Kulana Malama
Inspection history, citations, penalties and survey trends for this long-term care facility in Ewa Beach, Hawaii.
- Location
- 91-1360 Karayan Street, Ewa Beach, Hawaii 96706
- CMS Provider Number
- 125057
- Inspections on file
- 16
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kulana Malama during CMS and state inspections, most recent first.
A resident experienced two unplanned tracheostomy decannulations during care, both of which were managed without distress or complications. Although the incidents were reported in facility incident reports, there was no corresponding documentation in the EHR by nursing or respiratory staff, contrary to facility policy requiring such documentation for changes in condition.
A resident with a history of traumatic brain injury and complex medical needs experienced a fall, after which nursing staff failed to perform and document complete neurological assessments, did not recognize or respond promptly to significant changes in condition, and delayed notifying the physician and transferring the resident for higher-level care. Staff lacked training, competency validation, and access to necessary equipment for neurological checks, and facility policies were insufficiently specific regarding post-fall assessment requirements.
A resident with cognitive impairment, quadriplegia, and nonverbal status following a traumatic brain injury did not have a care plan that included specific interventions for staff to communicate with him using his established nonverbal methods, such as blinking and eye tracking. The care plan lacked documentation of these communication techniques, resulting in the absence of consistent guidance for staff.
A resident who was fully dependent on staff for all ADLs and nonverbal, with quadriplegia and contractures, fell from bed when a CNA left at least one bed rail down, the bed unlocked, and the room poorly lit while moving to the other side of the bed during perineal care. This failure to follow the facility's fall prevention policy directly led to the resident's fall.
A resident with a complex medical history, including TBI, hydrocephalus with shunt, tracheostomy, and quadriplegia, experienced a fall and subsequent decline in condition. Nursing staff were unable to reach the assigned physician for over four hours despite multiple attempts, and did not transport the resident to the ER in a timely manner. The physician was eventually reached and instructed staff to send the resident to the ER, resulting in a delayed transfer.
A resident who was fully dependent on staff for care experienced a preventable fall due to staff not securing safety rails and not following the required two-person assist protocol. The facility did not complete a thorough incident report or root cause analysis, failed to ensure timely physician response and emergency transfer, and did not review these events in its QAPI program. Nursing staff lacked competency in post-fall assessment and documentation, and leadership did not investigate or act on staff concerns, resulting in missed opportunities to identify and address systemic care issues.
A resident in a persistent vegetative state did not receive auditory stimulation, such as music or television, as outlined in their care plan. Despite family requests and care plan interventions for sensory activities, observations showed the resident in a quiet room without stimulation. The Recreation Coordinator noted that dependent residents should have a television on, but this was not consistently done, as confirmed by a nurse who turned on the TV only after being questioned.
A facility failed to ensure a clean environment for a resident when the mesh netting inside her crib became soiled during care and was not promptly cleaned or changed. The resident, who frequently placed her legs against the mesh, had a large liquid bowel movement that soiled the mesh, which was observed over several days. This increased the potential for exposure to an unsanitary environment, as confirmed by a nurse during an interview and record review.
A facility failed to properly document and communicate necessary information during the discharge of a resident with complex medical needs. The physician's discharge summary was insufficient, and there were no documented discharge orders. The RN confirmed verbal communication with the caregiver but did not complete the required discharge instruction form, violating facility policy.
A facility failed to ensure a safe environment for a resident by not conducting a safety assessment after installing a crib canopy. The resident, a 2-year-old with complex medical needs, experienced an unwitnessed fall from her crib. Although a canopy was added as a safety measure, the facility did not evaluate its potential hazards or its impact on the resident's development, as confirmed by staff interviews.
A resident was given insulin despite a blood glucose level below the physician-ordered hold parameter, leading to a critical drop in blood glucose later that day. The error was identified and reported by facility staff, and the resident's physician adjusted the insulin dosage.
The facility failed to provide routine dental care for two residents, with one resident's last dental consult in 2020 and another in 2021, despite care plans requiring regular dental visits. Observations showed poor oral hygiene, and there was no documentation of recent dental exams.
A facility failed to accurately document a medication order for a resident, leading to a discrepancy in the narcotic medication record. The record incorrectly stated a dosage of 8 ml of Lacosamide oral solution via J-Tube twice a day, while the correct dosage was 12 ml as verified by the RN with the electronic medical record and MAR. The RN acknowledged the error and noted that the narcotic form should have been updated.
The facility failed to ensure proper infection control practices, as observed in two incidents. An RN did not perform hand hygiene between glove changes after administering medication via a gastrostomy tube, contrary to facility policy. Additionally, a DCS member was seen with a face mask improperly worn under the chin while providing care, exposing their mouth and nose. These actions were confirmed by interviews with facility staff, highlighting lapses in infection prevention protocols.
