Inspection Report

Avalon Care Center - Honolulu: Oxygen Therapy Oversight - HI

October 10, 2025

Honolulu, HI

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HONOLULU, HI - Avalon Care Center failed to provide appropriate respiratory care for a resident requiring oxygen therapy, lacking proper care planning and equipment maintenance protocols during a health inspection conducted in April 2025.

Missing Care Plan for Critical Oxygen Therapy

The facility's most significant violation involved Resident 77, who required oxygen therapy but did not have this critical treatment included in their comprehensive care plan. During the inspection, the MDS Director confirmed that the resident's care plan completely omitted oxygen therapy protocols, despite the resident's documented need for supplemental oxygen.

This oversight represents a fundamental breakdown in care coordination. Comprehensive care plans serve as the roadmap for all aspects of a resident's treatment, ensuring that every staff member understands the specific interventions required. Without oxygen therapy documented in the care plan, staff may be unaware of monitoring requirements, equipment needs, or emergency protocols specific to respiratory support.

The Director of Nursing acknowledged during the inspection that the resident should have had a dedicated care plan for oxygen therapy that included all physician orders related to respiratory treatment.

Equipment Safety and Maintenance Concerns

Inspectors also discovered that the resident's oxygen tubing lacked proper labeling indicating when it was last replaced. This violation poses significant infection control risks, as oxygen delivery equipment requires regular replacement to prevent bacterial contamination and ensure optimal function.

Medical equipment in healthcare facilities must follow strict replacement schedules. Oxygen tubing that remains in use beyond recommended timeframes can harbor harmful bacteria, potentially leading to respiratory infections or pneumonia. These complications can be particularly dangerous for residents already experiencing breathing difficulties.

Incomplete Physician Orders

The inspection revealed that physician orders for the resident's oxygen therapy were incomplete, missing critical parameters such as delivery method and specific administration guidelines. Proper oxygen therapy orders must specify the type of delivery system, flow rates, timing of administration, and monitoring requirements.

Without complete physician orders, nursing staff cannot safely administer oxygen therapy. Flow rates that are too high can cause oxygen toxicity, while insufficient oxygen delivery fails to address the resident's respiratory needs. The delivery method - whether through nasal cannula, mask, or other devices - directly impacts treatment effectiveness and patient comfort.

Medical Standards for Respiratory Care

Proper respiratory care in nursing facilities requires multiple safety protocols. Oxygen saturation levels must be monitored regularly to ensure the therapy is achieving therapeutic goals without causing complications. Staff should also monitor for skin integrity issues, as oxygen delivery devices can cause pressure sores or irritation when not properly managed.

The facility's own policy, established in July 2018, clearly outlined requirements for respiratory care including identification of oxygen delivery systems, administration schedules, equipment settings for prescribed flow rates, monitoring of oxygen saturation levels and vital signs, and surveillance for complications such as skin breakdown.

Industry Standards and Best Practices

Federal regulations require nursing facilities to provide respiratory care consistent with professional standards and physician orders. Care plans must be individualized based on comprehensive resident assessments and updated regularly to reflect changing medical needs.

When residents are admitted with existing oxygen therapy, nursing staff and MDS personnel are responsible for immediately incorporating these requirements into the care planning process. This ensures continuity of care and prevents dangerous gaps in treatment.

Proper documentation and labeling of medical equipment protects residents from healthcare-associated infections and ensures equipment functions as intended. Regular replacement schedules for oxygen delivery components are standard practice across healthcare settings.

Additional Issues Identified

The inspection also revealed that the facility's respiratory care protocols were not being implemented according to their own established policies. Staff training on oxygen therapy management and care plan development appeared inadequate based on the violations identified.

The facility's failure to follow its own written procedures regarding respiratory care monitoring and documentation represents a systemic issue requiring immediate attention and staff retraining.

This case highlights the critical importance of comprehensive care planning and proper equipment management in nursing facilities, where residents depend on staff expertise for life-sustaining treatments like oxygen therapy.

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.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 20, 2026 · Our methodology

Quick Answer

AVALON CARE CENTER - HONOLULU, LLC in HONOLULU, HI was cited for violations during a health inspection on April 3, 2025.

This oversight represents a fundamental breakdown in care coordination.

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.

Frequently Asked Questions

What happened at AVALON CARE CENTER - HONOLULU, LLC?

This oversight represents a fundamental breakdown in care coordination.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in HONOLULU, HI, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from AVALON CARE CENTER - HONOLULU, LLC or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 125020.

Has this facility had violations before?

To check AVALON CARE CENTER - HONOLULU, LLC's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.