Kalakaua Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1723 Kalakaua Avenue, Honolulu, Hawaii 96826
- CMS Provider Number
- 125066
- Inspections on file
- 19
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Kalakaua Gardens during CMS and state inspections, most recent first.
Kitchen staff failed to follow dishwasher sanitizing requirements, with final rinse temperatures logged below the machine’s required 180 degrees F. Staff also left prepared foods uncovered and unlabeled, kept meats past the facility’s discard-by date, and left opened beverages without opened-on dates, including soy milk that was to be used within 7 to 10 days once opened.
Unsanitary Ice and Water Machines: Surveyors observed hardened dark brown sediment/material around the bottom edges of the plastic chute on the 4th and 5th floor ice/water machines used by residents, staff, and visitors. The DON confirmed the 4th floor machine was not clean, and the EVSM stated housekeepers only cleaned the drip tray and front portion, not the inside, and that there was no cleaning log for either machine.
Surveyors found respiratory equipment left uncovered, undated, or improperly stored for multiple residents receiving oxygen, nebulizer treatments, and suctioning. In one room, oxygen tubing, a humidifier bottle, and suction equipment were not covered or dated; in two other rooms, nebulizer masks, chambers, and tubing were left uncovered on bedside furniture; and in another room, suction tubing and a yankauer lacked a date label. The DON and RN confirmed the expected storage and labeling practices for this equipment.
A resident was ordered Trazodone HCL 50 mg at bedtime for insomnia, but the EHR, consents, and progress notes did not show that the resident or representative was informed in advance of the medication’s risks and benefits or of treatment alternatives. The DON later confirmed no documentation could be found showing the review had occurred.
Unclean equipment and resident room: A resident receiving hospice care was observed with an unused O2 concentrator covered in dust, heavy dust on the wall behind the headboard, and a suction cannister with clear secretions and tubing that were not dated or labeled. An RN confirmed the concentrator had never been used and verified the dust in the room.
A resident with Parkinson’s disease and non-Alzheimer’s dementia was prescribed PRN quetiapine for hallucinations for 30 days, even though the pharmacy consultant recommended limiting the PRN antipsychotic order to 14 days and reassessing. The MDS showed the resident was severely cognitively impaired and did not have coded hallucinations or behaviors, and the facility policy stated PRN antipsychotic orders are limited to 14 days with no exceptions.
A resident who was cognitively impaired and dependent on staff did not consistently receive resident-centered activities aligned with her interests. Records showed she enjoyed news, music, and watching sports on TV, but observations found her in bed with the TV off while awake, and family reported the remote was not working. Although the care plan and activity sheet listed music and TV/video, the documented daily activity provided was only talking and repositioning.
Incomplete splint order transcription and lack of staff training and follow-up on therapy recommendations: A resident with left hemiplegia and dependent ADL needs had splint/brace orders that were not correctly transcribed to the MAR/TAR, staff described the splint and brace as the same equipment, and documentation of training for additional nursing staff could not be provided. Therapy also recommended a left palm splint, but follow-up with the MD and nursing documentation for that recommendation were not found.
Medication carts were not stored and locked properly. An RN found individually sealed Vancomycin, Cephalexin, and Midodrine doses in a cart without the required labeling information, and stated some doses should have been discarded while extra Midodrine doses were pulled from the ADC and stored for later use. Another medication cart was observed left unlocked, and the DON confirmed carts must be locked before staff leave them.
Therapy services did not follow a physician order for a resident with a left femur fracture who was ordered NWB and no ROM to the left distal femur. PT was provided to both lower extremities, including stretches and active/passive ROM to the left leg, and the TD confirmed no new order had been received and that the therapy documentation showed movement performed despite the restriction.
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.
A resident experienced two falls due to inadequate supervision in the bathroom. Initially, the resident was left unattended, resulting in a fall and fractures. Despite recommendations to prevent future falls, the care plan was not updated, leading to a second fall with head injuries. The DON confirmed the care plan was not revised, acknowledging the second fall could have been avoided.
The facility was found to have deficiencies in food handling and storage practices. Boxes of food were improperly stored on the floor, and a container of tuna salad was used beyond the facility's policy limit. Additionally, staff were observed not wearing required hair restraints in the kitchen. These issues indicate non-compliance with professional standards for food safety.
A resident with multiple diagnoses, including hemiplegia and dysphagia, was found with an open wound on the right buttock due to a lack of a person-centered care plan. The care plan required two-person assistance for peri-care, but a CNA was observed providing care alone. The comprehensive care plan did not address the resident's functional abilities or include interventions to prevent skin integrity issues. The DON confirmed the care plan's deficiencies.
A resident experienced two falls in the bathroom due to the facility's failure to update their care plan with necessary interventions after a significant change in condition. Despite recommendations to accompany the resident to the restroom, they were left unattended, resulting in injuries including a head laceration and fractures.
The facility failed to ensure that QC solutions used for glucose meter testing were not expired. During an inspection, a pouch with a glucose meter, test strips, and two QC solutions was found, with the solutions being past their use-by date. An RN confirmed that QC testing is done daily and that the expired solutions were used, as indicated by the QC log. The DON provided documentation stating that control solutions should be discarded 90 days after opening or upon expiration.
The facility failed to follow up on an out-of-range temperature recording for a medication refrigerator, risking the effectiveness of stored medications. The Director of Nursing acknowledged the oversight, suggesting the recording might have been an error. Facility policy requires proper storage and temperature monitoring, which was not adhered to in this instance.
A facility failed to maintain complete and accurate medical records for a resident admitted for hospice care. The baseline care plan was dated four days after admission and lacked the name of the staff member and completion date. Interviews revealed delays and discrepancies in documentation, potentially affecting all residents.
A resident with a complex medical history experienced a decline in condition due to nursing staff's failure to recognize and report changes in consciousness, administer oxygen timely, and notify the physician about held blood pressure medication. The resident was transferred to the hospital with sepsis and fluid overload and later passed away. Interviews revealed inconsistencies in notifying physicians about changes in residents' conditions.
A facility failed to involve a resident's representative in decisions regarding an advance health care directive (AHCD). The resident, with cognitive deficits due to dementia, was documented as agreeing to a full code status, despite being incompetent to make such a decision. A conflicting DNR order was also present. The facility's policy requires staff to verify and document the resident's wishes, involving the representative if necessary, but the resident's representatives were not notified or involved in the process.
