Avalon Care Center - Honolulu, Llc

F-F641, Accuracy of Assessments. The facility failed to ensure Resident R77's comprehensive assessment reflected she had O2 therapy.

Cross reference to

F-F656, Development of Comprehensive Care Plans. On 04/02/25 at 09:00 AM, observed Resident R390 with right upper arm fistula pressure dressing still on from yesterday's HD treatment. Resident 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). Resident R390 stated he will usually be the one that takes it off. Resident R390 stated he came back from dialysis yesterday at 04:30 PM.

On 04/02/25 at 9:30 AM, record review of Resident 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 Resident 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 Resident R390's room to confirm that Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 On 04/02/25, record review of the facility's policy on Quality of Care, Dialysis, with revised date of 04/2018, it stated that the facility will provide residents, who require, dialysis, care and service consistent with Level of Harm - Minimal harm or professional standards of practice in the Guidelines section of the policy, it also states, 13. Facility will potential for actual harm monitor and document the status of the resident's access site upon return from the dialysis treatment center to observe for bleeding or other complications. The facility did not meet this guideline as evident by pressure Residents Affected - Few dressing not removed after two hours from Resident R390's return from dialysis treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 43414

Residents Affected - Some Based on interviews and record review the facility failed to ensure sufficient nursing staff were available to provide restorative services for one of three residents (Resident (R) 29) sampled for limited range of motion (ROM). As a result, Resident R29 did not receive consistent restorative nurse aide treatment and services to maintain and/or prevent a decline in ROM. This deficient practice puts 30 residents in the RNA program at risk for a decline in ROM.

Findings include:

Cross reference to

F-F657 Care Plan Timing and Revision - Despite identifying worsening of Resident R136's MASD with a fungal infection to her sacrum and bilateral buttocks the facility failed to update Resident R136's care plan and aquire a physician order for an antifungal to treat Resident 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 Resident R136 at her bedside. Inquired with Resident 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. Resident 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 Resident R136's electronic health record (EHR) revealed Resident R136 is a [AGE] year-old female who was admitted to the facility on [DATE REDACTED] 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 Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Continued record review found third wound evaluation of Resident R136's MASD was done on 04/01/25 which included the following dimension measurements area 122.22 cm^2 +473 %, length 24.67 cm +158 % and Level of Harm - Minimal harm or width 23.18 cm +394 %. Below this box of measurements included the following statement *Negative potential for actual harm percentage values indicate wound is getting smaller. Resident R136's measurements included positive percentages which indicates the wound was getting bigger. Residents Affected - Few Continued review of Resident R136's EHR revealed she had an order for Moisture-associated skin damage (MASD) to her sacrum extending to her bilateral buttocks that was being treated by Apply Triad Paste cleanse with NSS [Normal Saline Solution] and pat dry before application every shift for 14 days *[W1] Indicate status to surrounding skin (I)ntact (E)rythmatous (M)acerated *[W2] Assess for s/sx [signs and symptoms] of infection or other complication (+) Complication noted, notify MD (-) No complication noted. Order start date 03/14/25 at 2300. This treatment was stopped on 03/28/25 with the last entry of treatment on 03/28/25 Eve1. After this treatment there were no other physician orders found to treat Resident R136's MASD to her sacrum and her bilateral buttocks on 03/29/25 - 04/03/25 at 10:24 AM.

Concurrent record review of Resident R136's care plan did not include any updates to treat Resident R136's MASD with an antifungal.

Focus

The resident has MASD to sacrum r/t [related to] incontinence

Date Initiated: 03/18/2025

Revision on: 03/18/2025

Goal

The resident's MASD will heal by review date.

Date Initiated: 03/18/2025

Revision on: 03/27/2025

Target Date: 06/14/2025

Interventions/Tasks

Avoid scratching and keep hands and body parts from excessive moisture.

Date Initiated: 03/18/2025

Increase out of bed activity as tolerated.

