Palolo Chinese Home

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents were free from abuse by failing to adequately protect one of three residents reviewed for abuse allegations (R) 12). Specifically, a staff member willfully pushed R12's head without a care related purpose. This failure placed residents at risk of abuse and harm. Findings Include: Cross reference to F609, Reporting of Alleged Violations. The facility failed to ensure that a staff member who witnessed an incident involving another staff member willfully hitting a resident in the head immediately reported the incident to the administrator. On 05/04/26, the facility submitted a completed event report to the State Agency (SA), Intake #2999087. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a staff member who witnessed an incident involving another staff member willfully hitting a resident in the head immediately reported the incident to the administrator for one of three residents (Resident (R) 12) reviewed for allegations of abuse. This failure had the potential to delay the facility's response to allegations of abuse and place residents at risk for harm. Findings Include: Cross reference to F600, Free from Abuse and Neglect. The facility failed to ensure that R12 remained free from abuse when a staff member was witnessed willfully pushing/hitting the resident's head without a care-related purpose. On 04/29/26, the facility submitted an initial event report to the State Agency (SA), Intake #2999087. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an agency staff (AS) 10 who was a full-time employee completed the required training and competency evaluation program, or a competency evaluation program approved by the State for certification within four months of hire for one of three facility-reported staff-to-resident abuse allegations reviewed (Intake #2659390). This failure had the potential to place residents at risk for inadequate care and abuse. Findings Include:On [DATE] at 10:36 AM, record review was done. Review of facility document titled, Agency Staff Checklist for Credentials with staff credentials and hire dates revealed no specific Start Date for NA10. C.N.A. Certification did not also include any License Number and Expiration Date for NA10 indicating not certified. On [DATE] at 11:12 AM, an interview was conducted with Administrator. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an agency staff (AS) 10 providing nurse aide services was listed on the state nurse aide registry prior to working in the facility for one of three facility-reported staff-to-resident abuse allegations reviewed (Intake #2659390). This deficient practice placed residents at risk for care being provided by unqualified staff and had the potential to affect resident safety and well-being. Findings Include:Cross reference to F0728 - Facility Hiring and Use of Nurse On 05/21/26 at 11:12 AM, an interview was conducted with Administrator. Administrator confirmed that AS10 did not meet competency evaluation requirements or a certification for nurse aide. Administrator also stated that AS10 received on-the-job training as caregiver but would not be appropriate for the Long-Term Care program. [...]

Inspectors wroteBased on interviews and record review, the facility failed to identify and intervene for an acute change in a resident's condition related to a stroke for one (Resident (R) 4) of three residents sampled, resulting in the family telling the facility to transport the resident to the hospital. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurate documentation in a medical record for one (Resident (R) 4) of three residents sampled. Late entries affected the care the resident was provided and did not reflect an accurate presentation of the resident. Finding Include: (Cross Reference to F684- Quality of Care)1) Review of R4's Electronic Health Record (EHR) documented Registered Nurse (RN) 12 wrote a late entry progress note on 08/15/25 at 02:13 AM for 08/14/25 at 05:58 AM, after the resident was discharged to the hospital. The progress note written documented, endorsed to CNAs (Certified Nurse Aide) and will endorse to morning shift that R4's Head of Bed (HOB) needs to stay elevated. However, this progress note was entered into the resident's Electronic Health Record (EHR) late. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident's/representatives with the name and contact information of the facility grievance official and did not inform them of the right to receive the findings of the investigation and conclusion in writing. In addition, three out of four Resident (R) grievances reviewed, did not include findings, conclusions or if any corrective action was, or would be taken. This deficient practice could affect all Residents because the facility does not provide them the required information for them to file a grievance, and obtain an acceptable resolution.

Inspectors wroteBased on interviews and record review, the facility failed to provide protections for the health, welfare and rights of each resident residing in the facility by developing and fully implementing policy/procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not (1) include how the facility would ensure contract/agency caregivers who provide care on behalf of the facility would receive the required training elements, and (2) four of a sample size of six contracted Nursing Assistants did not have evidence of the required training. As a result of this deficiency, the facility can not ensure contracted staff have the required knowledge to recognize and prevent abuse, which may result in negative outcomes.

Inspectors wroteBased on interviews, record review and observation, the facility admission staff accessed one Resident's (R)1 external medical records from an acute care Hospital (H)1 through a portal/link used to facilitate referrals and admissions without R1's consent, after she left the facility against medical advice (AMA). As a result of this deficient practice, R1's rights were violated.

Inspectors wroteBased on interviews, document and record review (RR) the facility failed to report to authorities an allegation of potential abuse of one Resident (R)1 of a sample of one. R1 reported she woke up with someone lying next to her in bed. The facility did not identify this incident as potential abuse, and failed to report the allegation to the Office of Healthcare Assurance (OHCA), Adult Protective Services (APS), or the Police. As a result of this deficiency external agencies investigations were delayed and the facility failed to meet their mandated reporting requirements.

