Oahu Care Facility

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective discharge planning process was developed and implemented which considered the care giver's availability, capacity, and capability to perform needed care, to meet the needs of the resident following discharge for one out of three residents sampled. This deficient practice resulted in an unsafe discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and promote quality of life for 1 of 1 resident (Resident (R)68) sampled for dignity by ensuring that he was treated with the respect and consideration any reasonable person would expect. Specifically, the facility failed to ensure staff provided feeding assistance in a manner that considered proper pacing and dignity. As a result of this deficient practice, R68's dignity was compromised, and he was placed at risk of a decreased quality of life.

Inspectors wroteBased on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately record the type of discharge in the RAI, Minimum Data Set (MDS) for one Resident (R)92 of three residents sampled. As a result of this deficiency, the facility put R92 at risk for further RAI, MDS inaccuracy.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 2 of 3 residents (Residents (R)8 and R84) sampled for pressure ulcers received the necessary monitoring, treatment, and services, consistent with professional standards of practice and their comprehensive care plans, to promote healing and prevent worsening. Specifically, the facility did not monitor/document the wound status of the pressure ulcers. As a result of this deficient practice, there was no way to measure if the treatment being provided was effective or needed to be modified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident (R)68) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services, to increase mobility or prevent further decrease in ROM. As a result of this deficient practice, R68 was placed at risk of decreased mobility and comfort and hindered from reaching his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident sampled for smoking (Resident (R) 12) with an ashtray made of non-combustible material while he was smoking, and the facility's designated smoking area did not contain a metal container with a self-closing cover device to dispose of cigarette butts and ashes. This deficient practice did not ensure the safety for R12 and other residents in the facility that smoke.

Inspectors wroteBased on observation, interview, and record review the facility had no defined policy and procedure on how to manage the disposition for discontinued non-controlled medications located in the medication administration cart. This deficient practice creates a potential unsafe situation where discontinued medications could inadvertently be administered to residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the medication regimen for 1 of 6 residents (Resident (R)45) sampled for unnecessary medications. Specifically, the facility failed to monitor for and appropriately document episodes of excessive sleepiness despite identifying it as a problem. As a result of this deficient practice, R45 was placed at risk of avoidable accidents related to adverse effects of potentially unnecessary medication(s).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections as evidenced by: 1) 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), wearing and cleaning proper personal protective equipment (PPE), keeping dedicated equipment in the room, and 2) Failing to label and properly store a nasal cannula. As a result of the deficiencies, the facility put the residents at increased risk to communicable disease and infections.

Inspectors wroteBased on interviews, medical record review and document review, the facility failed to provide adequate supervision of one Resident (R)3 of three residents sampled that were high risk of elopement. R3 eloped on 02/09/2025 and suffered harm. When she was found, she was taken to the hospital where she was treated for abrasions from a fall and discharged back to the facility. The facility met the following three criteria for past non-compliance 1) Not in compliance with the regulatory requirement at the time the situation occurred; 2) The noncompliance occurred after the exit date of the last recertification and 3) There is evidence that the facility corrected the noncompliance and is in substantial compliant at the time of this survey.

Inspectors wroteBased on record reviews and interviews, the facility failed to meet regulatory requirements for Baseline Care Plans (BCP) for three of three Residents (R)1, R2, and R4. Specifically, R1 did not have a BCP developed within 48 hours of admission, R4's BCP did not include the Stage 2 Pressure Ulcer that was present on admission, and two residents were not provided summaries of the BCP. This deficient practice places residents at risk for not receiving appropriate and timely care, delays the development of care to address resident's immediate health and safety needs, hinders continuity of care, and impedes communication amongst nursing home staff.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide repositioning, the standard of care for pressure ulcers (PU/ injury to the skin and tissue below the skin due to pressure on the skin for a long time), and as directed in care plans for three Residents (R)1, R2 and R4 out of a sample size of three. This deficient practice puts residents with PU's at risk of worsening the wound, and increases the potential of those at risk to develop one.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan (CCP) for one Resident (R)1 of a sample size of three. Specifically, R1's CCP did not address his safety needs in a timely manner. As a result of this deficiency, R1 may have been at higher risk of falls. The deficient practice of not addressing resident's needs timely in the CCP could affect any resident and be a barrier to meeting their highest potential of physical and mental well-being.

