Hale Nani Rehabilitation And Nursing Center

F-F550. The facility failed to ensure Resident R29 are treated with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement to her quality of life. Resident R29 was not provided accessibility to her belongings, including clothes, when moved to a different room/unit after returning to the facility.

On 07/15/24 at 10:09 AM, Resident R29 expressed she was confused on why she was in this room. Observed her room to have peeled paint behind her bed. Resident R29 inquired why the facility would put her in a room with wall damage and pointed out the paint peeling all around her room. Concurrently observed the paint to be peeled off all around the room.

On 07/18/24 at 11:18 AM, an interview with DOM was done. DOM reported the maintenance department does a walk around the facility once a week and if they see paint peeling in a room, they will patch the room when it is unoccupied due to the smell. It takes about 24 hours for them to mud, sand, and paint the walls. DOM stated they just patched up Resident R29's room yesterday, 07/17/24, after the resident moved back to her previous room. DOM confirmed the maintenance department did not get a work order to patch the peeled paint in the room prior to the facility putting Resident R29 in the room with peeled paint across the walls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0584 3) On 07/18/24 at 01:57 PM, during a meeting with Resident Council members, Resident R231 reported her toilet has not been flushing properly for weeks and feels it is not sanitary if the residents are unable to flush. Resident R231 Level of Harm - Minimal harm or share the bathroom with three other residents. Resident R231 stated that maintenance would come in and fix it, but it potential for actual harm would just break again.

Residents Affected - Few On 07/19/24 at 08:56 AM, an observation was done of Resident R231's bathroom. The toilet water could be heard running and when attempted to flush the toilet the toilet did not flush. Attempted to flush the toilet three more times and the toilet flushed on the fourth try. Attempted to flush six more times and the toilet flushed on the seventh try.

At 08:58 AM, an interview with CNA5 was done. CNA5 confirmed the toilet sometimes does not flush and it depends on how you push the flush lever down.

On 07/19/24 at 10:56 AM, a concurrent observation and interview with DOM done. DOM stated the facility had work orders on Resident R231's bathroom in June regarding the toilet, dated 06/15/24, 06/17/24, and 06/18/24.

The facility replaced the inside of the toilet then. Concurrent observation of Resident R231's toilet, DOM reported the toilet will not flush properly because the handle was bent, and the seal was off set. The toilet will continue to not flush properly unless they fix the bent handle.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that 1 of 2 residents Residents Affected - Few (Resident 92) sampled was free from physical restraints that were not required to treat her medical symptoms. As a result of this deficient practice, Resident (R)92's patient rights were violated, and she was placed at risk of avoidable injury and/or a decline in her psychosocial well-being.

Findings include:

Resident (R)92 is a [AGE] year-old female admitted to the facility on [DATE REDACTED] for long-term care.

On 07/15/24 at 11:05 AM, the state agency (SA) observed Resident R92 quietly lying at the far end of the Unit 2 hallway in a Geri-chair that was fully reclined, with a wheelchair wedged under the extended/elevated footrest of the Geri-chair in such a way that even if Resident R92 could physically put the Geri-chair down (using the side handle to set the chair upright), the chair would not go down.

A review of the facility's Physical Restraint policy and procedure (P&P), last revised 03/2023, revealed the following:

The resident has the right to be free of abuse and is not limited to freedom from . any physical or chemical restraint not required to treat the resident's medical symptoms.

The P&P defines a physical restraint as:

. any manual method, physical or mechanical device, equipment or material that meets all the following criteria:

a. Is attached or adjacent to the resident's body;

b. Cannot be removed easily by the resident; and

c. Restricts the resident's freedom of movement or normal access to his body;

d. The resident will be able to be [sic] remove the restraint or device intentionally by the same manner as it was applied by the staff.

On 07/17/24 at 09:38 AM, an interview was done with Nurse Manager (NM)2 at the Unit 2 Nurses' Station (U2NS). When alerted of the observation on 07/15/24, NM2 did not appear surprised, and agreed that wedging a wheelchair under the extended footrests of a Geri-chair is a physical restraint, and should never happen. NM2 confirmed that due to restless/anxious behavior and a history of falling, Resident R92 required frequent supervision and ongoing medication adjustment, however, physical restraints were not appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245

Residents Affected - Few Based on observation, interview, and record review, after receiving report of an injury of unknown origin from Resident (R)25's wife, the facility failed to report the allegation to the State Survey Agency (SA) and adult protective services (APS). In addition, the facility failed to report an allegation of abuse for one other Resident (Resident R209), out of three residents sampled for abuse, to other officials, including Adult Protective Services (APS). As a result of this deficiency, the facility did not allow the resident further review of the abuse by APS.

Findings include:

1) Resident (R)25 is an [AGE] year-old male admitted to the facility on [DATE REDACTED] for long-term care. Resident R25's diagnoses include, but are not limited to, dementia, heart failure, muscle weakness, and lack of coordination.

A review of Resident R25's Minimum Data Set (MDS) Quarterly Review Assessment with an Assessment Reference Date (ARD) of 04/24/24 noted Resident R25 had been assessed as completely dependent for all eating, hygiene, toileting, and mobility activities. In addition, his Staff Assessment for Mental Status indicated he had Memory problem[s], was not oriented to place, time, or staff names and faces, and his Cognitive Skills for Daily Decision Making had been determined as Severely impaired - never/rarely made decisions.

On 07/16/24 at 03:30 PM, observations of Resident R25 and a concurrent interview was done with his family member (FM)2 at the bedside. FM2 reported that on 07/15/24, she noticed that Resident R25's right hand, which he doesn't move [on his own], was all bruised and swollen. FM2 stated that she noticed the injury when she went to hold his right hand and he screamed in pain. When she questioned him about how it happened, Resident R25 indicated to her that a small man had hurt his hand. Observation of Resident R25's right hand noted dark purple bruising of the thumb pad portion of his palm extending to the lateral surface of his thumb. An interview was attempted with Resident R25 by the SA however, he was unable to respond verbally to any questions asked. FM2 also reported that a few weeks ago Resident R25 had a suspicious bruise on the bridge of his nose, like someone hit him, and several months ago, he had a bruise on his right hip that she had no idea how he could have gotten.

On 07/18/24 at 08:04 AM, an interview was done with the Assistant Director of Nursing (ADON) and the Director of Infection Control (DIC), in the Administration Office. The ADON and DIC stated that the injury to Resident R25's right hip occurred in February 2024 and had been reported to the SA, but not to APS. The two more recent incidents had not been reported to either agency.

On 07/18/24 at 01:32 PM, an interview was done with the Assistant Administrator in the Conference Room.

The Assistant Administrator confirmed that the bruising to Resident R25's right hip was not reported to APS, but it should have been. She also confirmed that the bruising to Resident R25's nose from a few weeks ago was not reported to the SA or to APS but should have been since it was an injury of unknown origin. Regarding the current bruising to Resident R25's right hand, the Assistant Administrator reported that the facility had classified it as

an injury of known origin, and therefore had not reported it to the SA or to APS. The SA asked how it was determined to be an injury of known origin if the injury was initially identified by FM2 and reported to the facility for investigation? The Assistant Administrator stated she would check with the Director of Nursing (DON) and the DIC and report back.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0609 On 07/18/24 at 02:36 PM, an interview was done with the ADON, the DIC, and the Assistant Administrator in

the Administration Office. The three confirmed that the facility initially investigated the right-hand injury as an Level of Harm - Minimal harm or injury of unknown origin, and through the process of investigation, determined that the source of the injury potential for actual harm was known.

