Avalon Care Center - Honolulu, LLC

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement the person-centered care plan for one of three residents (Resident (R)1) sampled for accidents. R1 did not receive the six-time-a-week active range of motion (AROM) exercises as noted in the care plan. This deficient practice has the potential to affect all residents requiring ROM exercises to maintain their strength and mobility. Findings Include:Cross reference to F688R1 was admitted to the facility on [DATE] with a diagnosis of but not limited to weakness, pain, and history of falling.05/21/26 at 10:00 AM, observed R1 sitting on her rollator in the activities room not participating in the balloon toss activity. When R1 was asked why she was not participating in the activity, R1 shook her head and motioned that she could not lift her arms. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement the active range of motion (AROM) exercises for one of three resident (Resident (R)1) sampled for accidents. R1 did not receive the six-time-a-week AROM exercises as noted in the care plan. This deficient practice has the potential to affect all residents requiring ROM exercises to maintain their strength and mobility. Findings Include:R1 was admitted to the facility on [DATE] with a diagnosis of but not limited to weakness, pain, and history of falling.05/21/26 at 10:00 AM, observed R1 sitting on her rollator in the activities room not participating in the balloon toss activity. When R1 was asked why she was not participating in the activity, R1 shook her head and motioned that she could not lift her arms. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections were implemented. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (additional measures used to help stop infection transmission when a patient/resident has been found to be infected or colonized with certain infectious agents) by wearing the proper personal protective equipment (PPE), followed standard precautions (the basic level of practices used to prevent the spread of infection) by performing hand hygiene, and had PPE and PPE disposal receptacles readily available both inside and/or outside the rooms. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accommodate the needs of six of six sampled residents (Residents (R) 19, R54, R338, R36, R136 and R39) by not ensuring that call devices were placed within residents' reach and positioned so the residents could activate them. As a result of this deficient practice the residents were placed at risk of not having their emergent needs met in a timely manner and prevented them from achieving independent functioning with regards to calling for help. This deficient practice has the potential to affect all the residents in the facility who can activate a call light.

Inspectors wroteBased on interviews and record review the facility failed to ensure sufficient nursing staff were available to provide restorative services for one of three residents (Resident (R) 29) sampled for limited range of motion (ROM). As a result, R29 did not receive consistent restorative nurse aide treatment and services to maintain and/or prevent a decline in ROM. This deficient practice puts 30 residents in the RNA program at risk for a decline in ROM.

Inspectors wroteBased on observation and interview, the facility failed to ensure personal information was protected for one of one randomly sampled resident (Resident (R) 88). The Electronic Health Record (EHR) was left open. As a result of this deficient practice, residents are at risk of their health information not remaining private.

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive resident assessment accurately reflected the resident's status for one of 21 residents sampled (Resident (R) 77) for accuracy of assessment. R77's admission comprehensive assessment did not include oxygen (O2) therapy as a respiratory treatment R77 was receiving at the facility. As a result, R77's O2 therapy was not care planned, O2 physician orders were not reviewed, and her O2 tubing was overlooked.

Inspectors wroteBased on interviews and record review, the facility failed to furnish a copy of the baseline care plan (BCP) for one of two residents (Resident (R) 385) sampled for care plan meetings. The facility not providing the BCP to the residents does not keep them informed of the initial plan for delivery of care and services residents are to receive.

Inspectors wroteBased on observation, record reviews and interviews the facility failed to develop a person-centered comprehensive care plan for one of two residents (Resident (R) 77) sampled for respiratory, one of two residents (R390) sampled for dialysis, and one of one resident (R387) sampled for catheter care. As a result of this deficient practice, staff did not have the information necessary to adequately care for R77's oxygen (O2) therapy, R390's dialysis needs and post-treatment, and R387's catheter care.