A facility failed to include a resident's representative in the care planning process and did not have the resident's physician attend IDT meetings. The resident, admitted for therapy after a stroke, was confused and unable to understand the meeting content. Although a baseline care plan was reviewed with family members, there was no documentation of their invitation to the IDT meeting, and the physician's absence was noted.
A resident's care plan was not updated to include new diagnoses and treatments, such as dehydration, UTI, IV fluids, antibiotics, and a PICC line, following a stroke. Facility staff confirmed that the care plan should have been revised by the nurse who received the new orders or initiated the therapy, highlighting a lapse in protocol.
A facility failed to ensure a resident received a required face-to-face physician visit within 30 days of admission. The resident, admitted for therapy after a stroke, did not have an in-person evaluation, as confirmed by staff and the physician. Instead, telemedicine or phone consultations were used, inaccurately documented as face-to-face encounters. The resident was later transferred to a hospital and expired. Nursing notes suggested the physician's presence, but lacked corresponding documentation.
Kitchen Food Safety and Labeling Failures
Penalty
Summary
The facility failed to follow the dishwasher manufacturer’s sanitizing guidelines for dishware and utensils. During the initial kitchen tour, the dishwasher was observed to be an American Dish Service Corporation Model ADC-44 multi-tank rack conveyor dishmachine. The dishwasher/warewashing log showed final rinse temperatures ranging from 110 to 185 degrees Fahrenheit over the reviewed period, while the machine’s NSF data plate stated that the hot water sanitizing final rinse minimum temperature was 180 degrees Fahrenheit. The dishwasher staff stated they recorded temperatures from the machine thermometers and did not use test strips, and the Dining Services Director stated the logs were reviewed at the end of the month and that the vendor had not explained how to use temperature strips to verify the required temperatures. The facility also failed to label opened beverages and prepared foods and failed to discard meats by the facility’s discard-by date. In the refrigerator, sliced mushrooms, loose spinach, grated cheese, chopped red bell peppers, chopped tomatoes, and chopped onions were found uncovered and not labeled with the date they were prepared. Two large containers of chopped Portuguese sausage and chopped ham were dated 2/9, and the Dining Services Director stated these should have been thrown away because they had been kept for one week. An opened container of orange juice and an opened container of soy milk were also found without an opened-on date, and the soy milk container stated it should be refrigerated and used within 7 to 10 days once opened.
Unsanitary Ice and Water Machines
Penalty
Summary
The facility failed to ensure that 2 of 2 resident ice and water machines were kept in clean and sanitary condition in accordance with professional standards for food service safety. On 02/17/26 at 10:35 AM, surveyors observed a buildup of hardened dark brown sediment/material around the bottom edges of the plastic chute dispensing ice and water from the machine in the 4th floor dining room. The same condition was observed again on 02/18/26 at 08:33 AM at that same machine. On 02/18/26 at 08:37 AM, the DON was interviewed at the 4th floor machine and confirmed the hardened dark brown sediment/material was present and stated the machine was not clean. The DON stated Maintenance was responsible for cleaning the ice/water machine. At 08:44 AM, the EVSM stated housekeepers cleaned the drip tray and front portion of the machine but not way inside. On 02/18/26 at 08:53 AM, surveyors observed hardened dark brown sediment/material around the bottom edge of the plastic chute on the 5th floor dining room ice/water machine. On 02/19/26 at 06:40 AM, the EVSM confirmed the presence of the hardened dark brown sediment/material on both the 4th and 5th floor machines and stated there was no cleaning log for either machine.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to ensure respiratory equipment was maintained within professional standards of practice for 4 residents sampled for respiratory/tracheostomy care and suctioning. In R12’s room, surveyors observed an undated humidifier bottle with undated tubing connected to an oxygen concentrator, uncovered oxygen tubing connected to an oxygen tank beside the bed, and an uncovered yankauer suction tip catheter attached to suction tubing and connected to the suction machine, hanging down and leaning against the bedside dresser. R12 had active physician orders for suctioning orally as needed for increased secretions and oxygen at 1-4 liters per nasal cannula for shortness of breath. In R45’s room, surveyors observed an uncovered mask with attached medication chamber and undated tubing connected to the nebulizer machine on the bedside dresser, and R45 had an active order for ipratropium-albuterol solution via nebulizer as needed for shortness of breath or wheezing. In R24’s room, surveyors observed an uncovered and dry nebulizer mask with medication chamber on a paper towel next to the nebulizer machine with uncovered tubing attached on the bedside dresser, and R24 had active orders for sodium chloride inhalation nebulization solution and ipratropium-albuterol inhalation solution via nebulizer as needed. In R26’s room, surveyors observed a suction cannister with clear secretions and tubing connected to a yankauer placed in a nightstand drawer without a date label. RN17 stated the yankauer was used by CNAs for oral care and that the tubing should be labeled when changed, but the inspected suction equipment had no date label on the tubing or yankauer wrapper.
Failure to Document Informed Consent for Trazodone
Penalty
Summary
The facility failed to inform 1 of 5 residents, R2, of the risks and benefits of taking Trazodone HCL 50 mg at bedtime for insomnia and did not document that R2 or his representative was informed in advance of the medication or of treatment alternatives. During record review on 02/19/26, R2's EHR showed an order for Trazodone HCL 50 mg, one tablet by mouth at bedtime for insomnia, but review of consents and progress notes did not reveal documentation that the risks and benefits were reviewed or that other options were offered. When the DON was asked for documentation showing that the facility reviewed the risks and benefits of Trazodone with R2 or his representative, she confirmed later that no such documentation could be found and stated this should have been done.
Unclean equipment and resident room
Penalty
Summary
The facility failed to provide clean personal care equipment and a clean living space for Resident 26, who was asleep in bed and receiving hospice care. During observation, an oxygen concentrator that was not being used was found in the corner next to the bed with dust on top of the unit, and thick dust was observed on the wall behind the resident's headboard. On the nightstand beside the bed, a suction cannister containing clear secretions and tubing connected to a yankauer were observed without a date or label, and there was no date or time written on the wrap or tubing. The RN stated that the resident had never used the oxygen concentrator, that hospice had ordered it and the medical supplier brought it to the room, and that staff could clean the machine if it was dusty while the medical supplier would provide maintenance. The RN later observed the room and verified the heavy dust on the equipment and wall.
