Nuuanu Hale

limited to receiving treatment and supports for daily living safely.

observation and staff interviews, the facility failed to have maintain a sanitary and clean shower room

facility if appropriate cleaning of the showers are not done.

Findings include: On 02/03/25 at 09:00 AM, a walkthrough of the 2nd floor [NAME] Wing shower room noted black substance on the left bottom corner caulking through the bottom middle caulking, extending to the right corner side caulking of the shower stall.

The Ewa Wing shower room also noted black substance on the bottom right corner caulking of the shower stall.

On 02/05/25 at 09:20 AM, interviewed Certified Nurses Aid (CNA) 15 and identified that the black substance was mold and wasn't sure how housekeeping cleaned it.

At 09:30 am, during an interview with Housekeeper (H)1 and H2, they housekeepers acknowledged the black substance and noted that they didn't know what it was and have tried to remove it by scrubbing it.

On 02/05/25 at 12:40 PM, met with Maintenance Director (MD), MD accompanied surveyors to observe the Ewa Wing shower room and noted that he already removed the black substance after surveyors brought it up to housekeeping staffs' attention. He initially stated the black substance was black caulking that was applied by previous maintenance worker, but when asked why would the maintenance worker mix black and white caulking between the tiles, MD then stated the black substance was dirt. MD confirmed he used tools to scrape the caulking earlier today and applied grout. He acknowledged the black subtance should've been taken cared of sooner.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

ombudsman, before transfer or discharge, including appeal rights.

record review and interview, the facility failed to provide documentation that written notice of

the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for one of five resident samples.

This deficient practice has the potential to affect resident or resident's representative(s) right to appeal the discharge.

Findings include: Resident (R) 69 was sent to the Emergency Department and admitted to the hospital on [DATE].

Record review was done on 02/05/25 at 12:26 PM for two forms titled, Discharge/Transfer Notice and [Provider] Notice of Discharge.

Information for R69 was noted on both forms, but no documentation was found that it was sent to the resident's representative or Long-Term Care Ombudsman.

The Social Services Director (SSD) was interviewed, in her office, on 02/25/25 at 12:33 PM, and stated that there is nothing documented that the written discharge/transfer notification was sent to the resident's representative. In addition, the SSD was not able to provide a copy of any fax confirmation notice.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

resident?s bed in cases of transfer to a hospital or therapeutic leave.

record review and interview, the facility failed to provide documentation that written notice of

emergency transfer for one of one resident (Resident (R) 69) reviewed for closed record.

This deficient practice does not ensure the resident's right to have a place to return and does not provide continuity of care.

Findings include: Resident (R) 69 was sent to the Emergency Department and admitted to the hospital on [DATE].

Record review was done on 02/05/25 at 12:26 PM for two forms titled, Resident Progress Notes and [Provider] Bed Hold Agreement At Time of Transfer/Discharge.

The Resident Progress Note entry dated 01/02/25 noted, SS [Social Services) received call from sister/POA [Power of Attorney] informing facility that resident/family unable to pay to hold the bed for the resident .

The bed-hold agreement noted oral notification was provided by the facility, but the section titled, Written Notification was not completed.

The Social Services Director (SSD) was interviewed in her office on 02/05/25 at 12:33 PM, and stated that the bed-hold agreement was mailed to the resident's representative who did not send it back. SSD confirmed that documentation of written notification sent should be in the progress notes but was not done.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

During record review of R20's Electronic Health Record (EHR) found he has an active diagnosis of Contracture of muscle, left upper arm dated 02/15/24.

On 02/06/25 at 09:48 AM interviewed Director of Nursing (DON) and asked if R20's MDS Quarterly assessment dated [DATE] had the active diagnosis, Contracture of muscle, left upper arm, and she stated she was not able to find it.

Inquired if this should have been included and she confirmed it should have been included. 2) Cross Reference to F-F656 (Comprehensive Care Plan).

During record review of R21's Electronic Health Record (EHR) found he was sent to and admitted to the hospital on [DATE] for rectal bleeding. R21 was discharged from the hospital on [DATE] and returned to the facility.