Residents Affected - Few A review of the facility's policy and procedure (P&P) for Abuse Reporting and Responsibilities of Covered Individuals, last revised 03/2023, revealed the following:

Allegations of abuse . including injuries of unknown source . will be reported to the State Survey Agency and other agencies in accordance with applicable law.

In response to allegations of abuse . the facility will:

a. Report immediately, but not later than 2 hours, all alleged violations involving abuse . including injuries of unknown source .

39754

2) Review of an allegation of abuse event report for Resident R209, the report was forwarded to the State Survey Agency but not to APS.

During staff interview on 07/17/24 at 03:15 PM, Assistant Administrator (AA) acknowledged that the abuse event report for Resident R209 was not sent to APS. AA said they were not aware that they were obligated to report

this event to APS.

Review of policy on Freedom from Abuse, Neglect and Exploitation read Purpose, to ensure reporting any reasonable suspicion of crime against a resident or individual receiving care from the facility within prescribed time frames. To ensure alleged violations involving abuse, neglect, exploitation, or mistreatment are reported and the results investigations of the allegations are reported within the prescribed timeframes. Policy, the facility will report to the State Agency and law enforcement any reasonable suspicion of a crime against any individual who reside or who is receiving care from the facility within the time frames required by federal and state law. The facility will notify covered individuals at least annually of their reporting obligations related to reasonable suspicion of a crime against a resident. The facility will report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and submit investigation results, according to regulatory guidelines and in accordance with State law and within the time frames required by federal and state law . Alleged violations will be reported to the facility administrator and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 potential for actual harm Based on interview and record review, after being informed by adult protective services (APS) of an Residents Affected - Few allegation of abuse of 1 of 3 residents (Resident 569) sampled, the facility failed to document and provide evidence that the allegation had been thoroughly investigated.

Findings include:

Resident (R)569 is a [AGE] year-old female admitted to the facility on [DATE REDACTED] for short-term rehabilitation and skilled nursing services. Resident R569 was transferred to an acute care hospital on 04/26/24 with a diagnosis of hyperkalemia (a high level of the electrolyte potassium in her blood), and after refusing to go to hemodialysis.

On 05/21/24, the State Agency (SA) received a referral from APS (ACTS #10973) as a result of allegations of neglect made by Resident R569 against facility staff. A review of the referral from APS revealed possible indicators that Resident R569 had been physically and/or sexually abused at the facility as well.

On 07/16/24 at 10:45 AM, the SA requested from the Assistant Administrator the facility's investigation packet related to Resident R569's allegation(s).

On 07/18/24 at 07:54 AM, an interview was done with the Assistant Administrator and the Director of Infection Control (DIC) in the Administration Office. The DIC confirmed that on 05/23/24, APS requested Resident R569's entire record directly from medical records. APS also asked that someone from facility administration contact them. The interim Director of Nursing (IDON), who no longer works for the company, was responsible to contact APS at that time. The DIC reported that the facility was unable to locate any documentation by IDON of what her conversation with APS entailed. IDON simply reported that she had taken care of it. The DIC and Assistant Administrator both agreed that they would have wanted to know what specifically APS was investigating so that the facility could initiate their own investigation into it. They also confirmed that they would expect to see the APS discussion documented somewhere, but since there was no documentation, a facility investigation was not initiated, and nothing had been reported to the SA. In addition, both acknowledged that if APS was investigating, it stood to reason that it involved allegations covered under the facility's Freedom from Abuse, Neglect and Exploitation P&P.

A review of the facility's Freedom from Abuse, Neglect and Exploitation policy and procedure (P&P) for Abuse Reporting and Responsibilities of Covered Individuals, last revised 03/2023, revealed the following:

Allegations of abuse, neglect, exploitation, or mistreatment . will be reported to the State Survey Agency and other agencies in accordance with applicable law.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47783

Residents Affected - Few Based on observation, interviews and record review, the facility failed to complete a comprehensive assessment for one resident sampled for being a smoker. As a result of this deficient practice, the facility failed to identify resident (R) 38 as a smoker and no plan of care was developed to address the health and safety risks associated with smoking.

Findings Include:

On 07/15/24 at 12:24 PM, observed Resident R38 up in his wheelchair in the hallway at Unit 4, propelling himself to one of the doors that open to the parking lot. Resident R38 stopped to talk to Registered Nurse (RN) 6 as she was preparing medications. Resident R38 then proceeded to exit Unit 4 and went to the parking lot unsupervised. Asked RN6 where Resident R38 was going, she said he was going to the parking lot to smoke. At 01:13 PM, observed Resident R38 come back into Unit 4. Resident R38 had a pack of cigarettes and a lighter in his shirt pocket. Asked Resident R38 how long he has been smoking. Resident R38 responded, Since I was [AGE] years old.

On 07/16/24, a review of Resident R38's Electronic Health Record (EHR) was conducted. Resident R38 was admitted to the facility on [DATE REDACTED]. Review of current care plan dated 06/05/24 revealed that there was no documentation of

the resident being a smoker and no smoking assessment was found in the EHR.

On 07/18/24 at 07:56 AM, interview was conducted with RN6 outside of Resident R38's room. Asked RN6 if they keep Resident R38's cigarettes and lighter locked in the medication cart. RN6 said they do not since he is cognitively intact and only smokes when he goes outside to the parking lot or when he goes out of the facility for his dialysis treatments.

On 07/18/24 at 11:16 AM, a concurrent interview and record review with the Director of Nursing (DON) was conducted in the conference room. Asked DON if there should be a care plan for residents that smoke. DON said, Yes. Reviewed care plan for Resident R38 with DON, no care plan was found to address him being a smoker. DON said she will check if the assessment was done.

On 07/18/24 at 01:27 PM, an interview with Licensed Practical Nurse (LPN)2 was conducted at the Unit 4 nurse's station. LPN2 confirmed that the comprehensive assessment did not identify the resident as a smoker, so no smoking assessment was done. LPN2 added that since he was not identified as a smoker, there was also no care plan developed.

Review of facility policy titled Physical Environment, Facility with Independent and Supervised Smokers stated, . Residents who wish to smoke will be assessed for smoking safety by nursing. assessment will be completed on admission, quarterly, . and as needed .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43414

Residents Affected - Few Based on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan for one of 37 residents sampled (Resident (R) 29). Resident R29's was not care planned for diabetic foot nail care.

Findings include:

Cross reference to

F-F677. The facility failed to carry out daily living activities (ADLs) to maintain good grooming for Resident R29 dependent on ADL care. Resident R29 did not receive proper foot nail care. This puts the resident at risk for cuts and wounds on her feet.

Resident R29 was admitted to the facility on [DATE REDACTED] with diagnoses, not limited to, restless legs syndrome, type 2 diabetes, hyperlipidemia, hypertension, dementia, and peripheral vascular disease.

On 07/16/24 at 10:11 AM, an interview with Family Member (FM) 4 was done. FM4 reported Resident R29's left big toe was amputated due to an infection and gangrene. FM4 was not sure how she got the wound on her toe

in the first place because Resident R29 was not mobile and stated after the facility informed her of the wound and the progression to an infection, it happened so fast. FM4 mentioned that the facility does not cut Resident R29's toenails, her toenails are long, thick, and close to the nail bed. FM4 did not recall the last time Resident R29 had her toenails cut, and believed she did not get them cut since she was admitted in 2022. FM4 stated Resident R29 has not seen a podiatrist.

On 07/16/24 at 01:00 PM, concurrent observation of Resident R29's right foot toenails with FM4 were done. Resident R29's toenails were long, thick, and digging into her nailbed.

On 07/17/24 at 02:27 PM, an interview with Certified Nurse's Aide (CNA) 5 was done. CNA5 reported the facility had never cut Resident R29's toenails because she was diabetic.

