Hale Malamalama

F-F600 Free from Abuse/neglect

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 125050 Department of Health & Human Services Printed: 09/10/2025 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 125050 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Malamalama 6163 Summer Street Honolulu, HI 96821

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 0610 The facility failed to protect Resident R1 from verbal abuse and neglect to provide needed services of toileting. CNA2 refused to assist Resident R1 to the toilet, witnessed shouting at Resident R1 and reported to have made other inappropriate Level of Harm - Minimal harm or comments. CNA2 stated during interview that she told Resident R1 to urinate in her diaper. As a result of these willful potential for actual harm acts, Resident R1 suffered mental anguish and emotional harm.

Residents Affected - Few 2) Resident R3 was a [AGE] year old female admitted to the facility on [DATE REDACTED]. Her medical diagnosis included but not limited to chronic kidney disease, Type 2 Diabetes, hypertension, dysphasia, Hemiplegia and hemiparesis affecting right dominant side following stroke, full incontinence of bowel and bladder. Resident R3 is dependent on staff for meeting emotional, physical and social needs due to her physical limitations. She was on hospice and expired on [DATE REDACTED].

The facility was notified by APS that they opened a case for Resident R3 and requested documents.

Reviewed a typed unsigned statement that included On [DATE REDACTED]. I was the evening Charge Nurse .when 1 CNA came to me and told me that the agency CNA and a regular staff of the facility are arguing loudly inside room [ROOM NUMBER]. I went to intervene and saw them close to eachother still arguing. Prior to the incident, I learned that they were arguing about resident assignment .When asked if she (agency CNA) can change the said resident (Resident R3), the agency CNA agreed to change her.After separating them, I was not really sure what happened why they came to a point where they are shouting to each other. I just wanted to separate them.

On [DATE REDACTED] at 10:00 AM, interviewed the DON in the conference room. At that time, she said she was aware of a situation with Resident R3 on [DATE REDACTED], and that she was in charge at that time. The DON confirmed the unsigned statement referenced above was hers. She went on to say there was an issue with CNA assignments at change of shift but that the issue had been resolved and assignments had been worked out. The DON said apparently Resident R3 was found to be soiled by the assigned CNA, and there was a question of why she had been assigned to that particular resident. The DON said she had recently been made aware that there was a APS case opened on Resident R3. When inquired if she reviewed Resident R3's medical records to identify any potential care issues and specifically if she had reviewed the CNA task documentation for timely brief changes on [DATE REDACTED], since

this had been brought to her attention, she replied no. The DON reviewed the documentation and agreed there was lack of evidence Resident R3 had been checked every two hours for incontinence that day.

There was no investigation to identify any care issues or neglect to provide services conducted by the facility

after the CNA expressed concern of staff not changing residents in a timely manner and the incident that occurred on [DATE REDACTED]. It was viewed as an interpersonal conflict between staff related to assignments which was considered resolved.

Cross Reference

F-F684 Quality of care

The facility failed to provide the needed incontinence care and standards of practice for Resident R3, which was to check her every two hour checks to ensure she was clean and dry. RR revealed staff did not provide these checks on multiple occasions, which put her at increased risk of skin breakdown. On review of CNA task documentation revealed on [DATE REDACTED], Resident R3 was checked at 12:00 PM, and not again until 07:25 PM.

3) Reviewed the facility policy titled Protection of Residents During Abuse Investigations with date at bottom of page ,d+[DATE REDACTED]. The policy included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 125050 Department of Health & Human Services Printed: 09/10/2025 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 125050 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Malamalama 6163 Summer Street Honolulu, HI 96821

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 0610 -The policy statement Our facility will protect residents from harm during investigations of abuse allegations.

Level of Harm - Minimal harm or - 1. During abuse investigations, residents will be protected from harm by the following measures: a. potential for actual harm Employees accused of the alleged abuse will be immediately reassigned to duties that do not involve contact with any resident or will be suspended with or without pay until the findings of the investigation have been Residents Affected - Few reviewed by the administrator or representative clearing the employee of any wrong doing. b. Duties that do not involve contact with any resident include work in the dietary department or the administrative office.

Reviewed the facility policy titled Abuse Investigations with date ,d+[DATE REDACTED] at bottom of page. The policy included:

- Policy statement: All reports of resident abuse, neglect, and injuries of an unknown source shall be promptly and thoroughly investigated by .management.

- 3. The individual conducting the investigation will , at [sic] a minimum: . i. Interview other residents to whom

the accused employee provides care or services; .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 125050 Department of Health & Human Services Printed: 09/10/2025 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 125050 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Malamalama 6163 Summer Street Honolulu, HI 96821

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39853

Residents Affected - Few Based on interviews and record review, the facility failed to timely update one Resident's(R)1 care plan. Resident R1 initially required one assist for toileting/transfers. When her condition declined, she required two person assist and then the Hoyer lift to safely transfer her, but the facility did not revise her CP in a timely manner. As a result of this deficiency, there was the potential not all staff were aware of what assistance Resident R1 required to provide safe transfers, increasing the potential for falls with injury or harm.