Date Initiated: 03/18/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 On 04/03/25 at 10:37 AM, interviewed DON in the Administrator's office. Inquired about Resident R136's MASD which had gotten worse since admission. DON stated resident has Baza ordered (antifungal cream) for MASD to Level of Harm - Minimal harm or apply every day and evening shift. potential for actual harm Subsequent to the interview with the DON, on 04/03/25 at 11:59 AM, reviewed Resident R136's orders and found an Residents Affected - Few order for Baza Antifungal External Cream 2% had been ordered for Resident R136 on 04/03/25 at 11:07 AM and an update to the care plan that included The resident has MASD to sacrum with fungal rash r/t incontinence and Interventions/Tasks Apply tx [treatment] as ordered by MD. Date Initiated: 04/03/2025. Resident R136 had not received treatment from 03/29/25 till 04/03/25, after DON was interviewed by surveyor about resident's MASD worsening.

Focus

The resident has MASD to sacrum with fungal rash r/t incontinence

Date Initiated: 03/18/2025

Revision on: 04/03/2025

Goal

The resident's MASD will heal by review date.

Date Initiated: 03/18/2025

Revision on: 03/27/2025

Target Date: 06/14/2025

Interventions/Tasks

Apply tx as ordered by MD.

Date Initiated: 04/03/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43414

Residents Affected - Few Based on observations, interviews, and record review, the facility failed to ensure one of three residents (Resident (R) 29) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM, as evidenced by inconsistent application of splint and ROM exercises. This puts Resident R29 at risk of a decline in ROM and further contractures.

Findings include:

Cross reference to

F-F684).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a medication error rate of Residents Affected - Few less than 5%, as evidenced by two medication errors observed out of 28 opportunities for errors, for an error rate of 7%. Safe and timely medication administration practices are essential for the health and well-being of

the residents. As a result of this deficient practice, Resident (R) 56 was placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff.

Findings include:

On 04/01/25 at 08:30 AM, began observing Registered Nurse (RN)14 as he prepared and administered medications to a resident in room [ROOM NUMBER]. RN14 was observed completing medication preparation, entering room [ROOM NUMBER], and returning to the medication cart without entering any other rooms. RN14 was also not observed with a blood pressure monitor.

On 04/01/25 at 08:40 AM began observation of RN14 preparing and administering medications to Resident (R)56 in room [ROOM NUMBER]. Observed RN14 prepare (amongst other medications) the following:

Senna-Plus (a stool softener and stimulant laxative combination), two (2) tablets.

Amlodipine (used to treat high blood pressure and chest pain) 5 milligrams (mg), one (1)

tablet, with instructions to hold the medication if resident's systolic blood pressure (the force of the blood flow when blood is pumped out of the heart) is less than 100. 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 Resident 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 Resident R56 the cup of water mixed with Clearlax and stated, I also have some water for you. Resident 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 Resident R56 why she did not want to take the Senna-Plus. Resident R56 responded that it makes me dizzy, and I want to control my functions (motioning to her lower abdomen). After Resident R56 swallowed

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 At 08:50 AM, an interview was done with RN14 outside of Resident R56's room. Asked RN14 if he knew why Resident R56 had refused the Senna-Plus. He stated, she doesn't like to take a laxative. Asked RN14 if Resident R56 knew there was a Level of Harm - Minimal harm or laxative in the 'water' he gave her since he did not mention it. RN14 answered that Resident R56 knows there is potential for actual harm laxative in the water, admitted he did not say it, but should have. Stated Resident R56 frequently refuses the Senna-Plus but takes the Clearlax. Residents Affected - Few At 08:53 AM, interviewed Resident R56 in her room. When asked if she was aware that there was a laxative mixed into the water Resident R14 had given her (which still had more than half a cup remaining). Resident R56 answered no, and asked SA does it affect my digestion? SA informed her that it is used to treat constipation and will cause her to poop. Resident R56 stated she wanted to refuse it. SA informed RN14 that Resident R56 wanted to refuse the remaining Clearlax and asked if it is his normal process to leave the room before all medications have been consumed. RN14 confirmed that he should not have left the room until all medications were consumed.