Review of discharge summary from the hospital revealed he was admitted to the hospital with pressure ulcers (PUs) to bilateral heels and discharged with PUs to his heels.

Review of R21's skin assessments upon return to the facility did not include documentation of PUs to R21's heels.

Review of R21's MDS Quarterly Review dated 12/16/24 did not include PUs to R21's heels.

On 02/06/25 at 12:47 PM interviewed Minimum Data Set Coordinator (MDSC) 2.

Reviewed discharge paperwork with MDSC2 who confirmed the discharge summary from the hospital stated resident was admitted and discharged with pressure ulcers to his heels.

Inquired if staff completed a skin assessment upon R21's return to the facility and DON and MDSC2 were unable to provide one that included documentation of R21's PUs to his heels. DON confirmed this information should have been included on the admission skin assessment.

Inquired of MDSC2 if the PUs to R21's heels should have been included in his 12/16/24 MDS Quarterly Review under skin conditions and she confirmed this should have been included.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

Review of R56's CP reviewed/revised on 01/25/25 documented R56 .has impaired range of motion to right arm and right leg r/t [related to] previous stroke and contractures .will have no unaddressed complications related to limited range of motion through the review, .Monitor for presence of pain, intolerance, or muscle spasm during range of motion .OT/PT [Occupational Therapy/Physical Therapy] to eval [evaluation] and treat as indicated.

Encourage to follow guidelines set from therapy.

Multiple observations of R56 in bed were done on 02/03/25 at 08:41 AM and 11:35 AM, 02/04/25 at 08:05 AM, and 02/05/25 at 08:41 AM and 12:59 PM. R56's arms were observed to be bent to chest with closed fists holding rolled hand towels in both hands.

Right leg was bent, knee toward stomach and left leg was positioned straight.

Review of R56's Electronic Health Record (EHR) found no documentation that range of motion was done including monitoring for pain, intolerance, or muscle spam during range of motion as indicated in the CP.

Documentation for hand towels on both hands recommended and assessed by therapy, physician ordered, and in CP was not found.

On 02/05/25 at 02:11 PM, an interview with Director of Nursing (DON) was done. DON reported the facility does not have a Rehabilitation Nursing Aide (RNA) program so the Certified Nurse Aids (CNA) are encouraged to do passive range of motion (PROM) for residents. DON confirmed there was no documentation in R56's EHR because there is no place for the CNAs to document and do not have a way to keep track of residents receiving PROM services.

Inquired if R56 was assessed to use hand rolls, if it was physician ordered, and care planned, DON stated she did not see the treatment in R56's EHR.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

residents highest practical physical, mental, and psychosocial well-being .Any services that would

treatment .Resident specific interventions that reflect the resident's needs and preferences that align with the resident's cultural identity, as indicated.

The P&P further documented The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .objectives will be utilized to monitor the resident's progress.

Alternative interventions will be documented, as needed and the resident will be informed of .risks and benefits of proposed care, of treatment, and treatment alternatives/options.

The facility will attempt alternate methods for refusal or treatment and services document such attempts in the clinical record, including discussions with the resident .

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

During survey no staff were observed using an interpreter when communicating with R55.

Review of R55's MDS Quarterly Review dated 09/16/24 identifies resident's language as Cantonese and Yes was checked off that he needs or wants an interpreter to communicate with a doctor or health care staff.

Review of R55's CP did not include use of interpreter services when communicating with a doctor or health care staff.

On 02/06/25 at 09:02 AM an interview was done with the DON.

Inquired of DON if R55's need for an interpreter should have been included on his care plan and she confirmed resident should have had a CP for an interpreter.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

resident-centered activities program that addressed the needs of 1 of 2 residents sampled for

Resident (R)37 could perform. As a result of this deficient practice, R37 was placed at risk of a decline in his psychosocial well-being.

This deficient practice has the potential to affect all residents at the facility.

Findings include: Resident (R)37 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. A review of R37's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 12/09/24 notes that R37 had been identified as Vision Impaired - sees large print, but not regular print in newspapers/books.

On 02/03/25 at 01:35 PM, concurrent observations and interview were done with R37 at the bedside.