PRN Antipsychotic Ordered Beyond Allowed Duration
Penalty
Summary
The facility failed to ensure that one resident sampled for unnecessary psychotropic medication was not prescribed a PRN antipsychotic medication for longer than 14 days. Resident 3, an elderly male admitted to the facility with Parkinson’s disease and non-Alzheimer’s dementia, was receiving quetiapine for mild, moderate, and severe hallucinations. The Medication Regimen Review dated 01/31/26 included a recommendation to order the PRN antipsychotic for no more than 14 days and then reassess, but the physician wrote a 30-day order and signed it on 02/05/26. The physician orders showed quetiapine fumarate 25 mg tablets ordered PRN every 12 hours for mild hallucinations and PRN every 12 hours for moderate to severe hallucinations, each for one month. The MDS dated 01/04/26 indicated the resident was severely cognitively impaired and did not have delusions, hallucinations, or behaviors coded on the assessment. The DON stated the pharmacy consultant reviews the drug regimen monthly and that recommendations are placed in a binder for the physician to review, and the pharmacy consultant confirmed the recommendation was for no more than 14 days with reassessment. The facility policy stated PRN antipsychotic orders are limited to 14 days with no exceptions.
Resident-Centered Activities Not Implemented for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement resident-centered activities based on a resident’s interests for 1 of 2 residents sampled for activities. Resident 44 was observed multiple times in her room in bed with the television off and the room quiet while she was awake. She was non-verbal and smiled during observation. A family member stated that the resident really seemed to engage with the TV and wished it could be turned on because there was something wrong with the remote. Record review showed that Resident 44 was cognitively impaired and dependent on staff for care. Her MDS indicated it was very important to her to keep up with the news and somewhat important to listen to music she liked. The care plan listed that she enjoyed 1:1 room visits, talking with staff, listening to music, and watching TV. Social services documented that a nephew requested a work order for the resident’s TV because she seemed to enjoy watching sports and followed along with the TV, but it was not always working. During a later observation, a nurse turned on the TV to a sports channel, and the resident smiled when the volleyball match appeared. The activity participation task flow sheet listed music and TV/video, but only talking and repositioning were checked each day.
Incomplete splint order transcription and lack of staff training and follow-up on therapy recommendations
Penalty
Summary
Nurses and nurse aides did not have the appropriate competencies to care for a resident with left hemiplegia following cerebral infarction and dependent ADL needs. Resident 37 was observed sleeping in bed with his left arm and leg bent, and two braces were seen on the shelf near his bedside. Review of his physician orders and February 2026 MAR/TAR showed that the active orders for a left elbow orthosis splint and a left knee contracture splint were transcribed and signed off, but the 03/08/24 order for the left knee contracture splint to be worn 3 times a week for a total of 4 hours was not transcribed to the MAR/TAR. The DON confirmed that the newer splint orders should have replaced the older brace orders on the MAR/TAR. RN16 stated that the left elbow and knee splint were both applied daily in the daytime for 2 hours and that the splint and brace were the same equipment. The TD stated that therapy training on recommended equipment was done with the RNA or nurse on duty, and the DON stated additional nursing staff would be trained using a train-the-trainer method, but documentation of training with additional staff could not be provided. Therapy also completed a communication form recommending a left palm splint for up to 8 hours daily after OT ended, and RN11 signed the form as receiving instructions. However, the DON stated follow-up with the physician regarding the left palm splint recommendation was not done, and nursing documentation regarding the left palm splint and physician orders to use it could not be found.
Medication carts left unlocked and unlabeled doses stored improperly
Penalty
Summary
Medications in 2 of 4 medication carts were not stored and locked in accordance with professional standards. On 02/19/26 at 07:43 AM, the 4th floor medication cart B was inspected with RN 16 present, and the first drawer contained three individually sealed capsules of Vancomycin Hydrochloride 125 mg and one individually sealed capsule of Cephalexin 250 mg in a container that also held sealed Acetaminophen and Bisacodyl suppositories. The individually sealed capsules were not stored in packaging with the minimum information required, including the medication name, prescribed dose, strength, expiration date when applicable, resident name, and route of administration. RN 16 stated he did not know which resident the Vancomycin and Cephalexin were prescribed for, why they were stored individually in the container, and said the medications should have been discarded. In another compartment of the same cart drawer, two individually sealed capsules of Midodrine 2.5 mg were found in a medication cup. RN 16 stated an order had been received on 02/18/26 to start Midodrine 2.5 mg three times daily for a resident, and that three doses were pulled from the automated medication dispensing cabinet, with one dose given that evening and the other two doses stored in the cart for the next day because delivery was not expected until later. RN 16 acknowledged it was not good practice to pull multiple doses and store them in the medication cart without labeling for the resident or administration instructions. On 02/17/26 at 01:07 PM, another 4th floor medication cart was observed left unlocked, and RN 7 confirmed it should have been locked. The DON later confirmed that medication carts are to be locked before nurses leave them and that extra doses should not be pulled and stored in the cart.
Therapy Did Not Follow Physician ROM Restrictions
Penalty
Summary
Therapy services failed to follow a physician-ordered restriction for a resident with an unspecified fracture of the left femur managed non-operatively. The resident re-entered the facility from the hospital with an order dated 02/26/25 for non-weight bearing (NWB) and no range of motion (ROM) for the left distal femur fracture. Record review and interviews showed that physical therapy was provided from 04/29/25 through 06/27/25, and ROM was performed to the resident’s bilateral lower extremities, including the ankle, knee, and hip. The Therapy Director confirmed that no new order had been received during that therapy period and that the physician orders should have been checked for restrictions before therapy began. She also confirmed that the therapy notes documented movement to the resident’s left leg in the form of stretches and active and passive ROM. After therapy ended, a Therapy to Restorative Nursing Communication dated 06/27/25 recommended everyday ROM, and the Therapy Director stated that the recommendation should have been more specific about which extremities were to receive ROM.
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.
