Oahu Care Facility: Elopement, Wound Care Failures - HI
Her medical history included Stage 5 Chronic Kidney Disease and dementia....
Latest reports, citations, and penalties from CMS data
Her medical history included Stage 5 Chronic Kidney Disease and dementia....
The surveyor observed Certified Nursing Assistant (CNA) 8 wheeling Resident 47 away from the Northwest area of the facility....
The citation under **F610** addresses requirements for facilities to investigate and report allegations of abuse, neglect, and exploitation....
Similarly, the anti-anxiety medication lorazepam (Ativan) was documented as removed from stock on January 24 at 3 a.m....
Immediate jeopardy is the highest severity level that federal surveyors can assign to a nursing home deficiency....
These concerns were echoed at a family meeting held the previous day, where relatives questioned facility leadership about reduced staffing levels....
Residents who elope face significant risks including exposure to weather extremes, traffic hazards, falls, and inability to access medications or medical care....
According to the inspection report, CNA #3 was observed removing gloves from her pocket and putting them on without first performing hand hygiene....
According to the inspection report, the resident was admitted in September 2024 with heart failure and chronic obstructive pulmonary disease....
On February 8, 2025, the resident left the facility and did not return....
Burns occurring in oxygen-enriched environments tend to be more severe and can happen almost instantaneously....
Despite these clear instructions, inspectors observed multiple instances where staff ignored the requirement entirely....
Without this information accessible to all caregiving staff, residents may receive incorrect oxygen levels or miss treatments entirely....
According to the Nursing Home Administrator, proper staffing levels should include **one cook and three dietary aides for each shift**....
This program must demonstrate a "good faith attempt" to address quality issues systematically rather than reactively....
According to the inspection report, a resident in the memory care unit pulled off a clean-out drain cap on December 18, 2024....
According to the inspection report, staff used a "shower or toilet" sling rather than the standard transfer sling required for bed transfers....
When questioned about the missing records, the facility administrator acknowledged the oversight....
The resident remained on a regular diet with no nutritional modifications despite consuming only **26-75% of meals**....
However, the medication was never transcribed into the facility's medication administration system and was therefore never given to the resident....