R37 stated he had reading glasses at home in Chuuk but did not bring it with him when he moved.

Observed a regular-print Word Search book on his bedside table, sitting untouched.

When asked about it, R37 stated he enjoys word search puzzles but cannot see them without reading glasses.

A review of R37's Comprehensive Care Plan (CP) noted that although his visual deficit had been identified in his ADLs (activities of daily living) Functional Status/Rehabilitation Potential CP, there were no interventions (such as provide reading glasses) planned to address it beyond the following: Monitor for changes in vision as it affects ADLs functioning.

Update MD [Physician] as necessary.

A review of R37's Activities CP noted that it did not identify his visual deficit and only had the following intervention: Activities to encourage participation, support and engage socially, provide adaptations (if needed), and encourage positive coping strategies.

On 02/06/25 at 12:30 PM, an interview was done with the Activities Director (as listed by the facility on their Staff List) in the Activities Room.

The Activities Director (AD) stated that she was no longer the AD and that the position was currently unfilled.

Reported there currently was an Activities Aide (AA) however she was out sick.

When asked about R37, AD stated she was aware of his visual deficit and that he could not see small (or regular) print. A concurrent review of his Activities CP was done, and AD agreed that his visual deficit should have been identified and addressed.

When asked about resident-specific interventions based on activity needs, AD seemed unclear what the State Agency (SA) meant.

Asked if it was normal to have only one generalized intervention in the Activities CP, AD responded yes, all residents' activity care plans usually just have the one intervention.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

Camphor-Menthol lotion ordered on 10/11/24, Apply a thin layer to BUE [bilateral upper extremities]

effectiveness.

On 02/06/25 at 10:22 AM, an interview was done with UM1 in her office. UM1 confirmed that the different interventions the facility has used to address R32's pruritis (including the Camphor-Menthol lotion) should have been added to his CP since his pruritis has been an issue since admission.

During a concurrent review of his CP, UM1 validated that R32's CP did not include these resident-centered interventions.

On 02/06/25 at 01:29 PM, an interview was done with Certified Nurse Aide (CNA)6 outside of room [ROOM NUMBER]. CNA6 confirmed that he is familiar with R32's care and has noticed R32 is frequently itchy and scratching his arms, stating, oh yeah, [he scratches] all the time. CNA6 also confirmed that he has frequently observed spots of blood on R32's linen and reported that he has observed multiple bleeding areas on both R32's arms and back. CNA6 stated that R32 complains about the itchiness a lot, which CNA6 consistently reports to the nurse.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

documented in the EHR.

repositioning schedule: every two hours, using both side-lying and back positions.

Reposition in bed,

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

Review of R56's Therapy Communication to Nursing dated 12/13/23 including nursing staff signatures with comments to continue perform bed exercises (PROM) to optimize joint mobility. PTA1 reported nursing staff and residents are trained on PROM exercises when recommended. OTA2 reported if a resident had contractures, it would be noted by the therapist in the notes and discharge summary.

PTA1 confirmed contractures was not included in the discharge summary diagnoses. OTA2 stated if a resident developed contractures nursing staff would usually make a referral to therapy.

Inquired if nursing staff used hand rolls should that be assessed by therapy, OTA2 stated if there were contractures to the hands nursing staff would make a referral to OT and OT would assess and make treatment recommendations.

For hand rolls the treatment would include what time and how long it is to be used, and nursing staff should monitor for redness or complications. OTA2 confirmed therapy did not assess or recommend hand rolls for R56.

Referrals from nursing staff to assess R56 after discharge on [DATE] was not done.

On 02/05/25 at 02:11 PM, an interview with Director of Nursing (DON) was done. DON reported the facility does not have a Rehabilitation Nursing Aide (RNA) program so the Certified Nurse Aids (CNA) are encouraged to do passive range of motion (PROM) for residents. DON confirmed there was no documentation in R56's EHR because there is no place for the CNAs to document and do not have a way to keep track of residents receiving PROM services. DON was not able to provide documentation that the CNA's were providing PROM services for R56.

