Nuuanu Hale
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 2900 Pali Highway, Honolulu, Hawaii 96817
- CMS Provider Number
- 125024
- Inspections on file
- 22
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Nuuanu Hale during CMS and state inspections, most recent first.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
The facility failed to provide written transfer/discharge notices to resident representatives for multiple residents who were hospitalized, failed to notify the LTC ombudsman of one resident’s discharge, and used a notification form that did not include the Ombudsman address or appeals rights information. The affected residents had serious conditions including low platelets with subdural hematoma, SBO, hospice care, respiratory failure, MRSA septicemia, and sepsis.
Food items in the kitchen were found stored without required labels and discard dates. Frozen vegetables and meats in the freezer were unlabeled, and refrigerator items such as vegetables, soup base, and minced onion lacked proper dating. The DM said freezer items were not labeled because food was ordered and used weekly, relied on a trust system to judge spoilage, and stated the facility did not have a Food Storage and Labeling policy. The Administrator later confirmed the freezer still had no labels and acknowledged the need for a labeling and discard system.
A facility failed to keep the dishwasher temperature gauge in safe operating condition. Staff documented the dishwasher at 125 degrees on the log for an extended period, but during an observed wash cycle the gauge stayed at 100 and did not move. The DA admitted she was not physically checking the gauge and was only recording 125 degrees, while the DL said they did not know the gauge was broken. The MD later stated he was not responsible for the repair and that the DM should track and call the vendor, and the facility policy required dish machine temperatures to be monitored daily and equipment to be maintained in working order.
Staff failed to timely report a large, dark bruise of unknown origin on a resident’s left hip and thigh. A CNA first observed the bruise during a night shift but did not notify the nurse on duty and only relayed the information to an incoming CNA. Later, a CNA, an RNA, and an RN observed and discussed the bruise during care, and the RN assessed it but assumed it had already been reported and did not document an initial entry or initiate required notifications. The RNA later noted another large bruise and informed an LPN. Despite multiple staff being aware of the injury, the DON, Administrator, physician, resident representative, and State Agency were not notified within the required 2-hour timeframe specified in the facility’s abuse and injury-of-unknown-source reporting policy.
Nursing staff failed to perform and document timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. A CNA first observed the bruise and did not report it to a nurse, only relaying it to another CNA, and when an RN later assessed the bruise, the RN assumed it had already been reported and did not complete an initial assessment entry. An LPN subsequently noted the large purplish bruise, found no prior documentation, and initiated an event, while weekly skin assessments by an RN repeatedly documented no new skin impairments and omitted the bruise. Nursing notes recorded that the bruise was visible and then fading over time, but lacked complete assessment details such as size, shape, and full description, and the incorrect event form was used, resulting in incomplete documentation of the injury.
Failure to treat a resident with respect and dignity during ADL care. A resident’s representative reported that staff sometimes talked rough to the resident, and the Acting DON acknowledged prior reports of staff talking rough to residents. An event report also documented a CNA being rough during care and ignoring a resident’s call light, with the resident requesting education for the CNA.
Failure to Inform Residents of Right to Formulate AHCD: The facility did not ensure two residents were informed of their right to complete an AHCD. One cognitively intact resident with multiple chronic conditions had no AHCD on file and stated she had not been asked about one, while another resident with metabolic encephalopathy, muscle weakness, and pneumonitis also had no AHCD or supporting documentation in the record. Staff confirmed the AHCD was not completed for the second resident, despite the facility policy requiring advance directive status to be determined on admission.
A resident was observed in bed with bilateral upper quarter bed rails in use, and she stated she uses them when she needs to hold onto them and that staff use them. Review of the EHR showed her care plan did not include bed rail use, and the Acting DON confirmed the care plan was missing and should have included this intervention.
Inconsistent splint use and ROM services for a resident with contractures. A resident admitted after cerebral infarction was observed multiple times without the ordered right hand and right foot splints, despite EHR orders for splint use for at least 4 hours daily as tolerated. The care plan also called for ROM exercises 2-3 times per week, but the restorative nurse aide said she only provided ROM once weekly and had not applied the splints because she was busy with CNA duties during short staffing. Record review showed restorative treatments were only documented once weekly on several dates, and the DON and RN confirmed the resident should have had splints on and restorative nursing treatments more frequently.
Failure to monitor fluid intake for a resident on dialysis. The resident had a renal diet, puree texture, thin liquids, and a 1200 mL/day fluid restriction. CNAs documented intake at meals, but the MAR did not show fluid monitoring with med passes. An LPN said fluids were measured and provided with meals and med pass, and the DON confirmed the monitoring order had been discontinued during a hospital transfer and was not restarted when the resident returned.
Failure to Assess Bed Rail Entrapment Risk Before Use: The facility failed to complete bed rail risk assessments before using bilateral upper quarter bed rails for two residents. One resident had dementia, agitation, and hemiplegia/hemiparesis, and the other had CHF, COPD, and dementia. Both were observed with bed rails in use, and the DON confirmed that neither resident had the required assessment completed prior to bed rail use.
An unlocked medication cart was left unattended in a hallway where residents were present, and an RN later confirmed the cart was assigned to her and acknowledged it should have been locked. Facility policy required drugs and biologicals to be stored in locked compartments and kept under direct observation during med pass.
Regular inspection of bed frames, mattresses, and bed rails was not conducted for two residents with bilateral upper quarter bed rails in use. One resident was observed in bed with the rails up, another stated she uses the rails if she needs to hold onto them and that staff use them, and the Maintenance Supervisor said staff only tighten loose bolts and do not keep logs of the work.
A resident with significant functional decline was discharged home without adequate assessment of caregiver availability or capacity, despite therapy recommendations for 24-hour supervision and maximum assistance. The primary caregiver was unable to provide necessary care, and attempts at caregiver training were unsuccessful. The home health agency declined services due to an unsafe environment, and required post-discharge follow-up was not documented.
The facility failed to maintain sanitary conditions in two shower rooms, with black substance observed on the caulking. A CNA identified it as mold, while housekeepers were unsure of its nature and had tried scrubbing it off. The Maintenance Director later removed the substance, initially claiming it was black caulking, then dirt, and acknowledged it should have been addressed sooner.
