Deficiencies (last 3 years)
Deficiencies (over 3 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
122% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 18
Date: Apr 3, 2025
Visit Reason
Routine inspection of Avalon Care Center - Honolulu, LLC to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within residents' reach, protection of personal health information, accuracy of resident assessments, care planning, infection control practices, medication management, and staffing adequacy for restorative nursing services.
Deficiencies (18)
F0558: Facility failed to ensure call devices were placed within reach of six sampled residents, risking delayed assistance.
F0583: Facility failed to protect personal health information when an Electronic Health Record was left open and visible.
F0641: Facility failed to ensure comprehensive resident assessment accurately reflected oxygen therapy for one resident.
F0655: Facility failed to furnish baseline care plan copy to one resident, limiting resident's awareness of care plan.
F0656: Facility failed to develop comprehensive care plans for residents with respiratory, dialysis, and catheter care needs.
F0657: Facility failed to update care plan and acquire physician order for antifungal treatment of resident's worsening moisture-associated skin damage.
F0679: Facility failed to care plan and implement residents' individual activity preferences and accommodate special needs for two residents.
F0684: Facility failed to provide ordered bowel regimen for one resident and failed to treat worsening skin damage for another resident.
F0688: Facility failed to provide consistent restorative nursing assistance and splint application for one resident with limited range of motion.
F0689: Facility failed to ensure resident's wheelchair had leg rests during transport, risking accident and injury.
F0695: Facility failed to provide safe respiratory care; oxygen tubing was not labeled timely and orders lacked required details.
F0698: Facility failed to remove dialysis pressure dressing within two hours post-treatment, risking access clotting.
F0725: Facility failed to ensure sufficient nursing staff to provide restorative nursing services, resulting in missed care.
F0755: Facility failed to ensure accurate narcotic documentation and timely removal of expired/discontinued medications.
F0756: Facility failed to document rationale for not implementing pharmacist's medication regimen review recommendations.
F0759: Facility failed to ensure medication error rate below 5%; observed medication administration errors including improper communication and documentation.
F0761: Facility failed to ensure medication carts were locked when unattended, risking medication security.
F0880: Facility failed to implement infection prevention and control program adequately; staff did not consistently use PPE or follow precautions, and catheter care was deficient.
Report Facts
Medication error rate: 7
Blood pressure parameter noncompliance: 69
RNA staffing: 1
Distance wheelchair pushed without leg rests: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN14 | Registered Nurse | Involved in medication administration errors and improper communication with resident R56. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication, care planning, and staffing. |
| MDSD67 | MDS Director | Interviewed regarding assessment and restorative nursing aide staffing deficiencies. |
| RN56 | Registered Nurse | Failed to document narcotic administration properly. |
| RN65 | Registered Nurse | Confirmed expired medications were not removed from medication cart. |
| CNA75 | Certified Nurse Aide | Observed not applying splint and explained staffing issues affecting restorative nursing services. |
| RN94 | Registered Nurse | Observed call light placement and confirmed PPE use requirements. |
| CNA48 | Certified Nurse Aide | Observed not wearing required PPE entering COVID positive resident's room. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 5, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to maintain a safe, clean, and comfortable environment and failure to provide timely written notification to residents or their representatives before transfer or discharge.
Complaint Details
The investigation was complaint-driven, focusing on environmental cleanliness and notification procedures for resident transfers and discharges. The complaints were substantiated with findings of unsanitary conditions and failure to provide required written notifications.
Findings
The facility failed to keep vents and ceilings outside residents' rooms clean, posing a potential infection risk. Additionally, the facility did not provide timely written notification to four sampled residents or their representatives regarding transfers or discharges as required by policy.
Deficiencies (2)
F 0584: The facility failed to assure the vent and ceiling outside residents' rooms were kept clean, with black residue observed on vents and ceilings, potentially increasing infection risk.
F 0623: The facility failed to provide timely written notification to four sampled residents or their representatives before transfer or discharge, violating policy requirements.
Report Facts
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heavy Cleaner (HC) 1 | Interviewed regarding black residue on vents and ceiling | |
| Housekeeping Director (HD) | Interviewed about cleaning procedures and logs | |
| Administrator | Interviewed regarding transfer/discharge notification procedures and documentation | |
| Social Services Aide (SSA) 7 | Interviewed about notification practices for transfers/discharges |
Inspection Report
Routine
Deficiencies: 17
Date: Apr 5, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements and resident care standards at Avalon Care Center - Honolulu, LLC.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, personal funds management, advance directives documentation, environmental cleanliness, transfer/discharge notifications, care planning, pain management, medication administration, infection control, and equipment safety.
Deficiencies (17)
F 0550: Facility staff referred to residents as feeders and used personal phones while assisting with meals, failing to maintain resident dignity.
F 0568: Facility failed to provide quarterly statements and statements upon request for resident personal funds management.
F 0578: Facility failed to ensure physician documentation of residents' lack of capacity for healthcare decisions for surrogate forms.
F 0584: Facility failed to maintain clean vents and ceilings, with black residue observed, increasing infection risk.
F 0623: Facility failed to provide timely written notification of transfer/discharge and bed hold policy to residents and representatives.
F 0641: Facility failed to ensure accurate discharge assessment documentation for a resident discharged home.
