Avalon Care Center - Honolulu, Llc

F-F656, Development of Comprehensive Care Plans. On 04/02/25 at 09:00 AM, observed R390 with right upper arm fistula pressure dressing still on from yesterday's HD treatment. R390 stated that staff will take it off when they have time and do not really check for the thrill and bruit (a thrill is a palpable sensation felt over the fistula and bruit is a swooshing sound heard with a stethoscope which indicates good blood flow and fistula function). R390 stated he will usually be the one that takes it off. R390 stated he came back from dialysis yesterday at 04:30 PM.

On 04/02/25 at 9:30 AM, record review of R390's care plan noted, HD focus that was initiated on 03/20/25, interventions included to monitor, document, and report as needed any signs and symptoms of infection to access site redness, swelling, warmth or drainage, but did not include any interventions to assess for thrill and bruit in care plan.

Treatment Administration Records (TAR) showed the dialysis fistula checks for thrill and bruit check were being done every shift.

On 04/02/25 at 09:05 AM, interview with Registered Nurse (RN) 30 completed. RN30 stated they remove the dressing when R390 comes back after dialysis. RN30 stated, We follow the orders and observe the access site for any signs and symptoms of redness, bleeding, and for the thrill/bruit. RN30 also noted the last assessment was done last night at 12:10 AM, and that he has not done his assessment yet this morning. RN30 was asked by surveyor to accompany surveyor to R390's room to confirm that R390's dressing was still on.

When asked, why the dressing was still on, RN30 replied, I'm not sure, I will have to check our facility's policy.

On 04/02/25 at 10:00 AM, interview with Director of Nursing (DON) confirmed that they should be checking for the thrill and bruit before and after dialysis and every shift. DON also stated that they should be removing the dressing but was not sure how soon after dialysis they must remove it.

On 04/02/25 at 12:00 PM, observed R390's right arm fistula without pressure dressing.

On 04/02/25 at 03:02 PM, interview with a dialysis charge nurse (DCN) from a dialysis facility was completed. DCN confirmed that the recommendations to remove the fistula pressure dressing is two hours after dialysis treatment.

When asked why after two hours, DCN replied, This is to prevent clotting. If left too long, it will most likely end up clotting the access.

125020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125020 B.

Wing 04/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Care Center - Honolulu, LLC 1930 Kamehameha IV Rd Honolulu, HI 96819

F-F657 Care Plan Timing and Revision - Despite identifying worsening of R136's MASD with a fungal infection to her sacrum and bilateral buttocks the facility failed to update R136's care plan and aquire a physician order for an antifungal to treat R136's fungal infection from 03/29/25 until 04/03/25.

On 03/31/25 at 03:09 PM, an interview was held with R136 at her bedside.

Inquired with R136 if she had any skin breakdown such as rash or pressure injury to her back and buttocks and she confirmed she had MASD to her bottom and rash on her back which she explained was from a reaction she had from the adult briefs. R136 explained facility staff switched out the adult briefs for the pull up type and she stated her rash was getting better.

On 04/03/25 at 10:24 AM, record review of R136's electronic health record (EHR) revealed R136 is a [AGE] year-old female who was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, encounter for orthopedic aftercare following surgical amputation, type 2 diabetes mellitus with hyperglycemia, and other specified soft tissue disorders.

Reviewed documentation of resident's skin assessments with pictures which revealed resident's MASD had gotten worse since admission.

First wound evaluation of R136's MASD was done on 03/14/25 at 19:11 (07:11 PM).

Dimensions documented included area at 21.3 cm^2 (centimeter), length 9.57 cm and width 4.69 cm.

Continued record review found second wound evaluation dated 03/26/25 at 12:53 PM of R136's MASD revealed it had gotten worse, no measurements were included in this documentation but a picture was.

The Woundcare Nurse Registered Nurse (RN) 24 documented under Progress section notes Resident reports itchiness to brief.

Switched resident to pull upbrief (sic.) 3/25/25, resident reports relief of itchiness.

Resident with fan in room to help circulate air. RN24 documented the practitioner was notified along with resident/responsible party. RN24 documented under Treatment section Dressing Appearance None Cleansing Solution Normal Saline Debridement None Primary Dressing Antifungal Secondary Dressing No secondary dressing Modalities None Additional Care Moisture barrier, Moisture control.

125020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125020 B.