While reconciling the other medications during record review, noted the discrepancy of two different blood pressures documented for Resident R56 for high blood pressure medications (with two different parameters) given at

the same time.

On 04/01/25 at 10:00 AM, when Resident R56 was asked if RN14 had taken her blood pressure at any time that morning, Resident R56 answered no.

At 10:05 AM, an interview was done with RN14 at Nurses' Station 2. When asked about the discrepancy in blood pressures documented on the MAR for medications given at the same time, RN14 stated he took Resident R56's blood pressure at around 08:30 AM, did not write it down, but remembered the reading at 08:46 AM when he documented the blood pressure as he was preparing the Lisinopril. RN14 stated he took the blood pressure himself because there was no blood pressure available in the electronic health record (EHR) that morning. SA informed RN14 that a measurement of 113/77 was in the EHR, and he used it to document the blood pressure when he prepared Resident R56's Amlodipine, which he did shortly before he prepared her Lisinopril. Asked RN14 about Resident R56's cognition. He stated that Resident R56 was alert and oriented times four [fully alert and oriented to person, place, time, and event]. Informed RN14 that SA had observed him from 08:30 AM and made no observation of him taking any residents' blood pressure or entering Resident R56's room. In addition, Resident R56 stated she did not remember RN14 taking her blood pressure that morning. RN14 could not explain why there was no evidence to validate that he had taken Resident R56's blood pressure that morning.

On 04/02/25 at 11:57 AM, an interview was done with Director of Nursing (DON) outside the Administrator's office. DON confirmed the expectation is that when taking a blood pressure, it is either written down or put into the EHR immediately. DON also confirmed that all medication should be consumed before walking away from the resident, not left at the bedside, and that RN14 should have informed Resident R56 there was a laxative in her water, especially if she refused laxative pills.

Review of Resident R56's MAR for March 2025 noted that Resident R56's blood pressure was too low to meet the parameter for Lisinopril administration 43 out of 62 opportunities, or 69% of the time. This reflects the importance of ensuring her blood pressure is taken and accurate prior to administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 37954 Residents Affected - Few Based on observation and interview, the facility failed to ensure all medications used in the facility were stored in accordance with professional standards for one of four medication carts observed. Proper storage of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications.

Findings Include:

On 04/01/25 at 08:22 AM, observed an unlocked medication cart left outside of a resident's room with no staff in sight. At this time the Infection Prevention Registered Nurse (RN) 94 was seen near by and inquired of RN94 if the medication cart is to be locked by the nurse before leaving it and she confirmed it is supposed to be locked. At 08:23 AM, RN85 returned to the medication cart. Inquired of RN85 if she was educated to lock her medication cart before she passes medication and she confirmed she had and acknowledged the medication cart was supposed to be locked before leaving it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37954 potential for actual harm Based on observation and interview, the facility failed to ensure appropriate protective and preventive Residents Affected - Many measures for communicable diseases and infections were implemented. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (additional measures used to help stop infection transmission when a patient/resident has been found to be infected or colonized with certain infectious agents) by wearing the proper personal protective equipment (PPE), followed standard precautions (the basic level of practices used to prevent the spread of infection) by performing hand hygiene, and had PPE and PPE disposal receptacles readily available both inside and/or outside the rooms. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Findings include:

1) On 03/31/25 at 10:28 AM, Certified Nurse Aide (CNA) 48 was observed coming out of Resident R78's room wearing only a surgical mask. Resident R78 is in quarantine because she tested positive for COVID. Inquired of CNA48 if she is supposed to wear other personal protective equipment (PPE) such as a shield, N95, gown and gloves when going into Resident R78's room. CNA48 stated no that she was delivering diapers.

On 03/31/25 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 93. Inquired if staff are expected to use gown, gloves, N95 and face shield when going into resident's room who has COVID. RN93 stated staff are expected to use PPEs mentioned when going into a room where a resident is positive for COVID. Shared observation and asked if this was okay as CNA stated she was delivering diapers and RN93 confirmed it was not, staff are expected to use PPEs.

