dizziness, and orthostatic hypotension, sustained an unwitnessed fall resulting in a right hip fracture. She was found on the floor on her right side without shoes, socks, or her walker, and stated she had been trying to go to the bathroom. The care plan had not been updated to fully reflect her current needs for consistent walker use, and staff did not fully adhere to existing interventions regarding walker availability and use at the time of the incident. Nursing staff interviews indicated that this resident required line‑of‑sight supervision and “eyes on her” because she would suddenly stand without warning and was unsteady, yet at the time of the fall she had been placed in the dining area in front of the nurse’s station and was left unsupervised when the RN and CNA were called away. Kitchen staff later found her on the floor, and she reported being on the floor for about 15 minutes before help arrived. She was diagnosed with a right hip fracture, underwent surgery, was admitted to the ICU for hypotension, and subsequently died; the unwitnessed fall with hip fracture was determined to be a contributing event that exacerbated her overall medical decline, though not the primary cause of death.
Failure to Implement Standby Assist and Walker Use Care Plan Resulting in Fall Injury
Penalty
Summary
The facility failed to implement a person-centered intervention for standby assistance with ambulation as outlined in the comprehensive care plan for one resident, resulting in an unwitnessed fall with major injury. The resident had multiple risk factors for falls, including debility, legal blindness, congestive heart failure, diabetes mellitus, medication side effects, and a history of prior falls. The care plan, revised on 01/23/2026, identified the resident as at risk for falls and included an intervention for standby assist with ambulation, updated on 01/22/2026, with a goal that the resident would be free of falls through the review date of 03/25/26. Prior to the incident, the resident had experienced two falls in the facility, one witnessed fall onto the buttocks while fixing clothing by a mirror and one guided fall after losing balance while walking. On 02/06/26, the resident sustained an unwitnessed fall in building 1 on the B unit while attempting unsupervised ambulation without her walker, resulting in a right hip fracture and transfer to the ER for evaluation and surgery. Interviews with nursing staff confirmed that the resident was known to suddenly stand without warning, was unsteady, and required someone present when walking, and that she needed continuous visual supervision due to her fall risk. At the time of the fall, the RN reported having to walk away and the CNA was occupied with another resident, leaving no one available to assist the resident to get up. The final investigation summary noted that the care plan had not been updated to fully reflect the resident’s current needs for consistent walker use and that staff did not fully adhere to existing care plan interventions regarding the availability and use of the walker at the time of the incident.
Inadequate Infection Control in Catheter Care, Water Management, and Waste Handling
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, particularly related to urinary catheter care, use of personal protective equipment (PPE), implementation of a water management plan for Legionella, and timely trash disposal. For one resident with an indwelling urinary catheter, the surveyor observed the catheter bag on the floor inside a gray bin with the catheter tubing extending out of the bin and in direct contact with the floor. The tubing showed visible discoloration and white sediment. The resident later reported itchiness outside the vagina and leaking from the catheter. A registered nurse acknowledged awareness of the sediment, stated the catheter was changed monthly, and indicated she planned to contact the physician for more frequent changes. She also stated the tubing could be irrigated with saline and confirmed that catheter tubing should not be on the floor for infection control reasons. The Infection Preventionist (IP), when shown a photograph of the tubing on the floor with sediment, confirmed the tubing should have been changed and that tubing should not be on the floor due to infection risk. Another resident, a male with a history of stroke and benign prostatic hyperplasia requiring an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP) with orders for catheter care every shift and as needed. During observation, his catheter tubing was seen lying directly on the floor when the bed was in the lowest position. The nurse present acknowledged that the tubing should not be on the floor and adjusted the bed and tubing placement. In a separate observation, a CNA performed catheter care for this resident, including emptying the catheter bag and cleaning the lower catheter tubing and the floor area near the bag, while only wearing gloves and no gown, despite a noticeable urine-like odor at the bedside. The IP confirmed that the resident was on EBP due to having a Foley catheter and stated staff should wear PPE, including a gown, when performing catheter care such as emptying the collection bag in case of splashes. The CNA acknowledged she was supposed to wear PPE for catheter care and indicated PPE was stored down the hall on a wall shelf, not immediately near or outside the resident’s room, despite the facility’s EBP policy stating gowns and gloves should be made available immediately near or outside the room for high-contact care activities such as urinary catheter care. The facility also failed to effectively implement its water management plan for Legionella prevention and control. The written plan described a central hot water system with recirculation, specified hot water storage tank setpoints at or above 140°F and distribution temperatures above 124°F, and listed monitoring procedures including monthly hot water temperature checks by maintenance, as well as verification and validation steps such as reviewing monitoring logs, infection surveillance data, and water testing results. However, the Maintenance Director reported there were no storage or water heater tanks with water temperatures greater than 140°F, and only one month of temperature logs was available, showing