Inspectors wroteBased on observation and interview the facility failed to ensure staff use non-expired test strips for their kitchen three compartment sink to test for levels of strength of sanitizer solutions, failed to store clean meal lids on a rack that did not have rusty colored debris and failed to label opened beverages with the opened-on date. Findings Include: 1) Observation on 08/26/24 at 10:40 AM had kitchen staff test the strength of sanitizer in their three compartments sink and found facility was using expired Hydrion test strips with an expiration date of [DATE]. Food Service Worker (FSW) 11 confirmed the test strips were expired and got new test strips and tested the water which was in range. 2) On 08/28/24 at 10:57 AM while observing tray line observed a rack in the kitchen near the stove, which held clean lids for resident meals, had rust colored debris. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents on isolation. The facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to residents on transmission-based precautions (TBP). This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.

Inspectors wroteBased on record review and interview, the facility failed to inform a resident of the risks and benefits of the use of psychotropic drugs and obtain consent for one of five residents (Resident (R)3) sampled for unnecessary medications. As a result of this deficiency, the resident was placed at risk for more than minimal harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident's right to be free from physical restraint for staff convenience and not required to treat the resident's medical symptoms for one resident (Resident (R)5) sampled. Positioning wedges were placed under R5's mattress and under the resident's fitted sheet in a manner which could not be removed by the resident, which hindered the resident from freely moving at will. An interview with staff confirmed the positioning wedges were not used to reposition R5 and the resident is capable of independently moving around in bed. As a result of this deficient practice, residents with the ability to move independently are at risk of the potential for more than harm.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for two of the five residents (Resident (R)6, and 167) sampled for hospitalization. As a result of this deficient practice, there was a potential for miscommunication. This has the potential to affect all the residents that are transferred to an acute care hospital.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a comprehensive person-centered care plan was implemented for one resident (Resident (R)56) sampled. R56's person-centered care plan included an intervention to use alternative communication tools (i.e. interpreter services, available for staff use) for this Korean speaking resident. Staff did not implement the use of interpreter services intervention when conducting the Brief Interview for Mental Status (a tool used to assess the resident's cognition). As a result of this deficient practice, all non-English speaking residents are at risk of the potential for more than minimal harm.

Inspectors wroteBased on record review and interview, the facility failed to develop a discharge plan for two of 18 residents (Resident (R)61 and R219) sampled. The discharge needs and/or discharge goals for these residents were not identified to ensure the residents are ready for discharge according to their individual needs. As a result of this deficient practice, residents are at risk for more than minimal harm related to an unsafe discharge from the facility and/or a readmission to the facility.

Inspectors wroteBased on interviews and record review the facility failed to ensure Resident (R)122 is provided appropriate services for communication. As a result of this deficient practice, non-English speaking residents are at potential risk for more than minimal harm.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the environment remains as free of accident hazards and adequate supervision to prevent accidents for one resident (Resident (R)56) sampled. A nurse's scissor was left unattended in an area accessible to resident and not properly stored. R56 was not adequately supervised, had access to a scissor, and managed to elope from the facility without staff's knowledge. As a result of this deficient practice, residents are at risk of more than minimal harm.

Inspectors wroteBased on interview and record review, the facility also failed to ensure the records for controlled medications were maintained and accurate. As a result of this deficient practice, there is a potential for the diversion of a controlled medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly store physician prescribed topical ointment for one resident (Resident (R)22) and failed to ensure medicated ophthalmic drops were properly labeled with an expiration date for two residents (Resident (R)32 and 52) sampled. As a result of this deficient practice, residents who receive prescribed cream, ointment and medicated ophthalmic drops are at risk for more than minimal harm.