Findings include:

Resident R1 is a [AGE] year old female admitted to the facility from the hospital on 12/11/2023 for skilled nursing services. She had a history that included, but not limited to hypertension, cardiomyopathy, heart failure, atrial fibrillation, malignant neoplasm of stomach, malignant ascites, Type 2 Diabetes, difficulty in walking and muscle weakness.

Reviewed the electronic medical record which included the following entries:

01/03/2025 at 02:44 PM, Nursing note: .Toileted by staff with extensive assist as per request.

01/05/2025 at 03:37 AM, Nursing note: While trying to put her in recliner, knee buckled and staff slide [sic] and guided down the Res (resident) to the floor. No c/o of pain. Able to get up with 2 assist with good weight bearing.:

01/06/2025 09:35 PM, Nursing note: .CNA reports resident requiring more assistance with toileting.

01/07/2025 12:52 PM, Nursing note: Resident had her last PT (physical therapy) session this shift and able to participate with some activities given by the therapist, but weakness noted per PT.

01/22/2025 02:10 PM, Social Services note: Late entry significant change for 01/16/2025: Resident was readmitted to .Hospice on 01/08/2025 as she was previously on hospice before she had a fall and sent to the hospital. She has hospice diagnosis of Gastric Cancer .she requires extensive to total assistance with her ADL's (activities of daily living) and care due to increased weakness. She is unable to ambulate but can bear weight partially and requires 2-3 staff assistance during transfers.

Reviewed Resident R1's active care plan (CP), which included the focus The resident has an ADL self-care performance deficit r/t (related to) impaired mobility, muscle weakness. The interventions included the following:

- Toilet Use: The resident requires substantial/maximal assistance by (1) staff for toileted. Date initiated 12/26/2024. Revision on 01/15/2025.

- Transfer: The resident requires substantial/maximal assistance by (1) staff to move between surfaces as necessary. Revision on 01/15/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 125050 Department of Health & Human Services Printed: 09/10/2025 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 125050 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Malamalama 6163 Summer Street Honolulu, HI 96821

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 Resident R1 was documented to require more assistance with toileting on 01/06/2025 and on 01/22/2025, indicated

she required 2-3 staff assistance for transfers. On 01/28/2025, it was documented she required the Hoyer lift Level of Harm - Minimal harm or for transfers. The CP was not revised to include these changes in a timely manner. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 125050 Department of Health & Human Services Printed: 09/10/2025 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 125050 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Malamalama 6163 Summer Street Honolulu, HI 96821

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 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39853 potential for actual harm Based on observation, record review (RR) and interviews, the facility failed to provide the needed Residents Affected - Few incontinence care and standards of practice for two residents, (R)2 and Resident R3, of a sample size of three that needed incontinence care. This deficient practice has the potential to affect any resident requiring incontinence care.

Findings include:

1) Resident R2 is a [AGE] year old female admitted to the facility on [DATE REDACTED]. She has a medical history that includes but not limited to dementia, retention of urine, muscle weakness, difficulty walking and syncope. She is chairfast and has very limited ability to change position without moderate to maximum assistance, and is considered high risk for developing pressure sores.

Reviewed Resident R2's Care plan (CP) which included the following:

- Date initiated: [DATE REDACTED]: The resident has bladder incontinence r/t (related to) Dementia, Impaired Mobility.

- Interventions initiated [DATE REDACTED] included Brief use: The resident uses disposable briefs. Check every 2 hours and prn (as needed) and change prn., and Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.

Reviewed the documentation of Certified Nurse Assistant (CNA) tasks for the period of [DATE REDACTED] through [DATE REDACTED], which revealed bladder elimination was not checked and documented every two hours per Resident R2's CP, facility policy, or current standard of care. The entries below are not all inclusive of missed checks for incontinence care by the nursing staff:

- [DATE REDACTED] checked at 11:27 PM. (incontinent). Next check [DATE REDACTED] at 09:48 AM (did not void).

- [DATE REDACTED] checked at 11:21 PM. Next check [DATE REDACTED] at 06:00 AM (incontinent both times).

- [DATE REDACTED] checked at 11:10 PM. Next check [DATE REDACTED] at 06:00 AM (incontinent both times).

- [DATE REDACTED] checked at 12:00 PM. Next check [DATE REDACTED] at 05:11 PM (incontinent both times).

- [DATE REDACTED] checked at 11:36 PM. (incontinent). Next check [DATE REDACTED] at 09:42 AM (did not void).

- [DATE REDACTED] checked at 01:10 PM. Next check [DATE REDACTED] at 07:33 PM (incontinent both times).

