Ann Pearl Nursing Facility: Medication Errors in HI
KANEOHE, HI - Federal inspectors cited Ann Pearl Nursing Facility for nine significant violations during a February inspection, including failures in medication administration, infection control, and trauma-informed care that put residents at risk of harm.
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Medication Errors Create Risk for Multiple Residents
The most serious violation involved a 16% medication error rate, more than three times the federal maximum of 5%. Inspectors observed five medication errors during 31 administration opportunities, affecting at least three residents.
During observations on February 27, nursing staff failed to administer blood pressure medication to one resident for six consecutive days, documenting it as "unavailable" when the medication was actually accessible in the facility's electronic storage system. The same nurse was observed opening a delayed-release capsule and mixing it with applesauce, despite facility policies prohibiting this practice with extended-release medications.
Medical Context: Medication errors in nursing homes can have severe consequences. Blood pressure medications must be given consistently to prevent cardiovascular events. Opening delayed-release capsules destroys their time-release mechanism, potentially causing dangerous drug level fluctuations. The observed error rate indicates systemic medication management failures that could affect all 125 residents at the facility.
In another incident, a nurse left partially consumed medication at a resident's bedside despite policies requiring direct observation of complete ingestion. Federal regulations mandate that nursing homes maintain medication error rates below 5% to ensure resident safety and therapeutic effectiveness.
Infection Control Failures During Wound Care
Inspectors documented serious infection control violations during wound care for a resident with methicillin-resistant Staphylococcus aureus (MRSA), a dangerous antibiotic-resistant bacteria. During a wound dressing change on February 25, staff failed to perform hand hygiene between removing contaminated gloves and putting on new ones.
The resident, who was on contact precautions due to MRSA infection in leg wounds, required specialized wound care protocols. However, staff removed gloves, requested additional supplies, and put on new gloves without sanitizing hands - a critical breach of infection control standards.
Medical Analysis: MRSA is a serious healthcare-associated infection that can spread through improper hand hygiene and contact with contaminated surfaces. The bacteria can cause life-threatening infections including pneumonia, bloodstream infections, and surgical site infections. Proper hand hygiene between glove changes is essential to prevent transmission to other residents, particularly those with compromised immune systems or open wounds.
The facility's breach occurred during a high-risk procedure involving wound care, creating potential for MRSA transmission throughout the facility. Contact precautions require strict adherence to hand hygiene protocols specifically because of the serious nature of resistant infections.
Trauma-Informed Care Deficiencies
The facility failed to provide adequate trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). Despite admission documentation noting PTSD with avoidant behavior, staff never developed a trauma-informed care plan to address the resident's specific triggers and needs.
The resident reported inability to sleep due to disruptive noises from other residents and staff talking loudly in hallways. According to facility policy, residents should be screened for trauma upon admission and quarterly thereafter, with care plans developed to address identified triggers.
Clinical Importance: PTSD in nursing home residents requires specialized care approaches that minimize re-traumatization. Untreated trauma responses can worsen mental health conditions, increase agitation, and interfere with medical treatment compliance. Environmental triggers like loud noises and disruptions can cause significant distress for trauma survivors.
Industry standards require facilities to implement trauma-informed care that recognizes trauma's impact on residents' behavior and health. Without proper assessment and intervention, residents with PTSD may experience increased anxiety, depression, and behavioral symptoms that complicate their overall care.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ANN PEARL NURSING FACILITY in KANEOHE, HI was cited for violations during a health inspection on February 28, 2025.
Inspectors observed five medication errors during 31 administration opportunities, affecting at least three residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.