A facility failed to document that written notice of transfer or discharge was provided to a resident and their representative, and that a copy was sent to the Long-Term Care Ombudsman. A resident was sent to the Emergency Department and admitted to the hospital, but there was no documentation that the discharge/transfer forms were sent to the necessary parties. The Social Services Director confirmed the lack of documentation and was unable to provide a fax confirmation notice.
The facility failed to develop and implement comprehensive care plans for several residents, including those with language barriers, pressure ulcers, and limited range of motion. This lack of care planning led to potential risks in residents' quality of life and well-being. The Director of Nursing confirmed the absence of documentation and a system for tracking care services.
The facility failed to update comprehensive care plans for four residents, leading to unaddressed needs such as meal assistance, range of motion exercises, oxygen therapy preferences, and pressure ulcer management. These deficiencies were confirmed by staff interviews and record reviews.
A long-term care facility failed to maintain an effective infection prevention and control program. Observations included a dirty pill cutter, improper hand hygiene by staff, and inadequate use of personal protective equipment. Clean medical supplies were placed on unclean surfaces, and a lancet was improperly discarded. Additionally, a urinary catheter bag was found on the floor, contrary to facility policy. These deficiencies put residents, staff, and visitors at risk of infection.
A facility failed to support a resident's bathing preferences and address his pruritic skin condition. The resident, with multiple health issues, reported that daily showers alleviated his itching, but was only allowed to shower twice a week. Staff interviews revealed a lack of documentation regarding his preferences and skin issues, and a CNA noted the resident's desire for more frequent showers.
A facility failed to provide written notification of the bed-hold policy to a resident's representative within 24 hours of an emergency hospital transfer. Although oral notification was given, the written section on the bed-hold agreement was incomplete, and there was no documentation confirming the mailing of the agreement. This oversight affects the resident's right to return and continuity of care.
Errors were found in the MDS Quarterly Assessments for two residents. One resident's active diagnosis of a contracture was omitted, and another resident's pressure ulcers were not documented upon return from the hospital. The DON and MDS Coordinator confirmed these omissions.
The facility failed to provide necessary communication support for three residents with limited English proficiency, leading to a deficiency in care. Despite being identified as needing language assistance, these residents were not provided with communication tools or interpreter services, and their care plans did not address their language needs. This oversight affected their ability to communicate effectively with staff, as confirmed by the Director of Nursing.
A facility failed to provide a resident-centered activities program for a visually impaired resident, who was unable to participate in preferred activities due to the lack of appropriate visual aids. The resident's care plans did not include specific interventions for his visual deficit, and the Activities Director confirmed that care plans typically contained only one generalized intervention. This oversight placed the resident at risk of a decline in psychosocial well-being.
A facility failed to implement an effective hydration program for a resident with chronic conditions, leading to inadequate fluid intake and potential dehydration. The resident's care plans identified risks but lacked specific interventions, and his fluid intake was not monitored. Another resident with a pruritic skin condition was not adequately addressed in his care plan, leading to frequent itching and bleeding lesions. Facility staff confirmed the lack of appropriate interventions and monitoring for both residents.
A resident with a stage 4 pressure ulcer did not receive necessary repositioning every two hours, as required by facility guidelines. Despite the resident's cognitive awareness and requests for assistance, staff failed to provide adequate support, and documentation of refusals and repositioning was lacking in the electronic health record.
The facility failed to provide appropriate care for three residents with limited ROM, leading to a risk of decline. A resident with a left-hand contracture did not have his splint applied or monitored, and there were no physician orders or care plan interventions. Another resident with quadriplegia did not receive necessary interventions to prevent worsening of his condition, and the facility lacked a Restorative Nursing Assistant program. A third resident with hemiplegia was observed with hand rolls not assessed or recommended by therapy, and there was no documentation of ROM exercises being performed.
A resident with a history of hemiplegia and hypoxemia was found with her oxygen face mask not properly positioned and the tubing disconnected from the concentrator, despite physician orders for continuous oxygen. The resident preferred to manage her own oxygen, but the RN confirmed the tubing should have been connected. This oversight placed the resident at risk for respiratory distress.
A facility failed to implement a physician-ordered gradual dose reduction for a resident's antidepressant medication. Despite a recommendation from the Consultant Pharmacist and the physician's directive to reduce the Citalopram dosage from 10mg to 5mg daily, the order was not executed. The Director of Nursing confirmed the oversight, highlighting a lapse in the facility's medication management and monitoring procedures.
A facility failed to ensure proper medication management, leading to potential medication errors. A resident's Carvedilol order was incorrectly labeled, and an expired Lantus insulin pen was found during an inspection. These issues highlight lapses in medication storage, labeling, and administration practices.
A resident, admitted for short-term rehabilitation, eloped from the facility due to an unsecured sliding door in the staff lounge leading to the courtyard. The resident, assessed as not at risk for elopement, was found across the street. Staff interviews revealed that the sliding door was typically left open during the day, with only a screen door closed, which lacked a latch. The facility's policy on elopement was not followed, as the courtyard was not a safe area for unsupervised residents.
A resident with multiple medical conditions, including blindness, was allowed to self-transfer to a floor mattress without proper evaluation of environmental hazards. The facility did not monitor the safety or effectiveness of this intervention, resulting in the resident sustaining multiple injuries. The resident was found tangled in cords and unable to use the call light, highlighting a lack of adequate supervision and safety measures.
A resident, dependent on staff for toileting, was found naked and tangled in cords on the floor, calling for help. The resident was left without a clean brief, exposed to their roommate, and in an unsafe environment. Staff failed to follow the care plan for frequent checks, and the call light was non-functional, leaving the resident at risk of infection and undignified conditions.