Failure to Document Unplanned Tracheostomy Decannulations in EHR
Penalty
Summary
The facility failed to ensure proper documentation in the electronic health record (EHR) for two unplanned decannulations of a resident's tracheostomy tube. On two separate occasions, the resident experienced unplanned decannulations while being cared for by certified nurse aides, with both incidents being witnessed and reported in facility incident reports. In both cases, the tracheostomy tube was reinserted without difficulty, and the resident did not show signs of distress or decreased oxygen saturation. However, a review of the resident's EHR revealed that there were no progress notes written by a nurse or respiratory therapist regarding these unplanned decannulations, despite the facility's policy requiring nursing staff to document care provided and changes in the resident's condition in the medical record. Interviews with staff, including the respiratory therapist and the director of nursing (DON), confirmed that the expectation was for the nurse who responded to the incident to document the event in the EHR. The respiratory therapist involved in the incident stated he did not believe it was expected of him to chart the change in the EHR. The DON confirmed that the nurse should have documented the incident. The facility's documentation policy, provided by the DON, specifies that nursing staff are required to document care and changes in the resident's condition in the medical record, including through progress notes.
Failure to Ensure Nursing Staff Competency in Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide safe and appropriate care for residents with complex medical needs, particularly those with neurological impairments. Multiple licensed staff did not demonstrate competency in performing and documenting neurological assessments, identifying medical emergencies requiring timely intervention, or using critical thinking to determine the need for thorough assessments after a fall with potential head or neck injury. Documentation revealed that after a resident with a history of traumatic brain injury, craniectomy, and quadriplegia sustained a fall, staff did not complete full neurological assessments, including level of consciousness and pupillary response, as required by facility policy and standard care protocols. The resident, who had a baseline of neurological impairment and communicated by blinking, experienced a fall from bed while being changed by a CNA. Initial and subsequent nursing documentation focused primarily on vital signs, with incomplete or missing neurological assessment data. Staff failed to consistently document or perform assessments of the resident's level of consciousness and pupil response, and did not recognize or act upon significant changes in the resident's condition in a timely manner. There was a delay in notifying the physician and transferring the resident to a higher level of care, despite clear evidence of altered mental status and neurological decline. Interviews and record reviews indicated that staff were unclear about the components and frequency of neurological assessments, lacked access to necessary equipment such as penlights, and had not received adequate training or competency validation in these areas. The facility's policies lacked specificity regarding post-fall neurological assessments, and there was no evidence of structured training or competency checks for staff involved in the resident's care. The deficiency was determined to be immediate jeopardy due to the involvement of multiple staff and the serious nature of the failures.
Failure to Develop Comprehensive Communication Care Plan for Nonverbal Resident
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident with significant cognitive impairment and nonverbal status following a traumatic brain injury. The resident, who was quadriplegic, had a tracheostomy and a PEG tube, was unable to communicate verbally and relied on nonverbal cues such as blinking, laughing, and tracking with his eyes to interact with staff. Medical records and staff interviews confirmed that the resident used specific blinking patterns to indicate 'yes' or 'no' responses, and also responded with laughter and eye movements. Despite this, the resident's care plan did not include detailed interventions or instructions for staff on how to communicate with him using these established nonverbal methods. The care plan only generally addressed altered communication and cognition, with interventions limited to assessing pain using a specific pain scale. There was no documentation in the care plan about the resident's unique communication methods, such as blinking or tracking with his eyes, nor was there information about his baseline behaviors like laughing or smiling. This omission meant that staff did not have consistent, documented guidance on how to effectively communicate with the resident.
Failure to Secure Bed Rails Results in Resident Fall
Penalty
Summary
A resident with quadriplegia, contractures, and a history of traumatic brain injury, who was completely dependent on staff for all activities of daily living and nonverbal, experienced a fall from bed. The incident occurred when a CNA was changing the resident's diaper and turned the resident onto his right side. The CNA then moved to the opposite side of the bed, leaving at least one bed/safety rail down, the bed unlocked, and the room poorly lit. As a result, the resident fell from the bed while the CNA was on the other side. Facility records and staff interviews confirmed that the side rail on the side closest to the window, where the resident fell, was lowered at the time of the incident. The facility's fall prevention policy required that side rails be kept in the raised position when a resident is in bed. The DON confirmed that the fall was avoidable and that the CNA did not ensure the safety rails were secure and in place before leaving the resident's side, directly leading to the accident.
