Maunalani Nursing And Rehabilitation Center

F-F641.

EHR review of orders and wound care notes dated 08/22/24. Resident with stage three ulcer to right buttocks. Orders to turn and reposition every (Q) hour. Orders to sit no longer than 30 minutes.

Observed Resident R2 in her room in her bed on 08/26/24 at 11:15 AM. Her eyes were closed, lying on her back center with the head of bed up at 45-degree angle.

Observation and interview with Resident R2 in her room on 08/27/24 at 09:42 AM. Head of bed is up at a 45-degree angle, and she is on her back center. When asked if Resident R2 has a sore on her back or her bottom, she said, something is there. When asked if she has a wound or a dressing, she said yes, they are taking care of it.

The nurses are coming in to do change it.

Observed Resident R2 in the activity room on 08/27/24 at 03:30 PM Sitting up in her wheelchair with a Bingo card on

the table with pieces on it.

08/28/24 11:31 AM observed sleeping in her bed with the head of bed up 45 degrees. She was laying on her back center.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 125013 Department of Health & Human Services Printed: 09/11/2025 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 125013 B. Wing 08/29/2024

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

Maunalani Nursing and Rehabilitation Center 5113 Maunalani Circle Honolulu, HI 96816

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 0686 Interview and concurrent record review with Licensed Practice Nurse (LPN)25. On 08/29/24 at 11:20 AM on

the unit near Resident R2's room. The surveyor asked LPN25 where the ulcers are located and are they healing? She Level of Harm - Minimal harm or now has two ulcers on her buttocks. The left buttock was moisture associated skin damage (MASD) on potential for actual harm 04/02/24, and now it's a stage three. The right buttock started in 05/2024 as a round open area. Now it is a stage three. We get her up for only 30 minutes when she attends Bingo once a week every Tuesday only for Residents Affected - Few 30 minutes. The orders vary if it changes. She is being turned every two hours.

Interview and concurrent record review with the Director of Nursing (DON) during the Quality Assurance Performance Improvement (QAPI) meeting in the Administrators office on 08/29/24 at 12:58 PM. The surveyor asked the DON to verify in the record when the resident received the pressure ulcers and if they were acquired in the facility after admission. The DON confirmed that Resident R2's pressure ulcers were acquired in April and May 2024 after the admission and progressed to a stage three. The DON added that the coding in

the MDS will need to reflect two stage three facility acquired pressure ulcers.

Mauna [NAME] Nursing and Rehabilitation Center Policy for Pressure Injury 08/14/2024 revised reviewed. A. Minimize pressure, friction, and shearing .Limit amount of time resident may be in one position without moving in bed or chair by repositioning resident during a purposeful rounding or more frequently depending upon the resident's condition and specific needs .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 125013

F-F696.

Electronic Health Record (EHR) review of the Minimum Data Set (MDS) Annual assessment date 02/27/2024. Resident R2 did not have any unhealed pressure ulcers. RR of MDS change of status assessment date 04/11/2024. Resident R2 has a stage three pressure ulcer that was coded as present on admission.

Review of the Minimum Data Set (MDS) quarterly review 07/12/24. Resident R2 is cognitively intact with impairment

on bilateral upper and lower extremities and dependent on staff for self-care and mobility. Resident R2 is coded with having a stage three pressure ulcer that was present on admission.

Interview and concurrent record review with the Director of Nursing (DON) on 08/29/24 at 12:58 PM. The DON confirmed that Resident R2's pressure ulcers were facility acquired and said that the coding in the MDS is incorrect and will need to be updated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 125013 Department of Health & Human Services Printed: 09/11/2025 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 125013 B. Wing 08/29/2024

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

Maunalani Nursing and Rehabilitation Center 5113 Maunalani Circle Honolulu, HI 96816

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38870 potential for actual harm Based on observation, interview, and record review, the facility failed to provide care consistent with Residents Affected - Few professional standards of practice to prevent the development of two stage three (full thickness skin loss) pressure ulcers (a localized damage to the skin and/or underlying tissue, as a result of intense pressure in combination with shear) while in the facility for one resident (R) 2 of three in the sample. The facility staff failed to turn and reposition Resident R2 every 1-2 hours. The deficient practice placed the resident at an increased risk of infection and poor health outcomes. All residents who require assistance from staff for mobility are at risk.

Findings include:

Resident R2 is a [AGE] year-old female. Primary diagnoses includes other neurological conditions, and coronary artery disease. Resident R2 was readmitted to the facility after being discharged to the hospital on 12/29/2023 per Electronic Health Record (EHR) review of the census and face sheet. Review of the facility matrix revealed that Resident R2 had a stage three pressure ulcer not present on admission.

Observation and interview with Resident R2 on 08/26/24 at 09:00 AM. Observed Resident R2 lying on her back center, the head of her bed up at a 45-degree angle working on a word search tablet. When asked if she likes to get up and go to activities, she stated, only Bingo on Tuesdays. I prefer to stay in my room.

EHR review of the following Minimum Data Set's (MDS): Annual assessment date 02/27/2024; Change of status assessment date 04/11/2024, and Quarterly review dated 07/12/2024, cross reference to