resident room and water heater temperatures between 105°F and 115°F, which did not align with the Legionella prevention temperature guidelines referenced from CDC. The IP, newly in the role, stated she was not familiar with the water management plan, that collaboration with maintenance was non-existent, and that no control measures, weekly flushing of shower heads and faucets, or monthly temperature monitoring were being done. Additionally, the facility did not ensure prompt disposal of trash, resulting in trash bags being piled outside the trash bin and on an exterior stairwell landing. Surveyors observed multiple trash bags outside the facility next to the trash bin and on the stairwell landing, blocking access to the staircase. Housekeeping staff reported that trash from the second floor was placed in the bin about every hour but sometimes had to wait for the maintenance worker, who had the only key to open the bin. Another housekeeper stated she left heavy trash bags by the bin twice a day because she could not lift them into the bin and relied on the maintenance worker to place them inside, noting she had notified him about trash needing to be placed in the bin about an hour earlier. The maintenance worker stated he had been told by aides to hold off putting trash in the bin but did not know why. The Maintenance Director later confirmed that housekeepers should be putting trash in the bin more frequently and acknowledged that trash pile-up can lead to unsanitary conditions affecting the facility and neighborhood. Overall, these observations and interviews show that the facility did not maintain catheter tubing off the floor or address visibly soiled tubing, did not consistently use required PPE for residents on EBP during high-contact catheter care, did not implement or monitor its Legionella water management plan as written, and did not ensure timely placement of trash into secured bins, resulting in accumulated trash in exterior areas.
Failure to Timely Report Injury of Unknown Source Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source that resulted in serious bodily injury for one resident. Staff first observed a large, dark bruise on the resident’s left hip and thigh around midnight during a night shift, but the CNA who discovered it did not notify the night shift nurse, stating she was busy and forgot, and instead only told an incoming day shift CNA. The day shift CNA later informed the RN on duty while assisting with the resident’s care. The RN assessed the bruise, describing it as purple and located on the posterior left thigh; the resident did not recall how it occurred and denied pain or discomfort. The RN assumed the bruise had already been reported to licensed staff on the prior shift and did not make an initial entry or initiate required notifications. Subsequently, the restorative nurse aide (RNA) and another CNA observed the large bruise in the lower hip area while assisting with a shower and confirmed with each other that the on-duty RN had been informed. The next day, the RNA observed another large bruise on the resident’s thigh and reported it to an LPN. Despite multiple staff being aware of the bruising over more than one shift, the DON, Administrator, physician, resident representative, and State Agency were not notified until several days after the bruise was first seen. This sequence of inaction and miscommunication occurred despite the facility’s abuse policy requiring that allegations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source that result in serious bodily injury be reported immediately, but no later than two hours after the allegation is made, with immediate notification of the Administrator or designee to initiate reporting to state agencies.
Failure to Perform and Document Complete Skin Assessment for Large Hip/Thigh Bruise
Penalty
Summary
The facility failed to ensure licensed nursing staff demonstrated appropriate competencies and skills to perform timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. Staff first observed the bruise on 07/30/25, but no initial assessment was conducted at that time. A CNA working the night shift observed the bruise and did not report it to the Charge Nurse, instead only telling the incoming day shift CNA the next day. The day shift CNA then informed an RN, who assessed the bruise as purple in color on the posterior left thigh, with the resident unable to recall how it occurred and denying pain or discomfort. The RN assumed the bruise had already been reported to licensed staff and did not complete an initial assessment entry. On 08/01/25, an LPN observed the large purplish bruise extending from the resident’s lower hip to the thigh, found no prior assessment or event note documenting the bruise, and then created an event and notified the DON. An X-ray ordered by the physician showed soft tissue swelling without acute fracture, dislocation, or bony lesions. Despite the presence of the bruise, weekly skin assessments completed by the RN on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 did not document the bruise on the left hip and thigh. These assessments repeatedly documented that there were no new onset skin impairments and described only dry scattered scabs to the bilateral shins treated with Medihoney gel. Nursing notes associated with the event report initiated on 08/01/25 documented that the bruise on the left hip and thigh was visible and then fading over multiple subsequent dates, with color changes from purple to yellow. However, these notes did not include a complete skin assessment or detailed documentation of the bruise’s progression, such as size, shape, initial appearance, or date of resolution. During interviews, the IP and Administrator confirmed that the RN’s weekly skin assessments should have included the bruise, that staff should perform a full skin assessment and initiate an RMC Injury/Integumentary Alteration event when a new skin issue is identified, and that the event report used by the LPN was not the correct form and did not capture a complete assessment. The report also cross-referenced F609, noting that the injury of unknown source resulting in serious bodily injury was not reported to the Administrator within two hours of discovery, as it was first observed on 07/30/25 but not reported until 08/01/25.