Inquired if R56 was assessed to use hand rolls, if it was physician ordered, and care planned, DON stated she did not see the treatment in R56's EHR.

DON confirmed hand rolls should not be used since R56 was not assessed to use hand rolls by therapy or ordered by the physician.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

Review of R38's physician orders for O2 included, continuous O2 at two liters per minute (LPM) via face mask, may titrate flow to keep saturation (SATS) greater than (>) 90 percent (%) and O2 at 0-5 LPM via nasal cannula or face mask (per resident preference) as needed, may titrate flow to keep SATS > 90%.

On 02/06/25 at 08:01 AM observed R38 in her room, R38's O2 face mask was not covering her mouth or nose but located on the side of her face.

The tubing connecting the O2 face mask to the O2 concentrator was not connected, and the connection end of the tubing was touching the floor.

The O2 concentrator was on and running. R38 reported she needs to utilize O2 treatment all day and night.

On 02/06/25 at 10:14 AM, a concurrent observation and interview with Registered Nurse (RN) 5 was done. RN5 reported R38 puts on and off her own face mask for O2 because R38 wanted the O2 on all the time. RN5 clarified and stated R38 does not necessarily need the O2 concentrator to be on continuously but more so wants it on continuously.

Concurrent observation of R38's O2 tubing from the face mask to the concentrator was not connected while the concentrator was on. RN5 confirmed it should have been connected.

Review of the facility's policy and procedure Oxygen Administration reviewed/revised on 06/2023 documented, Oxygen is administered under orders of a physician .Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

Based on interview and record review, the facility failed to manage and monitor the medication

physician ordered gradual dose reduction (GDR) for an antidepressant.

This deficient practice does not protect residents from the possible side effects of overmedication and has the potential to affect other residents prescribed with psychotropic medications.

Findings include: On 02/06/25 at 01:45 PM, a review of the Medication Regimen Review (MRR) for Resident (R) 18, dated 09/25/24, and done by the Consultant Pharmacist, recommended that R18's Citalopram 10mg be reviewed for an annual GDR versus clinical contraindication. On the same form, R18's physician (MD) 1 marked the option titled, Condition stable: Attempt dose reduction to and handwrote in 5 QD [milligrams daily].

The bottom of the form contained his signature and date of 9/27/24.

Upon review of R18's September and October 2024 physician orders, no order change for Citalopram 10mg to 5mg was noted.

There was also no indication of a Citalopram order change noted in the progress notes dated from 09/25/24 to the end of October 2024. R18's current Citalopram order, dated 01/26/24, noted 10mg.

On 02/06/25 at 01:45 PM, an interview was conducted with the Director of Nursing (DON).

The DON validated that MD1's notation of 5 QD on the MRR meant to reduce the Citalopram dosage to 5mg daily.

The DON also confirmed that MD1's written date at the bottom of the MRR was 09/27/24.

The DON stated that the facility receives the MRRs monthly, and a review is done by the DON, Unit Manager and clinical team.

When MD1 visits the facility on Tuesday and Fridays, orders are obtained, documented in the progress notes, and carried out.

The DON then confirmed that R18's Citalopram order for dose reduction was not carried out.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

professional principles; and all drugs and biologicals must be stored in locked compartments,

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

were stored, labeled, and administered according to professional standards.

Proper labeling and administration practices of medications are necessary to decrease the risk of medication errors.

This deficient practice has the potential to affect all residents in the facility.

Findings include: 1) On [DATE] at 07:56 AM, Medication pass observations were done with Registered Nurse (RN) 12.

For Resident (R) 10, the Carvedilol 25mg order on the Medication Administration Record (MAR) was listed to be given twice a day at (08:00 AM and 05:00 PM).

The label on the medication blister pack noted Carvedilol to be given every 12 hours.

A review of the physician orders was done on [DATE] at 11:15 AM for R10's Carvedilol.

The current physician order for R10's Carvedilol, dated [DATE], stated it to be given 25mg twice a day.