2) On 03/31/25 at 12:50 PM, observed Resident R89 resting/sleeping in her bed. Inquired of Registered Nurse (RN) 21 if Resident R89 was going to eat her lunch (covered lunch tray was on her bedside table). RN21 stated she would get another staff to assist her to move resident up in her bed so that she can help her with her meal. Resident woke up at brief intervals. Two RNs, RN21 and RN65, put on PPEs (gown, gloves and mask) as Resident R89 had enhanced barrier precautions (EBP). Resident was moved up in her bed by RN21 and RN65 using her draw sheet. Resident's head of bed was raised and resident was positioned comfortably as staff spoke to her. RN21 moved resident's personal items from the bed side table to her small dresser top near her bed. RN21 moved two pillows from her bed onto a metal chair near Resident R89's bed. RN21 then started to feed resident. Resident R89 took one very small amount of mashed potatoes with gravy. Resident R89 did not appear to want to eat any more but did want to drink some milk when it was offered by RN21. RN21 opened the milk container and noticed she did not have a straw available for resident to use. RN21 took off her gloves, went to the door and requested a straw from staff in the hallway. At this time, RN21 also got a new pair of clean gloves. RN21 threw away the dirty gloves and put on the clean gloves, RN21 did not perform hand hygiene. At this time surveyor shared observation with RN21 and asked if she should have done anything after taking off her dirty gloves and she stated, I thought my hands were clean. RN21 also did not identify need to change gloves

after positioning resident prior to assisting her with her meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of facility's policy titled Infection Prevention and Control Program (IPCP) revised on 06/08/22 states Purpose The facility will establish and maintain an infection prevention and control program designed to Level of Harm - Minimal harm or provide a safe, sanitary and comfortable environment and to help prevent the development and transmission potential for actual harm of communicable diseases and infection. Standard Precautions . 2. Staff will perform hand hygiene, even if gloves are used: a. Before and after contact with the resident: . d. After removing PPE;. Residents Affected - Many 3) On 04/01/25 at 08:16 AM, observed CNA16 wearing full PPEs of face shield, N95, gown and gloves who had brought out a breakfast tray from a quarantined room with a resident who was positive for COVID. CNA16 returned Resident R78's breakfast tray to the cart before doffing PPEs. Inquired if residents with COVID have paper products instead of a tray. CNA shared the tray on the cart was from the resident who has positive for COVID.

4) On 04/02/25 at 09:05 AM, went to Resident R39's room to observe if resident's call light was within his reach. Resident was observed sleeping in his bed and call light was observed on the ground. Inquired with RN94 if call light should be near resident. RN94 confirmed the call light is to be left with the resident before staff leave the room. RN94 picked up the call light and put it on the resident's bed. RN94 did not clean the call light before putting it on the resident's bed.

5) On 04/02/25 at 09:27 AM, Resident R18 was observed sitting in the hallway outside of her room in her wheelchair. Resident R18 has an indwelling urinary catheter that had a privacy bag hanging from the wheelchair that was resting

on the ground.

On 04/02/25 at 09:30 AM, interviewed Director of Nursing (DON) who was walking in the hallway near Resident R18. Inquired of DON if Resident R18's privacy bag for her indwelling urinary catheter bag should be resting on the ground and she said No and I will get a new one.

On 04/02/25 at 01:13 PM, interviewed facility Infection Preventionist (IP) nurse in the Director of Nursing's office. Inquired regarding PPEs use for residents with COVID versus EBP for doffing PPEs and she stated there is no difference. Inquired about placement of trash cans outside of COVID positive patient's bedroom door and IP nurse stated there is no room in the resident's room for the trash can and that is why it is kept in

the hallway. Inquired about staff coming out of resident's room who is on Contact Precautions and there is no rubbish can for used PPEs, surveyor shared an observation with IP that another surveyor had of staff who walked across the hallway and took off their PPEs and threw it away in the rubbish can. IP stated staff are not to do this they are to take off PPEs and dispose of it in the trash can that is right outside the room or dispose of inside the room.