On 07/17/24 at 01:48 PM, an interview and concurrent record review with Nurse Manager (NM) 1 was done. NM1 reported that nail care for diabetic residents is done by the charge nurse, however, for toenails, it is normally referred to the podiatrist if the nails are thickened and the resident is diabetic. Concurrent review of Resident R29's EHR, found Resident R29's care plan did not include foot nail care for diabetes and/or to be referred to a podiatrist for foot care. NM1 stated this should be care planned.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 42160

Residents Affected - Some Based on interview and record review, the facility failed to ensure resident's care plan meetings were completed quarterly, and resident's care plans was revised and prepared by an Interdisciplinary (IDT) team, that includes but is not limited to the attending physician, registered nurse, nurse aide, and the resident's representative(s) for four residents (Resident (R) 58, Resident R168, Resident R253, and Resident R38) sampled.

Findings include:

1) Reviewed Resident R58's EHR. Reviewed documentation of Resident R58's most recent IDT meeting, conducted on 06/25/24 and 03/21/24, revealed the disciplines represented in the IDT meetings were social services and recreation services staff and did not include the resident's attending physician, registered nurse, or a nurse aide.

During an interview with Resident R58 on 07/18/24 at 09:43 AM, it was confirmed the resident's attending physician, a registered nurse, and a nurse aide did not attend or participate the resident's IDT meeting conducted on 06/25/24.

On 07/18/24 at 01:14 PM, conducted a concurrent record review and interview with the Director of Nursing (DON) regarding Resident R58's IDT care plan meetings. DON confirmed social services and recreation services were

the only disciplines which attended Resident R58's care plan meetings on 03/21/24 and 06/25/24. DON also confirmed

the resident's attending physician, registered nurse, and if possible, a nurse aide should be attending each resident's IDT care plan meetings.

43414

2) On 07/16/24 at 08:59 AM, an interview with Resident R168 was done. Resident R168 reported he had not been invited to his care plan meeting regarding his nursing care and treatment. Resident R168 stated if they did invite him, he would go.

Review of Resident R168's last IDT meeting on 01/22/24 documented the social services assistant and a recreation staff member attending the IDT meeting. The attending physician, a registered nurse, and nurse aide was not documented to attend the meeting. The sign-in sheet did not include Resident R168's signature, the signature line was left blank.

On 07/17/24 at 02:56 PM, an interview with Social Worker (SW) 1 was done. SW1 reported IDT meetings are conducted quarterly and annually and for long-term care residents, nursing staff and the physician do not attend the IDT meetings. SW1 confirmed the last IDT meeting for Resident R168 was done on 01/22/24 and the next quarterly meeting should have been done in April.

3) On 07/16/24 at 09:15 AM, an interview with Resident R253 was done. Resident R253 expressed she does not recall a care plan meeting regarding her nursing care and treatment and stated it would be helpful to have one and wouldn't mind attending.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 Review of Resident R253's last IDT meeting on 06/20/24 documented the social services assistance, the registered dietician, and a recreation staff member attending the IDT meeting. The attending physician, a registered Level of Harm - Minimal harm or nurse, and nurse aide was not documented to attend the meeting. The sign-in sheet did not include Resident R253's potential for actual harm signature, the signature line was left blank.

Residents Affected - Some On 07/17/24 at 02:56 PM, an interview with SW1 was done. SW1 confirmed nursing staff and the physician did not attend the IDT meeting.

47783

4) On 07/15/24 at 01:33 PM, an interview was conducted with Resident R38. Asked Resident R38 if he was invited to his care plan meetings or participated in the development of his plan of care. Resident R38 replied that he would like to attend

in person but was not given a choice. Resident R38 stated that the paper invitation he gets from the facility has the option to attend crossed out with a note stating that option was not available.

On 07/16/24, a review of Resident R38's EHR was conducted. Reviewed the last three IDT meetings on 11/10/23, 03/29/24 and 07/12/24. On the attendance sign-in sheet for all three IDT meetings, only the social services and recreational services staff attended. Resident's name was also on the sign-in sheets but there was no signature. Review of the invitation letters for all three meetings also revealed that the option to attend the meeting in person was crossed out with a notation that stated, Option 1 not available at this time.

On 07/18/24 at 08:51 AM, an interview with SW1 was conducted. Asked SW1 why the option to attend the IDT meeting was not available. SW1 said, It's an old letter used during COVID time. SW1 added that they did meet with Resident R38 on 07/12/24 to go over his care plan. SW1 said that if Resident R38 wanted to change something, they would note it. If Resident R38 had any questions, they would bring it up with the physician, registered nurse or dietitian as needed. SW1 confirmed that the care plan was already completed before they met with Resident R38 on 07/12/24. When asked why the physician and the registered nurse did not attend the IDT meeting with Resident R38, SW1 said,

They may have not been available at the time.

On 07/18/24 at 10:48 AM, an interview with the DON was conducted in the conference room. DON confirmed that the all the IDT members which included the physician and the registered nurse need to be present for

the care plan meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43414 potential for actual harm Based on observation, interview, and record review, the facility failed to carry out daily living activities (ADLs) Residents Affected - Few to maintain good grooming for one of two residents sampled (Resident (R) 29) dependent on ADL care. Resident R29 did not receive proper foot nail care. This puts the resident at risk for cuts and wounds on her feet.

Findings include:

Resident R29 was admitted to the facility on [DATE REDACTED] with diagnoses, not limited to, restless legs syndrome, type 2 diabetes, hyperlipidemia, hypertension, dementia, and peripheral vascular disease.

Review of Resident R29's Electronic Health Record (EHR) found on 06/16/24 Resident R29 had a wound to her left big toe. A nursing progress note dated 06/16/24 documented a skin check and assessment of Resident R29 left big toe done, .a small amount of pus came out when .cleaned .up .dry skin on the front of the toe came out, showing a pinkish red color. Bottom of the resident left big toe was reddish purplish in color. On 06/28/24, Resident R29 was sent to the emergency room for further evaluation of an infection of the left big toe and admitted to the hospital due to wound infected with pseudomonas orzyhabitans and gangrene of the left big toe. On 07/07/24 Resident R29's left big toe was amputated. Resident R29 was readmitted to the facility on [DATE REDACTED].

On 07/16/24 at 10:11 AM, an interview with Family Member (FM) 4 was done. FM4 reported Resident R29's left big toe was amputated due to an infection and gangrene. FM4 was not sure how she got the wound on her toe

in the first place because Resident R29 was not mobile and stated after the facility informed her of the wound and the progression to an infection, it happened so fast. FM4 mentioned that the facility does not cut Resident R29's toenails, her toenails are long, thick, and close to the nail bed. FM4 did not recall the last time Resident R29 had her toenails cut, and believed she did not get them cut since she was admitted in 2022. FM4 stated Resident R29 has not seen a podiatrist.

On 07/16/24 at 01:00 PM, concurrent observation of Resident R29's right foot toenails with FM4 were done. Resident R29's toenails were long, thick, and digging into her nailbed.

On 07/17/24 at 02:27 PM, an interview with Certified Nurse's Aide (CNA) 5 was done. CNA5 reported the facility had never cut Resident R29's toenails because she was diabetic.