Inadequate Infection Control in Catheter Care, Water Management, and Waste Handling
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, particularly related to urinary catheter care, use of personal protective equipment (PPE), implementation of a water management plan for Legionella, and timely trash disposal. For one resident with an indwelling urinary catheter, the surveyor observed the catheter bag on the floor inside a gray bin with the catheter tubing extending out of the bin and in direct contact with the floor. The tubing showed visible discoloration and white sediment. The resident later reported itchiness outside the vagina and leaking from the catheter. A registered nurse acknowledged awareness of the sediment, stated the catheter was changed monthly, and indicated she planned to contact the physician for more frequent changes. She also stated the tubing could be irrigated with saline and confirmed that catheter tubing should not be on the floor for infection control reasons. The Infection Preventionist (IP), when shown a photograph of the tubing on the floor with sediment, confirmed the tubing should have been changed and that tubing should not be on the floor due to infection risk. Another resident, a male with a history of stroke and benign prostatic hyperplasia requiring an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP) with orders for catheter care every shift and as needed. During observation, his catheter tubing was seen lying directly on the floor when the bed was in the lowest position. The nurse present acknowledged that the tubing should not be on the floor and adjusted the bed and tubing placement. In a separate observation, a CNA performed catheter care for this resident, including emptying the catheter bag and cleaning the lower catheter tubing and the floor area near the bag, while only wearing gloves and no gown, despite a noticeable urine-like odor at the bedside. The IP confirmed that the resident was on EBP due to having a Foley catheter and stated staff should wear PPE, including a gown, when performing catheter care such as emptying the collection bag in case of splashes. The CNA acknowledged she was supposed to wear PPE for catheter care and indicated PPE was stored down the hall on a wall shelf, not immediately near or outside the resident’s room, despite the facility’s EBP policy stating gowns and gloves should be made available immediately near or outside the room for high-contact care activities such as urinary catheter care. The facility also failed to effectively implement its water management plan for Legionella prevention and control. The written plan described a central hot water system with recirculation, specified hot water storage tank setpoints at or above 140°F and distribution temperatures above 124°F, and listed monitoring procedures including monthly hot water temperature checks by maintenance, as well as verification and validation steps such as reviewing monitoring logs, infection surveillance data, and water testing results. However, the Maintenance Director reported there were no storage or water heater tanks with water temperatures greater than 140°F, and only one month of temperature logs was available, showing resident room and water heater temperatures between 105°F and 115°F, which did not align with the Legionella prevention temperature guidelines referenced from CDC. The IP, newly in the role, stated she was not familiar with the water management plan, that collaboration with maintenance was non-existent, and that no control measures, weekly flushing of shower heads and faucets, or monthly temperature monitoring were being done. Additionally, the facility did not ensure prompt disposal of trash, resulting in trash bags being piled outside the trash bin and on an exterior stairwell landing. Surveyors observed multiple trash bags outside the facility next to the trash bin and on the stairwell landing, blocking access to the staircase. Housekeeping staff reported that trash from the second floor was placed in the bin about every hour but sometimes had to wait for the maintenance worker, who had the only key to open the bin. Another housekeeper stated she left heavy trash bags by the bin twice a day because she could not lift them into the bin and relied on the maintenance worker to place them inside, noting she had notified him about trash needing to be placed in the bin about an hour earlier. The maintenance worker stated he had been told by aides to hold off putting trash in the bin but did not know why. The Maintenance Director later confirmed that housekeepers should be putting trash in the bin more frequently and acknowledged that trash pile-up can lead to unsanitary conditions affecting the facility and neighborhood. Overall, these observations and interviews show that the facility did not maintain catheter tubing off the floor or address visibly soiled tubing, did not consistently use required PPE for residents on EBP during high-contact catheter care, did not implement or monitor its Legionella water management plan as written, and did not ensure timely placement of trash into secured bins, resulting in accumulated trash in exterior areas.
Missing transfer and discharge notifications
Penalty
Summary
The facility failed to provide written notification to the resident representative for three residents who were transferred or hospitalized, and failed to notify the long term care ombudsman of one resident’s discharge. Record review showed that one resident was sent to the ER for critically low platelets, received a blood transfusion, was admitted for a subdural hematoma, and remained hospitalized, but no written discharge/transfer notification to the family representative or Ombudsman was found. Another resident reported going to the hospital for abdominal pain; record review showed admission for a small bowel obstruction, but no written notification to the family representative or Ombudsman was provided. A third resident was transferred to the hospital multiple times for changes in condition, including decreased level of consciousness, acute hypoxemic respiratory failure, MRSA septicemia due to CVC infection, and sepsis, and the record showed no written notification to the resident or representative and no documentation that the Ombudsman was notified. For one resident discharged home on hospice care after admission from an acute care hospital, the Ombudsman discharge notice was not found in the facility’s binder. The social services aide confirmed that no discharge notification was sent to the Ombudsman and stated he was the only aide covering at the facility at the time of discharge. The report also states that the facility’s notification form did not include the Ombudsman address or appeals right information.
Food items stored without required labels and discard dates
Penalty
Summary
The facility failed to ensure that food items stored in the walk-in freezer and refrigerators were properly labeled and that old food was discarded. During an initial kitchen walkthrough with the Dietary Lead, frozen vegetables and meats were observed in the walk-in freezer without labels, and the refrigerator contained vegetables and soup base items without receive and discard dates. A minced onion container with a best used by date of 01/26/26 was also observed still in the refrigerator. The Dietary Lead confirmed that freezer items were not being labeled with received/discard dates and that refrigerator items were only labeled with discard dates. During interview, the Dietary Manager stated that frozen foods were not labeled because items were ordered based on usage and were used, consumed, and reordered weekly. Invoices reviewed for several food items did not show received-by signatures or received dates, except for one invoice that did include both. When asked what system was in place to ensure food was discarded appropriately when items lacked receive/discard labels, the Dietary Manager stated he used a trust system and relied on employees with over 30 years of experience to judge food by appearance, smell, and taste. The Dietary Manager also stated the facility did not have a Food Storage and Labeling policy. The Administrator later confirmed that a Food Storage Policy should exist and acknowledged there should be a system for labeling and discarding food, not just trust. On a later walkthrough, the Administrator again confirmed there were no labels on food items stored in the freezer.