Failure to Update Care Plan Leads to Repeated Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent a second fall for a resident, resulting in physical injuries. Initially, the resident was left unattended in the bathroom by a CNA, leading to a fall where the resident hit her head against the wall and sustained a right superior and inferior ramus fracture, along with skin tears. The facility's Fall Scene Investigation Tool identified the root cause as the resident's loss of balance while getting off the toilet, with a recommendation that the resident should not be left unattended in the bathroom. Despite these recommendations, the resident's comprehensive care plan was not updated to include these interventions. Consequently, the resident experienced a second fall when left unattended again, resulting in a head injury requiring sutures, a skin tear, and multiple bruises. The Director of Nursing confirmed that the care plan was not revised to prevent a similar fall, acknowledging that the second fall could have been avoided if the resident had not been left unattended.
Food Handling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food handling and storage, as observed during a survey. During an initial tour of the kitchen, six boxes of various food items were found on the floor of the dry storage area, and five boxes were on the floor of the walk-in freezer. The Dietary Director (DD) confirmed that these items should not have been on the floor and attributed the issue to a recent delivery. Additionally, a large metal pan with partially covered cooked noodles was stored in the refrigerator, which the DD explained was due to the noodles being hot when placed inside. Furthermore, a container of tuna salad dated 01/08/25 was found in the refrigerator, and a Dietary Aide (DA2) intended to use it for sandwiches, despite the facility's policy stating that such items should be used within four days. The survey also noted that the DD and a Dietary Aide (DA1) were not wearing required hair restraints while in the kitchen area. The DD acknowledged this oversight and immediately took corrective action by obtaining a hairnet. These observations indicate a lack of compliance with the facility's policies and procedures regarding food storage, handling, and personal hygiene, potentially affecting the safety and quality of food served to residents, visitors, and staff.
Deficient Care Plan Implementation for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was person-centered and implemented for a resident, leading to a risk of more than minimal harm. During an observation, a resident was found lying in bed with a wedge partially under their right hip, and an open wound was observed on the right buttock. The Certified Nurse Aide (CNA) providing care was unaware of the wound and mentioned that a wedge was being used to offload the resident's weight. The resident's family member confirmed that the resident did not have an open wound upon admission. A review of the resident's electronic health record revealed that the resident was admitted with diagnoses including hemiplegia, hemiparesis, pneumonitis, dysphagia, and atrial fibrillation. The baseline care plan required two-person assistance for peri-care, but the CNA was observed providing care alone. The comprehensive care plan did not include the resident's functional abilities or the necessary staff assistance. It documented potential skin integrity issues but lacked interventions to prevent the worsening of the open area or the development of pressure ulcers. An assessment noted Moisture Associated Skin Damage (MASD) on the intergluteal cleft, which was in-house acquired. The Director of Nursing confirmed that the care plan was not person-centered and did not include the resident's functional abilities, which should have been addressed.
Failure to Revise Care Plan Leads to Resident Harm
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan with person-centered interventions following a significant change in condition assessment. This deficiency resulted in the resident being physically harmed on two occasions. Initially, the resident was left unattended in the bathroom by a CNA, leading to a fall from the toilet. The resident sustained a head injury and fractures as a result of this incident. Despite the facility's Fall Scene Investigation Tool identifying the need for the resident to be accompanied to the restroom and not left unattended, these recommendations were not incorporated into the resident's care plan. Subsequently, the resident experienced a second fall in the bathroom under similar circumstances, where they were again left unattended. This fall resulted in a head laceration requiring sutures, as well as additional bruises and skin tears. The Director of Nursing confirmed that the care plan was not updated to prevent such incidents, acknowledging that the second fall could have been avoided if the resident had not been left unattended.
Expired QC Solutions Used for Glucose Meter Testing
Penalty
Summary
The facility failed to ensure that the supplies used for Quality Control (QC) testing of the blood glucose meter were not expired or beyond their discard date. During an inspection of a medication cart, a pouch containing a glucose meter, test strips, and two QC solutions was found. The QC solutions had a green sticker indicating an open date and a use-by date, which had already passed. Registered Nurse (RN)12 confirmed that QC testing is performed daily by the night shift nurse and acknowledged that the QC solutions were beyond their stated use-by date and would be discarded. Upon reviewing the QC log, RN12 confirmed that the staff had used the expired QC solutions, as the lot number matched the log. The Director of Nursing (DON) provided a document stating that unused control solutions should be discarded 90 days after first opening or after the expiration date.
Failure to Follow Up on Out-of-Range Temperature in Medication Refrigerator
Penalty
Summary
The facility failed to follow up on an out-of-range temperature recording for a medication refrigerator, which was observed during a survey. On the specified date, several medications were stored under temperature control, and the temperature log for the refrigerator showed an out-of-range recording that was neither followed up on nor reported. This oversight was acknowledged by the Director of Nursing (DON) during a staff interview, who suggested that the out-of-range temperature might have been recorded in error. The facility's policy on the storage of medications requires that medications and biologicals be stored properly, following manufacturers' or provider pharmacy recommendations, to maintain their integrity and ensure safe, effective drug administration. The policy also mandates that medications requiring refrigeration be kept within a specific temperature range, with a temperature log maintained to verify compliance. Despite these requirements, the facility did not adhere to its policy, as evidenced by the lack of follow-up on the out-of-range temperature recording, posing a risk to the effectiveness of the stored medications.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident admitted for hospice care. The resident's baseline care plan, which is a critical component of their medical record, was found to be incomplete and inaccurately documented. Specifically, the baseline care plan was dated four days after the resident's admission, and it lacked the name of the staff member who completed it and the date of completion. This discrepancy was identified during a review of the resident's Electronic Health Record (EHR), where it was noted that the baseline care plan was scanned into the EHR four days post-admission, contrary to the facility's practice of completing it on the day of admission. Interviews with the Medical Records Specialist and a Registered Nurse revealed further issues with the documentation process. The Medical Records Specialist confirmed that the baseline care plan was scanned into the EHR after her return to work, indicating a delay in documentation. The Registered Nurse, who admitted the resident, was unable to provide documentation confirming that the baseline care plan was completed within 48 hours of admission. This lack of documentation and adherence to professional standards in maintaining medical records has the potential to affect all residents admitted to the facility.