On 07/17/24 at 01:48 PM, an interview and concurrent record review with Nurse Manager (NM) 1 was done. NM1 reported that nail care for diabetic residents are done by the charge nurse, however, for toenails, it is normally referred to the podiatrist if the nails are thickened and the resident is diabetic. Concurrent review of Resident R29's EHR, found there was no indication that Resident R29 had seen or was referred to a podiatrist since she was admitted to the facility. No documentation that Resident R29 had toenail care while in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0677 Review of the facility's policy and procedure QUALITY OF CARE Foot Care dated 03/2023, documented The facility will provide care and treatment to maintain mobility and good foot health. Foot care and treatment will Level of Harm - Minimal harm or be in accordance with professional standards of practice, including efforts to prevent complications from the potential for actual harm resident's medical conditions. The facility will assist in making necessary appointments with a qualified person and arranging transportation to and from appointments .1. Treatment includes preventive care to Residents Affected - Few minimize podiatric complications in residents with diabetes and circulatory disorders. 2) Residents with complicating disease processes will be referred to qualified professionals for foot care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure there was an ongoing Residents Affected - Few resident-centered activities program that fully identified and met the resident's needs, for 2 of 3 residents sampled for activity (Residents 171 and 198). As a result of this deficient practice, both residents were placed at risk of experiencing a decline in their psychosocial well-being and quality of life. This deficient practice has the potential to affect all residents at the facility.

Findings include:

1) Resident (R)171 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] for long-term care. Resident R171's admitting diagnoses include, but are not limited to, heart disease, diabetes, dementia, depression, and history of a right above the knee amputation. A review of Resident R171's Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 02/05/24 noted Resident R171 had been assessed with a Brief Interview for Mental Status (BIMS) score of 13, indicating a determination that he was cognitively intact.

On 07/16/24 at 08:36 AM, an interview was done with Resident R171 at his bedside. When asked about activities, Resident R171 stated that staff do not take him out of his room to activities. When he asks to get up out of bed for activities, he is told you cannot walk, you have to lay there. Resident R171 complained that staff never get him up out of bed, and no one comes into his room to offer him individual activities such as puzzles or books either. Resident R171 stated he would like to go out to activities occasionally, but staff refuse to get him up.

On 07/17/24 at 01:01 PM, an interview was done with the activities director (AD) in her office. When asked how often one-to-one activities are offered to residents who do not leave their rooms, AD responded that in-room activities should be offered 3-4 times a week. Resident R171's activity log for the last three months was requested, however AD reported she can only provide a log for the last 30 days. During a concurrent review of Resident R171's activity log for the last 30 days, AD confirmed that she did not see documentation of any activities being offered to Resident R171. AD reported that the facility does have dog therapy three times a week, and that she knows Resident R171 enjoys that, but that too should be documented on the activity log. AD could not explain why there was no documentation found of any activities being offered. AD confirmed that even if Resident R171 had been offered but refused activities, it should still be documented on the activity log.

2) Resident R198 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] for long-term care. Resident R198's diagnoses include, but are not limited to, left-sided paralysis and weakness following a stroke, aphasia (a language disorder that affects how you communicate; caused by damage in the part of the brain that controls language expression and comprehension), depression, and generalized muscle weakness.

On 07/15/24 at 09:16 AM, an observation was done of Resident R198 lying in bed awake in a silent room. Resident R198 had no visible television or radio and appeared bored.

On 07/16/24 at 08:20 AM, observed Resident R198 again lying awake in bed in a room that was completely silent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0679 On 07/17/24 at 08:43 AM, an interview was done with Resident R198 as he lay in bed. When asked about activities, Resident R198 stated that he does not want to go out to activities but would like to listen to music in his room. Resident R198 Level of Harm - Minimal harm or expressed that he was often bored with nothing to do and confirmed that he had no access to a radio or potential for actual harm television.

Residents Affected - Few A review of Resident R198's Comprehensive Care Plan (CCP) notes the following under the Focus of Activity/Recreation:

Staff to provide/encourage 1:1 [one-to-one] visits with resident consist [sic] with music and sensory.

On 07/17/24 at 01:10 PM, an interview was done with the AD in her office. During a concurrent review of Resident R198's activity log for the last 30 days, the AD noted documentation of 1:1 activities being offered five times

in 30 days. The AD stated that she knew Resident R198 often declined activities that were offered, however, reviewing his activity log, it did not appear that staff were documenting his declinations as they should be. The AD stated she would expect to see 1:1 activities offered 3-4 times a week. When asked about a television or radio for him, the AD stated televisions must be provided by the resident, but she could offer Resident R198 a radio to keep at his bedside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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** 42160 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the nursing treatment and Residents Affected - Few care provided met the needs of 2 of 37 residents (Residents 188 and 171) in the sample and was in alignment with standards of good clinical practice. As a result of this deficient practice, the residents were placed at risk of avoidable injury and/or complications and were hindered from attaining their highest practicable well-being.

Findings include:

1) Resident R188 was returned to the facility on [DATE REDACTED] from an acute hospital. Review of the acute hospital's discharge summary, Resident R188 presented on 04/03/24 with sepsis with suspected sacral Skin and Soft Tissue Infection (SSTI) and associated complications. A blood culture confirmed bacteremia with gram positive cocci which is known to cause skin infections, pneumonia, endocarditis (life-threatening inflammation of the inner lining of the heart's chambers and valves), septic arthritis (painful infection in a joint that travel through

the bloodstream to other parts of the body), osteomyelitis (swelling or inflammation that occurs in the bone), and abscesses (a buildup of pus under the skin which can affect any part of the body).

Review of Resident R188's skin assessments confirmed the resident currently has a stage 4 Pressure Ulcer (PU) (full thickness tissue loss with exposed bone, tendon, or muscle) on the sacral region; stage 4 PU of the left hip;

a Deep Tissue Injury (DTI) which is a purple/maroon localized area of blood filled blister due to damage of underlying soft tissue due from pressure and/or shearing; and four (4) open lesion to the front left knee, the front loser lateral leg, right dorsum foot, and front right knee. Resident R188 is currently on contact precautions, which require staff to don gloves and a gown for all interactions that may involve contact with the resident or resident's environment to contain pathogens which could be spread to other residents.

Review of Resident R188's most recent annual MDS, with an ARD of 02/27/24, documented the resident BIMS score of 11 indicating the resident has moderate cognitive impairment. Section GG- Functional Abilities and Goals documented Resident R113 has functional limitation in ROM with impairment on one side for the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. Resident R188 is dependent (helper does all the effort. resident does none of the effort to complete activity) on staff for toileting hygiene, shower/bathe, lower body dressing, personal hygiene, putting on/taking off footwear, and chair to bed transfers.

- Observations of Resident R188's physical environment on 07/17/24 at 09:17 AM, the shower room contained dark green and black organic growth, which was fuzzy and raised in appearance, with a strong musty smell on the shower floor room, wall, the connection points of the handheld showerhead tubing, and showerhead spout.

The organic growth was persistent throughout the handheld shower that it clogged the small holes on the showerhead which the water comes out of directly onto the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 On 07/19/24 at 10:30 AM, conducted an interview with HK2 regarding the visible organic growth in the resident's shower room. After viewing the shower room with this surveyor and CNA59 it was confirmed Level of Harm - Minimal harm or shower rooms should be cleaned daily by housekeeping staff and the amount of organic growth in Resident R188's potential for actual harm shower appears as if it had not been cleaned in over 2 weeks, at a minimum. CNA59 also confirmed Resident R188 currently uses this shower at least twice a week. HK2 cleaned the shower, however, was not able to entirely Residents Affected - Few remove all the organic material and has not cleaned the showerhead.

- On 07/18/24 at 10:58 AM, while sitting at the nursing station, this surveyor heard Resident R188 calling out for staff, saying Hello, can anybody hear me? Hello and calling out for RN42. Observed two CNAs walk past Resident R188's room and did not address the resident's calls for help. A moment later, RN42 walked to the medication cart located across Resident R188's room door, while the resident continued to yell out for staff. RN42 was on the computer located on the medication cart and not passing any medication. At 11:12 AM, RN42 entered the room and addressed Resident R188's calls for staff assistance.