On 04/ 03/25 at 10:10 AM, observed facility had posted instructions from the Centers for Disease Control and Prevention (CDC) Use personal protective equipment (PPE) when caring for patients with confirmed or suspected COVID-19 dated 06/03/20 which stated Doffing (taking off the gear):

More than one doffing method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of doffing.

1. Remove gloves. Ensure glove removal does not cause additional

contamination of hands. Gloves can be removed using more than one

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 technique (e.g., glove-in-glove or bird beak).

Level of Harm - Minimal harm or 2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can potential for actual harm be broken rather than untied. Do so in gentle manner, avoiding a forceful Residents Affected - Many movement. Reach up to the shoulders and carefully pull gown down and

away from the body. Rolling the gown down is an acceptable approach.

Dispose in trash receptacle. *

3. HCP may now exit patient room .

51870

6) On 03/31/25 at 11:45 AM, observed Resident R387 with indwelling catheter, secured to his right leg, draining yellow urine, partially covered with a dignity bag and resting on the floor without a barrier.

On 03/31/25 at 12:00 PM, interviewed CNA45, and showed her the catheter on the floor. CNA45 confirmed that catheter should not be on the floor, and it was also full and needed to be emptied.

On 04/02/25 at 11:00 AM, interview with DON confirmed that catheter care included the catheter not being

on the ground for risk of infection.

43245

7) On 03/31/25 at 12:28 PM, observed CNA78 delivering Resident R86's lunch tray to her. It was noted at this time by

the transmission-based precautions (TBP) signage outside the door, that Resident R86 was on Contact Precautions (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment). Review of the TBP signage outside the door noted that gloves and a gown should be donned (put on) prior to entering the room. Observation of CNA78 noted that

she was not wearing gloves or a gown as she delivered Resident R86's lunch tray, pressed up against Resident R86's bed as

she cut Resident R86's food, and set up her lunch for her.

Interview was done with CNA78 at 12:33 PM outside Resident R86's room. When asked about Resident R86's TBP, CNA78 stated that she was told by nurses earlier that morning that she did not need to wear any PPE unless she was touching the resident. CNA78 could not verbalize the difference between Contact Precautions (TBP) and Enhanced-Barrier Precautions (protective precautions but not TBP), or when each would be used.

8) On 03/31/25 at 12:42 PM, observed signage outside of room [ROOM NUMBER] indicating that both residents in the room were on Enhanced-Barrier Precautions requiring staff to don PPE if in direct contact with residents. Also noted that resident in 105B was on Contact Precautions. Made observations at this time that neither room had a trash receptacle for used/dirty PPE disposal either directly inside or directly outside

the rooms. Observed CNA78 exit room [ROOM NUMBER], cross the hallway with her dirty gown on, stop at

the trash receptacle outside the room across the hall, doff (take off) her used PPE, and throw it away.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 04/02/25 at 08:45 AM, made observation outside room [ROOM NUMBER] that staff were exiting the room to grab clean gloves from the top drawer of the PPE cart outside the room. Also observed that not Level of Harm - Minimal harm or every room had a PPE cart outside of it. Concurrent interview was done with CNA92 outside room [ROOM potential for actual harm NUMBER]. When asked about the availability of gloves, CNA92 stated that gloves are available in the rooms but only in the bathroom, and if there is a PPE cart outside the room, gloves are available inside the top Residents Affected - Many drawer as well. CNA92 agreed that if there is no PPE cart outside the room, and a resident is in (or blocking)

the bathroom, it can be difficult to access a clean pair of gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 125020

F-F688, Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide consistent application of splint and ROM exercises for Resident R29.

On 04/03/25 at 08:31 AM, observed Resident 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 Resident R29 has a splint for her hand and knee, CNA75 reported Resident 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 Resident 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 Resident R29 gets services daily. RNA reported that Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 04/03/25 at 10:54 AM, an interview with CNA75 was done. CNA75 stated she was trained to provide RNA services and has not provided RNA services in a long time due to needing CNAs on the floor. Inquired Level of Harm - Minimal harm or if CNA75 would be able to provide RNA services when assigned as a CNA, CNA75 stated it would be too potential for actual harm much.

