Federal inspectors documented widespread infection control failures during a February 6 visit to the Pali Highway facility, finding violations that put residents at risk for contamination and respiratory distress.
The most alarming discovery involved a resident who required continuous oxygen therapy. Inspectors found the patient's face mask positioned on the side of her face rather than covering her mouth and nose. The tubing connecting her oxygen mask to the concentrator had come loose, with the connection end touching the floor while the machine ran uselessly.
The resident told inspectors she needed oxygen treatment all day and night. When confronted, Registered Nurse 5 acknowledged the tubing should have been connected but claimed the resident "does not necessarily need the oxygen concentrator to be on continuously but more so wants it on continuously."
The facility's oxygen administration policy requires staff to monitor for complications and take precautions to prevent them. The patient had physician orders for continuous oxygen at two liters per minute to keep her oxygen saturation above 90 percent.
Medication contamination posed another serious risk. During inspection of a second-floor medication cart, surveyors found a pill cutter filled with "large amounts of white/brown sediments." The registered nurse administering medications from that cart confirmed seeing the contamination and acknowledged "it could be from not cleaning it."
The nurse admitted the cutter should be cleaned after each use. The device was being used to cut pills for multiple residents, potentially spreading contamination between patients.
Staff also failed to follow basic hand hygiene protocols. Inspectors observed a certified nursing assistant feed a resident lunch immediately after removing dirty gloves without washing her hands. The aide had repositioned the resident in bed using a draw sheet, disposed of soiled gloves, then sat beside the bed to feed the patient without performing hand hygiene.
When questioned, another nursing assistant confirmed staff are expected to sanitize hands after removing gloves. The Director of Nursing stated the proper protocol is to wash hands if soiled and use hand sanitizer if not.
During wound care for a resident with a pressure ulcer, inspectors watched a registered nurse place clean gauze directly on an unwashed bedside table. The nurse also put on clean gloves after removing dirty ones without washing her hands between glove changes.
The nurse, who had worked at the facility for six months, acknowledged she should wash her hands before putting on clean gloves. When asked about hand hygiene training, she said she hadn't received refresher training "in a while" but confirmed receiving training during orientation.
A resident under Enhanced Barrier Precautions received improper care when she soiled herself. The registered nurse entered the room wearing only gloves despite posted signs requiring gowns and gloves for contact care. After wiping the resident's hands and assessing her stomach, the nurse removed her gloves and grabbed a new pair without hand washing.
The Infection Preventionist confirmed nursing staff must wear gowns and gloves during high-contact care for Enhanced Barrier Precautions residents to prevent infections and multidrug-resistant organisms.
Inspectors found an opened lancet on a resident's bed with its cover on the bedside table. The registered nurse confirmed the lancet had been used to puncture the resident's finger for blood sugar testing but acknowledged used lancets should be discarded in sharps containers to prevent needle stick injuries and blood-borne pathogen transmission.
A urinary catheter bag was discovered on the floor next to a resident's bed, violating infection control protocols. A certified nursing assistant confirmed the bag should be elevated in a basin to serve as a barrier. The facility's catheter policy specifically requires drainage bags to be positioned below bladder level and "clear from the floor."
Beyond infection control, inspectors documented failures in resident care planning and medication management. One stroke patient with contractures was observed repeatedly with arms bent to chest, fists clenched around rolled hand towels, and one leg bent toward the stomach.
The resident's care plan called for range of motion exercises and monitoring for pain during movement, but no documentation existed showing staff performed these interventions. Physical therapy had discharged the resident in December 2023, recommending assistance with a functional maintenance program, but nursing staff never documented providing the prescribed exercises.
The facility's Director of Nursing acknowledged there was no system for certified nursing assistants to document range of motion services and no way to track which residents received them. She confirmed the hand towels had not been assessed by therapy or ordered by physicians.
Another resident continued receiving the wrong antidepressant dosage for months after a physician ordered a reduction. In September 2024, the consulting pharmacist recommended reviewing the resident's Citalopram for a gradual dose reduction. The physician signed an order to reduce the dose from 10 milligrams daily to 5 milligrams daily on September 27.
But the dose reduction was never implemented. The resident continued receiving 10 milligrams daily through February 2025, despite the signed physician order. The Director of Nursing confirmed the facility receives medication regimen reviews monthly and that the physician's reduction order was not carried out.
A medication labeling error created additional confusion. Inspectors found a resident receiving Carvedilol from a blister pack labeled for every 12 hours, while the medication administration record showed twice daily dosing. The registered nurse confirmed the labels didn't match and produced a correctly labeled package from a drawer, admitting the incorrectly labeled medication should have been discarded when the resident returned from the hospital.
Inspectors also discovered an expired insulin pen that had passed its discard date still stored in a medication cart.
The violations at Nuuanu Hale demonstrate how basic care failures can compound, leaving vulnerable residents at risk for infections, medication errors, and inadequate treatment of their medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nuuanu Hale from 2025-02-06 including all violations, facility responses, and corrective action plans.