Dishwasher Temperature Gauge Not Maintained in Working Order
Penalty
Summary
The facility failed to maintain the dishwasher temperature gauge in safe operating condition. During the initial kitchen walkthrough, the dishwasher temperature daily log showed 125 degrees for the entire month of January through 02/24/26, and the Dietary Aide was observed completing a wash cycle while the dishwasher temperature gauge did not move and stayed at 100 throughout the process. The Dietary Aide acknowledged that she had not been physically checking the temperature gauge daily and had only been documenting 125 degrees on the log. The Dietary Lead stated they did not know the gauge was broken. Later observations and interviews showed inconsistent function of the dishwasher gauge and uncertainty among staff about responsibility for repair and monitoring. The Maintenance Director stated he was not responsible for repairing the gauge and said it was the Dietary Manager’s responsibility to track it and call the vendor. Review of the facility’s sanitation policy showed that dish machine items were to be washed at a minimum of 120 F, that water temperatures were to be monitored and documented daily, and that equipment used for dishwashing was to be maintained in working order with a preventative maintenance schedule documented.
Failure to Timely Report Injury of Unknown Source Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source that resulted in serious bodily injury for one resident. Staff first observed a large, dark bruise on the resident’s left hip and thigh around midnight during a night shift, but the CNA who discovered it did not notify the night shift nurse, stating she was busy and forgot, and instead only told an incoming day shift CNA. The day shift CNA later informed the RN on duty while assisting with the resident’s care. The RN assessed the bruise, describing it as purple and located on the posterior left thigh; the resident did not recall how it occurred and denied pain or discomfort. The RN assumed the bruise had already been reported to licensed staff on the prior shift and did not make an initial entry or initiate required notifications. Subsequently, the restorative nurse aide (RNA) and another CNA observed the large bruise in the lower hip area while assisting with a shower and confirmed with each other that the on-duty RN had been informed. The next day, the RNA observed another large bruise on the resident’s thigh and reported it to an LPN. Despite multiple staff being aware of the bruising over more than one shift, the DON, Administrator, physician, resident representative, and State Agency were not notified until several days after the bruise was first seen. This sequence of inaction and miscommunication occurred despite the facility’s abuse policy requiring that allegations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source that result in serious bodily injury be reported immediately, but no later than two hours after the allegation is made, with immediate notification of the Administrator or designee to initiate reporting to state agencies.
Failure to Perform and Document Complete Skin Assessment for Large Hip/Thigh Bruise
Penalty
Summary
The facility failed to ensure licensed nursing staff demonstrated appropriate competencies and skills to perform timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. Staff first observed the bruise on 07/30/25, but no initial assessment was conducted at that time. A CNA working the night shift observed the bruise and did not report it to the Charge Nurse, instead only telling the incoming day shift CNA the next day. The day shift CNA then informed an RN, who assessed the bruise as purple in color on the posterior left thigh, with the resident unable to recall how it occurred and denying pain or discomfort. The RN assumed the bruise had already been reported to licensed staff and did not complete an initial assessment entry. On 08/01/25, an LPN observed the large purplish bruise extending from the resident’s lower hip to the thigh, found no prior assessment or event note documenting the bruise, and then created an event and notified the DON. An X-ray ordered by the physician showed soft tissue swelling without acute fracture, dislocation, or bony lesions. Despite the presence of the bruise, weekly skin assessments completed by the RN on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 did not document the bruise on the left hip and thigh. These assessments repeatedly documented that there were no new onset skin impairments and described only dry scattered scabs to the bilateral shins treated with Medihoney gel. Nursing notes associated with the event report initiated on 08/01/25 documented that the bruise on the left hip and thigh was visible and then fading over multiple subsequent dates, with color changes from purple to yellow. However, these notes did not include a complete skin assessment or detailed documentation of the bruise’s progression, such as size, shape, initial appearance, or date of resolution. During interviews, the IP and Administrator confirmed that the RN’s weekly skin assessments should have included the bruise, that staff should perform a full skin assessment and initiate an RMC Injury/Integumentary Alteration event when a new skin issue is identified, and that the event report used by the LPN was not the correct form and did not capture a complete assessment. The report also cross-referenced F609, noting that the injury of unknown source resulting in serious bodily injury was not reported to the Administrator within two hours of discovery, as it was first observed on 07/30/25 but not reported until 08/01/25.
Failure to Treat a Resident with Respect and Dignity During ADL Care
Penalty
Summary
The facility failed to assure staff treated a resident with respect and dignity during assistance with ADLs. During a family interview, the resident’s representative stated that staff sometimes talked rough to the resident and that they would directly tell staff when they observed it. The representative said they had not reported the concern to the unit manager or DON and were afraid for the resident, worried the behavior might be happening when they were not present. The resident stated they felt safe in the facility during the interview. During a later interview, the Acting DON acknowledged there had been reports of staff talking rough to residents and reviewed an event report from a prior incident in which a resident reported a CNA was rough during care and ignored her when she pressed her call light. The DON’s investigation found the CNA had provided care and then returned after rounding with other residents. The resident requested education for the CNA and wanted to continue working with that CNA. The facility policy stated residents are to be treated in accordance with their rights and prohibited verbal abuse, including disparaging or derogatory language that can cause intimidation, threat, harm, mental anguish, or fear.
Failure to Inform Residents of Right to Formulate AHCD
Penalty
Summary
The facility failed to ensure that two residents were informed of their right to formulate an Advanced Health Care Directive (AHCD). One resident, admitted with diagnoses including peripheral vascular disease, type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction, venous insufficiency, atherosclerotic heart disease, cardiomyopathy, COPD, polyneuropathy, epilepsy, bilateral above-the-knee amputations, hypertension, and hyperlipidemia, had a quarterly MDS showing a BIMS score of 14 out of 15 and was documented as cognitively intact. Review of the electronic record showed no AHCD on file. A social services note stated the resident did not wish to designate a POA at that time and wanted to continue making her own decisions, but the resident later stated that no one had asked her about formulating an AHCD and that she did not know what it meant to formulate one. She also stated she would like to complete an AHCD and designate her daughter to assist with health care decisions if she became incapacitated. A second resident, admitted with diagnoses including metabolic encephalopathy, muscle weakness, and pneumonitis, also had no AHCD or supporting documentation in the electronic record, progress notes, or care plan. A request for the resident’s AHCD and/or supporting documentation was made to the Administrator, but no documentation was received. Social Services Aide 1 confirmed that the AHCD was not completed for this resident. The facility’s Residents’ Rights Regarding Advance Directive policy stated that on admission the facility will determine whether the resident has executed an advance directive and, if not, determine whether the resident would like to formulate one.