Residents Affected - Some On 04/03/25 at 11:26 AM, an interview with Director of Nursing (DON) was done. DON reported if there is not enough CNAs on the floor they would need to ask the RNAs to work as CNAs and there would be no coverage for RNA.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 43245

Residents Affected - Few Based on observations, interviews, and record review, the facility failed to implement a thorough process in narcotic log documentation and reconciliation for two of four medication carts observed. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of the controlled medications used to meet the needs of the residents. In addition, the facility failed to implement a process that assures the accurate and timely disposition of discontinued and/or expired medications. This deficient practice hinders the promotion of safe administration practices that decrease the risk for medication errors.

These deficient practices have the potential to affect all residents in the facility who take medications.

Findings include:

1) On 04/02/25 at 09:33 AM, an inspection of medication cart 1C was done with Registered Nurse (RN) 56. Observed a blister pack card of Oxycodone (a narcotic) IR 5 milligrams (mg) with 22 pills remaining for Resident (R) 236. Review of the Controlled Drug Record noted that there should have been 24 pills remaining. Concurrent interview with RN56 revealed that she had administered one pill to Resident R236 at 09:18 AM but had neglected to sign it out on the Controlled Drug Record. RN56 also stated that she had dropped a tablet and wasted it but had neglected to sign that wasted tablet out of the inventory count on the Controlled Drug Record. When asked what the normal process was to sign off/document narcotics, RN56 answered that narcotics are signed off on the Controlled Drug Record after they administer it because they [the resident] might refuse it.

On 04/02/25 at 10:00 AM, an interview was done with Director of Nursing (DON) in the Training Room. When asked about narcotic administration and documentation, DON stated that narcotics should be signed out on

the Controlled Drug Record upon preparation of the medication, when they pop it, prepare it. DON confirmed staff should not be signing narcotics out after administration, agreeing that if a resident refuses a narcotic that is signed out, then the medication is wasted and documented on the Controlled Drug Record as refused.

Review of the Controlled Substances policy and procedure, last updated 11/17, revealed the following:

4. When a controlled medication is administered, the licensed nurse . immediately enters the following information on the accountability record when removing dose from controlled storage . Date and time of administration . Amount administered .

5. Administer the controlled medication and document dose administration on the MAR [medication administration record].

2) On 04/02/25 at 09:06 AM, an inspection of medication cart 2B was done with RN28. Observed a 100-count box of Ferrous Gluconate 324 mg with an expiration date of 3/25 that was more than half-filled. Also observed a 30-count blister pack card of Methocarbamol for Resident R67. Concurrent interview with RN28 confirmed that the Ferrous Gluconate was expired, and that Resident R67 had been discharged from the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 04/02/25 at 09:18 AM, an interview was done with RN65 (who also served as 1 of 2 Assistant Directors of Nursing) at Nurses' Station 2. RN65 confirmed that the expired Ferrous Gluconate should have been Level of Harm - Minimal harm or removed from the medication cart and disposed of. Regarding the Methocarbamol, RN65 confirmed that Resident R67 potential for actual harm had been discharged from the facility to home on 03/17/25 and stated that usually all medications are sent home with residents upon discharge. Concurrent record review noted that the Methocarbamol had been Residents Affected - Few discontinued on 02/28/25. RN65 confirmed the medication should have been pulled from the medication cart at that time and placed in the medication room for disposal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 43414

Residents Affected - Few Based on record review and interview, the facility failed to document the rationale for not making any changes to the pharmacist's recommendations during a monthly medication regimen review (MRR) for one of five residents (Resident (R) 285) sampled for unnecessary medications. This puts Resident R285 at risk for complications due to medications administered.

Findings include:

Review of Resident R285's Interim Medication Regimen Review dated 03/13/25, the pharmacist documented the following action required and high-risk medication monitoring recommendations; Aspirin EC .Do not crush,

On Antiplatelet: Aspirin, Clopidogrel .Monitor for s/s [signs and symptoms] of bleeding bruising; monitor for thromboembolism. On Diabetic agent: Degludec, R Insulin .Monitor for s/s of hypoglycemia; monitor for s/s hyperglycemia and On Opioid agent: Oxycodone .Monitor for constipation; monitor for s/s delirium/ over sedation/ change in mental status and reduced respirations. The facility documented they accepted the recommendation for do not crush aspirin and signed the MRR on 03/13/25.