Inspectors wroteBased on interview and record review the facility failed to update Resident (R) 136's care plan to include a new intervention to treat resident's moisture-associated skin damage (MASD) with an antifungal once identified, for one of four residents sampled for skin conditions (non-pressure). The deficient practice put R136 at risk for worsening of fungal infection with MASD to her sacrum and buttocks which could lead to a pressure injury and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to care plan and implement residents' individual activity preferences and accommodate special needs for two of two residents (Resident (R) 19 and R338) sampled for activities. This deficient practice has the potential of not supporting the physical, mental, and psychosocial well-being of residents and not creating a meaningful life for residents residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to provide resident centered needed care and services for two of six residents (Resident (R) 77 and R136), R77 who was one of one sampled for constipation/diarrhea and R136 who was one of four residents sampled for skin conditions (non-pressure). The facility did not follow the physician ordered bowel regimen for R77. This deficient practice put R77 at potential risk for discomfort and fecal impaction. The facility failed to treat R136's Moisture-associated skin damage (MASD) with fungal infection to her sacrum and to her bilateral buttocks from 03/29/25 until 04/03/25 which the facility identified as worsening. This put R136 at risk for harm from possibly developing a pressure injury and pain.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one of three residents (Resident (R) 29) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM, as evidenced by inconsistent application of splint and ROM exercises. This puts R29 at risk of a decline in ROM and further contractures.

Inspectors wroteBased on observation and interview the facility failed to provide an environment free of accident hazard for one of two sampled resident (Resident (R) 25) observed for accidents. R25 was observed pushed in her wheelchair with her leg rests not in place putting the resident at risk for an accident that could result in harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure respiratory care was provided consistent with professional standards for two of two (Resident (R) 77 and R10) sampled for respiratory. R77's comprehensive assessment did not include oxygen (O2) therapy, it was not included in her care plan, her nebulizer and O2 tubing was not labeled with the date it was last replaced and the physician O2 orders did not include parameters and delivery method. R10's O2 tubing was not labeled with the date it was last replaced. This deficient practice put R77 and R10 at risk for respiratory complications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one of two residents (Resident (R) 390) sampled for dialysis, was provided with professional standards of practice. The facility failed to remove R390's pressure dressing after two hours from the completion of R390's Hemodialysis (HD) treatment. This deficient practice puts residents on dialysis at risk for access clotting and complications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a thorough process in narcotic log documentation and reconciliation for two of four medication carts observed. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of the controlled medications used to meet the needs of the residents. In addition, the facility failed to implement a process that assures the accurate and timely disposition of discontinued and/or expired medications. This deficient practice hinders the promotion of safe administration practices that decrease the risk for medication errors. These deficient practices have the potential to affect all residents in the facility who take medications.

Inspectors wroteBased on record review and interview, the facility failed to document the rationale for not making any changes to the pharmacist's recommendations during a monthly medication regimen review (MRR) for one of five residents (Resident (R) 285) sampled for unnecessary medications. This puts R285 at risk for complications due to medications administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two medication errors observed out of 28 opportunities for errors, for an error rate of 7%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, Resident (R) 56 was placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure all medications used in the facility were stored in accordance with professional standards for one of four medication carts observed. Proper storage of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications. Findings Include: On 04/01/25 at 08:22 AM, observed an unlocked medication cart left outside of a resident's room with no staff in sight. At this time the Infection Prevention Registered Nurse (RN) 94 was seen near by and inquired of RN94 if the medication cart is to be locked by the nurse before leaving it and she confirmed it is supposed to be locked. At 08:23 AM, RN85 returned to the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), as well as follow standard precautions by performing hand hygiene in between glove changes. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Inspectors wroteBased on record review and interview the facility failed to assure three of six residents sampled (Resident (R) 147, R67 and R48) who had surrogate forms filled out also included the physician's documentation stating R147, R67 and R48 did not have capacity to make their own healthcare decisions, as according to State Law. The deficient practice could affect other residents in the facility who do not have advanced healthcare directives and who have surrogate forms filled out incompletely.

Inspectors wroteBased on staff interview and record review, the facility failed to provide, four of four sampled residents (Resident (R) 40, R48, R58, and R246) or their representatives, written notification of transfer/discharge as soon as practical or at least 30 days before residents are transferred or discharged

Inspectors wroteBased on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to three residents of four sampled (Residents (R) 40, R48, R58) and their representative. This deficient practice has the potential to affect all residents at the facility who are discharged to an acute care hospital. Findings Include: 1) R40 was transferred and admitted to the hospital on [DATE] for sepsis (blood infection). A review of the R40's Electronic Health Record (EHR) was conducted. The EHR did not contain documentation, that a written notification regarding the facility's bed hold policy was provided to R40's representative. Interview was conducted with the Administrator on 04/04/24 at 02:00 PM. During the interview, the Administrator failed to provide documentation that the facility's bed hold policy was provided to R40's representative. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and manage pain adequately for 3 of 3 residents sampled for pain (Residents (R) 197, R146, and R13). Specifically, the facility failed to effectively evaluate pain on admission so that an effective, resident-centered care plan could be developed. As a result of this deficient practice, these residents were prevented from attaining or maintaining their highest practicable level of well-being.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to promote care for residents in a manner that maintains and enhances each residents' dignity for three of 22 sampled residents (Resident (R) 32, R47, and R40). Staff members referred to R47 and R32 as feeders; and a staff member stood over R40 and used her personal phone while providing assistance during meals.