Review of Resident R188's fall care plan documented interventions including, Anticipate and meet the resident's needs, he usually doesn't call for assist (date revised 04/26/2024). and Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance (Date initiated: 11/21/2023).

- On 07/19/24 at 11:27 AM, entered Resident R188's room and observed the resident's right foot was not properly placed in the boot for pressure ulcer prevention and the open lesion on the side of the resident's big toe was

in direct contact with the bed sheet. There were dried blood stains on the bedsheet from the open lesion indicating the resident's foot had not just recently become dislodged from the protective boot. Observed Resident R188's catheter bag in direct contact with the ground. The catheter bag cover was present but had not been properly applied. on the ground with no covering. The resident appeared to be struggling to grab the side rail attached to the bed. When asked what he was doing, the resident requested for this surveyor to pass him the pancake call light which was located on top a drawer located out of the resident's reach. Inquired why the call light was on the drawer out of reach the resident's reach. Resident R188 reported that staff often puts the call light

on the drawer because staff tell him he calls for staff too much. At 11:31 AM, CNA81 entered Resident R188's room and inquired about Resident R188's boot, which was not properly applied, the catheter bag uncovered and, on the floor, and the call light being out of the resident's reach. CNA81 confirmed Resident R188 is totally dependent on staff and confirmed Resident R188's foot should have been placed in the boot properly, the catheter bag should have been covered and hanging off the ground, and the call light should have been within the resident's reach but was not. CNA81 then placed the call light next to the resident, picked up and covered the catheter bag and hung

it from the bedside, then grabbed the resident's hand and assisted the resident with grabbing the side rail and was not wearing a gown or gloves. Inquired if CNA81 should be wearing a gown and gloves to be following proper PPEs for a resident on contact precaution. CNA81 confirmed he/she should have donned a gown and glove prior to being in direct contact with Resident R188 or the resident's physical environment.

43245

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 2) Resident (R)171 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] for long-term care. Resident R171's admitting diagnoses include, but are not limited to, heart disease (with a pacemaker), diabetes, dementia, Level of Harm - Minimal harm or depression, and history of a right above the knee amputation. A review of Resident R171's Minimum Data Set (MDS) potential for actual harm Admission Assessment with an Assessment Reference Date (ARD) of 02/05/24 noted Resident R171 had been assessed with a Brief Interview for Mental Status (BIMS) score of 13, indicating a determination that he was Residents Affected - Few cognitively intact.

On 07/16/24 at 08:52 AM, observed Resident R171 lying in bed with both arms severely bruised with old and new bruises. His left leg was also noted to have extensive old and new bruises. Resident R171 stated he did not know how

he was getting the bruises because he is never allowed to get up out of bed.

A review of Resident R171's physician orders noted Resident R171 was taking Apixaban (an anticoagulant that decreases the clotting ability of the blood and helps prevent harmful clots from forming) 5 mg (milligrams) twice a day.

A review of Resident R171's Comprehensive Care Plan (CCP) for the Focus of Anticoagulant/Antiplatelet revealed the following intervention:

Bleeding Precautions: Report any bruising to the nurse. Observe gentle handling during care.

For the Focus of Skin Impairment, the following intervention was noted initiated on 06/05/24:

The resident needs protective sleeves for the arms.

A follow-up review of the physician orders noted no orders for any type of skin protection or covering to help minimize the risk of bruising.

On 07/17/24 at 09:58 AM, an interview was done with Nurse Manager (NM)2 at the Unit 2 Nurses' Station (U2NS). NM2 confirmed that Resident R171 rarely is gotten up out of bed into a wheelchair because he has poor trunk control. When asked about the bruising on Resident R171's extremities, NM2 reported that staff is aware of the bruising, but does not think Resident R171 has been offered skin protection before. NM2 agreed given the extent of

the bruising despite being bed-bound, skin protection is something that should have been implemented.

On 07/18/24 at 10:46 AM, a follow-up interview was done with NM2 at the U2NS. NM2 confirmed that after finding no Geri-sleeves (skin protection for arms) in Resident R171's possession the previous day, she had the facility issue him a pair and they were applied. NM2 agreed that the intervention should have been implemented before.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Residents 199 and 20) sampled for limited range of motion (ROM) received the appropriate treatment and services to prevent, or delay, further decrease in their ROM, mobility, and independence. As a result of this deficient practice, Resident (R)199 can no longer be transferred into his motorized wheelchair, and Resident R20 now has contractures to her left hand that were not present at admission. These outcomes hinder both their abilities to reach their highest practicable well-being. This deficient practice has the potential to affect all the residents at

the facility.

Findings include:

1) Resident (R)199 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] for long-term care related to his diagnosis of Amyotrophic Lateral Sclerosis (ALS), a disease affecting nerve cells in the brain and spinal cord, causing progressive loss of voluntary movements and muscle control, and eventually leading to death.

A review of Resident R199's MDS Significant Change in Status Assessment with an ARD of 04/05/24 noted Resident R199 had been assessed with a BIMS score of 15, indicating a determination that he was cognitively intact.

On 07/15/24 at 01:57 PM, an interview was done with Resident R199 at his bedside on Unit 2. When asked about staffing, Resident R199 stated that since November 2023, there has been a real lack of staff. As a result, he feels that

the care has decreased since he got here a year ago. Resident R199 reported that the unit seems especially short in

the mornings because of showers, morning hygiene, toileting, and breakfast. Resident R199 explained that he has filed multiple grievances regarding staffing and quality of care, but things have not changed. States that he is so tired of being told we [the facility] are short-staffed by management. When asked how the staffing problems may have contributed to a specific outcome for him, Resident R199 stated that from January through March of 2024, he should have had half an hour of Restorative Nurse Assistant (RNA) services five (5) days a week, but he didn't. As a result of his ALS, Resident R199 is paralyzed from the neck down, and needs passive range of motion (PROM) to be performed regularly. During those 3 months I should have been getting it [PROM] 5 days a week, I think I got it maybe 5 times total. Resident R199 further explained that on Christmas Day 2023, he was able to stand and pivot with assistance and sit in his $50,000 motorized wheelchair. Now he cannot even be mechanically transferred to sit in his wheelchair because his knees have locked up and can no longer bend. Resident R199 feels that if he had received the RNA services as scheduled, he would still be able to bend his knees, sit in his wheelchair, and have home visits. Resident R199 stated he has not been out since Christmas day. Resident R199 also stated that he has not had RNA services for weeks because they are always pulling the RNA to do CNA [Certified Nurse Aide] duties.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0688 On 07/17/24 at 10:15 AM, an interview was done with RNA1 on Unit 2. RNA1 stated he has been an RNA at

the facility since 2020. RNA1 confirmed that Resident R199 should be receiving RNA services 5 days a week. RNA1 Level of Harm - Minimal harm or also confirmed that the facility is aware of the contractures (permanent tightening of the muscles, tendons, potential for actual harm skin, and nearby tissues that causes the joints to shorten and become very stiff) to Resident R199's knees and that

they can no longer bend without great pain. RNA1 could not remember when he first noticed the knee Residents Affected - Few contractures but confirmed that Resident R199 did not have them on Christmas day 2023 when he sat in his motorized wheelchair and went home for a visit. RNA1 acknowledged that the unit was especially short-staffed from January to March 2024, yeah, it was bad. Explained that RNAs are responsible for RNA treatments Monday through Saturday, and to weigh the residents on Sundays. RNA1 stated that there are no relievers so when

he is off, there is no RNA coverage on the unit. When asked about how often Resident R199 has missed receiving RNA/PROM services, RNA1 explained that the RNAs are like the CNAs, we're short-staffed and we get to as many people per day as we can. RNA1 stated that there are 31 residents on Unit 2 scheduled to receive RNA services 5 days a week, there is no way one RNA can get through that many residents in one day.