Nursing Staff Competency Deficiencies Lead to Resident Harm
Penalty
Summary
The facility nursing staff failed to demonstrate the necessary competencies to meet the needs of a resident, leading to a critical situation. The staff did not identify a change in the resident's level of consciousness, failed to report the trend of high blood pressure medication being held due to low blood pressure, administered medication twice when it should have been held, and did not administer oxygen timely or notify the physician when the resident's oxygen level remained below the required threshold. These deficiencies resulted in the resident's changing condition not being recognized and reported to the physician, preventing timely interventions. The resident, a female with a complex medical history including hyperlipidemia, chronic kidney disease, atrial fibrillation, and dementia, was admitted to the facility for short-term rehabilitation following a stroke. During her stay, the resident experienced a decline in her condition, including lethargy and low oxygen saturation levels, which were not adequately addressed by the nursing staff. The resident's medication administration records showed that her blood pressure medication was held multiple times due to low readings, yet the physician was not consistently notified of these occurrences. Additionally, the resident's oxygen saturation levels were not monitored as frequently as required, and oxygen was not administered promptly when levels dropped below the target. Interviews with nursing staff revealed inconsistencies in the practice of notifying physicians about changes in residents' conditions, such as low blood pressure or changes in consciousness. The Assistant Director of Nursing acknowledged the lack of a clear policy for notifying physicians when blood pressure medication is held. The resident's condition deteriorated, leading to her transfer to the hospital, where she was diagnosed with sepsis and fluid overload and subsequently passed away. The failure to recognize and act on the resident's changing condition highlights significant deficiencies in the facility's nursing care practices.
Failure to Involve Resident's Representative in Advance Directive Decisions
Penalty
Summary
The facility failed to provide information to a resident's representative about the right to formulate an advance health care directive (AHCD). The resident, who was admitted for short-term therapy following a stroke and had cognitive deficits due to dementia, was documented as having been provided with advanced directive information and agreed to a full code status. However, the resident was not competent to make such a decision, and her representative was not involved in the process. Additionally, there was a conflicting physician order for do not resuscitate (DNR) upon admission, which was not aligned with the documented full code status. The facility's policy on resident rights and advanced directives requires staff to verify and document the resident's wishes regarding advance directives, involving the resident's representative if necessary. Despite this, the interdisciplinary team meeting documentation showed that the resident's representatives were not invited or notified, and the resident, who could not understand the meeting content, was in attendance. The social services staff member involved could not recall the meeting, indicating a lack of adherence to the facility's policy and procedures for ensuring the resident's wishes were accurately communicated and documented.
Failure to Include Resident's Representative in Care Planning
Penalty
Summary
The facility failed to include a resident's representative in the development of a comprehensive care plan and did not have the resident's physician attend the interdisciplinary team (IDT) meetings. The resident, a female admitted for short-term physical and occupational therapy following a stroke, had a history of Alzheimer's, hypertension, atrial fibrillation, and other conditions. Upon admission, she was confused and oriented only to herself. Although a baseline care plan was developed and reviewed with the resident's family members on the day of admission, the IDT meeting held shortly after did not include the resident's representatives, and there was no documentation that they were invited or notified. The IDT meeting documentation indicated that the resident attended, but due to her confusion, she would not have been able to understand the meeting's content. The facility's social services staff acknowledged that the usual practice is to invite family members to a welcome meeting within a few days of admission, but there was no documentation to confirm that this occurred. Additionally, the resident's physician did not attend the IDT meetings, and the facility could not provide documentation of a subsequent meeting with the family member.
Failure to Update Care Plan with New Diagnoses and Treatments
Penalty
Summary
The facility failed to ensure the timely revision of a resident's care plan to include changes in therapy and new diagnoses, compromising the continuity of care and communication with the resident and family. The resident, an elderly female admitted for short-term physical and occupational therapy following a stroke, experienced several changes in her medical status during her stay. These changes included diagnoses of dehydration and a urinary tract infection (UTI), requiring treatments such as intravenous fluids and antibiotics, as well as the placement of a PICC line due to IV infiltration. Despite these significant changes, the resident's care plan was not updated to reflect the new diagnoses or the associated treatments. Interviews with facility staff, including the Assistant Director of Nursing and a Registered Nurse, confirmed that the care plan should have been revised by the nurse who received the new orders or initiated the therapy. The failure to update the care plan with the new diagnoses and treatments was acknowledged by the staff, indicating a lapse in the facility's protocol for maintaining accurate and current care plans.
Failure to Conduct Required Physician Face-to-Face Visit
Penalty
Summary
The facility failed to provide evidence that a resident received the required physician face-to-face initial comprehensive visit within 30 days of admission. The resident, an elderly female with a history of Alzheimer's, hypertension, atrial fibrillation, orthostatic hypotension, muscle weakness, and age-related physical debility, was admitted for short-term physical and occupational therapy following a stroke. Despite the requirement for a face-to-face evaluation, the physician did not conduct such a visit, as confirmed by interviews with nursing staff and the physician himself. The physician admitted to using telemedicine or phone consultations instead of in-person visits, which was not documented accurately in the progress notes. The resident was transferred to an acute care hospital for a change of condition and later expired. The progress notes for the resident's admission and transfer were in a template format, indicating a face-to-face encounter that did not occur. Nursing progress notes suggested the physician was present in the facility on certain dates, but there were no corresponding physician notes to confirm these visits. This discrepancy highlights the facility's failure to ensure that the resident's needs were met through proper physician evaluations, potentially affecting all new admissions.
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Multiple failures to maintain resident dignity and timely care were identified, including a resident left waiting over an hour for assistance to urinate despite documented mobility deficits, and two residents with indwelling urinary catheters whose drainage bags were left uncovered and visible from the hallway contrary to facility policy. During a Resident Council meeting, residents reported that certain CNAs did not consistently provide basic morning hygiene, ignored or delayed responses to call lights, and sometimes turned off call lights after learning a request involved incontinence care without returning, resulting in residents remaining soiled for extended periods and care being left for the next shift.
Staff failed to keep call systems within reach for three LTC residents who were incontinent and dependent on staff for ADLs, including residents with arthritis, bipolar disorder, chronic pain, stroke with one-sided impairment, and hemiplegia/hemiparesis. Surveyors observed call lights and call pads placed toward the head of the bed, behind the bed on a light fixture, or hanging on the wall above the bed, all out of the residents’ reach during multiple observations. These practices did not follow the facility’s policy requiring call lights to be within reach and accessible while residents are in bed.