Inspectors wroteBased on interviews, observation, record and document review, the facility failed to thoroughly investigate one alleged abuse of a sample of one, reported by Resident (R)1. Specifically, the facility did not; 1) interview R1's roommate, and all staff working, 2) summarize the findings of review of the video surveillance, and 3) document the results of their independent, internal investigation and report them to the Office of Healthcare Assurance. As a result of this deficient practice, there is the potential important information is missing from the investigation, necessary to determine the outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to a dignified existence for two (Residents (R) 395 and R18) of three residents sampled for dignity. As a result of this deficient practice, residents dependent on staff are at risk for more than minimal physical and/or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary assistance to help maintain functional mobility and independence on one of two sampled residents (Resident (R)18), for accommodation of needs. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident's right to choose aspects of the resident's life that are significant to the resident for two (Resident (R) 394 and R395) of two residents sampled. R394 prefers to brush her teeth in the morning, but staff regularly assist the resident in the afternoon. R395 receives hospice service and family reported not wanting the resident up in the wheelchair for more than 15-20 minutes (for meals) to allow the resident to rest in bed. As a result of this deficient practice, residents are at risk for more than minimal negative psychosocial and/or physical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to obtain a copy of the resident's Advance Health Care Directive (AHCD) and did not inform the resident of his/her right to develop one, provide assist in doing so, and/or periodically assess the residents' preference for formulating an AHCD for 2 of 2 residents (Residents (R) 46 and R12) sampled. This deficient practice does not allow residents, when incapacitated, the right to have their health care choices identified and honored.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' environments were clean and homelike, as well as, protecting residents' personal property from loss, for two of four residents (Resident (R) 8 and R65) sampled for environment. A staff member did not dispose of soiled and dirty trash items properly, leaving it on top of R8's personal property in her room. This has the potential to cause unpleasant odors and an unsanitary environment. R65's personal lamp was removed from his room without explanation or follow-up. The facility did not exercise reasonable care for the protection of the resident's property from loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's comprehensive assessment accurately reflected the resident's status at the time the assessment was completed for one of seven residents (Resident (R) 293) reviewed for falls. Staff members were utilizing the bed/chair alarm as an intervention for falls and it was not reflected in the assessment under restraint. This deficient practice put R293 at risk of an inaccurate assessment of the bed/chair alarm and its appropriateness as an intervention.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for two (Residents (R)30 and R56) of 22 sampled residents. As a result of this deficient practice, residents were placed at risk for decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to revise the comprehensive person-centered care plan for one of seven residents (Resident (R) 293) reviewed for falls, and one of one resident (R12) sampled for urinary catheters. R293's care plan did not include new interventions for falls after sustaining a fall with major injury. As a result, R293 experienced additional falls that may have been avoided. By not revising R12's care plan to include urinary catheter care, R12 was placed at risk for adverse catheter-related issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of seven residents (Resident (R) 293 and R29) reviewed for falls were free from accident hazards. R293, whom previously had a fall with major injury (a fracture to the left thigh bone that required surgery), had no new interventions care planned for falls, then had a subsequent fall putting R293 at risk for further injuries. R29 was inappropriately transferred via 1-person manual transfer instead of a 2-person mechanical lift, and as a result suffered a fall with a fracture to her right ankle.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff competency in completing Fall Risk Evaluations accurately for 3 of 7 residents (Residents (R)293, R294, and R28) sampled for falls. This deficient practice placed the affected residents at risk of avoidable adverse outcomes.

Inspectors wroteBased on observation, interviews, and review of facility's medication administration policy, the facility failed to keep medications secured for one of twelve residents (Resident (R), 69) observed during medication administration. This deficient practice has the potential to affect all residents in the facility taking medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's menu with selected food choice was followed for one of two residents (Resident (R) 66) sampled for food preferences. The facility did not follow-up/communicate with R66's food choice after identifying the selection may have an ingredient he is allergic to, and did not give R66 the opportunity to choose what he wanted to eat. As a result, R66 received a meal that was not listed on the menu provided in advance that he did not want to eat, causing the resident confusion.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food in the consistency ordered by the physician to meet the needs of 2 of 2 residents (Resident (R) 13 and R69) sampled for appropriate preparation of food. This deficient practice increases the risk of aspiration for residents who have a modified consistency diet order for dysphagia (difficulty swallowing).

Inspectors wroteBased on observation and interviews, the facility failed to check the refrigerator temperature for one of five refrigerators in the kitchen for two consecutive days on the evening shift. This deficient practice puts resident at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's (Resident (R) 8) soiled incontinence item and dirty gloves were properly disposed of, and a staff member used appropriate personal protective equipment (PPE) for a resident (R84) under enhanced barrier precautions (EBP) for one of four units (Unit W) observed for infection control. These deficient practices increase the risk of the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors.