Failure to Assess and Educate Caregiver on Foley Catheter Care Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate discharge plan and caregiver education for a resident who was discharged home with an indwelling urinary catheter. The resident, an older female admitted for short-term rehabilitation after an acute hospitalization, had multiple medical conditions including diabetes, spinal stenosis, chronic back pain, muscle weakness, gait and mobility abnormalities, and end-stage renal disease requiring dialysis. While in the facility, she developed urinary retention and required an indwelling urinary catheter, which remained in place at the time of discharge home with her son as the designated caregiver. The nursing progress note documented that the resident was discharged home with her son, to be followed by her primary care provider and home health services, and that staff assisted with transfer to the son’s car. The note also indicated “Education/Training Response as indicated: n/a,” and there was no documentation that the caregiver received education on Foley catheter care. Following a report of concern to the Office of Health Care Assurance that the resident did not have needed resources after discharge and that the caregiver could not safely manage the urinary catheter, surveyors reviewed records and interviewed staff. The Social Services Assistant, after consulting the Social Worker, reported that a vendor provides caregiver training on the mechanical lift when delivering the equipment to the home, but the Social Worker did not know if nursing had provided catheter care education. It was acknowledged that although the son had cared for the resident prior to hospitalization, she did not have a urinary catheter at home before this admission. In an interview, the Administrator confirmed that nursing was responsible for assessing caregiver training needs, providing and documenting the training, and documenting that the caregiver was willing, capable, and had the capacity to provide the required care. The facility was unable to provide evidence that such assessment and education on Foley catheter care were completed or documented for this caregiver.
Failure to Ensure Safe Discharge Planning and Follow-Up for a Resident Discharged Home Alone
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s transfer/discharge plan met his needs and preferences and that he was adequately prepared and supported for a safe discharge to the community. The resident was an older male admitted after a stroke for medical management and rehabilitation, with a history of encephalopathy, muscle weakness, gait and mobility abnormalities, Type 2 DM on insulin, chronic heel ulcers, and hypertension. While in the facility, he was incontinent of bladder and bowel and wore disposable briefs. Prior to the stroke, he lived alone with community supports including a care coordinator, meals on wheels, transportation, a life alert system, help from a neighbor with groceries, and a friend who cleaned his house. He did not have a power of attorney. During the stay, an interdisciplinary care conference note documented that the resident would be discharged “home with family,” that he lived alone but had community services and a health coordinator, and that he would return home with established services and home health PT/OT/nursing. The discharge planning section inaccurately indicated that he had family and identified a wife as the primary caregiver, and it documented an intervention to evaluate and discuss prognosis, limitations, risks, benefits, and needs for independence. However, the resident did not have a wife or family caregiver, and the private hire caregiver was arranged by the facility. There was no evidence that the facility discussed with the resident the prognosis for independent living with minimal supervision, his limitations, or that he fully understood the risks. There was also no evidence that the provider was aware that the final discharge arrangement would involve only minimal supervision rather than the ordered level of care. The resident’s discharge orders specified a need for 24-hour care and home health services including PT, OT, speech therapy, nursing, and medication management, and therapy documentation indicated he was not safe to be home alone and required increased assistance at home. PT and OT notes recommended 24/7 care or at least a caregiver for 20 hours per week, and the resident’s modified Barthel ADL score reflected moderate dependence. The discharge MDS showed he required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers and mobility, but it documented him as always continent despite nursing documentation of multiple episodes of urinary and bowel incontinence in the week prior to discharge. The social services assistant confirmed the resident had no family or full-time caregiver, knew there would be a lag before community services resumed, and arranged a private hire caregiver for only two hours per day without knowing the caregiver’s qualifications. She acknowledged that the resident needed to be checked on daily and that he required daily insulin injections, which she stated nursing was responsible to ensure could be safely managed, but the facility could not provide evidence that the resident was competent to self-inject insulin or that a capable caregiver was identified and trained. Additional documentation and interviews showed that the care coordinator had informed the social services assistant that the resident had no support at home and that community services such as meals on wheels would not resume immediately, and that home health evaluation and possible services would not start until several days after discharge. The social services assistant did not document her discharge planning communications with the care coordinator in the medical record at the time and later produced a retrospective typed note. The friend who cleaned the resident’s home reported that upon discharge he struggled to get out of a chair, walked slowly, had frequent accidents on the floor, and could not figure out how to set his insulin pen correctly. The PT and OT confirmed that the resident had memory issues, was not at his pre-stroke baseline, could not change his own brief, and still needed assistance and cues for toileting and hygiene. The DON stated that nursing was responsible to ensure the resident could self-inject insulin or that a trained caregiver was identified, and confirmed the facility lacked evidence of such competence or caregiver training. The deficiency also included a failure to ensure appropriate follow-up for an ordered diagnostic test prior to discharge. Nursing documentation showed the resident had persistent diarrhea and stomach upset, and a stool culture and O&P were ordered along with a probiotic. The laboratory later reported that the stool sample was received in a sterile container instead of stool media, was no longer stable for testing, and that the resident was no longer at the facility so recollection was not needed. There was no documentation that the provider, primary medical doctor, or resident was notified that the stool culture was not completed. The DON confirmed that the stool culture and sensitivity had not been done and that the provider should have been notified to ensure follow-up after discharge.