Delay in Emergency Physician Response and Resident Transfer
Penalty
Summary
The facility failed to ensure the availability of a physician for emergency care for one resident who experienced a fall and subsequent change in condition. The resident, a male with a history of traumatic brain injury, subdural hematoma, decompression craniotomy, post-traumatic hydrocephalus with a shunt, tracheostomy, PEG tube, and quadriplegia, fell from bed while being changed by a CNA. Following the fall, the resident exhibited a drop in oxygen saturation and became increasingly lethargic, eventually becoming unresponsive to painful stimuli and verbal questions. Despite these significant changes in condition, nursing staff were unable to reach the assigned physician for over four and a half hours, making multiple attempts to contact him directly and through the physician exchange service. During this period, staff did not transport the resident to the emergency room in a timely manner, despite the inability to reach the physician and the resident's deteriorating condition. The physician was eventually reached after more than four hours and instructed staff to send the resident to the ER, at which point 911 was called and the resident was transferred. Interviews with staff and the DON confirmed the delay in reaching the physician and uncertainty about the appropriate steps to take when the physician could not be contacted, especially as the physician was reportedly out of the country at the time.
Failure to Analyze and Address Quality Deficiencies After Resident Fall and Unplanned Hospitalizations
Penalty
Summary
The facility failed to systematically analyze and address quality deficiencies related to a resident's adverse events, including a fall and two unplanned hospitalizations for altered mental status. The resident was completely dependent on staff for all activities of daily living, including toileting, bed mobility, and transfers, and required a two-person assist and mechanical devices due to weight. Despite these needs, staff did not ensure safety rails were secure before leaving the resident unattended, resulting in a preventable fall. The incident report for the fall was incomplete, lacking documentation on whether the care plan was followed and if appropriate transfer techniques were used. The root cause analysis did not identify that incontinence care was provided by only one staff member instead of the required two, and there was no reminder to staff about the two-person assist requirement. The facility also failed to ensure 24-hour physician availability for emergency care, as the physician could not be reached for over four hours after the resident's fall and condition change. Staff did not transport the resident to the emergency room in a timely manner when unable to reach the physician. The Quality Assurance and Performance Improvement (QAPI) program did not review or identify delays in physician response or unplanned transfers, and did not address staff feedback regarding these issues. QAPI meeting minutes did not include any discussion of the resident's fall or related unplanned hospitalizations, and data elements related to rehospitalization and medical record audits were marked as compliant or not applicable, despite the events. Nursing staff demonstrated deficiencies in competency, including failure to perform and document neurological assessments, identify medical emergencies requiring timely transfer, notify providers of baseline condition changes, and conduct comprehensive assessments after the fall. Leadership received staff feedback about these deficiencies but did not investigate or develop action plans. The Director of Nursing was aware of the fall but did not personally investigate or review the medical record, and the administrator confirmed that unplanned discharges were not routinely reviewed for quality improvement opportunities. As a result, system and process issues were not identified or addressed to ensure nursing care met recognized standards of practice.
Failure to Provide Auditory Stimulation for Resident in Vegetative State
Penalty
Summary
The facility failed to enhance the quality of life for a resident who was in a persistent vegetative state by not providing auditory stimulation such as music or television. Observations over several days showed the resident in bed, either awake with eyes closed or sleeping, in a quiet room without any auditory stimulation. The resident's family member expressed concern about the lack of television or music, stating they had previously requested cartoons or similar programs to be played. Despite these requests, the facility did not consistently provide auditory stimulation. The Recreation Coordinator indicated that the presence of auditory stimulation depended on the resident's activity level, with more active residents having access to devices like iPads or cell phones. However, for dependent residents, a television should be on unless it is time to sleep. The resident's care plan included sensory stimulation activities, yet these were not implemented as observed. A Registered Nurse, when questioned, mentioned that activities would occur later in the day and subsequently turned on the television to a sports channel, highlighting a lack of consistent implementation of the care plan's interventions.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean environment for a resident, identified as R12, who was observed to have soiled mesh netting inside her crib. During care, the mesh netting came into contact with a soiled bedsheet after the resident had a large liquid bowel movement. Despite the resident's tendency to place her legs against the mesh, staff did not clean or change the soiled mesh immediately. Observations over several days confirmed the resident's continued contact with the soiled mesh, increasing the potential for exposure to an unsanitary environment. The deficiency was confirmed during an interview and record review with a registered nurse, who acknowledged the need for the mesh to be changed.