Inspectors wroteBased on interviews, and record review, the facility failed to implement interventions in a care plan for one out of three sampled residents (Resident (R) 2). This deficient practice resulted in R2 sustaining a fall and has the potential to affect all the residents in the facility. Findings Include: (Cross reference to F689-Free Of Accident Hazards/Supervision/Devices) A review of R2's Electronic Health Record (EHR) was conducted on 11/22/24. R2's EHR noted that R2 sustained an unwitnessed fall in the dining room on 10/24/24 at 08:40 PM. Furthermore, R2's current care plan noted the following interventions to prevent her from falling, 6/17/24 Staff to ensure common areas (i.e. dining room) are supervised at all times. Staff to communicate with one another when they have to leave the premises. A review of the facility's investigative note on R2's fall on 10/24/24 was conducted. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision to prevent two out of three sampled residents (Resident (R) 1 and R2) from falling. Due to this deficient practice R1 sustained a fall that resulted in a laceration to the head. This deficient practice has the potential to affect all the residents who are at risks for falls in the facility. Findings Include: (Cross reference to F656-Develop/Implement Comprehensive Care Plan) 1)R1 is a [AGE] year-old male admitted to the facility on [DATE]. R1 has a diagnosis that include, but not limited to, spinal stenosis, mild cognitive impairment, and generalized arthritis. A review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/24, noted that R1's score for Brief Interview for Mental Status (BIMS) was a seven. Which means, R1 has severe cognitive impairment. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure that one of the three sampled residents (Resident (R) 1) received treatment and care in a timely manner and in accordance with professional standards of practice. This failed practice has the potential to affect all the residents in the facility. Findings Include: R1 is a [AGE] year-old female admitted to the facility on [DATE]. R1 has medical diagnosis including but not limited to Moyamoya disease, heart failure, gastrostomy tube (feeding tube), aphasia (communication disorder) following cerebrovascular disease (condition that affects blood flow in the brain). A review of R1's Electronic Health Record (EHR) was conducted. R1's EHR noted that R1 was diagnosed with a fracture of the left upper arm on 07/12/24. Interview was conducted with R1's spouse on 07/25/24 at 11:50 AM. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff members, including contracted staff, followed the proper use of personal protective equipment (PPE) for a resident under contact precautions (Resident (R) 1). This deficient practice encourages the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an environment free from any physical restraint imposed for purposes of convenience, and not required to treat the resident's medical symptoms to one of the sampled residents (Resident (R) 28). Findings Include: R28 is a [AGE] year-old-female admitted to the facility on [DATE]. R28 has a medical history not limited to dementia and Alzheimer's. Observation was conducted on 03/04/24 at 09:18 AM in R28's room. R28 was laying in bed with two wedges tucked underneath the left side of her fitted bed sheet. Observation was conducted on 03/05/24 at 07:47 AM in R28's room. R28 was positioned with the head of her bed elevated while having breakfast with the assistance of one of the staff. Two wedges were observed tucked under the left side of R28's fitted sheet. [...]

Inspectors wroteBased on observations, record review and interview the facility failed to report an injury of unknown source to resident(R) 22's hands (bruising on top of her hands) to the Director of Nursing which impeded the investigation. This injury of unknown source to R22's hands was also not reported within five working days to the State Survey Agency. Findings Include: On 03/04/24 at 08:50 AM introduced self to R22 who was laying in her bed. At this time observed R22 had a bruise, which covered the top of her right hand, and appeared to be healing. Inquired if resident knew how she got the bruise and she did not remember how she got it. On 03/04/24 Record Review (RR) of R22's Electronic Health Record (EHR) found her diagnoses include, but are not limited to,vascular dementia (memory loss) and Paroxysmal Atrial Fibrillation (irregular rapid heart rate) which is treated with medication. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide assistance for Resident (R) 19 to maintain her personal grooming and oral hygiene and failed to provide proper perineal care (cleaning genital and anus) for R22 putting them at risk for infection. This deficient practice could affect any resident who requires assistance with activities of daily living (ADLs) putting those residents are risk for infection. Findings Include: Cross-reference to F880 Infection Control. 1) On 03/05/24 at 10:40 AM entered R19's room and observed her eyes were dirty. R19's eyelashes were covered with a thick clear discharge which made it hard for resident to open her eyes. R19's mouth was dirty and edges of mouth were dry. At this time interviewed Certified Nurse Aide (CNA)5. [...]