F 0656: Facility failed to develop and implement a person-centered care plan for a resident's contracture treatment.
F 0657: Facility failed to review and revise a resident's care plan to address new diagnosis of diabetes.
F 0684: Facility failed to effectively assess, identify, and manage constipation for a resident, causing distress.
F 0688: Facility failed to provide appropriate care and treatment to prevent further decrease in range of motion for a resident's contracture.
F 0689: Facility failed to provide adequate supervision and assistance to prevent accidents during feeding for a resident.
F 0697: Facility failed to fully evaluate and manage pain for three residents, resulting in incomplete pain care plans.
F 0726: Facility failed to ensure staff competency in narcotic log documentation and reconciliation, risking medication diversion.
F 0761: Facility failed to ensure all medications were properly labeled, including an unlabeled used albuterol inhaler.
F 0842: Facility failed to ensure accurate medical record documentation and falsely marked contracture treatment as completed.
F 0880: Facility failed to implement infection prevention and control program, including improper PPE use and handling of contaminated items.
F 0908: Facility failed to maintain resident's bed control cord in safe condition, with frayed cord posing electrocution risk.
Report Facts
Residents sampled: 22
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medication count discrepancy: 1
Unlabeled medication: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN37 | Registered Nurse | Observed medication administration and narcotic log discrepancy |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, pain management, and medication practices |
| UM87 | Unit Manager Registered Nurse | Interviewed regarding supervision and infection control |
| CNA40 | Certified Nurse Aide | Observed using personal phone while assisting resident with feeding |
| UM90 | Unit Manager | Interviewed regarding pain evaluation completion |
| MDSD13 | MDS Director | Interviewed regarding discharge assessment accuracy |
| LPN1 | Licensed Practical Nurse | Interviewed regarding contracture treatment documentation |
| ADON2 | Assistant Director of Nursing | Interviewed regarding medication labeling |
| IP | Infection Preventionist | Interviewed regarding infection control practices |
Inspection Report
Deficiencies: 0
Date: Sep 5, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Avalon Care Center - Honolulu, LLC, related to a regulatory survey completed on 09/05/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Mar 17, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, advance directives, safe and homelike environment, abuse prevention, notification of transfers and bed-hold policies, comprehensive care planning, maintenance of activities of daily living, nursing competency, medication management, infection control, and equipment maintenance.
Deficiencies (17)
F 0550: Staff failed to treat residents with dignity and respect, including speaking another language residents could not understand and inappropriate staff behavior during care.
F 0578: Facility failed to ensure residents had the right to formulate advance directives and follow-up discussions for four sampled residents.
F 0584: Facility failed to provide a safe, clean, comfortable, and homelike environment, including unsanitary conditions and excessive noise disturbing residents.
F 0600: Facility failed to protect residents from abuse and neglect, including failure to respond to call lights and turning off call lights without assistance.
F 0623: Facility failed to provide timely written notification of transfer and discharge to residents and representatives.
F 0625: Facility failed to provide written notice of bed-hold policy duration to residents and representatives.
F 0656: Facility failed to develop and implement complete, person-centered care plans for residents, including monitoring for medication side effects and communication needs.
F 0657: Facility failed to review and revise care plans timely to address residents' declining abilities and needs.
F 0676: Facility failed to maintain residents' activities of daily living and communication abilities, placing residents at risk of decline.
F 0689: Facility failed to ensure a resident was free from accident hazards when a shower chair broke causing a fall.
F 0726: Nursing staff failed to demonstrate competency in applying pain medication patches as ordered, risking unrelieved pain.
F 0732: Facility failed to update nurse staffing data daily as required.
F 0761: Facility failed to ensure medications were securely stored and properly labeled, including unlocked medication carts and improperly labeled insulin vials.
F 0804: Facility failed to ensure food was palatable, attractive, and served at an appetizing temperature for residents.
F 0842: Facility failed to maintain and clean medical equipment properly, including visibly soiled oxygen concentrator without documented maintenance.
F 0880: Facility failed to implement infection prevention and control practices, including improper PPE use and hand hygiene, risking disease transmission.
F 0908: Facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, including oxygen concentrator maintenance.
Report Facts
Residents affected: 7
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 11 | Registered Nurse | Named in incident of sticking tongue out at resident and improper medication patch application |
| CNA 37 | Certified Nurse Aide | Named in incident of providing water from communal bathroom and refusal to assist resident |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, abuse, and medication application |
| Social Services Manager | Social Services Manager | Interviewed regarding advance directive documentation deficiencies |
| Administrator | Administrator | Interviewed regarding grievance and transfer notification deficiencies |
| Wound Care Nurse | Wound Care Nurse | Interviewed regarding nurse staffing data posting |
| Registered Nurse Unit Director 1 | Registered Nurse Unit Director | Interviewed regarding medication labeling and storage deficiencies |
| Certified Nurse Aide 26 | Certified Nurse Aide | Observed delivering trays without hand hygiene between residents |
| Physical Therapist 6 | Physical Therapist | Observed not wearing adequate eye protection in isolation zone |
| Certified Nurse Aide 16 | Certified Nurse Aide | Observed not following contact precautions and hand hygiene |
| Registered Nurse 20 | Registered Nurse | Observed and reported for improper medication patch application and PPE use |
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