Deficiency in Discharge Documentation and Communication
Penalty
Summary
The facility failed to ensure proper communication and documentation at the time of discharge for a resident identified as R32. The resident, a male with a history of spastic diplegic cerebral palsy, epilepsy, acute respiratory failure, and a tracheostomy, was discharged voluntarily. However, the necessary discharge documentation was incomplete. The physician's discharge summary merely noted a 'stable course' without providing a detailed account of the resident's stay and treatment. Additionally, there were no documented discharge orders from the physician, and the discharge instructions form was not completed or documented in the Electronic Medical Record (EMR). The Registered Nurse (RN) responsible for the discharge confirmed that she verbally communicated the discharge checklist to the resident's caregiver but failed to document this discussion or complete the required discharge instruction form. The facility's policy mandates that all discharges require a physician's order and that the assigned nurse must complete and review the discharge instructions with the resident and responsible party, which was not adhered to in this case. This lack of documentation and communication represents a deficiency in the facility's discharge process.
Failure to Conduct Safety Assessment for Crib Canopy
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, resulting in a deficiency related to the safety of a resident's crib. A resident, a 2-year-old female with complex medical conditions including George's syndrome, paralysis of vocal cords and larynx, and chronic respiratory failure, experienced an unwitnessed fall from her crib. The incident occurred after staff had suctioned her tracheotomy and left the room, only to find her on the ground later with her GJ tube dislodged. Following this incident, the facility implemented a crib canopy as a safety intervention but did not conduct a safety assessment or evaluate the potential accident hazards associated with the new equipment. The lack of a safety assessment after the installation of the crib canopy was confirmed during interviews with facility staff, including a registered nurse and the administrator. The canopy, made of heavy-duty plastic, distorted the images on the television that the resident watched, which was not considered in terms of its impact on the resident's development. The facility's failure to assess the safety of the canopy and its effects on the resident's environment and development contributed to the deficiency identified in the report.
Insulin Administration Error Due to Ignored Hold Parameter
Penalty
Summary
The facility failed to ensure that a resident's insulin was withheld when their blood glucose level was below the physician-ordered threshold. Specifically, the resident was administered 55 units of Lantus Solostar insulin despite having a blood glucose level of 79 mg/dl, which was below the hold parameter of 80 mg/dl. This incident occurred during the morning medication round, and the error was identified later that day by the facility staff. The resident's blood glucose level was monitored throughout the day, and it was found to drop to a critical level of 69 mg/dl in the evening, necessitating intervention with glucose tablets. The error was reported to the charge nurse, the Director of Nursing, the resident's physician, and the resident's son. The physician subsequently adjusted the insulin dosage and maintained the same hold parameters.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure routine dental care for two residents, R10 and R5, as evidenced by outdated dental consults. R10's most recent dental consult was conducted in November 2020, despite having a care plan initiated in January 2020 that required yearly and as-needed dental consults. During a record review, it was found that there was no documentation of R10 being seen by a dentist in 2023, and the Assistant Director of Nursing was unable to confirm any recent dental visits. Similarly, R5's last documented dental consult was in November 2021, although the resident's care plan required dental examinations twice a year. Observations revealed that R5 had poor oral hygiene, with yellow and dirty teeth and white residue in the mouth. Despite the facility's claim that the dentist visits once a year, there was no documentation of a dental exam for R5 after 2021. The Unit Clerk was unable to provide evidence of a 2023 dental visit, as the dentist's office was closed at the time of inquiry.
Incorrect Documentation of Medication Dosage
Penalty
Summary
The facility failed to accurately document a medication order in the narcotic medication record for a resident, identified as R20, during a medication administration observation. The narcotic medication record incorrectly stated that Lacosamide oral solution 10 mg/ml should be administered at a dosage of 8 ml via J-Tube twice a day. However, upon verification with the electronic medical record and the medication administration record (MAR), it was confirmed that the correct dosage was 12 ml. The Registered Nurse (RN) 23 acknowledged the discrepancy and noted that the narcotic form should have been updated to reflect the correct dosage. The medication bottle had small labels indicating that the dosage had been changed in the medical record, but this update was not reflected in the narcotic medication record, leading to the deficiency.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented by staff, leading to deficiencies in infection prevention and control. On June 5, 2024, a Registered Nurse (RN) was observed administering medication to a resident via a gastrostomy tube. After completing the task, the RN removed her dirty gloves and donned a new pair without performing hand hygiene in between. When interviewed, the RN stated that she did not believe her hands were dirty, indicating a lack of adherence to the facility's hand hygiene policy, which requires hand hygiene immediately after glove removal. This was confirmed by the Assistant Director of Nursing, who acknowledged the requirement for hand hygiene between glove use. Additionally, on June 3, 2024, a Direct Care Staff (DCS) member was observed providing suctioning to a resident and then entering another resident's room with their face mask pulled down under the chin, exposing their mouth and nose. This was confirmed during an interview with the Infection Control Physician, who stated that staff should wear a face mask properly covering the mouth and nose while in a resident's room and during procedures like suctioning. These observations highlight lapses in the facility's infection control practices, specifically regarding hand hygiene and proper use of personal protective equipment (PPE).
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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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