Ka Punawai Ola

Inspectors wroteBased on record review and interview, the facility failed to identify and intervene for an acute change in a resident's condition related to infection for one Resident (R) 10 resulting in R10's family member initiating the transfer to the Emergency Department. The resident was admitted to the hospital with respiratory distress, pulmonary edema, and septic shock. There was no documentation of the resident's vital signs or notification of the change in condition to the physician which preceded the transfer to the Emergency Department, cross reference to F580. The deficient practice caused harm to the resident related to complications of sepsis.

Inspectors wroteBased on interviews, and record review, the facility failed to implement and develop interventions to prevent avoidable falls for one of three residents (Resident (R), 30) investigated for falls. R30 had four fall incidents ([DATE], [DATE], [DATE], [DATE]) and one near fall incident ([DATE]) from the time he was admitted to the facility on [DATE]. This deficient practice has the potential to affect residents with balance deficits and strength impairments. Findings Include:Cross reference to F656On [DATE] at 08:00 AM, the Department of Health, Office of Health Care Assurance (OHCA) received a complaint from R30's Family Member (FM) 2 that R30 sustained three falls at the facility. The FM2 stated that R30 was admitted to the facility on [DATE] and was going through rehab, working with therapist to strengthen his legs which never quite healed. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the physician when one Resident (R) 10 of three sampled for hospitalizations, had an acute change in condition that resulted in a transfer to the Emergency Department (ED).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan that was individualized to address the needs for one of three residents (Resident (R), 30) to prevent falls and failed to implement the use of floor mats for one of three residents, R20 investigated for falls. Findings Include:1) On 04/21/26 at 09:00 AM, review of R30's electronic health record (EHR) noted that R30 is an 87-year male admitted to the facility on [DATE] with a diagnosis of but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, muscle weakness, difficulty walking, heart failure, and diabetes. [...]

Inspectors wroteBased on observation and interview, the facility failed to treat one of 2 residents sampled Resident (R)292 with respect and dignity by staff not responding in a timely manner to R292's request for assistance with food replacement. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to report an allegation of abuse for one Resident (R)27, out of one resident reviewed, to other officials including Adult Protective Services (APS). As a result of this deficiency, the facility did not allow further review of the abuse allegation by APS.

Inspectors wroteBased on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for one resident (Resident (R)42) sampled. As a result of this deficient practice, there is the potential for more than minimal physical harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers for one of three residents (Resident (R)294) sampled for pressure ulcers. Staff failed to report R294's refusal to be turned every two hours which delayed the implementation of new interventions to prevent the development of a new pressure ulcer. As a result of this deficient practice, R294 developed a Stage 2 pressure ulcer to her coccyx area and has the potential to affect other residents who are high risk for developing pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one resident (Resident (R)42) sampled. As a result of this deficient practice, there is the potential for more than minimal physical harm to the resident.

Inspectors wrote2) On 04/02/25 at 07:57 AM, observed RN7 during medication administration. RN7 asked R246 what her pain level was. R246 said, Six out of 10. RN7 opened the computer on the cart, logged R246's pain level and checked the medication to be given. RN7 then prepared Hydrocodone-Acetaminophen (opioid pain medication) 10-325 mg (milligrams) tablet and administered it to R246. After giving the medication, RN7 documented on the computer. Review of R246's Electronic Health Record (EHR) was conducted. The following orders for pain were noted: Hydrocodone-Acetaminophen Oral Tablet 10-325 mg every 6 hours as needed for severe pain and Hydrocodone-Acetaminophen Oral Tablet 5-325 mg every 6 hours as needed for moderate pain. On 04/02/25 at 10:11 AM, a concurrent interview and record review was conducted with RN7 just outside R246's room. Asked RN7 what numeric pain level is considered severe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals are stored in a locked compartment for one of six medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications.

Inspectors wroteBased on interview and record review, the facility failed to provide food that accommodates the food allergies for one of the two residents in the sample. Resident (R)294 is allergic to eggs and was served eggs for breakfast more than once. As a result of this deficient practice, residents are at risk for more than minimal physical harm.

Inspectors wroteBased on observation, resident interview, staff interview and record review, the facility failed to maintain a functioning clock for one Resident (R)143 out of three residents sampled. As a result of this deficiency, R143 did not know the time of day when referring to that non-functioning clock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the resident's choices, for 5 of 21 Residents (R32, R231, R22, R2, and R47) sampled. As a result of this deficient practice, the residents were placed at an increased risk for avoidable declines and/or injuries. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to support and honor the food preferences of one resident (R) in the sample, and one unsampled resident. This deficient practice has the potential to impact all the residents at the facility with food preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures to prevent the transmission of 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) and performing the proper form of hand hygiene at all appropriate times while caring for Resident (R)33. In addition, the facility failed to assure staff performed hand hygiene between glove changes while performing perineal care (cleaning genital and anus area) for R131. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, support, and honor one Resident's (Resident 32) preference to be informed of a time range that rehabilitation therapy services would occur. As a result of this deficient practice, R32 did not have her needs met and was placed at risk of not attaining her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility receiving therapy services.

Inspectors wroteBased on record review and interview the facility failed to follow-up and ensure residents were informed of their right to develop an advance health care directive (AHCD); or periodically reassessed in his/her decision-making capacity to do such according to State Law, for four of ten residents sampled (Resident (R) 2, R16. R40 and R7). As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable and homelike environment, as evidenced by uncomfortable temperatures in Resident (R) 283's and R284's room(s), and splatters on the kitchen ceiling. In addition, the facility failed to exercise reasonable care for the protection of one resident's clothing from loss, as evidenced by Resident (R)32's complaint that so many of her clothing pieces were not returned to her from laundry that she now had her family doing her laundry. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure written notification of discharge was provided to the resident or resident representative as soon as practicable before transferred or discharged and send a copy of that notice to a representative of the Office of the State Long-Term Care Ombudsman for three Residents ((R)25, R7, and R29) sampled.