A review of the RNA logs for January through March 2024 revealed documentation of Resident R199 receiving RNA services 14 out of the 65 times it was scheduled in that 3-month period. A review of the RNA log for July 1-17, 2024, revealed documentation that Resident R199 had received RNA services 1 out of the 12 times he was scheduled.

On 07/18/24 at 02:13 PM, an interview was done with the Director of Rehabilitation (DOR) and Occupational Therapist (OT)1. While both were unsure if contractures were unavoidable in residents with ALS, OT1 (who has worked with Resident R199) agreed that his knee contractures would not have occurred at the rate and severity it is now had he received the RNA services/PROM 5 times a week as ordered.

On 07/18/24 at 03:00 PM, an interview was done with the Director of Nursing (DON) in her office. DON acknowledged that contractures do occur when ROM/PROM is not done. Stated that she was uncertain if contractures were avoidable in residents with ALS and was looking for documentation.

2) Resident (R)20 is a [AGE] year-old female admitted to the facility on [DATE REDACTED] for long-term care. Resident R20's admitting diagnoses include, but are not limited to, left-sided paralysis and weakness following a stroke, heart disease, peripheral vascular disease, and lymphedema (swelling that generally occurs in an arm or leg, caused by a blockage in the lymphatic system). A review of Resident R20's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 05/29/24 noted Resident R20 had been assessed with a Brief Interview for Mental Status (BIMS) score of 14, indicating a determination that she was cognitively intact.

On 07/16/24 at 09:32 AM, an interview was done with Resident R20 at her bedside. Resident R20 stated that she currently has left finger contractures that she did not have when she was admitted here 2 years ago, somebody thought

they were helping me and massaging my tendons and they went a little too far. As a result, Resident R20 reported that

she wears a hand splint for a few hours every day. Resident R20 stated that the contractures did not bother her or hinder her from performing her activities of daily living.

On 07/18/24 at 10:59 AM, an interview was done with Registered Nurse (RN)15 and Nurse Manager (NM)2 at the Unit 2 Nurses' Station (U2NS). During a concurrent review of Resident R20's electronic health record (EHR), both confirmed that Resident R20 was not admitted with any contractures and that they should not have occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 43245

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, in addition to their physical, mental, and psychosocial well-being. As a result of this deficient practice, the residents experienced a decreased quality of life and were unable to attain their highest practicable well-being.

Findings include:

1) Cross-reference to

F-F688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide Restorative Nurse Assistant (RNA) and other services as scheduled to help prevent/minimize the formation and worsening of contractures in Residents (R)199 and Resident R20.

43414

2) On 07/18/24 at 01:57 PM, during an interview with resident council members, Resident R50 reported during their monthly resident council meetings, residents expressed the facility is short staffed and it has not been resolved. Resident council members reported that the residents have been told there should be at least six certified nurse's aides (CNA) on each floor, the same number of workers, but not based on units' acuity and census. However, residents are finding that there are only four to five CNAs on the units. Resident council members expressed the facility should staff the units based on acuity and census, and there are units with residents who need one on one supervision, but the facility cannot provide an assigned person which effects

the other residents' care. Staff who are floaters, take long to provide care because they are not familiar with

the resident and their routine. Instead of following the residents wishes on how they prefer to receive care

they treat them as a task and just do it how they want to provide the care.

Review of the resident council minutes for May 2024, June 2024, and July 2024 document short staffing on all floors, Nurses not assisting w/CNA when short on the floor, More Staffing on the floor. Scheduler removing staff who has already completed 3 hrs. [hours], More Staffing (CNA), Resident express more staffing (CNA) is needed on the floors, Resident had concerns regarding floating probation. DON [Director of Nursing] to follow up with staffing, and More Staffing.

On 07/18/24 at 10:57 AM, during an interview with Director of Nursing (DON), DON reported staff members have expressed they are short staffed, and the RNA staff will volunteer to provide extra support when short staffed.

On 07/19/24 at 12:12 PM, interview with Scheduler (S) 1 and S2 was done. S1 reported there is a criteria flow sheet (CNA matrix) they follow based on the census amount for each unit and staff accordingly. If there are residents who need one to one supervision, nursing staff communicate this and the schedulers will try to accommodate. Concurrent review of the facility's CNA matrix includes the ratio of one CNA for seven residents (1:7). During a full census on sampled units, Unit 2, Unit 4, and Unit 5, a minimum 36 residents. the matrix indicates six CNA's to be scheduled during the day shift on each unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0725 Reviewed a sample of three days of the facility's schedule and census, 06/05/24, 06/22/24, and 07/12/24. On 06/05/24, Unit 2 had a census of 44 residents with five CNAs assigned and working that day, a ratio of Level of Harm - Minimal harm or approximately 1:9. Unit 5 had a census of 50 residents with three CNAs assigned and working that day, a potential for actual harm ratio of approximately 1:16. On 06/22/24, Unit 2 had a census of 44 residents with three CNAs assigned and working that day, a ratio of approximately 1:14. Unit 4 had a census of 43 residents with four CNAs assigned Residents Affected - Some and working that day, a ratio of approximately 1:10. Unit 5 had a census of 49 residents with three CNAs assigned and working that day, a ratio of approximately 1:16. On 07/12/24, Unit 2 had a census of 44 residents with four CNAs assigned and working that day, a ratio of approximately 1:11. Unit 5 had a census of 50 residents with five CNAs assigned and working that day, a ratio of approximately 1:10.

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3) On 07/15/24 at 08:29 AM, initial interview conducted with Resident R42 in his room. Resident R42 said staffing has declined since COVID started in 2020 and it has affected the care provided to the residents.

On 07/16/24 at 09:13 AM, a follow-up interview was conducted with Resident R42. Asked Resident R42 how his care has been affected by the staffing decline he mentioned in an earlier interview. Resident R42 said that Unit 4 was supposed to have six CNAs on day shift but there are some days when they would only have five. Resident R42 said that when

they don't have enough staff, he would have to wait longer for service, up to 20 minutes. Resident R42 stated, I would suffer a bit since I'm not able to move. I always ask for two people to move me. If there's only one, it's hard

on them and me. It's safer if there are two. Resident R42 added that when they are short of staff, he would have to wait longer for his meals, would not get his scheduled shower, and the dressing change for his wounds are delayed.

On 07/17/24 at 08:23 AM, observed the staffing board at Unit 4 listed two registered nurses (RN) and five CNAs scheduled to work. Asked RN5 if they had enough staff schedule for the shift. RN5 said they were short one CNA since they are supposed to have six. When asked how often are they short of staff, RN5 did not answer the question. RN5 instead said, The administration tries their best to get us staff by asking for OT (overtime) or calling agency staff. Census for Unit 5 was 40.

On 07/19/24, the staffing board at Unit 4's nurse's station had two registered nurses and five CNAs scheduled to work. Census for Unit 5 was 40.

On 07/19/24 at 12:34 PM, an interview with S1 was conducted in his office. Asked S1 how many CNAs were supposed to be scheduled at Unit 4 on 06/22/24 with a census of 43. S1 said there were supposed to be six CNAs. When asked S1 if they had six CNAs working at Unit 4 on 06/22/24, S1 looked in the computer and said only five CNAs were working that day including one working overtime.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48351

Residents Affected - Few Based on observations and interviews, the facility failed to ensure that one of the licensed nurses had the specific competencies and skill sets necessary to care for residents' needs. This failed practice has the potential to affect all the residents on one of the five nursing units.