Failure to Care Plan O2 Therapy and Implement Heel Protector Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed all ordered treatments. For one resident receiving oxygen (O2) therapy, surveyors observed the resident on 1 L O2 via nasal cannula and later without O2, with no signs of respiratory distress. Record review showed a physician’s order for continuous O2 supplementation at 1–4 L/min via nasal cannula for shortness of breath or SpO2 < 90%, with an order to wean O2 as tolerated every shift. However, the resident’s care plan did not include any problems, goals, or interventions related to O2 therapy. The ADON confirmed that O2 therapy was not included in the care plan and acknowledged that the care plan is important as it directs the care provided. The facility’s Oxygen Administration policy stated that the resident’s care plan will identify the interventions of oxygen therapy based on assessment and orders. A second deficiency involved failure to implement the care plan intervention for bilateral heel protectors for a resident with bilateral lower extremity (BLE) edema and cellulitis. The resident was repeatedly observed in bed with BLE edema, redness, and dry, scaly skin, with BLE exposed and no socks or heel protectors applied, despite reporting pain at 8/10 and stating that pain medication and daily cream application provided relief. Record review showed a physician’s order for bilateral heel protectors and a care plan intervention to ensure heels are offloaded by floating heels while in bed. Nursing staff confirmed that heel protectors should have been reapplied after physical therapy and a shower to protect the resident from further skin breakdown. The facility’s Comprehensive Care Plan policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment.
Failure to Prevent Injury During Mechanical Transfer and Unsupervised Hallway Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries during transfers and while residents were out of bed. One resident with dementia, hemiplegia following a stroke, and fragile skin experienced recurrent skin tears associated with transfers using a Hoyer lift. Family members reported that staff needed to be more careful when using the lift because the resident’s skin tears easily and that problems with skin tears occurred during transfers. The resident was observed wearing Geri sleeves on both arms, and a nursing progress note documented a skin tear to the left elbow that occurred after transferring the resident back to bed. Family members had previously filed a grievance stating that a CNA was moving too fast during a transfer from bed to wheelchair, and that the CNA reported she was holding the Hoyer sling to help navigate the resident’s position during the transfer. The resident’s RN stated that CNAs follow an ADL schedule, that the resident receives showers four times per week, and that Geri sleeves are used as a preventive measure. The RN also stated that the resident often screams during Hoyer transfers and characterized this as the resident’s behavior. The DON reported that various considerations had been made for the resident at the family’s request, including an increased shower schedule and discussion about nail trimming, while confirming that the family declined staff trimming the resident’s nails. A second resident, an older female with dementia, debility, pain, and a history of lumbar fractures, was care planned as being at risk for falls, with an approach to observe her frequently and place her in a supervised area when out of bed. Despite this, she was placed in a hallway in a wheelchair for a meal and left unattended when the CNA who had been watching her went to assist another resident in a room. The charge nurse was in the Resident Care Manager’s office when a visitor alerted staff that the resident had fallen; the resident was found on the floor on her left side. The charge nurse later acknowledged that the resident was at high risk for falls due to dementia, should not have been left unsupervised, and that the CNA, a part-time staff member unfamiliar with the residents on that floor, should have called for help before leaving the hallway and losing sight of the resident and others.
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