Inspectors wrote4. On 10/11/2023 at 03:11 PM, during resident interview, R159 complained of call bell noise during the night, stated It rings 27 times before anyone answers it, I counted it. Complained that it rings so much when she is trying to sleep at night and reported not having a good nights sleep. Observation of the unit found the call light bell speaker is located outside of R159's room on the opposite wall with the speaker facing her room. 5. On 10/11/2023 at 03:21 PM during interview with R161 he reported his roommate (R164) was loud all night and kept him up, he was not able to sleep. R161 stated he was surprised his roommate was so quiet now as he was so loud previously yelling out and moaning. During this time the other resident in question was being assisted by facility staff. R161 said the resident in question will probably soon become loud. 6. [...]

Inspectors wroteBased on observation and staff interview the facility failed to place a Contact Precautions sign and PPE cart outside of R162's room for staff and guest notification and use, failed to clean a shower chair between resident use with noted brown substance on right handrail, failed to have a food services staff (FSS)3 cover a healing burn wound while cooking food, failed to have FSS4 use gloves when unloading clean dishes from the dishwasher, failed to have FSS2 use gloves when performing tray line temperature checks over open food, and failed to deliver a lunch tray that was free from a dirty crumpled up napkin to the second floor. Findings Include: 1. During initial observations of residents, on 10/11/2023 at 10:00 AM, found R162 had contact precautions in place, order read place resident on contact precaution for MRSA [Methicillin-resistant Staphylococcus aureus] at LLE wound. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not assure that 2 residents out of a sample of 4, Resident (R)38, and R161 was treated with dignity and maintenance of quality of life. Findings Include: 1) An attempt was made to interview R38 on 10/16/23 at 08:40 AM in the hall, across where the nursing station is and elevators. R38 was hard of hearing and distracted. R38 was not able to answer any questions. Surveyor noted that R38's hair was not brushed and hair was oily and messy. On the same day at 08:45, Registered nurse (RN1) put Ketoconazole cream to resident's scalp. RN1 stated that she had itching to her scalp and the cream is placed into her scalp by doctor's order. Inquiry was made regarding her shower schedule and when does she get a hair wash. RN2 stated that clinical assistant #2 (CN)2 does R38's shower. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet the document requirements for resident transfer for two out of two sampled residents (Resident (R) 31, 50). This deficient practice has the potential to negatively affect the continuation of care for the residents. Findings Include: Record review of R31 and R50's Electronic Health Record (EHR) indicated no documentation of R31 and R50's care plans being sent over to the receiving hospital. A review of the facility's document titled, Transfer Information Checklist, indicated that the resident's care plan is not included in the list of documents sent over to the receiving hospital. Interview with the Director of Nursing (DON) was conducted on 10/13/23 at 02:21 PM in the conference room. DON verbalized that the facility does not send over care plan records to the receiving hospital.

Inspectors wroteBased on record review (RR) and staff interview Resident (R)2 developed a stage two pressure ulcer (PU) on 09/29/2023, it deteriorated and became unstageable on 10/05/2023 which the Minimum Data Set (MDS) coordinator was not made aware of, a significant change was not reported to CMS using the Significant Change in Status Assessment (SCSA) and the Care Area Assessments (CAAs) was not completed within 14 days. Findings Include: During RR on 10/12/2023 noted R2 was being treated for a stage two pressure ulcer that was identified on 09/29/2023. Review of submitted MDS from facility to CMS found there was no SCSA and CAAs completed within 14 days from 09/29/2023. On 10/16/2023 at 12:57 PM met with MDS coordinator and inquired how she would know a resident develops a pressure ulcer. [...]