Missing Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to develop a care plan for bed rail use for one of six residents sampled for accidents, Resident 38. On 02/25/26 at 09:05 AM, R38 was observed lying in bed with bilateral upper quarter bed rails up, and she stated she uses them if she needs to hold onto them and that staff use them. Review of R38’s electronic health record on 02/25/26 showed that her care plan did not include use of bilateral upper quarter bed rails. During an interview on 02/27/26 at 10:42 AM, the Acting DON confirmed that R38 did not have a care plan in place for bed rail use and stated that this should have been included.
Inconsistent splint use and ROM services for a resident with contractures
Penalty
Summary
The facility failed to ensure that Resident 63 received appropriate treatment, equipment, and services to maintain or prevent decline in range of motion. Resident 63 was a male admitted with dysphagia following cerebral infarction and was observed with a right hand contracture and right foot contracture. During multiple observations on 02/24/26, 02/25/26, and 02/26/26, no splint was applied to the resident’s right hand or right foot, despite orders in the EHR for the resident to wear a right hand splint and right foot splint for a minimum of 4 hours daily as tolerated from 07:15 to 15:15. The care plan directed the resident to perform ROM exercises to the upper and lower body 2-3 times per week as tolerated and to continue wearing a soft ankle foot orthosis and resting hand splint for a minimum of 4 hours. The restorative nurse aide confirmed the resident should have had splints applied but stated she had not been able to apply them because she was busy doing CNA work when the facility was short-staffed, and also stated that CNAs and licensed staff could apply splints. She further stated she had only been able to provide active/passive ROM once a week. Record review showed restorative treatment occurred only once weekly on several dates in January and February 2026, and splints were not applied on multiple days in February 2026. The Acting DON and RN 1 confirmed the resident should have had splints on and that the care plan called for restorative nursing treatments 2-3 times per week.
Failure to Monitor Fluid Intake for Resident on Dialysis
Penalty
Summary
The facility failed to monitor one resident's fluid intake for one of one resident sampled for dialysis, Resident 6. Record review showed the resident was readmitted to the facility and received dialysis three times a week on Tuesday, Thursday, and Saturday. The resident had orders for a renal diet, puree texture consistency, and thin liquids with a 1200 mL/day fluid restriction. Meals and fluid intake were documented by CNAs at each meal, but the resident's MAR did not show monitoring of fluid intake with medication administration. An LPN stated the resident had fluids measured out and provided with meals and medication pass. The Acting DON confirmed that residents on fluid restrictions should have their fluids monitored and documented, and stated the resident's fluid restriction monitoring had been discontinued when he was discharged to the hospital on 02/12/26. She also stated the resident returned to the facility on [DATE] and there was no new order to restart monitoring his fluid intake, which should have been ordered when he returned.
Failure to Assess Bed Rail Entrapment Risk Before Use
Penalty
Summary
The facility failed to assess the risk of entrapment from bed rails before installing and using bed rails for two residents reviewed for accident hazards, R56 and R38. The report states that the facility did not complete a risk assessment for bed rail use for either resident, despite both residents having bilateral upper quarter bed rails in use. The deficiency was identified during observations, record review, and interviews, and it was also noted that the facility failed to implement a regular maintenance program to identify areas of possible entrapment with bed rail use for these residents. R56 was observed lying in bed with bilateral upper quarter bed rails up. Her record showed diagnoses including unspecified dementia with agitation and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Her MDS indicated substantial/maximal assistance was needed for rolling left and right, and her care plan addressed bed rail use with side rail padding/pillows and frequent checks, but no bed rail risk assessment was found. R38 was also observed in bed with bilateral upper quarter bed rails up, and she stated she used them if she needed to hold onto them and staff used them. Her record showed diagnoses including acute diastolic CHF, COPD, and unspecified dementia, and although she had signed consent for use of a grab bar or assist rail, no bed rail risk assessment was completed. The Acting DON confirmed that both residents should have had a risk assessment completed prior to bed rail use and that neither resident had one.
Unlocked Medication Cart Left Unattended in Hallway
Penalty
Summary
The facility failed to ensure a medication cart was locked and under direct observation of authorized staff when it was left unattended in the Ewa Unit hallway, where residents in wheelchairs were present and staff were walking by. After exiting a resident's room, an unlocked medication cart was observed in the hallway, and RN5 was later seen walking away from the cart area while carrying a pitcher of water and speaking briefly with another staff member near the nurse's station. RN5 confirmed the cart was assigned to her and stated that she had stepped away from it and acknowledged that it should have been locked. The facility policy stated that all drugs and biologicals are to be stored in locked compartments and that during medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area/cart.
Failure to Regularly Inspect Bed Rails and Bed Frames
Penalty
Summary
Regular inspection of bed frames, mattresses, and bed rails was not conducted as part of a regular maintenance program to identify possible entrapment areas for two residents reviewed for accident hazards, R56 and R38. On 02/24/2026, R56 was observed lying in bed with bilateral upper quarter bed rails up. On 02/25/2026, R38 was observed lying in bed with bilateral upper quarter bed rails in use, and when asked about the bed rails, R38 stated she uses them if she needs to hold onto them and that staff use them. On 02/27/2026, the Maintenance Supervisor stated that he and his staff tighten a bolt if it is loose but do not keep logs of this work, and he said they do not do anything else.
Failure to Ensure Safe Discharge Planning and Assessment of Caregiver Support
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who experienced a significant decline in functional status during their stay. Prior to admission, the resident was moderately independent with some assistance from a significant other, but at discharge, required maximum assistance for most activities of daily living, including transfers, toileting, bathing, and mobility. Despite recommendations from therapy staff for 24-hour care and maximum assistance, there was no evidence that the discharge plan adequately addressed the resident's need for continuous supervision or that the availability, capacity, and capability of the home caregiver were assessed. Interviews and record reviews revealed that the resident's significant other, who was identified as the primary caregiver, was herself disabled and unable to provide the necessary level of care. Attempts to involve the caregiver in training were unsuccessful, and there was no documentation that alternative discharge options were discussed or considered to ensure the resident's safety. The discharge planning notes lacked evidence of a comprehensive assessment of the home environment or the support system available to the resident. A referral was made to a home health agency for therapy and aide services, but the agency declined to admit the resident due to an unsafe home environment. Additionally, the facility's policy required a follow-up phone call after discharge to assess the resident's status and adjustment, but there was no evidence that this follow-up occurred. The lack of a thorough discharge plan and failure to ensure appropriate post-discharge support placed the resident at high risk for readmission and harm.