Review of Resident R285's physician orders, the facility did not make changes to Resident R285's aspirin to include in the order do not crush and did not include the high-risk medication monitoring recommendations for use of diabetes and opioid medications.

On 04/02/25 at 03:53 PM, an interview with Director of Nursing (DON) was done. DON stated they did not make changes to the orders or add the monitoring to the orders because it is the facility's standard of practice not to crush aspirin unless it is a chewable tablet and to monitor for the s/s hypoglycemia and hyperglycemia of diabetic medications and s/s of constipation for opioid medications and the facility does not document the monitoring.

During the interview reviewed, another resident (Resident R77) for constipation and opioid use. The review found nursing staff were not monitoring this resident for constipation related to use of opioid medication. (Cross reference to

F-F695, Respiratory Care. The facility failed to ensure Resident R77's respiratory care was provided consistent with professional standards. Resident 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 Resident 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 Resident 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

F-F698, Dialysis. On 04/02/25 at 09:00 AM, observed Resident R390, who was admitted to the facility on [DATE REDACTED], right upper arm fistula pressure dressing still on from yesterday's Hemodialysis (HD) treatment. Resident R390 also stated that staff will take it off when they have time and don't really check for the thrill and bruit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 04/02/25 at 9:30 AM, record review of Resident R390's care plan noted a focus on HD that was initiated on 03/20/25, with interventions to monitor, document, and report as needed any signs and symptoms of Level of Harm - Minimal harm or infection to access site redness, swelling, warmth or drainage, but did not include intervention to assess potential for actual harm access site for thrill and bruit. The Treatment Administration Record (TAR) showed the dialysis fistula checks for thrill and bruit were being done every shift. Residents Affected - Few

On 04/02/25 at 10:00 AM, interview with DON confirmed that they should be checking for the thrill and bruit

before and after dialysis and every shift. Asked DON to show Resident R390's care plan to see if there were interventions of checking for the thrill and bruit and confirmed it was not included in the resident's care plan but was noted in physician's orders. DON proceeded to add the interventions to care plan.

3) On 03/31/25 at 11:00 AM, observed Resident R387 with indwelling catheter, secured to right leg, draining clear yellow urine, covered with bag, but bag noted on the floor without any barrier. Concurrent interview with Resident R387, stated he came in without a catheter but asked for one because he was having a hard time urinating standing up. Resident R387 was admitted to the facility on [DATE REDACTED].

On 04/02/25 at 08:23 AM, record review of Resident R387's minimum data set (MDS) bladder/bowel section noted that Resident R387 is always continent. Review of progress note dated 03/26/25, stated bladder scan and straight cath [cathetor] every shift. Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 37954

Residents Affected - Few Based on interview and record review the facility failed to update Resident (R) 136's care plan to include a new intervention to treat resident's moisture-associated skin damage (MASD) with an antifungal once identified, for one of four residents sampled for skin conditions (non-pressure). The deficient practice put Resident R136 at risk for worsening of fungal infection with MASD to her sacrum and buttocks which could lead to a pressure injury and pain.

Findings include:

Cross reference to

F-F725, Sufficient Nursing Staff. The facility failed to ensure sufficient nursing staff were available to ensure restorative nursing assistance was provided.

Resident R29 was admitted to the facility on [DATE REDACTED] 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). Resident 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 Resident 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 Resident R29's Resident Representative (RR) 2 was done. RR2 reported

the facility is supposed to assist Resident 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 Resident 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 Resident R29 in bed her left arm was folded with fisted hand on chest and no splint.