Inspectors wroteBased on interviews and facility document review, the facility failed to provide quarterly statements and provide statements upon request to one of one residents sampled (Resident (R) 45). Findings Include: R45 is a [AGE] year-old female, admitted to the facility on [DATE]. Interview was conducted with R45 on 04/02/24 at 11:05 AM. R45 stated that her personal funds are managed by the facility. When asked how often the facility provides account statements, R45 stated that she had never received a statement since she had been admitted . Additionally, R45 stated that she had requested a statement a while ago and had not received one thus far. R45 did not know the balance on her account. Interview and attempted record review was conducted with facility Business Office Manager (BOM) on 04/03/24 at 03:34 PM. [...]

Inspectors wroteBased on observation and staff interview the facility failed to assure the vent and ceiling outside of residents rooms were kept clean. This deficient practice could affect all residents in the facility if their environment is not kept sanitary, putting them at risk for exposure to increased risk of infection. Findings Include: On 4/02/24 at 12:34 PM, while standing in the hallway outside of a resident's room looked up and saw the ceiling and vent had black residue of an unknown source. The black residue was on the edge of the vent that meets the ceiling and spread across the ceiling spreading to both walls outside of the resident's rooms. On 04/03/24 at 11:38 AM, approached facility staff, Heavy Cleaner (HC) 1, in the hallway under the vent with black residue and inquired why the vent had black residue. HC1 stated It's from the AC, I think it's mold. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Discharge Assessment for Resident (R) 94 accurately reflected the resident's discharge status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered Comprehensive Care Plan (CP) for one of 22 residents (Resident (R) 25) sampled. As a result of this deficient practice, staff did not have the information necessary to adequately care for R25 contractures, ensuring the resident meets his highest potential of physical and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's person-centered comprehensive Care Plan (CP) was reviewed and revised for one resident (Resident (R) 48) sampled. As a result of this deficient practice, R48 was at risk of a decline in his quality of life, not attaining his highest practicable well-being, and the potential for serious harm and/or death due to complications with his new diagnosis of diabetes.

Inspectors wroteBased on interview, and record review, the facility failed to effectively assess, identify, and manage, constipation for 1 of 1 resident (Resident (R) 197) sampled. As a result of this deficient practice, R197 experienced no bowel movements for more than five days and abdominal pain/discomfort causing her distress. This deficient practice has the potential to affect all the residents at the facility at risk of constipation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for one of two residents (Resident (R) 25) sampled. R25 was not provided proper care and treatment for contracture to his left hand as ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents to one of seven sampled residents (Resident (R) 40). This failed practice has the potential to negatively affect residents who require staff assistance with feeding. Findings Include: R40 is an [AGE] year-old male admitted to the facility on [DATE]. R40's medical diagnoses include but not limited to, hemiplegia (one sided paralysis), hemiparesis (one sided weakness) affecting the right side following cerebral infarction (reduced blood supply to the brain), and dysphagia (difficulty swallowing). Concurrent observation and interview were conducted on 04/03/24 at 08:01 AM with Certified Nurse's Aide (CNA) 40 in R40's room. CNA 40 was observed standing up near the head of R40's bed, looking down at her personal phone. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff competency in narcotic log documentation and reconciliation. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility taking medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's (Resident (R) 25) medical record was accurately documented.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain resident (R)148's bed cord control, that raises and lowers the bed, in safe operating condition. The bed cord was frayed in multiple places putting the resident and staff at risk for electrocution. The deficient practice could affect all residents with a bed control. Findings Include: On 04/02/24 at 12:32 PM, observed R148's bed control was placed in her dresser drawer at the bedside. Noticed the cord for the bed control was frayed in multiple places. R148 stated she was tired and was going to sleep because she had a rough night so was not able to answer any questions about the bed control. On 04/05/24 at 09:58 AM, met with Unit Manager Registered Nurse (UMRN) 87 who confirmed the bed control cord was frayed, not safe and she would have maintenance fix this.