An interview was done with RN12 on [DATE] at 11:30 AM. RN12 confirmed that R10's Carvedilol order on the MAR and the medication label on the blister pack did not match. RN12 then proceeded to bring out a full Carvedilol 25mg blister pack, obtained from the bottom drawer of the medication cart, with the label matching the MAR. RN12 stated that R10 went to the hospital on [DATE] and returned to the facility on [DATE].

Upon return, RN12 transcribed the Carvedilol 25mg order to be given twice a day.

However, the blister pack, with the label stating Carvedilol 25mg to be given every 12 hours, was kept in the medication cart and was being used. RN12 confirmed that blister pack should have been discarded. 2) On [DATE] at 12:49 PM, while inspecting the Right-Wing medication cart with the Director of Nursing, noted a Lantus insulin pen for Resident (R)37 that had been labeled as opened [DATE] with a discard date of [DATE]. DON confirmed the insulin pen was expired and should have been wasted.

Review of the electronic health record (EHR) , R68 has an indwelling catheter.

On 02/05/25 at 08:05 AM, observed R68's catheter bag on the floor.

Noted a basin adjacent to the catheter bag.

On 02/05/25 at 08:45 AM, Certified Nurses Aid (CNA) 5 verified that catheter bag should be off the floor and in the basin. CNA5 noted that they use the basin as a barrier.

Observed CNA5 place catheter bag in basin.

Staff interview on 02/05/25 at 11:50 AM, Director of Nursing stated that CNAs are supposed to clean catheters from top to bottom, reporting any signs/symptoms of foul-smelling odor, color of the urine, bag secured to their leg and that there should be a barrier between the catheter bag and the floor.

Staff interview on 02/06/25 at 12:40 PM, IP stated that catheters should be hung on the bed, should be off the floor, and basin used as a barrier.

She stated that this was to prevent contamination.

Review of the facility's catheter policy dated 07/2021 and revised on 01/11/24, Catheter care will be performed every shift and as needed by nursing personnel and catheter drainage bags will be positioned below bladder level, clear from the floor and will not be level with resident in while resident is in bed.

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Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

The facility failed to identify pressure ulcers (PUs) to bilateral heels on R21's Minimum Data Set (MDS) Quarterly Assessment after R21 returned to the facility from being hospitalized .

The facility failed to develop and implement a care plan to provide treatment and monitoring of R21's PUs on his heels.

3) Cross-reference to

Review of R56's quarterly admission Minimum Data Set (MDS) with assessment reference date of 01/06/25 found in Section GG.

Functional Abilities and Goals, R56 is dependent in self-care and has impairment on one side for upper and lower extremity range of motion.

125024

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125024 B.

Wing 02/06/2025

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

Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

F-F676 Activities of Daily Living (ADLs)/Maintain Abilities.

Despite identifying upon admission that her primary language was not English, the facility failed to develop and implement a Communication/Language Barrier care plan for R24.

125024

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125024 B.

Wing 02/06/2025

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

Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

F-F684 Quality of Care for R32 despite identifying and documenting an ongoing pruritic skin condition since September 2024, the facility failed to develop and implement a care plan that effectively monitored and addressed R32's itching.

6) Cross-reference to

The facility failed to provide R54 necessary treatment, consistent with professional standards of practice to promote healing of a stage 4 pressure injury.

potential for actual harm R54 was admitted to the facility on [DATE]. R54's diagnoses include, not limited to, stage 4 pressure ulcer of sacral region, posterior reversible encephalopathy syndrome, local infection of the skin and subcutaneous

of right leg above knee, type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of right lower leg with necrosis of bone, pain, and infection of amputation stump of right and left lower extremity.

Review of R54's quarterly Minimum Data Set (MDS) with assessment reference date of 12/17/24 found R54's Brief Interview for Mental Status (BIMS) scored a 15 (cognitively intact). In Section GG.

Functional Abilities and Goals, under Mobility, R54 needs substantial/maximal assistance to roll left and right, is dependent sit to lying and lying to sitting on the side of bed.

On 02/03/25 at 08:59 AM, observation and interview with R54 was done. R54 reported she has a pressure injury on her coccyx and had it for a while.