Findings include:

Resident R239 is an [AGE] year-old female admitted to the facility on [DATE REDACTED]. A review of Resident R239's Brief Interview for Mental Status (BIMS), with an Assessment Reference Date (ARD) of 05/09/24 was conducted. Resident R239's BIMS score was an 11, meaning Resident R239 had moderate cognitive impairment.

Observation was conducted on 07/15/24 at 09:00 AM in Resident R239's room. Resident R239 was lying in bed watching television. On her bedside table was a medication cup with four different pills. When asked about the medication cup, Resident R239 stated that she forgot it was there. She stated it was her morning medications that were left there by Registered Nurse (RN) 10.

State Agency (SA) then exited the room to look for RN10. RN10 was observed at the other end of the hallway performing medication administration. Registered Nurse Manager (NM) 1 was observed at the nurse's station.

Interview was conducted with NM1 on 07/15/24 at 09:04 AM. NM1 stated that medications should not be left

in the room. NM1 added that the nurse administering the medication should wait with the resident until she observes the resident taking it.

Interview was conducted on 07/18/24 09:03 AM with RN10 in the hallway. RN10 stated the Resident R239 did not want to take her medications when it was offered to her. RN10 added that when a resident is not ready to take their medications, the nurse would normally take the cup of medicine out of the room, but this time RN10 left it on top of Resident R239's bedside table.

Interview was conducted with Director of Nursing (DON) on 07/19/24 at 10:30 AM. DON stated that when a resident is not ready to take his/her medications when it is offered, the nurse must take the medications out of the room and properly store it, until the resident is ready.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 43414 potential for actual harm Based on observation, record review and interview, the facility failed to ensure the nurse staffing data was Residents Affected - Many posted daily at the beginning of each shift, in a prominent place readily accessible to residents and visitors, and ensure staffing information was complete with specific units reflected on the posting.

Findings include:

On 07/15/24 at 08:13 AM, during observation of Unit 3, including the nurse's station, the bulletin board, and

the elevators, the nurse staffing data posting was not found. Inquired with other surveyor team members if postings were found on their assigned units to screen, Unit 2 and Unit 4 were observed to not have the postings. The postings were not found at the entrance of the facility, near the facility elevators, or on the bulletin boards on the ground level.

On 07/15/24 at 08:32 AM, during a tour of Unit 2, no staff posting was observed near the elevators, on the bulletin board, or at the Nurses' Station.

On 07/15/24 at 10:43 AM, observed a staff posting had been brought up and placed on the bulletin board near the Unit 2 Nurses' Station. Review of the staff posting however, noted it pertained to the entire facility and did not provide residents and visitors information regarding the census and staffing hours specific to Unit 2.

On 07/17/24 at 08:51 AM, observed the posting on ground level at the bulletin board where staff members clock in and out, and announcements and information for staff members are posted. On Unit 3, observed the posting on the bulletin board next to the nurse's station dated Tuesday, 07/16/24, yesterday. The posting on Unit 3 did not have specific information regarding Unit 3 on the posting.

On 07/18/24 at 08:14 AM, interview and concurrent observation with Unit Manager (UM) 4 was done. Inquired where the facility posts their nurse staffing data, UM4 reported she did not know and inquired with

the nurse on the floor, who pointed to the whiteboard with staff names but not the nursing staffing data with required information. This surveyor directed UM4 to the bulletin board next to the nurse's station and concurrently observed the posting. UM4 confirmed the date on the posting was from two days ago, 07/16/24. Concurrent observation of the ground level posting on the staff bulletin board was conducted. Inquired if the posting was in area where residents or visitors would look when coming in and out of the facility, UM4 confirmed it was not, and stated it was not in an area visible to residents and visitors but more for staff members to see.

On 07/19/24 at 10:20 AM, interview with Director of Nursing (DON) and concurrent observation of the nurse staffing data posted on the ground level staff bulletin board was conducted. Inquired if the facility posts the document anywhere else. DON reported it should be on every unit. Inquired if the postings on the units include information related to the unit, DON reported it does not but includes the information for the entire facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0732 Review of the facility's policy and procedure NURSING SERVICES Posted Nurse Staffing Information dated 03/2023, documented At the beginning of each shift, on a daily basis, the facility will post: 1) the facility Level of Harm - Minimal harm or name; 2) the current date; 3) the total number and the actual hours worked by . [nursing staff] .responsible potential for actual harm for resident care per shift, and; 4) resident census. Data will be in a clear and readable format in a prominent place readily accessible to resident and visitors. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 43245

Residents Affected - Few Based on observation, interview, and record review, the facility failed to implement a thorough process in narcotic log documentation and reconciliation. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of the controlled medications used to meet the needs of the residents.

Findings include:

On 07/17/24 at 09:22 AM, an inspection of the Unit 2 Medication Cart #1 was done with Nurse Manager (NM)2. While reviewing the narcotic log, the following discrepancies in narcotic log documentation and actual narcotic count were observed by the State Agency (SA) and confirmed by NM2:

Oxycodone IR [immediate release] 5 milligrams (mg). Narcotic log shows there should be twenty-three (23) tablets remaining in the blister pack; only twenty-one (21) tablets observed.

Clonazepam 0.5 mg. Narcotic log shows there should be sixteen (16) tablets remaining in the blister pack; only fifteen (15) tablets observed.

Interview done with NM2 at the time confirmed that all narcotics should be signed out on the narcotic log when pulled from the medication cart, not after the medication(s) are given.

On 07/19/24 at 10:54 AM, an interview was done with the Director of Nursing (DON) in the Conference Room. DON stated the expectation is that narcotics should be signed out on the narcotic log as soon as they are dispensed from their containers/blister packs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper labeling of medications is necessary to promote safe administration practices, decrease the risk for medication errors, and decrease the risk for

the diversion of resident medications. This deficient practice has the potential to affect all residents in the facility who take medications.

Findings include:

1) On [DATE REDACTED] at 08:54 AM, an inspection was done of the Unit 2 medication cart #2 with Registered Nurse (RN)15. Observed a vial of Lantus insulin for Resident (R)8 where the open dates and discard dates written

on both the vial itself, and the box it was in, were completely unreadable. RN15 confirmed that since the information was indecipherable, the insulin vial needed to be discarded to ensure Resident R8 would not be administered expired insulin. At 09:03 AM, observed an Admelog Solostar insulin pen for Resident R8 that was labeled with an open date of [DATE REDACTED] but no discard date. RN15 confirmed that the insulin pen was not labeled correctly as it should also have a discard date written in.

Review of the facility's policy and procedure (P&P) Labeling and Storage of Drugs and Biologicals, last revised ,d+[DATE REDACTED], revealed the following:

Drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

47783

2) On [DATE REDACTED] at 12:55 PM, concurrent inspection of the medication cart in Unit 5 and interview with Registered Nurse (RN) 7 was conducted. An insulin pen was found with no open and discard dates in the top drawer of the cart. A pink sticker was on the pen that stated, Discard 28 days after opening. RN7 verified that

the insulin pen did not have open and discard dates and said it was used to administer a dose on [DATE REDACTED]. RN7 confirmed that the staff are supposed to write on the pink sticker the day it was first used as the open date and 28 days after the open date as the discard date.

On [DATE REDACTED] at 11:23 AM, an interview was conducted with the Director of Nursing (DON) in the conference room. DON confirmed that the insulin pen is only good for 28 days after opening and that is why it is important to note the open and discard dates on the supplied sticker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48351

Residents Affected - Few Based on observations, interviews, and record review, the facility failed to date and label a food item to prevent the potential for foodborne illness. This deficient practice has the potential to affect all the residents

on one of the five nursing units.