Wing 04/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Care Center - Honolulu, LLC 1930 Kamehameha IV Rd Honolulu, HI 96819

Review of the Medication Administration Record (MAR) noted that a blood pressure of 113/77 had been entered at 06:10 AM by Certified Nurse Aide (CNA) 71.

Lisinopril (used to treat high blood pressure) 5 mg, one (1) tablet, with instructions to hold the medication if resident's systolic blood pressure is less than 120.

Review of the MAR noted that a blood pressure of 122/77 had been entered at 08:46 AM by RN14.

Clearlax 17 grams (gm) of powder mixed in approximately 8 ounces of water.

At 08:47 AM, observed RN14 enter R56's room and hand her a small plastic cup of medications, stating he had her aspirin, blood pressure medications and Senna-Plus. RN14 then handed R56 the cup of water mixed with Clearlax and stated, I also have some water for you. R56 immediately refused the Senna-Plus. RN14 excused himself to grab gloves so he could remove the two Senna-Plus tablets from the cup.

While he was gone, the State Agency (SA) asked R56 why she did not want to take the Senna-Plus. R56 responded that it makes me dizzy, and I want to control my functions (motioning to her lower abdomen).

After R56 swallowed the remaining pills with a small sip of the water with Clearlax, RN14 left the room.

125020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125020 B.

Wing 04/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Care Center - Honolulu, LLC 1930 Kamehameha IV Rd Honolulu, HI 96819

The facility failed to provide consistent application of splint and ROM exercises for R29.

On 04/03/25 at 08:31 AM, observed R29 eating breakfast with assistance from Certified Nurse Aide (CNA) 75, in bed her left arm was folded with fisted hand on chest and no splint.

Inquired with CNA75 if R29 has a splint for her hand and knee, CNA75 reported R29 should be wearing her splint daily but the facility did not have an RNA today. CNA75 proceeded to explain that she could put the splint on.

Inquired with R29 in her native language, Korean, if the facility had been helping her with her exercises and stretches, she stated no and that she would like to continue her exercises and stretches.

On 04/03/25 at 08:37 AM, interview with MDS Director (MDSD) 67 was done. MDSD67 confirmed she oversaw the RNA program and R29 gets services daily. RNA reported that R29's services should continue even under transmission based precautions (TBP) and that she may not be getting services due to RNA staff called to floor as CNA. MDSD67 explained that there are limited number of staff that are trained to provide RNA services. If RNA staff are working as a CNA they are not able to see everyone or are too busy with their CNA duties to provide RNA services.

Review of the list of staff able to provide RNA services are a total of five staff, two assigned RNA staff and three CNAs that can cover.

On 04/03/25 at 08:53 AM, an interview and concurrent record review with Nursing Scheduler (NS) was done. NS confirmed there was no RNA staff today, 04/03/25. NS reported that the facility is supposed to have two RNA staff but most days they only have one available.

For CNA, there are usually 11-12 CNAs on the floor depending on the census with a maximum of 9-10 residents per CNA.

Concurrent review of the day shift Nursing Assignment from 03/26/25 to 04/03/25 document one RNA staff from 03/26/25 to 04/02/25 and no RNA staff on 04/03/25. NS was not able to fill the RNA positions due to the availability of CNAs those days (CNA staff calling in sick).

One of the two regular RNA staff were on vacation during the sampled timeframe.

On 04/03/25 at 09:59 AM, an interview with CNA39 was done. CNA39 stated she was trained to provide RNA services but has not provided RNA services in a long time.

Inquired if CNA39 would be able to provide RNA services when assigned as a CNA, CNA39 reported she would not have the time to do both and stated resident needs would get neglected due to the amount of time spent in providing RNA services.

125020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125020 B.

Wing 04/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Care Center - Honolulu, LLC 1930 Kamehameha IV Rd Honolulu, HI 96819

The facility failed to ensure R77's respiratory care was provided consistent with professional standards. R77's O2 tubing was not labeled with the date it was last replaced and the physician orders did not include parameters and delivery method.

On 04/02/25 at 02:06 PM, an interview and concurrent record review with MDS Director (MDSD) 67 was done. MDSD67 confirmed R77's comprehensive care plan did not include O2 therapy. MDSD67 reported if a resident was admitted to the facility with O2 therapy, nursing staff or the MDS staff would input it in the care plan.