Failure to Maintain Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a sanitary and clean environment in two of the four shower rooms observed, which could potentially affect all residents. During a walkthrough of the 2nd floor [NAME] Wing shower room, a black substance was noted on the caulking of the shower stall. Similarly, the Ewa Wing shower room had a black substance on the caulking. A Certified Nurses Aid (CNA) identified the substance as mold but was unsure of the housekeeping procedures for cleaning it. Housekeepers acknowledged the presence of the black substance but were unaware of its nature and had attempted to remove it by scrubbing. The Maintenance Director (MD) later removed the black substance after it was brought to the attention of the housekeeping staff. Initially, the MD claimed the substance was black caulking applied by a previous maintenance worker, but upon further questioning, he stated it was dirt. The MD confirmed using tools to scrape the caulking and applied grout, acknowledging that the issue should have been addressed sooner.
Failure to Document Transfer/Discharge Notification
Penalty
Summary
The facility failed to provide documentation that written notice of transfer or discharge was given to a resident and their representative, and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This deficiency was identified for one of five resident samples. Specifically, a resident was sent to the Emergency Department and admitted to the hospital. During a record review, it was found that while discharge/transfer forms were completed, there was no documentation indicating that these forms were sent to the resident's representative or the Long-Term Care Ombudsman. The Social Services Director confirmed that there was no documentation of the written discharge/transfer notification being sent and was unable to provide a fax confirmation notice.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for eight residents, leading to potential risks in their quality of life and well-being. For one resident, the facility did not include an active diagnosis of muscle contracture in the Minimum Data Set (MDS) Quarterly Assessment and failed to address the resident's limited range of motion needs. Another resident returned from hospitalization with pressure ulcers on both heels, but the facility did not update the MDS Quarterly Assessment or create a care plan for treatment and monitoring of these ulcers. Additionally, the facility did not develop communication and language barrier care plans for residents whose primary language was not English, despite identifying this need upon admission. The facility also neglected to create care plans for residents at risk of dehydration and those with ongoing skin conditions. One resident with a left-hand contracture did not have a care plan to address their limited range of motion needs. Another resident with hemiplegia and hemiparesis following a stroke had no documentation of range of motion exercises being performed, despite the care plan indicating the need for monitoring and therapy. The Director of Nursing confirmed the lack of documentation and stated that there was no system in place for Certified Nurse Aides to document passive range of motion services, nor was there evidence of physician orders or care planning for the use of hand rolls.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive person-centered care plans were reviewed and revised by the interdisciplinary team for four residents. For one resident, there was a significant change in their ability to feed themselves, requiring assistance with meals, which was not updated in their care plan. The Unit Manager confirmed that the care plan should have been updated to reflect this change. Another resident's care plan did not include the physical therapy recommendations for passive range of motion exercises, despite the resident's refusal to participate in physical therapy sessions. The Director of Nursing confirmed that the care plan should have included the physical therapy department's recommendations for passive range of motion exercises. Additionally, a resident's care plan did not reflect their preference for continuous oxygen use for comfort, nor did it document their ability to independently manage their oxygen mask. The facility's policy required that oxygen therapy interventions be included in the care plan. Furthermore, a resident with a stage 4 pressure ulcer did not have their care plan updated to include person-centered interventions for turning and positioning, despite their inability to reposition themselves effectively. The facility's policy required that interventions for pressure injury prevention and management be documented in the care plan.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. A pill cutter used for multiple residents was found with white and brown sediments, indicating it was not cleaned between uses. This was confirmed by a registered nurse who acknowledged the need for cleaning the cutter after each use. Additionally, a certified nurse assistant did not perform hand hygiene after removing dirty gloves before assisting a resident with her meal, which was against the expected practice as confirmed by the Director of Nursing. Further deficiencies were observed during wound care and other resident interactions. A registered nurse placed clean medical supplies on a dirty bedside table and failed to perform hand hygiene between glove changes while attending to a resident's pressure ulcer. The nurse admitted to not having recent training on hand hygiene, although the Director of Nursing confirmed that training is provided during orientation and annually. Another incident involved a nurse not wearing appropriate personal protective equipment while providing care to a resident under Enhanced Barrier Precautions, and failing to sanitize hands between glove changes. Additional issues included improper disposal of a lancet, which was left on a resident's bed instead of being discarded in a sharps container, posing a risk of blood-borne pathogen transmission. A urinary catheter bag was also observed on the floor, contrary to the facility's policy that requires it to be off the floor to prevent contamination. These practices collectively put residents, staff, and visitors at risk of infection and highlight significant lapses in the facility's infection control measures.
Failure to Support Resident's Bathing Preferences and Address Skin Condition
Penalty
Summary
The facility failed to identify and support the bathing schedule preference of a resident, leading to unmet needs and hindering the resident's well-being. The resident, a cognitively intact male with multiple health conditions including heart failure, high blood pressure, diabetes, and end-stage renal disease, was admitted for long-term care. Despite having an ongoing pruritic skin condition, the facility did not adequately address the resident's itching. Observations revealed the resident scratching his arm, with visible scratches and dried blood, and he reported that showering alleviated his itching. However, the resident was only allowed to shower twice a week, contrary to his preference for daily showers. Interviews with staff revealed a lack of documentation regarding the resident's shower preferences and skin issues in his care plan. The Unit Manager confirmed that the resident was on a twice-weekly shower schedule, and there was no documentation of an assessment of his shower frequency preference. A Certified Nurse Aide familiar with the resident's care stated that she would shower him daily when she worked in his area, acknowledging his preference for more frequent showers. This deficiency in supporting the resident's self-determination and addressing his skin condition was identified through observation, interview, and record review.