- [DATE REDACTED] checked at 11:03 PM. Next check [DATE REDACTED] at 09:22 AM (incontinent both times).

- [DATE REDACTED] checked at 11:18 PM. Next check [DATE REDACTED] at 09:45 AM (incontinent both times).

- [DATE REDACTED] checked at 01:30 PM. Next check [DATE REDACTED] at 07:44 PM (incontinent both times).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 125050 Department of Health & Human Services Printed: 09/10/2025 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 125050 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Malamalama 6163 Summer Street Honolulu, HI 96821

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 - [DATE REDACTED] checked at 11:07 AM. Next check [DATE REDACTED] at 07:23 PM (incontinent both times).

Level of Harm - Minimal harm or - [DATE REDACTED] checked at 12:57 PM. Next check [DATE REDACTED] at 08:43 PM (incontinent both times). potential for actual harm - [DATE REDACTED] checked at 03:44 PM. Next check [DATE REDACTED] at 08:45 PM (incontinent both times). Residents Affected - Few - [DATE REDACTED] checked at 11:07 PM. Next check [DATE REDACTED] at 10:01 AM (incontinent both times).

- [DATE REDACTED] checked at 12:00 PM. Next check [DATE REDACTED] at 08:16 PM (incontinent both times).

- [DATE REDACTED] checked at 10:56 PM. Next check [DATE REDACTED] at 11:10 AM (incontinent both times).

- [DATE REDACTED] checked at 12:54 PM. Next check [DATE REDACTED] at 08:22 PM (incontinent both times).

2) Resident R3 was a [AGE] year old female admitted to the facility on [DATE REDACTED]. Her medical diagnosis included but not limited to chronic kidney disease, Type 2 Diabetes, hypertension, dysphasia, Hemiplegia and hemiparesis affecting right dominant side following stroke, full incontinence of bowel and bladder. Resident R3 is dependent on staff for meeting emotional, physical and social needs due to her physical limitations. She was on hospice and expired on [DATE REDACTED].

Reviewed Resident R3's Care plan (CP) which included the following:

- Date initiated: [DATE REDACTED]: The resident has bladder incontinence r/t Impaired Mobility.

- Interventions initiated [DATE REDACTED] included Brief use: The resident uses disposable briefs. Check every 2 hours and prn and change prn. Clean peri-area with each incontinence episode, and Incontinent: Check every 2 hours and as required for incontinence episodes.

Reviewed the documentation of Certified Nurse Assistant tasks for the period of [DATE REDACTED] through [DATE REDACTED], which revealed bladder elimination was not checked and documented every two hours per Resident R3's CP, facility policy, or current standard of care. The entries below are not all inclusive of missed checks for incontinence by the nursing staff:

- [DATE REDACTED] checked at 12:58 PM. Next check [DATE REDACTED] at 07:06 PM (incontinent both times).

- [DATE REDACTED] checked at 11:00 PM. Next check [DATE REDACTED] at 05:51 AM (incontinent both times).

- [DATE REDACTED] checked at 01:13 PM. Next check [DATE REDACTED] at 07:45 PM (incontinent both times).

- [DATE REDACTED] checked at 10:56 PM. (incontinent) Next check [DATE REDACTED] at 06:00 AM (Did not void).

- [DATE REDACTED] checked at 12:00 PM. Next check [DATE REDACTED] at 07:25 PM (incontinent both times).

- [DATE REDACTED] checked at 11:23 PM. Next check [DATE REDACTED] at 11:45 AM (incontinent both times).

On [DATE REDACTED], the DON was made aware that Resident R2 had been found by oncoming CNA incontinent of bowel and bladder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 125050 Department of Health & Human Services Printed: 09/10/2025 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 125050 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Malamalama 6163 Summer Street Honolulu, HI 96821

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 3) Reviewed the facility policy (not dated) titled Perineal Care For The Incontinent Patient. The policy purpose included 2. Perineal care is completed every morning and/or after each incontinence episode. At the Level of Harm - Minimal harm or bottom of the policy was REMINDERS: *Check the patient every two hour for incontinence. potential for actual harm 4) On [DATE REDACTED] at 01:50 PM, interviewed CNA1 in the conference room. CNA1 said she was familiar Resident R3, and Residents Affected - Few she needed to have her briefs checked every one to two hours due to incontinence. At that time, she said the policy and expectation was that the staff were suppose to document every two hours whether the resident voided or not.

On [DATE REDACTED] at 10:40 AM, interviewed the Director of Nursing (DON) in the conference room. She said the facility policy for incontinence care was to check the resident every two hours to see if they needed to be changed, and to document in the computer if the resident was incontinent or did not void. At that time, reviewed the documentation of CNA tasks for incontinence checks on Resident R3 and the DON confirmed the gaps

in documentation. She said staff may have been busy and unable to document, but agreed it was the expectation to do so.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 125050