The wound team reportedly informed her on their last visit that the wound was getting bigger. R54 expressed that she was frustrated because she tries to do the turning and positioning herself by using the bed rails to hold on to and offload but cannot do it for long because it is sore and becomes more painful. R54 stated she must ask staff to be repositioned but if she doesn't ask, they do not help or reposition her.

Observed resident attempt to reposition herself by using her arm strength and holding on to the bed rail lifting herself up, for less than thirty seconds, before going back to a flat on her back position. No pillows or wedges were observed to be used to help reposition her.

During a second observation and interview with R54, on 02/04/25 at 08:36 AM, R54 was observed lying flat on her back and stated her arm was sore when turning herself.

Inquired if the facility offered a wedge to help reposition so she does not have to hold on to the bed rail and lift herself up, R54 reported she has a wedge, but it is a hard foam and every time they put it behind her back it is uncomfortable, so she takes it off. R54 reportedly requested for pillows instead to reposition, and staff tell her they will look but never come back with pillows.

On 02/06/25 at 03:28 PM, concurrent record review and interview with UM1 and Infection Preventionist (IP) was done.

Concurrent review of R54's EHR documented R54 has a stage 4 pressure injury. UM1 stated residents with pressure injuries or are at risk and are not able to turn themselves should be turned every two hours and may use a wedge to assist residents in repositioning. IP reported R54 uses her arm to turn herself and has a wedge and pressure mattress but R54 refuses the wedge because it is too hard.

Staff had offered covering the wedge with a blanket. UM1 stated if a resident refuses treatment, nursing staff should educate and reapproach or offer different interventions as well as education of risk and benefits.

Refusals should be documented in the progress notes. UM1 confirmed refusals were not documented.

Review of R54's CP, UM1 confirmed the resident's CP was not updated to reflect R54's pressure injury status, did not include person-centered intervention, to aid with turning and positioning every two hours and to use pillows/wedges or other devices to assist with turning and positioning and should have been care planned.

125024

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125024 B.

Wing 02/06/2025

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

Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817

The facility failed to ensure R56 with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion, and ensure treatment provided was evaluated by therapy, physician ordered, and/or care planned.

R56 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, history of occlusion and stenosis of unspecified cerebral artery, muscle weakness, and contracture of muscle right upper arm and right lower leg.

Review of R56's quarterly admission Minimum Data Set (MDS) with assessment reference date of 01/06/25 found in Section GG.

Functional Abilities and Goals, R56 is dependent in self-care and has impairment on one side for upper and lower extremity range of motion.

Review of R56's CP reviewed/revised on 01/25/25 documented R56 .has impaired range of motion to right arm and right leg r/t [related to] previous stroke and contractures .will have no unaddressed complications related to limited range of motion through the review, .Monitor for presence of pain, intolerance, or muscle spasm during range of motion .OT/PT [Occupational Therapy/Physical Therapy] to eval [evaluation] and treat as indicated.

Encourage to follow guidelines set from therapy.

Multiple observations of R56 in bed were done on 02/03/25 at 08:41 AM and 11:35 AM, 02/04/25 at 08:05 AM, and 02/05/25 at 08:41 AM and 12:59 PM. R56's arms were observed to be bent to chest with closed fists holding rolled hand towels in both hands.

Right leg was bent, knee toward stomach and left leg was positioned straight.

Review of R56's Electronic Health Record (EHR) found no documentation that range of motion was done including monitoring for pain, intolerance, or muscle spam during range of motion as indicated in the CP.

Documentation for hand towels on both hands recommended and assessed by therapy, physician ordered, and in CP was not found.

On 02/05/25 at 02:11 PM, an interview with Director of Nursing (DON) was done. DON reported the facility does not have a Rehabilitation Nursing Aide (RNA) program so the Certified Nurse Aids (CNA) are encouraged to do passive range of motion (PROM) for residents. DON confirmed there was no documentation in R56's EHR because there is no place for the CNAs to document and do not have a way to keep track of residents receiving PROM services.

Inquired if R56 was assessed to use hand rolls, if it was physician ordered, and care planned, DON stated she did not see the treatment in R56's EHR.

125024

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125024 B.

Wing 02/06/2025

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

Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817