Citations in Hawaii
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Hawaii.
Statistics for Hawaii (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Hawaii
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.
A resident with dementia, impaired mobility, a history of falls, and documented wandering behavior, who wore a functioning wander management bracelet, was able to leave the facility and go to a nearby family member’s home with the assistance of a visitor who was unaware of facility protocols and did not notify staff. The wander management system was set so doors locked when a bracelet approached and only sounded an alarm if the door was pushed for an extended period or was ajar. On the day of the incident, a staff member heard a door alarm, saw no residents nearby, and silenced the alarm without further checks. Staff did not realize the resident was missing until notified by the resident’s son, and the facility’s elopement policy and protocols did not require immediate accounting for residents wearing wander bracelets when an alarm was activated but no missing resident had yet been identified.
The facility did not have a comprehensive Water Management Program (WMP) to prevent Legionella and other waterborne pathogens, lacking a risk assessment, detailed water system description, and specific testing protocols. A resident with multiple health conditions tested positive for Legionella antigen after being admitted for rehabilitation, and the facility was unable to provide documentation of a completed risk assessment or a coordinated WMP at the time of the survey. Existing measures, such as water heater temperature logs and ice machine maintenance, were insufficiently documented and did not meet CDC and ASHRAE standards.
The facility failed to follow its Legionnaires' Disease infection prevention and control program by limiting pH and chlorine testing of potable water to a single first-floor sink instead of performing required monthly testing in multiple sinks/showers on every floor. Surveyors confirmed through logs that only first-floor pH and chlorine levels were monitored, although water temperatures were checked daily on all floors. A decorative water fountain at the facility entrance was not being tested annually for Legionella as required, despite acknowledgment by Maintenance, the Infection Nurse, and the Director of Facilities that such testing and broader water monitoring should have occurred. Policy review also showed requirements for daily cleaning and disinfecting of decorative water features, Legionella culture testing of those features, and monthly ice machine maintenance, which were not being fully carried out.
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.
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.
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.
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.
Elopement of Wandering Resident Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention measures for a resident assessed as at risk for elopement. The resident had dementia, used a wheelchair for mobility, had impairment of one lower extremity, and a history of falls. A recent MDS documented that the resident wandered 1 to 3 days during the assessment period and that this wandering behavior had worsened compared to prior assessments. The resident wore a wander management bracelet that was documented as present and functioning on the day of the incident. The facility’s wander management system was designed so that when a resident with a bracelet approached an exit, the door locked and a visual indicator changed color, with an audible alarm sounding only if the door was pushed for approximately 15 seconds or if the door was ajar and unable to lock. On the date of the incident, the resident left the facility and went to a family member’s home located in front of the facility with the assistance of a visitor of another resident. The visitor, who was unaware of facility protocols, opened the exit door, assisted the resident out of the building, and walked the resident to the nearby home without notifying staff. Staff only became aware the resident was missing when the resident’s son called to report that the resident was in their driveway. A nursing note documented that when the resident was wheeled back into the facility, the door alarm sounded, indicating the wander bracelet was working. During the facility’s investigation, the Administrator reported that a staff member had heard the door alarm earlier, did not see any residents nearby, and turned the alarm off without further action. The DON confirmed that facility protocols did not require staff to immediately check or account for all residents wearing wander management bracelets when an alarm sounded and no resident was observed, and the written elopement policy only addressed procedures after a resident was established as missing, with no guidance on staff response to an activated wander management alarm when no missing resident had yet been identified.
Failure to Implement Comprehensive Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to provide evidence of a comprehensive Water Management Program (WMP) necessary to prevent the spread of Legionella and other waterborne pathogens in the building water systems. During interviews and document reviews, it was found that the facility did not conduct a risk assessment to identify areas where Legionella and other pathogens could grow and spread. The WMP lacked a detailed description of the building water system, did not specify testing protocols, and omitted acceptable ranges for control measures. The documentation provided was a basic outline and did not include required elements such as a specific risk assessment, a detailed water system diagram, or a building description. A resident with multiple comorbidities, including chronic anemia, urinary retention, chronic kidney disease, and asthma, was admitted to the facility for rehabilitation after a hospital stay for septic shock. The resident later tested positive for Legionella antigen during a subsequent hospitalization for septic shock secondary to acute cystitis and pneumonia. The facility received notification of the positive Legionella case but was unable to provide documentation of a completed risk assessment or a comprehensive WMP at the time of the survey. The infection preventionist confirmed that the risk assessment was started only after the notification of the positive case and had not been completed. Further interviews revealed that the facility manager was unaware of when the current water system diagram was developed and confirmed that no risk assessment had been conducted as part of the WMP. Measures in place, such as water heater temperature logs and ice machine maintenance, lacked documentation of acceptable parameters and specific procedures. The facility relied on annual municipal water quality reports, which were not included in the current plan. The documentation and policies provided did not reflect a coordinated WMP consistent with CDC and ASHRAE standards, and there was a lack of documentation of program activities.
Failure to Implement Legionella Water Management and Monitoring Protocols
Penalty
Summary
The facility failed to implement its infection prevention and control measures for Legionnaires' Disease as outlined in its own Water Management Program and related policies. During an observation and interview with Maintenance, surveyors observed water testing being conducted only on a first-floor bathroom sink for pH, chlorine level, and temperature using a test strip and thermometer. Review of the Monthly Potable Water Log from late August 2024 through late November 2025 showed that pH, chlorine, and temperature monitoring was documented only for the first floor, even though the facility policy required testing pH in five sinks/showers per floor on a monthly basis. The Water Temperature Log did show daily temperature checks on all floors, but pH and chlorine testing were not performed or documented for upper floors. When questioned, Maintenance acknowledged that all floors should have been tested, monitored, and documented for pH and chlorine levels. Further observations and interviews revealed additional failures related to Legionella control. During a tour of the decorative water fountain at the front of the facility, Maintenance reported that the water pump had been turned off two days earlier and confirmed that the fountain water should be tested for Legionella annually per the facility’s Water Management Program, but this testing was not being done as required. In a subsequent interview, the Infection Nurse and Director of Facilities both confirmed that testing and monitoring for pH, chlorine, and water temperature should have been conducted on all floors, and that the decorative water fountain, where Legionella and other opportunistic waterborne pathogens can grow and spread, should have been tested. Review of the facility’s policy "Infection Prevention & Control Legionnaires' Disease" showed requirements for monthly pH monitoring in five sinks/showers per floor, annual Legionella testing of potable water, daily cleaning and disinfecting of decorative water features, Legionella culture testing of decorative water features by Maintenance, and monthly ice machine cleaning, all of which were not being fully implemented as observed and documented by surveyors.
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 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.
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.
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