Multiple rooms on one unit were found with environmental deficiencies, including broken and unsecured electrical outlets, damaged and stained walls and ceilings, improvised extensions on light cords using a plastic bag and a washcloth, dripping and constantly running sink faucets with discolored grout, and a strong urine odor in one room. A review of work orders and an interview with the Facilities Director showed that only two work orders had been submitted for this unit, both generated after surveyor observations, indicating that unit staff had not routinely initiated maintenance requests for these conditions.
The facility failed to adequately inform and assist multiple residents with Advance Health Care Directives (AHCDs). One resident requested an AHCD form but received no documented follow-up or assistance, and this issue was not addressed in later interdisciplinary team meetings. Another resident had a Five Wishes AHCD document on file that lacked required witness signatures, despite clear instructions that witnessing was necessary for validity. A third resident initially declined an AHCD, but the facility did not periodically revisit the discussion, and the resident later reported that no one had discussed AHCDs with him and expressed a desire to complete one.
Surveyors observed that the lab specimen refrigerator had brown stains on the door and bottom shelves and multiple small dead bugs on the door shelf, demonstrating that staff failed to maintain a clean environment in an area used for specimen storage. The Infection Prevention Nurse acknowledged the refrigerator was dirty.
Surveyors found that the facility failed to develop and maintain comprehensive care plans for two residents, one receiving an anticoagulant and psychotropic meds for vascular dementia with agitation, and another with a history of sacral pressure ulcers and a high Braden risk score. The first resident’s care plan did not address anticoagulant use or dementia-related care despite active orders and facility policy requiring individualized dementia care planning. The second resident’s care plan lacked any pressure ulcer prevention or management interventions, even though prior sacral ulcers had healed with documented preventive measures in place and the ulcer later reopened; staff confirmed the resident’s high risk and the absence of an active pressure injury prevention care plan during that time.
The facility failed to revise care plans for two residents to reflect current care needs and behaviors. One resident with multiple cardiac and pulmonary conditions, including HF, AFib, and COPD, reported frequent self-connection to a bedside pacemaker monitoring device known to staff, yet the comprehensive care plan contained no interventions or instructions regarding this monitoring. Another resident with CHF, alcohol-induced dementia, MRSA carrier status, and psychotic disorder was repeatedly observed with large urine puddles on the bedroom floor, and an RN stated that this resident urinated on the floor regularly and therefore had a private room, but the active care plan only addressed scheduled toileting and episodes of voiding in a trash can, without documenting the ongoing behavior of urinating on the floor.
A deficiency was identified in which three residents did not receive care according to professional standards and their care plans. One resident with severe cognitive impairment and multiple comorbidities experienced an acute change in condition, but staff did not perform or document ongoing neuro checks or vital sign and O2 monitoring after the initial assessment and were unable to initiate ordered IV fluids. Another resident with CHF, alcohol-induced dementia, and behavioral issues was repeatedly found with large puddles of urine on the floor, while behavior and continence documentation did not capture these episodes, and no scheduled toileting or bladder program was implemented despite assessments and facility policy indicating the need. A third resident on hospice with open shin lesions had physician orders for every-other-day and PRN wound dressings, yet was observed on multiple occasions without a dressing in place, even though the TAR reflected that treatments had been completed and nursing staff could not explain the discrepancy.
A resident with limited mobility, multiple chronic conditions, and a history of a recent unwitnessed fall was care planned as a one-person assist for ambulation using a device. On observation, the resident was moving rapidly down the hall with a front-wheel walker, calling out to staff, wearing an open gown with no underwear, no foot coverings, and with a left lower leg/foot dressing coming undone and visibly soaked with blood. The only staff present, an RN at the med cart, repeatedly instructed the resident to return to her room but did not stop to provide hands-on assistance or ensure safe return, despite the documented requirement for one-person assist. The unit manager confirmed that the resident required one-person assistance and that the RN should have helped her back to her room.
A resident receiving short-term rehab with an indwelling urinary catheter was observed in a wheelchair with the catheter drainage bag hung under the seat and touching the floor, despite facility documentation requirements that staff verify each shift that privacy bags are in place and drainage bags are not on the floor. An RN confirmed that catheter bags are not supposed to touch the floor, indicating a failure to follow established catheter care and infection control practices.
Failure to Maintain Resident Dignity, Privacy, and Timely Response to Care Needs
Penalty
Summary
The deficiency involves multiple failures to honor residents’ rights to dignity, respect, and timely assistance with care needs. One resident reported that after an activities session she informed staff she needed to urinate but was told to wait; staff did not return for over an hour, and it was the next shift that ultimately assisted her. She stated she did not feel treated with respect or dignity. Her electronic health record showed diagnoses including diabetes, chronic kidney disease, chronic pain, borderline personality, and schizoaffective disorder, and her care plan documented mobility and self-performance deficits due to significant muscle weakness and debility. Surveyors also observed two residents with indwelling urinary catheters whose drainage bags were positioned facing the bedroom door and visible from the hallway without privacy bags in place, despite multiple observations over several hours. The RN and DON both confirmed that catheter drainage bags should always be covered with privacy bags, and facility policy on catheter care and promoting/maintaining resident dignity required catheter bags to be covered at all times while in use and that staff maintain resident dignity and respect resident rights. During a Resident Council meeting, residents reported that certain CNAs did not consistently respond to care needs, did not provide basic morning hygiene such as wiping faces and hands, and sometimes turned off call lights after asking if the need involved urine or bowel movement without returning to provide incontinence care, leaving care for the next shift. Two residents reported remaining in their bowel movements for about one and a half hours after lunch when staff did not return after call lights were activated, and one resident stated staff respond more quickly when the bathroom call light is used.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failing to ensure that resident call systems were within reach for multiple residents who were dependent on staff for activities of daily living. One resident with arthritis, bipolar disorder, chronic pain, and total bowel and bladder incontinence was observed in bed with her call light cord positioned toward the head of the bed and out of her reach; when asked, she confirmed she could not reach it and requested that it be moved closer. Another resident with a history of stroke and one-sided impairment, who was incontinent and dependent on staff for ADLs, was observed lying in bed without access to the gray call pad, which was hanging on a light fixture behind the bed; he stated he was able to use the call pad, but it was not placed where he could reach it until a CNA later repositioned it. A third resident with hemiplegia and hemiparesis affecting the left non-dominant side, impaired left upper extremity, and functional limitation in upper extremity range of motion was repeatedly observed lying comfortably in bed while the call light was left hanging on the wall above the bed and out of reach. This resident was able to communicate verbally and move the right upper extremity, but the call light remained out of reach during multiple observations on different days and times. Review of the facility’s policy titled “Call Light: Accessibility and Response” showed that staff were required to ensure the call light was within reach of the resident and accessible while the resident was in bed, which was not followed in these instances.
