HONOLULU, HI - Federal inspectors found significant medication management violations and inadequate rehabilitation services at Avalon Care Center during an April 2025 inspection, raising concerns about patient safety and quality of care.
Medication Safety Violations Put Residents at Risk
During the inspection, healthcare surveyors discovered serious medication management deficiencies that compromised patient safety protocols. In one documented case, a registered nurse failed to properly account for narcotic medications, specifically oxycodone, which could potentially enable drug diversion or create dosing errors.
Inspectors found discrepancies in the controlled substance tracking system on medication cart 1C. The narcotic log indicated 24 oxycodone tablets should have been available for one resident, but only 22 tablets were physically present. The nurse revealed she had administered one pill at 9:18 AM but failed to immediately document it in the controlled drug record, and had also dropped and wasted another tablet without proper documentation.
This violation directly contradicted the facility's own policies, which require nurses to immediately document controlled substances when removing doses from storage. The Director of Nursing confirmed that narcotics should be signed out upon preparation, not after administration, to prevent medication tracking errors.
Proper narcotic management protocols exist to prevent medication diversion and ensure accurate dosing. Federal regulations require strict accountability for controlled substances because they carry high abuse potential and can cause serious harm if mismanaged. When nurses fail to document narcotic administration immediately, it creates opportunities for medications to be lost, stolen, or administered incorrectly.
Expired and Discontinued Medications Found on Patient Carts
Inspectors also discovered expired and discontinued medications remaining on medication carts, creating additional safety hazards. On cart 2B, surveyors found a half-filled bottle of ferrous gluconate that had expired in March 2025, along with methocarbamol tablets belonging to a resident who had been discharged from the facility.
The methocarbamol had been discontinued on February 28, 2025, but remained on the medication cart for over a month. The associated resident had been discharged on March 17, 2025, yet their medication was still present during the April inspection. An Assistant Director of Nursing acknowledged that all medications should have been removed from carts when discontinued and properly disposed of according to facility protocols.
Leaving expired or discontinued medications accessible creates multiple risks. Expired medications may lose potency or develop harmful breakdown products. Discontinued medications could be inadvertently administered to the wrong patient, potentially causing adverse drug reactions or therapeutic conflicts with current treatments.
Inadequate Pharmacist Recommendations Implementation
The facility failed to properly implement pharmacist recommendations for high-risk medication monitoring. During a March 2025 medication review, the consulting pharmacist provided specific monitoring guidelines for a resident taking multiple high-risk medications, including aspirin, diabetes medications, and opioid pain relievers.
The pharmacist recommended monitoring for bleeding and bruising due to antiplatelet therapy, hypoglycemia and hyperglycemia related to diabetes medications, and constipation and sedation from opioid use. While the facility acknowledged receiving these recommendations, they failed to incorporate them into physician orders or establish formal monitoring protocols.
Monthly pharmacist reviews serve as a critical safety net in nursing home care. These reviews help identify potentially dangerous drug interactions, inappropriate dosing, and necessary monitoring parameters. When facilities fail to implement pharmacist recommendations, residents face increased risks of adverse drug events, hospitalizations, and complications from unmonitored medication effects.
Federal regulations require facilities to document rationale when they choose not to implement pharmacist recommendations. This facility provided no documentation explaining why they ignored important safety monitoring guidelines.
Rehabilitation Services Understaffed and Inconsistent
The inspection revealed significant deficiencies in the facility's restorative nursing assistant (RNA) program, which provides essential range-of-motion exercises and mobility maintenance for residents. One Korean-speaking resident was found without her prescribed hand and knee splints, despite orders requiring daily use.
When asked in her native language whether the facility had been helping with exercises and stretches, the resident stated "no" and expressed desire to continue her therapeutic activities. The assigned certified nursing aide explained that no RNA staff were available that day and noted the limited number of qualified personnel.
The facility employed only five staff members trained to provide RNA services - two dedicated RNA staff and three CNAs with additional training. However, staffing challenges frequently left the program understaffed. When CNA coverage was inadequate, RNA-trained staff were reassigned to basic patient care duties, leaving rehabilitation services uncovered.
Range-of-motion exercises and proper splinting are essential for preventing contractures, maintaining joint mobility, and supporting functional independence. Without consistent therapy, residents can experience permanent loss of movement, increased pain, and reduced quality of life. Medicare and Medicaid regulations require facilities to maintain or improve residents' functional abilities whenever possible.
Staffing Challenges Compromise Patient Care
The inspection revealed systemic staffing issues affecting multiple departments. The nursing scheduler confirmed that the facility was supposed to maintain two RNA staff members but frequently operated with only one or none available. During the week of the inspection, only one RNA staff member was present from March 26 through April 2, with zero coverage on April 3.
CNAs trained in rehabilitation services indicated they could not effectively perform both roles simultaneously. One aide stated that providing RNA services while assigned CNA duties would result in neglected resident needs due to time constraints. Another reported it would be "too much" to handle both responsibilities.
Adequate staffing levels are fundamental to nursing home quality and safety. When facilities operate with insufficient personnel, residents face increased risks of missed medications, delayed care, and unmet basic needs. The dual-role expectations placed on staff can compromise both rehabilitation services and essential nursing care.
Industry Standards and Regulatory Context
Federal nursing home regulations require facilities to maintain comprehensive medication management systems, including proper controlled substance tracking, timely medication disposal, and implementation of pharmacist recommendations. These standards exist because medication errors represent one of the leading causes of preventable harm in healthcare settings.
The Centers for Medicare and Medicaid Services mandate that nursing homes provide rehabilitation services to help residents achieve their highest level of physical and mental well-being. This includes maintaining range-of-motion, preventing decline, and supporting functional independence through appropriate therapies and assistive devices.
Additional Issues Identified
Inspectors documented several other concerning practices during the survey. Staff training deficiencies were apparent in the inconsistent understanding of medication management protocols among nursing personnel. The facility's policy implementation showed gaps between written procedures and actual practice, particularly regarding narcotic documentation timing.
Communication issues were evident in the lack of coordination between departments regarding staffing assignments and patient care responsibilities. The inspection also revealed documentation inadequacies in tracking pharmacist recommendations and monitoring high-risk medications.
These violations reflect broader systemic issues affecting resident safety and care quality at the facility. While classified as causing minimal harm or potential for actual harm, they represent serious departures from accepted healthcare standards that could lead to significant patient complications if left unaddressed.
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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