Avalon Care Center - Honolulu, LLC

In the surveyor’s words

From the most serious findings on record at Avalon Care Center - Honolulu, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 22, 2022

  Based on observations, interviews, and record review, the facility failed to ensure staff implemented interventions to reduce accident hazard. Specifically, the staff did not lock a wheelchair which resulted in a fall. This deficient practice resulted in a major injury (left [CONDITION(S)]) and a potential for Resident (R)3 to lose the ability to walk and/or stand from a seated position. This deficient practice has the potential to affect resident that is dependant on staff to ensure a safe environment. Findings include: 1) The facility reported R3's fall and left [CONDITION(S)] to the State Agency (SA) on 06/30/22 at 01:00 PM. […]

• Actual harm, isolatedF726Jul 22, 2022

  Based on interviews and record review, the facility failed to ensure staff was competent in accurately evaluating and reporting the results of an x-ray. The nursing staff read Resident (R)3 hip x-ray negative after a fall, which resulted in a 13-day delay in identifying the fracture. Due to the deficiency, there was delay in appropriate pain management. In addition, R3 has the potential to lose her ability to walk and stand from a seat position, which will prevent her from reaching and maintaining her highest practicable physical, mental, and psycho-social well-being. […]

• Actual harm, isolatedF689Oct 28, 2021

  Based on interviews and record review (RR), the facility failed to provide adequate supervision to one resident (R)1, who was a high risk for falls. The interventions to prevent falls were not effective. R1 had 25 documented falls from January 1, 2021 through October 4, 2021 which resulted in harm. On 10/07/21 R1 requested to go to the Emergency Department after a nosebleed at which time she was admitted for acute care. Hospital x-ray results revealed R1 had a fractured (fx) vertebrae in her lumbar spine and a fx rib. It is unknown when the fractures occurred. As a result, R1 was not able to meet her highest practicable physical well being. This deficient practice could affect any resident at risk for falls and puts them at risk of serious harm. […]

• No harm, potential for more than minimal, widespreadF880Apr 3, 2025

  Based on observation and interview, the facility failed to ensure appropriate protective and preventive 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. […]

• No harm, potential for more than minimal, widespreadF880Apr 5, 2024

  Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), as well as follow standard precautions by performing hand hygiene in between glove changes. 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 04/02/24 at 08:20 AM, an interview was done with the Infection Preventionist (IP) in her office. IP reported that Resident (R) 18 had shingles and was currently on Droplet and Contact Precautions. […]