Failure to Maintain Homelike and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Pensacola 1 unit, as evidenced by multiple environmental deficiencies observed in six resident rooms. In one room, a wall clock was broken with a large piece missing and several white patches were visible on the wall. Another room had multiple large brown marks of unknown substance on the wall that were immediately visible upon entry. A separate room had a loud, constant buzzing noise whenever the bathroom light was turned on. Additional observations included several visible water marks on a ceiling, a broken electrical plug plate, and a heavily damaged wall behind a bed. Other rooms showed further environmental issues, including a wall light over a bed that had a cord extended with a plastic bag so the resident could reach it, and an electrical outlet at the head-of-bed wall that was not secure and was visibly coming out of the wall. One room had a dripping sink faucet and very discolored grout around the sink, while another had a strong smell of urine. Yet another room had a sink faucet that was constantly running, and one bed area had a washcloth attached to the light cord to extend its reach and six large screws or hooks in the wall. Interview with the Facilities Director revealed that unit staff were expected to complete work orders for needed repairs, but only two open work orders existed for this unit, both related to issues reported during the survey, indicating that routine work orders had not been submitted by unit staff for the observed problems.
Failure to Inform and Assist Residents With Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to properly inform and assist residents with formulating Advance Health Care Directives (AHCDs) and to ensure that existing AHCD documents were validly executed. For one resident (R17), the EHR showed that AHCD information was discussed and the resident requested a blank AHCD form on 04/14/25. However, there was no subsequent documentation that the resident completed an AHCD or that the facility provided follow-up assistance after that date. The Social Services Assistant (SSA) confirmed there was no follow-up documentation, and the most recent interdisciplinary team meeting record for this resident contained no reference to AHCD follow-up. For another resident (R170), the facility obtained a completed Five Wishes document intended to serve as an AHCD, but the document lacked required witness signatures, despite instructions on the form stating it must be signed and witnessed as directed to be legal and valid. The SSA confirmed the absence of witness signatures. For a third resident (R153), the EHR showed that AHCD information was last discussed on 12/10/24, at which time the resident declined to formulate an AHCD. There was no evidence that the facility revisited the discussion or reoffered assistance after that date. In a subsequent interview, this resident reported that the facility had not discussed an AHCD with him and stated he would like to complete one.
Unclean Lab Specimen Refrigerator Compromises Environmental Cleanliness
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when the lab specimen refrigerator was found to be unclean. During an observation of the refrigerator, brown stains were noted on the door shelf and bottom shelf, and multiple small dead bugs were present on the door shelf. In a subsequent interview, the Infection Prevention Nurse acknowledged that the lab specimen refrigerator was dirty. These conditions demonstrated that the facility failed to maintain a clean environment in the area where lab specimens are stored.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use, Dementia, and Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, individualized care plans addressing all identified needs for two residents. For one resident with vascular dementia and agitation, record review showed an active order for Eliquis 2.5 mg twice daily with instructions to monitor for adverse reactions, but the resident’s care plan did not address the use of this anticoagulant medication. During interview, the MDS RN confirmed that the anticoagulant should have been included in the care plan. The same resident had diagnoses including vascular dementia with agitation and was prescribed psychotropic medications, yet the care plan did not include dementia-related care. The MDS RN verified that dementia care should have been incorporated, despite the facility’s own dementia policy requiring individualized care plans that consider symptoms, disease progression, and co-existing conditions. The second resident had a history of sacral/buttocks pressure ulcers that had previously healed, with APRN documentation that preventive interventions such as scheduled repositioning, pressure-relieving devices, incontinence care, and protective dressings remained in place. A subsequent wound clinic note documented that the prior sacral ulcer site had broken down again, with fat layer exposed, and attributed contributing factors including moisture-associated skin damage and trauma from a shower chair. The resident reported that the wound may have reopened due to prolonged time in a wheelchair without repositioning assistance and stated that staff did not consistently assist with repositioning every two hours as recommended. Review of the care plan revealed no documented interventions for pressure ulcer prevention or management, despite a Braden Scale score of 11 indicating high risk. Nursing staff confirmed the resident was at high risk for pressure ulcer development and that the care plan did not include pressure ulcer prevention interventions, and the MDS RN reported that the pressure injury care plan had been discontinued after healing and was not reinitiated until after the wound reopened, leaving the resident without an active pressure injury prevention care plan during that period.
Failure to Revise Care Plans to Reflect Monitoring Device Use and Recurrent In-Room Voiding
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect current care needs and practices for two residents. One resident with a history of heart failure, paroxysmal atrial fibrillation, cardiomyopathy, stroke, diabetes, and COPD reported during interview that he had a pacemaker and frequently connected himself to a bedside monitoring machine, demonstrating the connection process and stating that staff were aware this was done frequently. Review of his electronic health record and most recent comprehensive care plan showed no interventions or instructions related to the use of this monitoring machine. The unit manager later acknowledged that the care plan had not been revised to include these interventions or instructions. For the second resident, who had a history including CHF, anemia, alcohol dependence with alcohol-induced dementia, MRSA carrier status, and alcohol-induced psychotic disorder with delusions and other behavioral disturbances, surveyors repeatedly observed large puddles of urine on the bedroom floor, including under the bed and in the middle of the floor, accompanied by a strong urine odor. A nurse stated that the puddles were urine and that this resident urinated on the floor all the time, which was the reason he had a private room and could not have a roommate. Review of the resident’s active care plan showed a focus on self-care deficit for toileting with scheduled toileting assistance and a behavioral focus noting episodes of verbal aggression and voiding in the trash can, but it did not include that the resident urinated on the bedroom floor until it was later revised to add that he had daily episodes of urinating on the floor.
