Avalon Care Center: Dignity Violation for Catheter Bag - HI
He noticed. He had always noticed.
When a federal inspector stopped to speak with him on June 1, the resident said he was concerned about it too, and that the bag should always be covered. He reached down under the wheelchair and tried to adjust the privacy pouch himself. He couldn't fix it.
The resident, identified in inspection records only as Resident 124, uses a catheter. He gets around on his own, propelling his wheelchair through the hallways and into the dining room. He was returning from physical therapy when the inspector first observed the exposed bag. Two days later, on June 3, he was back in the dining room, and the situation had changed, but not improved.
A nurse had switched him to a urinary leg bag, strapped directly to his right leg, and told him he needed to use the leg bag every time he left his room. There was no privacy covering on it at all.
He wears short pants.
"I do not feel comfortable using the leg bag since it does not have any privacy bag covering it," he told the inspector. He explained that the bag was always visible to the other people around him whenever he was outside his room.
The inspector then spoke with RN11, the nurse who had made the switch to the leg bag. Asked whether urinary bags should have a privacy covering that fully conceals them, the nurse agreed: all urinary bags should always be fully covered with privacy bags.
The Director of Nursing said the same thing when interviewed the following morning. All urinary bags, she confirmed, should always be fully covered with privacy or dignity bags. She also told the inspector that the facility was in the process of ordering new leg bags that come with dignity covers built in.
The bags had not yet arrived. The resident was still going to the dining room with his catheter bag in plain view.
Federal inspectors cited the facility for failing to protect the resident's right to a dignified existence, rating the violation as causing minimal harm or the potential for actual harm. It was the only deficiency documented in this inspection.
What the report captures, in the space of three days and four interviews, is something smaller and more persistent than a dramatic medical failure: a man who knew exactly what should be happening, who tried to fix it himself and couldn't, who told staff he was uncomfortable, and who kept showing up to meals anyway because he had no other choice.
He told the inspector the bag should always be covered. The nurse told the inspector the bag should always be covered. The Director of Nursing told the inspector the bag should always be covered. The facility's own written policy on resident rights, last revised in September 2022, states that residents have the right to be treated with respect and dignity.
None of that got the bag covered.
The facility is now waiting on a supply order. In the meantime, Resident 124 has been told to swap to the leg bag every time he leaves his room, a bag with no covering, attached to a leg he prefers to keep in short pants, visible to everyone in the dining room who happens to look his way.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center - Honolulu, LLC from 2026-06-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
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
AVALON CARE CENTER - HONOLULU, LLC in HONOLULU, HI was cited for violations during a health inspection on June 4, 2026.
When a federal inspector stopped to speak with him on June 1, the resident said he was concerned about it too, and that the bag should always be covered.
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.