Failure to Provide Written Bed-Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to a resident's representative within 24 hours following an emergency transfer to the hospital. Resident 69 was sent to the Emergency Department and admitted to the hospital. A review of the records revealed that while oral notification was given, the section for written notification on the bed-hold agreement was not completed. The Social Services Director confirmed that the bed-hold agreement was mailed to the resident's representative, but there was no documentation in the progress notes to confirm this action. This oversight does not ensure the resident's right to have a place to return and does not provide continuity of care.
Errors in MDS Quarterly Assessments for Two Residents
Penalty
Summary
Errors were identified in the Minimum Data Set (MDS) Quarterly Assessments for two residents in the facility. For one resident, an error was found in Section I, Active Diagnoses, where the resident had a documented contracture of the left upper arm that was not included in the MDS assessment. The resident was observed with a contracture in his left hand, and the Director of Nursing confirmed that this diagnosis should have been included in the MDS assessment. For another resident, an error was found in Section M, Skin Conditions. This resident was admitted to the hospital with pressure ulcers on both heels and was discharged with the same condition. However, upon returning to the facility, the skin assessments did not document these pressure ulcers, and they were not included in the MDS Quarterly Review. The Minimum Data Set Coordinator confirmed that the pressure ulcers should have been documented in the resident's MDS assessment.
Failure to Provide Communication Support for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate communication support for residents with limited English proficiency, leading to a deficiency in care. Three residents, identified as needing language assistance, were not provided with necessary communication tools or interpreter services. Resident 37, who speaks Chuukese, was observed without any communication aids at his bedside, and his care plan did not address his language needs. Despite his brother occasionally translating for him, the facility did not implement any formal communication strategies. Similarly, Resident 24, a Korean speaker, was not provided with communication tools or aids, and her care plan lacked any interventions for her language barrier. The MDS Coordinator acknowledged that such needs should be addressed in the care plan, but no actions were taken to include interpreter services or other communication aids for her. Resident 55, who speaks Cantonese, was also not provided with interpreter services despite being identified as needing them. The staff did not use interpreter services during interactions, and his care plan did not include any language assistance interventions. The Director of Nursing confirmed that the resident should have had a care plan for an interpreter, but this was not implemented, resulting in a deficiency in meeting the residents' communication needs.
Failure to Address Visual Impairment in Activities Program
Penalty
Summary
The facility failed to provide an ongoing resident-centered activities program that addressed the needs of a visually impaired resident. The resident, a male admitted for long-term care, was identified as having a visual deficit, specifically being able to see large print but not regular print. Despite this, the facility did not implement activities that the resident could perform, such as providing reading glasses, which he did not bring with him from home. The resident expressed enjoyment in word search puzzles but was unable to participate due to the lack of appropriate visual aids. The resident's Comprehensive Care Plan acknowledged his visual impairment but did not include specific interventions to address it, beyond monitoring for changes in vision. The Activities Care Plan also failed to identify the visual deficit and only included a generalized intervention for all residents. The Activities Director, who was no longer in the position, acknowledged the oversight and confirmed that the care plans typically contained only one generalized intervention. This lack of individualized planning placed the resident at risk of a decline in psychosocial well-being.
Deficiencies in Hydration and Skin Care Management
Penalty
Summary
The facility failed to implement an effective hydration program for a resident with chronic congestive heart failure and other conditions, who was not on any fluid restrictions. Despite being on diuretics and an antidiabetic medication that could lead to volume depletion, the resident was not provided with adequate fluids, as evidenced by the absence of water pitchers or cups at his bedside during multiple observations. The resident's care plans identified an increased risk for dehydration but lacked specific interventions to ensure adequate fluid intake. The resident's fluid intake was consistently below the facility's standard, and there was no monitoring or logging of his fluid intake, nor was he placed on the Hydration List for residents with low fluid intake. Another resident with a pruritic skin condition was not adequately addressed in his care plan. Despite having a history of heart failure, high blood pressure, diabetes, and end-stage renal disease, the resident frequently experienced itching, particularly on his arms and back, which led to multiple tiny scratches and bleeding lesions. The resident reported that showers provided relief, but he was only allowed to shower twice a week. Although a lotion was prescribed for the itching, there was no documentation of its effectiveness, and the care plan did not include interventions for the pruritic condition. Interviews with facility staff, including the Director of Nursing and Unit Manager, confirmed the lack of appropriate interventions and monitoring for both residents. The facility's policy on hydration maintenance was not followed, and the care plans did not reflect the necessary interventions for the residents' conditions. The deficiencies in hydration and skin care have the potential to affect all residents at the facility.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment consistent with professional standards of practice to promote healing of a stage 4 pressure injury for a resident. The resident, who was cognitively intact and required substantial assistance for mobility, was not turned and repositioned every two hours as needed. Despite having a pressure injury on her coccyx, the resident reported that she had to ask staff for assistance with repositioning, and if she did not ask, they did not help. Observations confirmed that the resident attempted to reposition herself using her arm strength, but no pillows or wedges were used to assist her. The resident expressed discomfort with the hard foam wedge provided and requested pillows instead, but staff did not follow through with this request. The facility's guidelines required routine repositioning every two hours, but this was not documented in the resident's electronic health record. The Unit Manager and Infection Preventionist confirmed that refusals and repositioning were not documented, and staff should have educated the resident on the risks and benefits of treatment, as well as documented any refusals.
Failure to Provide Appropriate ROM Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for three residents with limited range of motion (ROM), leading to a risk of decline in their condition. Resident 27, who had a left-hand contracture following a stroke, did not have his hand splint applied or monitored. The splint was found buried under his belongings, and there were no physician orders or care plan interventions addressing its use. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that the splint should have been documented in the care plan or physician orders. Resident 20, diagnosed with quadriplegia and left-hand contracture, did not receive the necessary interventions to prevent worsening of his condition. The care plan lacked interventions for his contractures, and there were no physician orders for treatment. The Unit Manager stated that the resident sometimes refused care, and the DON confirmed the absence of a Restorative Nursing Assistant program due to staffing shortages, which impacted the provision of passive range of motion (PROM) exercises. Resident 56, with hemiplegia and contractures, was observed with hand rolls that were not assessed or recommended by therapy. The care plan mentioned monitoring for pain during ROM, but there was no documentation of ROM exercises being performed. The Physical Therapy Assistant and Occupational Therapy Assistant confirmed that no referrals were made for therapy assessment after the resident's discharge from physical therapy. The DON acknowledged the lack of documentation and confirmed that hand rolls should not have been used without proper assessment and physician orders.