Failure to Follow Care Plans, Monitor Changes in Condition, and Implement Toileting and Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and person-centered care plans for three residents. For one resident with a history of stroke, paralysis, aphasia, dysphagia, dementia, seizures, and incontinence, staff did not complete appropriate ongoing assessments and monitoring after a significant change in condition. On the night of the change in condition, the RN documented that the resident was lethargic and unable to respond, with an SBAR note indicating increased stimulation (sternal rub) and stable vital signs at that time. Later documentation showed that IV fluids ordered by the provider could not be started due to difficulty inserting an IV line, and that the resident’s oxygen saturation dropped to 75% on 2 L O2, improving only slightly with increased oxygen. The Unit Manager later confirmed that when he assessed the resident that morning, the heart rate was below 60 and oxygen saturation was 75% on 20 L, and that there were no further neurological assessments or documentation of ongoing monitoring of vital signs or oxygen saturation after the initial change in condition. Another deficiency involved a resident with CHF, alcohol-induced dementia and psychotic disorder, MRSA carrier status, and behavioral disturbances, including voiding in inappropriate places. Surveyors repeatedly observed large puddles of urine on the floor of this resident’s room on multiple days, with a strong urine odor and urine under the bed and in the pathway to the exit. Nursing notes documented multiple episodes of the resident urinating on the floor throughout the month, including descriptions of the floor being urine soaked and housekeeping being called to clean. The resident’s care plan identified self-care deficits in toileting, behavioral issues including voiding in the trash can and on the bedroom floor, and goals to decrease behavioral episodes, with interventions such as offering toileting assistance after waking and meals, ensuring access to a urinal, providing reminders, and assisting with urinal use and emptying. However, behavior monitoring documentation did not reflect these urine-on-floor episodes, and behavior codes for other behaviors were not used. Bladder continence documentation lacked entries on days when urine was observed on the floor, and the 30-day look-back characterized the resident as sometimes continent and sometimes incontinent. Further review of this resident’s bowel and bladder screeners showed that he repeatedly met criteria as a candidate for scheduled toileting (timed voiding), yet the screener indicated that no toileting program was in use. The facility’s bowel and bladder program policy required incontinent residents to be scheduled for elimination tracking and placed on a continence plan, with individualized programs such as scheduled voiding, prompted voiding, or bladder retraining based on cognitive and functional status. Despite this, the MDS documented that no trial of a toileting program had been attempted since urinary incontinence was noted, and the Unit Manager confirmed there had been no evaluation of voiding patterns and no scheduled toileting or bladder program in place. Staff interviews indicated that CNAs documented such episodes simply as incontinence and were not aware of any specific plan to address the resident’s urinating on the floor, while housekeeping reported that the resident urinated on the floor every morning and that she cleaned it at the start of her shift and monitored for further episodes. A third deficiency involved a resident on hospice with a history of acute respiratory failure, muscle weakness, chronic pain syndrome, muscle spasm of the back, major depressive disorder, and Type 2 diabetes with chronic kidney disease, who required assistance with ADLs and had open lesions on the left shin. The physician’s order directed that the left shin be cleansed with normal saline, patted dry, and covered with hydrogel gauze, a non-adherent dressing, and kerlix, secured with tape, every other day and as needed for open lesions. During observation, the resident was seen in bed with a blood-soaked dressing on the left shin and foot, and she reported having open sores due to psoriasis that she picked at. On subsequent observations on two different days, the resident was in bed without any dressing on the left leg. Review of the Treatment Administration Record showed that dressing changes were documented as completed every other day, but there was no documentation on the TAR or in nursing progress notes explaining the absence of dressings on the days observed. The treatment nurse confirmed the wound care order and the documented schedule but could not explain why the resident did not have a dressing on the past two days. Collectively, these findings show that the facility did not ensure that residents received care and treatment according to physician orders, professional standards, and individualized care plans. For the first resident, there was a lack of ongoing neurological and vital sign monitoring after a documented change in condition and difficulty initiating ordered IV therapy. For the second resident, there was a pattern of unaddressed and incompletely documented urinary incontinence behaviors, absence of a toileting program despite policy and assessment findings indicating candidacy, and incomplete behavior and continence documentation. For the third resident, wound care orders for regular and as-needed dressing changes were not consistently implemented or documented in a manner consistent with observed care, as the resident was repeatedly observed without the ordered dressing in place.
Failure to Assist and Supervise Resident Requiring One-Person Ambulation Support
Penalty
Summary
The deficiency involves the facility’s failure to provide supervision and assistance consistent with one resident’s assessed needs and care plan to prevent accidents. The resident had a medical history that included acute respiratory failure, muscle weakness, chronic pain syndrome, muscle spasm of the back, major depressive disorder, and Type 2 diabetes with chronic kidney disease, and was on palliative care. Her care plan documented limited mobility related to her medical condition, with a goal to remain free of complications related to mobility and an intervention specifying that she required one staff member to assist with ambulation using a device for mobility. She had a prior unwitnessed fall that resulted in no injury. On the observed date and time, the resident was seen ambulating rapidly down the hall with a front-wheel walker, calling out to staff. She was wearing a patient gown and jacket, with the gown open in the back, no underwear, and her buttocks exposed. She had no foot coverings, and the dressing on her left lower leg/foot was coming undone and visibly soaked with blood. The only staff present in the area was an RN at the medication cart, who repeatedly told the resident to return to her room but did not stop her task to physically assist or ensure the resident’s safe return, despite the resident’s care plan requirement for one-person assist with ambulation. The unit manager later confirmed that the resident was a one-person assist and that the RN should have assisted her back to her room.
Catheter Drainage Bag Allowed to Touch Floor, Breaching Infection Control
Penalty
Summary
The facility failed to provide appropriate services to prevent urinary tract infections for one resident with an indwelling urinary catheter. A male resident admitted for short-term rehabilitation after a fall with a right femur fracture, and with diagnoses including malignant neoplasm of the prostate and secondary malignant neoplasm of the bone, was observed sitting in a wheelchair in the hallway with his indwelling urinary catheter drainage bag hung under the wheelchair seat and touching the floor. Facility records on the Treatment Administration Record showed staff were required to document each shift that the privacy bag was in place and that the urine collection bag was not touching the floor. During an interview, an RN confirmed that urine collection bags for all residents with indwelling urinary catheters are not supposed to touch the floor. This deficient practice exposed residents with urinary catheters to contaminants that may cause preventable urinary tract infections and had the potential to affect all residents with a urinary catheter.
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