Inspectors wroteBased on interviews and record review, the facility failed to notify in writing the transfer and discharge to hospital as indicated in regulation for two of two residents (Resident (R)14 and R20) sampled.

Inspectors wroteBased on interviews and record review (RR), the facility failed to provide written notice of bed-hold policy as indicated in regulation for 2 of 2 Residents (R)14 and R20 sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented to help prevent the development and transmission of communicable diseases and infections. As a result of this deficient practice, residents are at risk of exposure and contracting communicable disease(s) that has the potential to result in harm.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents were treated with respect and dignity for seven (Resident (R) R38, R37, R67, R5, R76, R82, and R51) residents sampled. Staff member stood over R37, R38, and R51 while providing assistance during meals; staff members were speaking another language while providing care to R5 and outside of residents' rooms; after R76 followed up for a requested item with nursing staff, a nursing staff member stuck her tongue at R76 and a nursing staff offered R76 drinking water from a communal bathroom sink; and while a nursing staff member was providing assistance to R82, the nursing staff member did not communicate to her in a way that promoted a dignified existence.

Inspectors wroteBased on observations and interview the facility failed to update the nurse staffing data daily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were securely stored in locked compartments, and failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper security and labeling of medications is necessary to promote safe administration practices, decrease the risk for medication errors, and decrease the risk for the diversion of resident medications. This deficient practice has the potential to affect all residents in the facility who take medications.

Inspectors wroteBased on observations, interviews, and record review (RR), the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. This deficient practice has the potential to result in harm to residents on supplemental oxygen therapy.

Inspectors wroteBased on interview and record review (RR), the facility failed to ensure the right to formulate an Advance Directive and/or ensure follow-up discussions regarding Advance Directives for four of six residents (Resident (R)50, R56, R5, and R76) sampled. As a result of this deficient practice, these residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on record review and interviews, the facility failed to assure a resident has the right to a sanitary and comfortable homelike environment for two of five residents (Resident (R) 76 and R67) sampled. R76 was not comfortable leaving a communal bathroom to go back to her bed due to staff putting unsanitary items on the walkway floor and the sound level in the room while R67 is resting.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents are free from abuse or deprived of services by staff, for three of four residents (Resident (R) 82, R11 and R76) sampled. The facility failed to respond to R82's call light timely; a nursing staff member turned off R11's call light multiple times without providing assistance; and a nursing staff member did not help R76 when she requested assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered Comprehensive Care Plan (CP) for three of five residents ((R)50, R8, and R77) sampled. As a result of this deficient practice, these residents were at risk of a decline in their quality of life, not attaining their highest practicable well-being, and the potential for serious harm and/or death due to adverse effects of an anticoagulant medication. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's person-centered comprehensive Care Plan (CP) was reviewed and revised for one Resident ((R)50) sampled. As a result of this deficient practice, staff did not have the information necessary to adequately care for R50 ensuring the resident meets the highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide the proper care and treatment to maintain the activities of daily living (ADLs) for Resident (R)50. In addition, the facility failed to provide the proper care and treatment, including assistive devices, to improve the communication abilities of R8. As a result, R50 experienced a decline in her ADL function and R8 was placed at an increased risk of not having her needs met. Both residents were placed at risk of experiencing a decline in their physical well-being, psychosocial well-being, and quality of life. This deficient practice has the potential to affect all residents at the facility placed on isolation in their rooms and/or with communication needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident was free of accident hazards for one of two residents sampled (Resident (R) 27). As a result of this deficient practice, the resident is at risk for potential harm.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure nursing staff demonstrated competency skills for one resident (Resident (R)76). Staff did not competently apply a pain medication patch as ordered by the physician. As a result of this deficient practice, R76 is at risk of the potential for harm related to unrelieved pain.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was palatable, attractive, and at an appetizing temperature for two residents (Resident (R)51 and R54). As a result of this deficient practice, residents are at risk for the potential of negative psychosocial and/or a decline in weight.

Inspectors wroteBased on observations, interview, and record review (RR), the facility failed to accurately document medical equipment maintenance and cleaning records for one resident (Resident (R)16) sampled. As a result of this deficent practice, the resident is at risk for the potential for exposure to dust and allergens that could adversely affect the resident.