Findings include:

Observation was conducted on 07/17/24 at 09:22 AM in one of the facility nutrition rooms. The freezer contained an unlabeled brown colored ice cream.

Interview was conducted with Registered Nurse Supervisor (RN) 12. RN12 stated that nursing staff usually checks expiration dates and throws them away if needed. When shown the unlabeled ice cream, RN12 stated that it must have been from one of the resident's food trays and one of the staff had placed it in the freezer. RN12 added that the staff should have labeled the ice cream with the resident's name and date.

A review of the facility's policy titled, Food Safety, dated 03/2023 was conducted. The policy noted, Food, including leftovers, will be labeled and dated in the refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 39754

Residents Affected - Few Based on observation, staff interview, and review of policy, the facility failed to safeguard medical record information against unauthorized use by not logging off of the Electronic Health Record (EHR) on a computer laptop left unattended in a nursing unit hallway. As a result of this deficiency, there was risk for violations of

the Health Insurance Portability and Accountability Act (HIPAA) privacy or security rules.

Findings include:

During observation of the second-floor nursing unit hallway on 07/16/24 at 08:15 AM, a computer laptop showing resident EHR was left unattended. No staff was in the immediate vicinity and there was risk of unauthorized access to the information.

During staff interview on 07/16/24 at 08:20 AM, the Unit Manager was made aware of the situation and acknowledged that the EHR should have been logged off when left unattended.

Review of facility policy on Resident Rights Privacy and Confidentiality read, Purpose, each resident has the right to privacy and confidentiality of personal care and medical records. Policy, the facility will respect the resident's right to personal privacy and the right to secure and confidential personal and medical records .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 43245 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure appropriate protective and Residents Affected - Some preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed standard precautions by performing hand hygiene, implemented enhanced barrier precautions when appropriate, and sanitized shared medical equipment after each use. 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 07/16/24 at 10:15 AM, an observation was done of Registered Nurse (RN)16 changing the dressing on

the gastric tube insertion site for Resident (R)199. RN16 was wearing gloves and a procedure mask, but no gown. Once the dressing was completed, observed RN16 change her gloves with no hand hygiene in between. She then administered a nasal spray to Resident R199, after which he requested some oral medication. Observed RN16 doff her gloves right before leaving the room but performed no hand hygiene after that.

On 07/16/24 at 10:31 AM, an interview was done with RN16 in front of the medication cart on Unit 2. When asked about hand hygiene between glove changes, RN16 stated she does not usually do hand hygiene between glove changes because the sink is not accessible at the bedside. When asked if the facility provided staff with alcohol-based hand rub (ABHR) that could be carried into the room and used for hand hygiene at

the bedside, RN16 responded no. RN16 acknowledged that facility policy is to perform hand hygiene between glove changes and after doffing gloves and agreed that she should have done it. When asked about enhanced barrier precautions (EBP) while doing the dressing change for Resident R199's gastric tube, RN16 agreed that she should have implemented EBP and donned a gown in addition to her gloves and mask for the dressing change.

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2) On 07/17/24 at 08:40 AM, during observation of Resident R180, Resident R180 began moaning and groaning, and stated he cannot breathe, observed his nasal cannula out of his nose. This surveyor requested Unit Manager (UM) 4 to assist Resident R180. UM4 quickly went into Resident R180's room without performing hand hygiene and adjusted Resident R180's nasal canula.

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3) On 07/15/24 at 12:25 PM, observed Certified Nurse Aide (CNA) 12 passing meal trays in Unit 4. CNA12 was coming out of resident (R)49's room when she stopped to check on Resident R44 who was up in her wheelchair

in the hallway. CNA12 readjusted Resident R44's mask, repositioned the blanket covering her lap then went back in

the room to check on Resident R183. When CNA12 got to Resident R183's bedside, she repositioned the meal tray on the bedside table, pulled her blanket up then proceeded to check on Resident R49. CNA12 moved Resident R49's table closer and repositioned the meal tray to the middle of the table. CNA12 then exited the room and proceeded to Resident R215's room and assisted her with her meal. CNA12 did not perform hand hygiene when moving from one resident to another.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0880 4) On 07/17/24 at 08:27 AM, observed Registered Nurse (RN) 5 as she was passing medications at Unit 4. RN5 placed the medications to be administered to Resident R11 in a plastic tray and entered room without performing Level of Harm - Minimal harm or hand hygiene. RN5 then placed the tray on Resident R11's bedside table, removed 2 cups from the table, donned a potential for actual harm pair of gloves, gave the inhaler (device used to deliver medication through the mouth directly into the lungs), then handed Resident R11 a cup of water and asked him to rinse his mouth. RN5 then administered Resident R11's insulin Residents Affected - Some (diabetes medication) injection to his right arm, removed her gloves, discarded the cup used to rinse his mouth and exited the room. RN5 went back to her medication cart, donned new gloves, and wiped the medication tray with disinfecting wipes. RN5 did not perform hand hygiene between glove changes.

5) On 07/17/24 at 08:54 AM, observed CNA13 enter a room where four residents were lying in their beds. CNA13 brought a shared equipment used to check the resident's blood pressure. When CNA13 came out of

the room, she performed hand hygiene using the alcohol-based hand rub (ABHR) dispenser mounted on the wall outside the room and entered the blood pressure readings on a tablet. Asked CNA13 if she disinfected

the shared blood pressure cuff. CNA13 said she did not but knows she was supposed to.

On 07/18/24 at 11:17 AM, an interview was conducted with the Director of Nursing (DON) in the conference room. DON confirmed that staff are supposed to perform hand hygiene before they enter and when exiting a resident's room, between glove changes, and when moving from one resident to another. DON also confirmed that the blood pressure cuff needs to be cleaned with disinfecting wipes immediately after use and

before being used on another resident.

Review of the facility policy Infection Prevention and Control Program (IPCP) stated, . Staff will perform hand hygiene, even if gloves are used . Before and after contact with the resident. After removing PPE (personal protective equipment which includes gloves) . multi-use equipment and supplies . will be de-contaminated prior to re-use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 125011 Department of Health & Human Services Printed: 09/17/2025 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 125011 B. Wing 07/19/2024

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

Hale Nani Rehabilitation and Nursing Center 1677 Pensacola Street Honolulu, HI 96822

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 39754 potential for actual harm Based on record review, staff interview and review of policy, the facility did not document the refusal of an Residents Affected - Few influenza vaccine for one Resident (R)63 out of five residents sampled. As a result of this deficiency, there was a risk for miscommunication and misadministration of the influenza vaccine.

Findings include:

Record review for Resident R63 showed no documentation of influenza vaccination administration or refusal for the last immunization time period '23-'24.

During staff interview with the Infection Preventionist (IP) on 07/18/24 at 10:20 AM, IP said that Resident R63's representative consented to the influenza vaccination and later Resident R63 refused but that was not recorded in the Electronic Health Record.

Review of policy on Infection Prevention and Control Influenza and Pneumococcal Immunizations read, Purpose, to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza and pneumococcal disease. Policy, the facility will provide influenza and pneumococcal immunizations to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza and pneumococcal disease. Residents and/or resident representatives will receive information related to the risks and benefits of immunizations. Immunizations will be administered according to the recommendations of The Advisory Committee on Immunization Practices unless medically contraindicated, refused or if the resident has previously been immunized. Administration of these vaccinations will occur based on this policy, specific physician orders are not needed prior to administration. Guidelines; Influenza, . 7. The resident record will reflect the provision of education and the administration or refusal of the immunization, or non-administration due to medical contraindication, precaution or other reason for non-administration of the vaccine .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 125011