Inspectors wroteBased on record review (RR) and staff interview the facility failed to develop and implement a baseline care plan for Resident (R)162's language barrier and R163's diabetes and dialysis. R162's primary language is Chinese and R163's admission diagnosis included Type 2 Diabetes Mellitus (DM) and orders for dialysis on Tuesday, Thursday and Saturday each week. Findings Include: 1.) On 10/11/2023 at 09:45 am while doing rounds with residents on the second floor noted R162 had a language barrier as he told me that he does not speak English when I greeted him. Resident repeated this when I asked how he slept. R162 was not able to communicate with surveyor. RR found R162's primary language is Chinese. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not assure that 1 resident out of a sample of 4, Resident (R)38, was provided care with hygiene-bathing to maintain activities of daily living. Findings Include: Surveyor noted that R38's hair was not brushed and hair was oily and messy. On the same day at 08:45, Registred nurse (RN1) put Ketoconazole cream to resident's scalp. RN1 stated that she had itching to her scalp and the cream is placed into her scalp by doctor's order. Inquiry was made regarding her shower schedule and when does she get a hair wash. RN2 stated that clinical assistant #2 (CN)2 does R38's shower. CNA2 does a really good job and blow dries her hair and her shower was yesterday. RN2 further stated that CNA2 was off yesterday and that CNA3 had given R38 a shower. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice when the staff did not continue the functional mobility services and therapy as ordered and care planned for 2 of 5 residents sampled (Resident (R)1) and R29. This deficient practice has the potential to harm R1 and R29 by decline in their mobility and worsening of contractures and haults their progress to reach their highest practicable level of health and wellbeing.

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications. Findings Include: Observation was conducted on 10/13/23 at 11:33 AM on the third floor. Registered Nurse (RN) 1 was observed leaving the medication cart unlocked while administering medications in room [ROOM NUMBER]. The medication cart was left unlocked in the hallway. The hallway had residents and staff members passing by. Interview was conducted with the Director of Nursing (DON) on 10/13/23 at 11:33 AM in the conference room. DON stated that the medication cart should have been locked when RN1 left it unattended. [...]

Inspectors wroteBased on observation of tray line and staff interview the facility failed to correctly plate the prescribed diet for Resident (R) 55 who was ordered a regular chopped diet with nectar liquids. The facility staff prepared a pureed diet for R55. This failed practice puts all the facility residents at risk for receiving a meal that does not meet their health needs. Findings Include: On 10/11/2023 at approximately 11:15 AM while observing food service staff (FSS) plate residents lunches surveyor requested to spot check a tray for accuracy. FSS1, who is temporarily covering as the kitchen manager, pulled a tray that was one of the last trays to be plated and we checked the meal card to what was plated. The tray chosen was for R55 who has a regular chopped diet with nectar liquids ordered. The plated meal appeared to be a pureed diet. [...]

Inspectors wroteBased on observation of the kitchen and staff interview the facility failed to store food in accordance with professional standards for food service safety and at the start of temperature taking of the trayline failed to correctly place thermometer in cooked food to register temperature. Findings Include: On 10/11/2023 at 08:30 AM, while doing brief tour of the kitchen, noted there were two separate containers of chopped meat (ham and Portuguese sausage) that were placed in a larger plastic container. Noted the saran wrap that had been placed over the larger plastic container had folded up upon itself when it was placed in the refrigerator that morning. It appears to have caught on the top of the shelf it was placed under. [...]

Inspectors wroteBased on resident interview, record review (RR) and staff interview the facility failed to maintain resident medical records that accurately documented the stage of a pressure ulcer (PU) on the care plan for Resident (R)2, diet order for R55, correct days of the week of dialysis on Occupational Therapy (OT) care plan for R163 and completely fill out communication documents to dialysis center for R163. Findings Include: 1. On 10/12/2023 at 12:52 PM during RR found R2 had developed a stage 2 PU on 09/29/2023. This PU deteriorated and on 10/05/2023 was documented as unstageable. Review of R2's care plan included care for a stage 2 PU. Care plan had been updated on 10/13/2023 with no change made to identify the decline of the pressure ulcer. 2. On 10/12/2023 met with and interviewed R163 who stated he receives dialysis three times a week on Tuesday, Thursday and Saturday. [...]