Inspectors wroteBased on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to one of four residents sampled (Resident (R) 7) and their representative.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Discharge Assessment for Resident (R)80 accurately reflected the resident's discharge status.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan was implemented for one resident (Resident 6) sampled. Resident (R)6 is totally dependent on staff for all care, was observed lying in bed with no activities implemented. As a result of this deficient practice, dependent residents are at risk of a lack of sensory stimulation.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's medical record was accurate for one resident (R)6 sampled. R6's hard medical record chart located in the nursing station contained a Physician Orders for Life Sustaining Treatment (POLST) which documented in the event of a medical emergency, R6 should receive cardiopulmonary resuscitation. However, a POLST located in the unit's POLST binder contained a POLST which documented R6 as Do Not Attempt Resuscitation (DNAR).

Inspectors wroteBased on observations, interviews with staff, and review of the facility's infection control policy, procedures, and protocols 1) the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections were implemented, 2) the facility failed to ensure measure to prevent the spread and transmission of communicable diseases were followed. Facility staff did not perform hand hygiene between glove use and did not disinfect shared equipment after use. This deficient practice has the potential to affect all residents, staff and visitors at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident (Resident (R)50) received a therapeutic diet as prescribed. As a result of this deficiency, R50 could have experienced harm due to aspiration had this surveyor not intervened prior to staff administering water that was not nectar thickened.

Inspectors wroteBased on observations and staff interview, the facility failed ensure that all foods were stored in a closed container and provide a clean area to prepared food. As a result of this deficient practice, there is an increased potential for a food-borne illness that could affect all residents, staff and visitors that the facility kitchen serves meals to. Findings Include: 1) On 05/02/23 at 08:02 AM, initial tour and observation was done in the kitchen with the Food Services Director (FSD). Observed an uncovered plastic container filled with a white powdered substance by the juice dispenser. Next to the container was a clear plastic cover that was of the same size. Asked FSD what the clear cover was for, he said it was for the uncovered container next to it that was filled with the powdered thickener they use to thicken liquids. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident's right to self-determination through support of a resident's choice was facilitated for one of seven (Resident (R)189) residents sampled. R189 had previously selected to have miso soup with lunch and did not receive the item. As a result of this deficient practice, there is the potential for psychosocial harm.

Inspectors wroteBased on interviews and record review (RR), the facility failed to provide written transfer/discharge notice upon hospitalization for one of three (Resident(R)88) residents sampled.

Inspectors wroteBased on record review, staff interview and review of policy, the facility failed to provide written notice of bed-hold policy for two Residents (R): 1) R139 of four residents sampled, 2) R88. As a result of this deficiency, there was potential for miscommunication.

Inspectors wroteBased on observations, interviews, and record review (RR), the facility failed to develop and implement a baseline care plan to provide effective and person-centered care of the resident that meets professional standards of quality care for one Resident (R)340.

Inspectors wroteBased on interviews and record review, the facility failed to ensure comprehensive person-centered care plans were developed/implemented for two residents (Resident (R)191 and R4) sampled. R191 wandered unsupervised out of the facility on 04/15/23 and the facility did not develop a care plan until 05/02/23. Review of monitoring sheets documented staff did not implement 30-minute checks of R191 for wandering behavior in accordance with the resident's interventions listed on the care plan. R4 was not being monitored for side effects of prescribed psychotropic (drugs affecting behavior, mood, thoughts, or perception) medications. This deficient practice has the potential to affect all residents with wandering behavior or those psychotropic medications and has the potential to result in harm. Findings Include: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure adequate supervision to prevent an elopement for a resident (Resident (R)191) with wandering behavior. R191 exited the facility unsupervised and without staff's knowledge and only became aware of the resident's absences after another resident alerted staff. As a result of this deficient practice, there was the potential for serious harm to the resident.

Inspectors wroteBased on observations, interviews, and record reviews (RR), the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of two (Resident (R)71 and R340) residents sampled.

Inspectors wroteBased on observations, interviews, and record reviews (RR), the facility failed to provide or arrange for the provision of physician services 24-hours a day, in case of emergency for one of two residents (Resident (R)342) sampled. As a result of this deficient practice, the facility failed to adequately assess a resident for a potentially contagious condition.

Inspectors wroteBased on record review and staff interview, facility failed to provide adequate monitoring for one of the residents (R) sampled. R4 was not being monitored for side effects of prescribed psychotropic (drug effecting behavior, mood, thoughts or perception) medication. As a result of this deficient practice, there is a potential for negative impact on R4's quality of life. This deficient practice has the potential to affect all residents on psychotropic medications. Findings Include: Cross reference to F656 (Develop/Implement Comprehensive Care Plan). Facility failed to implement intervention to monitor resident for side effects of antidepressant. Review of electronic health record (EHR) revealed that R4 was prescribed duloxetine HCL (antidepressant medication) 30 mg (milligrams) once a day for depression. [...]

Inspectors wroteBased on observation, staff interview, record review, and review of equipment service manual, the facility failed to ensure routine maintenance cleaning of the cabinet filter, based on the manufacturer's recommendation, for one out of three oxygen concentrators reviewed. This deficient practice put Resident (R) 44 at risk for the development and transmission of communicable diseases and infections.