Failure to Ensure Proper Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident's oxygen (O2) tubing was properly connected to the O2 concentrator, as required by professional standards of practice. This deficiency was observed in the case of a resident who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hyperlipidemia, hypertension, and hypoxemia. The resident had physician orders for continuous O2 at two liters per minute via face mask, with the option to titrate the flow to maintain oxygen saturation levels above 90%. However, during an observation, the resident's O2 face mask was found not covering her mouth or nose, and the tubing was disconnected from the concentrator, with the end of the tubing touching the floor, while the concentrator was running. During an interview with a registered nurse (RN), it was revealed that the resident preferred to manage her own O2 face mask and wanted the concentrator on continuously, although it was not deemed necessary by the RN. The RN confirmed that the tubing should have been connected to the concentrator. The facility's policy on oxygen administration, which was reviewed and revised in June 2023, states that oxygen is to be administered under physician orders and staff should monitor for complications and take precautions to prevent them. This oversight placed the resident at risk for respiratory distress due to not receiving the prescribed continuous oxygen therapy.
Failure to Implement Physician-Ordered Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to manage and monitor the medication regimen for a resident by not implementing a physician-ordered gradual dose reduction (GDR) for an antidepressant. The Consultant Pharmacist recommended a review of the resident's Citalopram 10mg for an annual GDR or clinical contraindication. The resident's physician marked the option to attempt a dose reduction to 5mg daily and signed the Medication Regimen Review (MRR) form. However, upon reviewing the resident's September and October physician orders, no change in the Citalopram dosage was noted, and the resident continued to receive the original 10mg dosage. An interview with the Director of Nursing (DON) confirmed that the physician's notation on the MRR indicated a reduction to 5mg daily, and the date on the form was verified as 09/27/24. The DON stated that the facility receives MRRs monthly, and they are reviewed by the DON, Unit Manager, and clinical team. Despite this process, the order for the dose reduction was not carried out, indicating a lapse in the facility's medication management and monitoring procedures.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were stored, labeled, and administered according to professional standards, which could lead to medication errors affecting all residents. During a medication pass observation, it was found that a resident's Carvedilol 25mg order on the Medication Administration Record (MAR) was listed to be given twice a day, while the label on the medication blister pack indicated it should be given every 12 hours. The discrepancy was confirmed by a Registered Nurse (RN), who admitted that the blister pack with the incorrect label was being used instead of being discarded. This issue arose after the resident returned from a hospital stay, and the RN transcribed the order incorrectly. Additionally, during an inspection of the Right-Wing medication cart with the Director of Nursing (DON), an expired Lantus insulin pen was found for another resident. The insulin pen had been labeled with an open date and a discard date, which had already passed. The DON confirmed that the insulin pen was expired and should have been wasted. These findings indicate a failure in the facility's medication management practices, specifically in ensuring proper labeling and timely disposal of medications.
Resident Elopement Due to Unsecured Facility Door
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, resulting in an elopement incident. A resident, admitted for short-term rehabilitation after knee surgery and assessed as not at risk for elopement, was able to exit the facility without authorization. The resident was last seen in her bed and later found across the street. An investigation revealed that the resident's belongings were found in the courtyard area, suggesting she exited through the staff lounge, where a sliding door leading to the courtyard was left unlocked. Interviews with staff indicated that the sliding door in the staff lounge was typically left open during the day, with only a screen door closed, which did not have a latch to secure it. The facility's policy on elopement and wandering residents was not adhered to, as the courtyard was not considered a safe area for unsupervised residents. The Administrator and DON acknowledged that the courtyard was not safe for residents without supervision, especially when the floor was wet, and that the resident likely exited through the unsecured staff lounge door.
Failure to Ensure Safe Environment for Resident
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R8, who was allowed to self-transfer from a bed to a floor mattress. The facility did not evaluate or address potential environmental hazards associated with this intervention. As a result, R8 sustained multiple skin tears, bruising, and wounds on both lower legs. The facility did not monitor the effectiveness or safety of the floor mattress intervention, which contributed to the resident's injuries. R8 was admitted with multiple diagnoses, including dementia with behavioral disturbances, spinal stenosis, and blindness due to a ruptured eye. Despite having intact cognition, R8 was dependent on staff for toileting and transfers, requiring two or more staff and a Hoyer lift. The care plan allowed R8 to self-transfer to a floor mattress, with bedrails to assist in mobility, as per the resident's power of attorney's request. However, the facility did not assess the room or floor space for potential hazards, nor did it monitor R8's safety while on the floor mattress. During an observation, R8 was found naked on the floor, tangled in cords, and unable to use the call light due to blindness. The resident reported that the call light was intentionally placed out of reach. The facility's director of nursing confirmed that no assessments were conducted to ensure the safety of the floor mattress intervention, and there was no follow-up after R8 sustained injuries. The facility's failure to identify, evaluate, and monitor environmental hazards and the effectiveness of interventions led to the resident's avoidable accidents.
Resident Left in Undignified and Unsafe Conditions
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence, resulting in a deficiency. The resident, who is dependent on staff for toileting and transfers due to impairments in upper and lower extremities, was found naked and tangled in cords on the floor, calling out for help. The resident's cognitive status was intact, and they had a history of myocardial infarction, dementia with behavioral disturbances, and other medical conditions. The care plan included interventions for disrobing behavior and frequent checks when the resident was on the floor mattress, but these were not adequately followed. During the night shift, staff left the resident without a clean brief after removing a soiled one, leaving the resident exposed and in an unsafe environment. A registered nurse confirmed that the resident's environment was hazardous, with the resident tangled in cords and sustaining wounds from being on the floor. The privacy curtain was left open, exposing the resident to their roommate, and the call light was not functional for the resident, who is blind. Interviews with staff revealed that the resident was left without clothing or a brief for at least 30 minutes, and there was no documentation of frequent checks or assistance with toileting during the night shift. The director of nursing confirmed the lack of documentation and acknowledged the undignified situation observed by the surveyor. The resident was at risk of infection due to direct contact with the floor, and the facility's failure to provide a safe and dignified environment was evident.
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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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