HONOLULU, HI — A federal health inspection completed on April 3, 2025, found that Avalon Care Center in Honolulu failed to provide a stroke patient with physician-ordered rehabilitation services for multiple consecutive days, while also citing the facility for respiratory care deficiencies and wheelchair safety hazards that placed residents at risk.
Stroke Patient Left Without Prescribed Rehabilitation
The most significant finding involved a resident identified as R29, who had been admitted to Avalon Care Center following a cerebral infarction — commonly known as a stroke — that left her with hemiplegia and hemiparesis affecting the left side of her body. The condition caused weakness and paralysis in her left arm, hand, and leg, requiring a structured rehabilitation program to maintain mobility and prevent further deterioration.
R29's physician had ordered a comprehensive restorative nursing program that included passive range of motion exercises to her left upper extremity with gentle stretching to both lower extremities — three sets of 10 repetitions, seven days per week. Additionally, R29 was prescribed active range of motion exercises using a two-pound dumbbell for her right upper extremity, four times per week. The resident also had physician orders for splints on her left hand, left elbow, and left knee, with a detailed schedule requiring the left elbow splint and hand grip orthosis to be applied for four to six hours daily beginning at 6 a.m.
Federal surveyors observed R29 on multiple occasions over several days and consistently found the same concerning picture: the resident lying in bed with her left arm folded, her hand clenched in a fist against her chest, and no splint in place. This observation was documented on March 31, April 2, and April 3, 2025.
A review of facility records revealed the extent of the lapse. Between March 25 and April 2, 2025, R29 received restorative nursing aide services on only one day — March 28. The resident went without her prescribed exercises and splinting program on March 26, March 27, and then for four consecutive days from March 29 through April 2.
When a surveyor asked R29 directly — communicating in Korean, her native language — whether the facility had been helping her with exercises and stretches, she stated no, and indicated she wanted to continue receiving them.
Why Missed Rehabilitation Matters After Stroke
For patients recovering from a cerebral infarction with resulting hemiplegia, consistent range-of-motion exercises and splinting programs are not optional comfort measures — they are medically necessary interventions that serve critical functions in preventing secondary complications.
When a limb is paralyzed or significantly weakened following a stroke, the muscles, tendons, and joint structures begin to shorten and tighten without regular movement. This process, known as contracture formation, can begin within days of immobility and progressively worsen over time. The fisted hand and flexed arm position that surveyors repeatedly observed in R29 is a hallmark presentation of developing upper extremity contractures in stroke patients.
Once contractures become established, they can be extremely difficult or impossible to reverse, potentially leading to permanent loss of function, chronic pain, skin breakdown in the creases of clenched hands, and difficulty with basic hygiene and dressing. Splinting programs are specifically designed to maintain the hand and arm in a functional position, counteracting the pull of spastic muscles and preserving the range of motion that still exists.
The passive range-of-motion exercises ordered for R29 serve a similar protective function. By moving the affected joints through their full range on a daily basis, these exercises help maintain joint flexibility, promote circulation, and reduce the risk of contracture. Missing these sessions for five out of eight days represents a significant gap in care that could accelerate functional decline.
Staffing Shortages at the Root
The inspection revealed a systemic explanation for R29's missed care. The facility's MDS Director, who oversaw the restorative nursing aide program, confirmed to surveyors that R29 was supposed to receive services daily — including while under transmission-based precautions due to a roommate's COVID-19 diagnosis.
However, the MDS Director acknowledged that R29 may not have been receiving services because restorative nursing aides were being pulled from their specialized duties to work as regular certified nurse aides on the floor. This staffing practice effectively eliminated the rehabilitation workforce to fill gaps in basic caregiving coverage.
The finding was cited under F725 — Sufficient Nursing Staff, which requires facilities to maintain adequate staffing levels to provide all necessary services, including restorative nursing programs. When facilities divert specialized rehabilitation staff to cover general nursing shortages, residents with physician-ordered restorative programs are left without the targeted interventions they need.
A certified nurse aide working with R29 on April 3 told surveyors that R29 "should be wearing her splint daily but the facility did not have an RNA today." The aide then indicated she could apply the splint herself, suggesting the barrier was not complexity of care but simply the absence of designated staff.
Wheelchair Safety Violation Places Resident at Risk
In a separate finding, inspectors cited Avalon Care Center under F689 — Accident Hazards after observing a resident being transported in a wheelchair without leg rests in place.
On March 31, 2025, surveyors observed Resident 25 being pushed in her wheelchair by a physical therapy assistant and an occupational therapy assistant without her leg rests attached. The resident was observed holding her feet up during transport — a compensatory measure that placed her at risk of injury.
When questioned, the physical therapy assistant stated they "were crunched for time" and that the leg rests were in the resident's room. The facility subsequently measured the transport distance at 146 feet — 39 feet from the first-floor gym to the elevator, plus 107 feet from the second-floor elevator to the resident's room.
For residents with limited strength or cognitive impairment, being transported without leg rests creates a risk of feet dropping into the path of the wheelchair, potentially resulting in foot and ankle injuries, falls from the wheelchair, or skin tears. The facility's own Director of Rehabilitation confirmed that staff should have had the leg rests in place when pushing a resident and that staff receive training on safety protocols.
The wheelchair itself lacked a holder on the back for storing detached leg rests — a standard accessory that would have made it easier for staff to keep them accessible during therapy sessions. The facility confirmed this was something that could be ordered and installed.
Respiratory Care Documentation Gaps
A third citation under F695 — Respiratory Care found that the facility failed to meet professional standards for two residents receiving oxygen therapy.
For Resident 77, inspectors found that the resident's comprehensive assessment did not include her oxygen therapy, and the treatment was not incorporated into her care plan. Additionally, R77's nebulizer and oxygen tubing lacked date labels indicating when they were last replaced — a basic infection control measure. The physician's oxygen orders also did not specify parameters or delivery method, creating ambiguity in how the therapy should be administered.
Resident 10 had a similar documentation gap, with oxygen tubing that was not labeled with a replacement date.
Oxygen tubing that is not regularly replaced can become a source of bacterial colonization, increasing infection risk for residents who are already medically compromised. Standard practice calls for clearly labeling all respiratory equipment with the date of last change and replacing tubing at regular intervals per manufacturer guidelines and facility policy.
Pattern of Care Gaps
All three citations were classified at the level of minimal harm or potential for actual harm, affecting few residents. While none reached the threshold of immediate jeopardy, together they paint a picture of a facility where staffing pressures and time constraints are leading to gaps in ordered medical care, safety protocols, and documentation standards.
The staffing-related rehabilitation failure is particularly concerning because it reflects a systemic problem rather than an isolated incident. When restorative nurse aides are routinely redirected to fill general CNA vacancies, every resident with a restorative nursing program is potentially affected — not just the one resident captured during the survey window.
Avalon Care Center, located at 1930 Kamehameha IV Road in Honolulu, is required to submit a plan of correction addressing each deficiency. The full inspection report, including the facility's corrective action plan, is available through the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center - Honolulu, LLC from 2025-04-03 including all violations, facility responses, and corrective action plans.
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