Review of Resident R29's electronic health record (EHR) found Resident 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, Resident 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. Resident R29's EHR further found Resident R29 has a physician order for splint to left hand and left elbow and splint to left knee. Resident 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 Resident R29's PROM, AROM, and splint program provided from 03/25/25 to 04/02/25 documented Resident R29 did not receive RNA services on 03/26/25, 03/27/25, and from 03/29/25 to 04/02/25. Resident R29 only received services once during that sampled time, on 03/28/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 On 04/03/25 at 08:31 AM, observed Resident 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 Resident R29 has a Level of Harm - Minimal harm or splint for her hand and knee, CNA75 reported Resident R29 should be wearing her splint daily but the facility did not potential for actual harm have an RNA today. CNA75 proceeded to explain that she could put the splint on. Inquired with Resident R29 in her native language, Korean, if the facility had been helping her with exercises and stretches, she stated no and Residents Affected - Few 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 Resident R29 receives services daily. RNA reported that Resident R29's services should continue even under TBP and that she may not be getting services due to RNA staff called to floor as CNA.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 37954

Residents Affected - Few Based on observation and interview the facility failed to provide an environment free of accident hazard for one of two sampled resident (Resident (R) 25) observed for accidents. Resident R25 was observed pushed in her wheelchair with her leg rests not in place putting the resident at risk for an accident that could result in harm.

Findings include:

On 03/31/25 at 10:43 AM, Resident R25 was observed pushed in her wheelchair by Physical Therapy Assistant (PTA) 5 and Occupational Therapy Assistant (OTA) 7 from the end of the hall to the hallway where her room is located. Resident R25 was seen pushed without her leg rests on her wheelchair and observed holding her feet up. Surveyor stopped staff and asked PTA5 and OTA7 where resident's leg rests were for her wheelchair. PTA5 stated they were crunched for time and leg rests are in her room. PTA5 and OTA7 proceeded to Resident R25's room.

On 03/31/25 at 10:46 AM, interviewed Physical Therapist (PT) 1 who was in the hallway outside of Resident R25's room. Inquired of PT1 what rehab staff are to do with the foot rests for residents who are receiving PT services. PT1 explained there is a holder on the back of the wheelchair where you can place the foot rests. PT1 and surveyor went into Resident R25's room and inquired with Resident R25 if we could look at the wheelchair she was sitting on. PT1 was able to move Resident R25's wheelchair and saw there is no holder on the back of Resident R25's wheelchair. Inquired with PT1 if this is something they can request to have put onto the wheelchair since PT1 identified the wheelchair as belonging to the facility. PT1 confirmed this is something the facility can order and put on the back of the wheelchair. Inquired how staff manage the foot rests when they are working with

the residents and PT1 explained staff will work with the residents and have them walk and then the staff will go back to the room and get the foot rests when they are needed. PT1 explained it might be hard for residents without good cognition to keep their feet up when wheelchair is being pushed and some residents are weak and cannot keep their feet up.

On 04/02/25 at 09:45 AM, inquired with OTA7 where Resident R25 was located when they started pushing resident in her wheelchair and OTA7 stated the gym on the first floor. At this time asked Director of Nursing (DON) to measure the distance from the gym to the resident's room. The gym to the elevator on the first floor was 39 feet (ft.) and from the elevator on the second floor to resident's room was 107 ft. which is a total of 146 ft. Resident R25 was pushed in the wheelchair without the leg rests.

On 04/03/25 at 12:49 PM, interviewed Director of Rehab (DOR) in the first floor gym. DOR stated she is also

a physical therapist. She confirmed staff should have had leg rests on the wheelchair when pushing a resident in their wheelchair. DOR stated staff receive training on safety when working with residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 34 125020 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43414 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care was Residents Affected - Few provided consistent with professional standards for two of two (Resident (R) 77 and Resident R10) sampled for respiratory. Resident R77's comprehensive assessment did not include oxygen (O2) therapy, it was not included in her care plan, her nebulizer and O2 tubing was not labeled with the date it was last replaced and the physician O2 orders did not include parameters and delivery method. Resident R10's O2 tubing was not labeled with the date it was last replaced. This deficient practice put Resident R77 and Resident R10 at risk for respiratory complications.

Findings include:

1) Cross reference to