HONOLULU, HI - State health inspectors documented multiple serious deficiencies at Avalon Care Center - Honolulu, LLC during an April 2025 inspection, including a medication error rate that exceeded federal safety thresholds and widespread failures in infection control practices that placed residents at risk for disease transmission.
Medication Error Rate Exceeds Federal Safety Standards
Inspectors observed a medication error rate of 7% during their review, significantly above the federally mandated maximum of 5%. The violations occurred during routine medication administration rounds and involved fundamental lapses in nursing protocols.
During an observation on April 1, 2025, at 8:40 AM, a registered nurse (RN14) prepared multiple medications for a resident including blood pressure medications that required specific vital sign monitoring before administration. The facility's medication administration record showed two different blood pressure readings documented for the same resident at the same time - 113/77 at 6:10 AM and 122/77 at 8:46 AM - raising questions about which reading was accurate.
When questioned about the discrepancy, RN14 stated he had taken the resident's blood pressure around 8:30 AM but did not write it down, claiming to remember the reading when documenting nearly 20 minutes later. However, the state surveyor who had been observing RN14 continuously since 8:30 AM reported never seeing the nurse take any resident's blood pressure or enter the resident's room prior to medication administration. The resident herself confirmed she did not recall having her blood pressure taken that morning.
This violation carries particular significance because the resident's medical record showed her blood pressure fell below the safety threshold for one of her medications - Lisinopril - 69% of the time during March 2025. Lisinopril is prescribed with specific parameters requiring the medication be held if systolic blood pressure drops below 120. Administering blood pressure medications when vital signs are outside safe ranges can cause dangerous drops in blood pressure, potentially leading to dizziness, falls, fainting, or inadequate blood flow to vital organs.
The second medication error occurred when RN14 failed to properly inform the resident about medications being administered. The nurse gave the resident a laxative powder (Clearlax) mixed in water, describing it only as "some water for you," without mentioning it contained medication. The resident had just refused Senna-Plus tablets - another laxative - specifically stating they made her dizzy and that she wanted to control her bowel functions. When informed by the surveyor that the water contained a laxative, the resident immediately wanted to refuse it.
Additionally, RN14 left the resident's room before ensuring all medications were consumed, contrary to standard nursing protocols. This practice creates risks that residents may not take prescribed medications as ordered, potentially compromising their treatment plans.
Infection Control Violations Identified Throughout Facility
Inspectors documented eight separate instances of infection control failures that violated Centers for Disease Control and Prevention guidelines and the facility's own policies. These violations involved both COVID-19 precautions and general infection prevention practices.
Improper Use of Personal Protective Equipment
Staff members were observed repeatedly failing to use required personal protective equipment when caring for residents with confirmed COVID-19 infections or those under enhanced barrier precautions. On March 31, 2025, a certified nurse aide (CNA48) exited a room housing a COVID-19 positive resident wearing only a surgical mask. When questioned, the aide stated she believed she did not need to wear additional protective equipment such as an N95 respirator, face shield, gown, and gloves because she was only delivering diapers.
Facility policy and CDC guidelines require full personal protective equipment when entering rooms of COVID-19 positive patients, regardless of the task being performed. This creates risk for disease transmission to the healthcare worker, other residents, and visitors.
In another instance, a certified nurse aide entered a resident's room requiring contact precautions without wearing the mandatory gloves and gown. The aide had physical contact with the resident's bed while setting up a meal tray. Contact precautions are implemented when residents have infections that can spread through direct contact with the person or contaminated surfaces.
Hand Hygiene Failures
Proper handwashing represents one of the most fundamental infection control measures in healthcare settings. Inspectors observed a registered nurse (RN21) caring for a resident under enhanced barrier precautions who removed contaminated gloves, obtained new gloves from another staff member, and put on the clean gloves without performing hand hygiene between glove changes.
When the surveyor pointed out the omission, the nurse stated, "I thought my hands were clean." This reflects a concerning gap in understanding of basic infection control principles. Gloves can develop microscopic tears during use, and hands can become contaminated during glove removal. Healthcare workers' hands serve as the primary vector for transmitting infections between patients in institutional settings.
The facility's own infection prevention policy specifically requires staff to perform hand hygiene "before and after contact with the resident" and "after removing PPE." Failure to follow these protocols can transmit dangerous pathogens between residents, including antibiotic-resistant bacteria such as MRSA or C. difficile.
Catheter Care Violations
Inspectors documented two separate instances of urinary catheter drainage bags resting directly on the floor without any barrier. Urinary catheters provide a direct pathway into the bladder, making proper care essential to prevent urinary tract infections, which represent one of the most common healthcare-associated infections.
When catheter drainage bags touch the floor, they can become contaminated with bacteria, which can then migrate up the catheter tubing into the bladder. Urinary tract infections in elderly residents can lead to serious complications including sepsis, delirium, falls, and hospitalization. One resident's catheter bag was observed not only on the floor but also full and requiring emptying - another infection risk factor as stagnant urine can promote bacterial growth.
Medication Storage Security Breach
On April 1, 2025, at 8:22 AM, inspectors observed an unlocked medication cart left unattended outside a resident's room with no nursing staff in sight. Federal regulations require all medications to be stored in locked compartments when not in immediate use to prevent unauthorized access, potential medication diversion, and accidental ingestion.
The infection prevention nurse who was nearby confirmed the cart should have been locked. When the responsible nurse (RN85) returned to the cart, she acknowledged she had been trained to lock the medication cart before leaving it unattended. Unsecured medication carts create risks for medication theft, tampering, or accidental access by confused residents who might consume medications not prescribed for them.
Inadequate Infection Control Infrastructure
Beyond individual staff failures, inspectors identified systemic problems with the facility's infection control infrastructure. Multiple resident rooms lacked readily accessible disposal receptacles for contaminated personal protective equipment. Staff were observed walking across hallways while still wearing contaminated gowns and gloves to reach the nearest trash receptacle.
This practice directly contradicts CDC guidance on proper doffing procedures, which specify that personal protective equipment should be removed at the point of use - either inside the patient's room or immediately outside the door - to prevent contamination of clean areas. The CDC's posted instructions at the facility stated that healthcare personnel "may now exit patient room" only after removing gowns - not while still wearing them.
Several rooms also lacked adequate supplies of clean gloves inside, with gloves only available in bathrooms. When residents occupied or blocked bathroom access, staff had difficulty obtaining clean gloves without leaving the room. This creates situations where staff might proceed with care tasks without proper hand protection or contaminate clean areas while seeking supplies.
Additional Issues Identified
The inspection report documented confusion among nursing staff about different types of isolation precautions. One certified nurse aide could not explain the difference between contact precautions and enhanced barrier precautions or when each should be used, despite being responsible for implementing these protocols.
The facility's infection preventionist acknowledged that trash receptacles for COVID-19 rooms were kept in hallways rather than inside rooms due to space constraints, contrary to proper infection control practices that minimize opportunities for environmental contamination.
Inspectors also noted inconsistencies in the facility's implementation of CDC guidelines, with posted instructions from June 2020 that may not reflect current recommendations for COVID-19 precautions and PPE use.
These documented violations reflect failures in both individual staff practices and systemic facility protocols. Federal regulations require nursing facilities to maintain infection prevention programs that create safe environments and prevent disease transmission. The multiple observed lapses suggest inadequate staff training, insufficient supervision, and gaps in the facility's quality assurance processes.
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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