On 04/02/25 at 04:07 PM, an interview with Director of Nursing (DON) was done. DON confirmed R77 should have had a care plan for her O2 therapy, and the care plan would include the physician orders.

Review of the facility's policy and procedure regarding respiratory care, number 695, dated 07/2018, documented, The resident's individualized care plan will identify the interventions for oxygen therapy, based on the resident's assessment and orders, such as, but not limited to:

i.

Type of oxygen delivery system;

ii.

When to administer, i.e. [for example] continuous or intermittent and/or when to discontinue;

iii.

Equipment setting for the prescribed flow rates;

iv.

Monitoring of SpO2 [oxygen saturation] levels and/or vital signs, as ordered; and

v.

Monitoring for complications i.e. skin integrity issues related to the use of a nasal cannula.

51870

2) Cross reference to

Review of progress note dated 03/26/25, stated bladder scan and straight cath [cathetor] every shift. R387 had 600 milliliters (ml) of urine retention on scan, indwelling catheter was inserted.

Physician's orders dated 03/26/25 noted to insert foley catheter for urinary retention.

Review of comprehensive care plan found no catheter focus, goals, and interventions.

On 04/02/25 at 11:00 AM, interview with DON, verified that R387 was having retention issues as much as 600 ml of urine retention on bladder scan and so indwelling catheter was inserted on 03/26/25.

Asked DON to review care plan and DON confirmed that there was no catheter care initiated and should have been added in the plan of care.

Review of the facility's Comprehensive Care Plans policy, dated 11/2017, in the guidelines section, it stated The care plan will be comprehensive and person-centered. It will drive the type of care and services that a resident receives and will describe the resident's medical, nursing, physical .needs and preferences; as well as how the facility will assist in meeting these needs and preferences. In the Policy section, it also stated, The facility interdisciplinary team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical .that are identified in the comprehensive assessment.

125020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125020 B.

Wing 04/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Care Center - Honolulu, LLC 1930 Kamehameha IV Rd Honolulu, HI 96819

The facility failed to ensure sufficient nursing staff were available to ensure restorative nursing assistance was provided.

R29 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness or paralysis on left side of the body) and neuralgia and neuritis (nerve inflammation or damage). R29's room was under Transmission Based Precautions (TBP), Droplet Precautions, due to her roommate with positive COVID-19 from 05/25/25 to 04/05/25.

On 03/31/25 at 02:02 PM, observed R29 in bed her left arm was folded with fisted hand on chest and no splint.

On 03/31/25 at 02:29 PM, an interview with R29's Resident Representative (RR) 2 was done. RR2 reported the facility is supposed to assist R29 with exercises and stretches to left knee, arm, and hand but does not think they have done it in a while.

On 04/02/25 at 08:15 AM, observed R29 eating breakfast (assistance with staff) in bed her left arm was folded with fisted hand on chest and no splint. At 11:34 AM, observed R29 in bed her left arm was folded with fisted hand on chest and no splint.

Review of R29's electronic health record (EHR) found R29 has a passive range of motion (PROM) and active range of motion (AROM) program with assistance from Restorative Nurse Aides (RNA) initiated on 02/17/25.

The physician order for PROM includes the RNA to provide PROM exercise to left upper extremity (LUE) with gentle stretching to bilateral lower extremity (BLE) three sets of 10 repetitions seven times a week as tolerated.

For AROM, R29 to be encouraged to due right upper extremity (RUE) exercises using two-pound (lbs.) dumbbell three sets of 10 repetitions four times a week (Monday, Wednesday, Thursday, Friday) as tolerated. R29's EHR further found R29 has a physician order for splint to left hand and left elbow and splint to left knee. R29's care plann specified her splint program documenting, RNA to assist with applying left elbow splint and left hand grip orthosis up to 4-6 hours (On: 6am off: 10am-12p) and left ankle brace x3 hours (on 6am, off: 9am) daily as tolerated.

Review of documentation of R29's PROM, AROM, and splint program provided from 03/25/25 to 04/02/25 documented R29 did not receive RNA services on 03/26/25, 03/27/25, and from 03/29/25 to 04/02/25. R29 only received services once during that sampled time, on 03/28/25.

125020

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125020 B.

Wing 04/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Care Center - Honolulu, LLC 1930 Kamehameha IV Rd Honolulu, HI 96819