Inspectors wroteBased on observation, interviews, 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: Concurrent observation and interview were conducted on 03/05/24 at 10:28 AM. A medication cart was observed left unlocked in the hallway near the dining room. Near the medication cart were four residents and two Certified Nurse's Aide (CNA). Registered Nurse (RN) 11 was observed in one of the resident's rooms. When RN11 returned to the medication cart, she realized she left the cart unlocked and was apologetic. RN11 stated that medication carts should not be unlocked while left unattended. [...]

Inspectors wrote2) During an observation of a semi-private resident room on 03/09/24 at 09:00AM, there were two different Isolation Precaution warning signs; Contact Isolation and Aerosol Precautions. The two signs did not indicate which resident was assigned to which isolation/precaution. During staff interview on 03/09/24 at 09:10AM, Registered Nurse (RN) 9 acknowledged that the two signs did not specify which resident was assigned to which isolation/precaution. RN9 added that staff, especially new staff, did not know which resident was assigned to which isolation/precaution. Review of facility policy on Isolation Practices read Contact Precautions Policy, it is the policy of this facility to use category-specific isolation techniques for residents who have infectious or communicable diseases that may necessitate the use of barriers in addition to those used for Standard Precautions. [...]

Inspectors wroteBased on observation, staff interview and review of policy, the facility failed to remove expired emergency equipment nasal cannula from the Code Crash Cart in the [NAME] Hall.

Inspectors wroteBased on observations, interviews with staff, and record review, the facility failed to assure a system was established to ensure the dish machine sanitization process was in proper working order and failed to ensure labeling of food items. This deficient practice has the potential to result in foodborne illnesses.

Inspectors wroteBased on staff interview, the facility failed to inform all residents, their representatives, and families of those residing in the facility by 5:00 PM the next calendar day of confirmed cases of COVID-19. This deficient practice fails to appropriately notify the residents and/or their representatives and families of an ongoing COVID-19 virus transmission in the facility.

Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for two residents (R), R92 and R73, out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of the reason for resident's discharge.

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), R92 and R73, out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of the facility's bed-hold policy.

Inspectors wroteBased on record review and interview with staff members, the facility did not assure assessments accurately reflected the residents' status for two (Residents 19 and 91) out of eighteen assessments reviewed. The facility inaccurately coded Resident (R)19 with a facility-acquired Stage III pressure ulcer and R91 as being discharged to the hospital, instead of to the community. This deficient practice has the potential to affect the development of a person-centered care plan, resulting in not meeting the needs of the residents.

Inspectors wrote4) On 03/25/23 at 12:23 PM, R86 was observed to have a urinary catheter with a tubing and bag system. On 03/29/23 at 09:21 AM, R86 was interviewed in her room. R86 had a urinary catheter tubing and bag system because of her diagnosis of retention of urine and hoped to have it taken out before she was discharged home soon. On 03/31/23 at 08:25 AM, R86 and Registered Nurse (RN)3 were interviewed in R86's room. R86 stated that the staff provided her education about caring for her urinary catheter with tubing and bag system. R86 was taught to clean the catheter insertion/exit site with a wet, soapy cloth and to keep catheter tubing and bag system clean. RN3 confirmed that education for care of her urinary catheter with tubing and bag system was provided to R86 and that R86 mostly does her own catheter insertion/exit site care, but at times may need assistance. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow bowel regimen protocol in accordance with the physician orders for one of one resident (R), R52, sampled with constipation. The facility also failed to have a lab drawn and follow up on the results for R42's blood sugar management. These deficient practices have the potential to result in adverse consequences in residents needing bowel or blood sugar management.

Inspectors wroteBased on record review and staff interview, the facility failed to draw laboratory tests for one resident (R), R2, as recommended by the consultant pharmacist. This deficient practice has the potential to cause adverse consequences for residents where the consultant pharmacist has recommended actions to be taken for medication management.

Inspectors wroteBased on record review and interview with staff members, the facility failed to assure pain medication was provided with adequate indication for its use for one resident (R), R35, of five residents sampled for medication review. The prn (as needed) medications for pain did not indicate the parameters for its use or include non-pharmacological interventions to relieve pain. This deficient practice has the potential to ensure the resident attains the highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observations and staff interview, the facility did not ensure that medication error rate was below five percent (%). Two administration errors to resident (R)243 out of a sample of 5 residents, were observed out of 32 opportunities, resulting in a 6.25% medication error rate. This deficient practice has the potential for inadequate administration of medications and/or adverse effects to residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure hand hygiene procedures were followed by staff between glove change during a dressing change for one resident (R), R45, and failed to ensure droplet precautions were maintained for another resident, R35, receiving aerosolized medication out of a total sample of 14 residents. These deficient practices encourages the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors.

Inspectors wroteBased on observations, interview, and record review, the facility failed to conduct COVID-19 testing correctly on staff being screened during a COVID-19 outbreak. This deficient practice has the potential to transmit the COVID-19 virus affecting the health and safety of residents, staff, and visitors.