Nuuanu Hale

F-F641 Accuracy of Assessments for Resident R21. The facility failed to identify pressure ulcers (PUs) to bilateral heels on Resident R21's Minimum Data Set (MDS) Quarterly Assessment after Resident R21 returned to the facility from being hospitalized . The facility failed to develop and implement a care plan to provide treatment and monitoring of Resident R21's PUs on his heels.

3) Cross-reference to

F-F656 (Comprehensive Care Plan)

Resident R56 was admitted to the facility on [DATE REDACTED] 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 Resident R56's quarterly admission Minimum Data Set (MDS) with assessment reference date of 01/06/25 found in Section GG. Functional Abilities and Goals, Resident R56 is dependent in self-care and has impairment on one side for upper and lower extremity range of motion.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 Review of Resident R56's care plan reviewed/revised on 01/25/25 documented Resident R56 .has impaired range of motion to right arm and right leg r/t [related to] previous stroke and contractures .will have no unaddressed Level of Harm - Minimal harm or complications related to limited range of motion through the review, .Monitor for presence of pain, potential for actual harm 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. Residents Affected - Few Multiple observations of Resident 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. Resident 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 Resident R56's Electronic Health Record (EHR) found no documentation that range of motion was done including monitoring for pain, intolerance, or muscle spasm 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 12:41 PM, interview and concurrent record review with Physical Therapy Assistant (PTA) 1 and Occupational Therapy Assistant (OTA) 2 was done. PTA1 reported Resident R56 was last seen on 12/08/23 by physical therapy (PT) and OTA2 reported she was not seen by occupational therapy (OT). Concurrent review of Resident R56's 12/08/23 PT Discharge Summary, documented Resident R56 was discharged from PT with right hip flexion of 50 percent (%) degrees and discharged with generalized muscle weakness. PT recommended assistance with a functional maintenance program and concluded Resident R56's prognosis to maintain current level of function if staff are consistent with follow-through.

Review of Resident 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 Resident R56. Referrals from nursing staff to assess Resident R56 after discharge on 12/08/23 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 Resident 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 Resident R56. Inquired if Resident R56 was assessed to use hand rolls, if it was physician ordered, and care planned, DON stated she did not see the treatment in Resident R56's EHR. DON confirmed hand rolls should not be used since Resident R56 was not assessed to use hand rolls by therapy or ordered by the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

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 ensure a resident's oxygen (O2) Residents Affected - Few tubing was connected to the O2 concentrator consistent with professional standards of practice for one of one resident sampled (Resident (R) 38) for respiratory care. As a result, Resident R38 was not receiving continuous O2 as physician ordered. This failure placed Resident R38 at risk for respiratory distress.

Findings include:

Resident R38 was admitted to the facility on [DATE REDACTED] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hyperlipidemia, hypertension, and hypoxemia.

Review of Resident 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 Resident R38 in her room, Resident 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. Resident 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 Resident R38 puts on and off her own face mask for O2 because Resident R38 wanted the O2 on all the time. RN5 clarified and stated Resident R38 does not necessarily need the O2 concentrator to be on continuously but more so wants it on continuously. Concurrent observation of Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm 51869 Residents Affected - Few Based on interview and record review, the facility failed to manage and monitor the medication regimen for one of five residents sampled for unnecessary medications, by not implementing a 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 Resident R18's Citalopram 10mg be reviewed for an annual GDR versus clinical contraindication. On the same form, Resident 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 Resident 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. Resident 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 Resident R18's Citalopram order for dose reduction was not carried out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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** 51869 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure all medications administered 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 REDACTED] 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 REDACTED] at 11:15 AM for Resident R10's Carvedilol. The current physician order for Resident R10's Carvedilol, dated [DATE REDACTED], stated it to be given 25mg twice a day.

An interview was done with RN12 on [DATE REDACTED] at 11:30 AM. RN12 confirmed that Resident 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 Resident R10 went to the hospital on [DATE REDACTED] and returned to the facility on [DATE REDACTED]. 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.

43245

2) On [DATE REDACTED] 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 REDACTED] with a discard date of [DATE REDACTED]. DON confirmed the insulin pen was expired and should have been wasted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51869 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and Residents Affected - Some control program to ensure a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections.

The facility failed to:

1) ensure a pill cutter, used for multiple residents, was cleaned between patient use, observed from one of three medication carts;

2) ensure staff perform hand hygiene after discarding dirty gloves before assisting resident (R) 123 with her meal, one unsampled resident;

3) ensure clean medical supplies to be used are kept on clean surfaces and follow standard precautions by performing hand hygiene between glove change for one of five residents (Resident (R) 54) sampled for wound care;

4) ensure a nursing staff member providing care used appropriate Personal Protective Equipment and performed hand hygiene between gloves for one of six residents (Resident R68) sampled with Enhanced Barrier Precautions (EBP);

5) ensure a lancet, a needle used to puncture the fingertip, was properly discarded for one of two residents (Resident R54) sampled with Transmission Based Precautions (TBP); and

6) ensure a urinary catheter bag was not left on the floor for one of one resident (Resident R68) sampled for urinary catheters.

These deficient practices could put residents at risk of contamination that receive medication(s) being cut by

the pill cutter, puts Resident R123, Resident R54 and Resident R68 at risk of infection, and puts residents, visitors, and staff members at risk for infection and blood-borne pathogen transmission.

Findings include:

1) During inspection of the facility's second floor Ewa medication cart on 02/05/25 at 08:17 AM, a pill cutter, located in the top drawer of the medication cart, was observed to have large amounts of white/brown sediments in the interior portion of the cutter. The Registered Nurse (RN) 12 administering medications from

this cart was concurrently interviewed. RN12 confirmed seeing the white and brown sediments in the pill cutter and stated it could be from not cleaning it. RN12 also stated that the cutter should be cleaned after each use.

37954

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 2) On 02/03/25 at 11:30 AM observed Certified Nurse Assistant (CNA)11 deliver a lunch tray to Resident R123 in her room. CNA11 had performed hand hygiene by applying hand sanitizer to her hands before picking up the Level of Harm - Minimal harm or lunch tray from the cart. CNA11 delivered the lunch tray and then put on clean gloves to re-position Resident R123 in potential for actual harm her bed. CNA11 used the draw sheet to raise Resident R123 up in her bed. CNA11 disposed of the dirty gloves and then used the bed control to raise resident's head of bed so Resident R123 was sitting up for her meal. CNA11 then Residents Affected - Some proceeded to assist Resident R123 with her lunch by sitting at the bedside and fed Resident R123. CNA11 did not do hand hygiene after disposing of the dirty gloves or before feeding Resident R123.

On 02/03/25 at 11:45 AM interviewed CNA12 and asked what staff are expected to do after wearing gloves to position a resident and disposing of gloves, he stated sanitize hands.

On 02/05/25 at 10:39 AM interviewed Director of Nursing (DON). Inquired what staff are expected to do when they take off dirty gloves and she stated staff are supposed to perform hand hygiene. Explained

observation that occurred with CNA11 to DON who confirmed best practice is to wash hands if they are soiled and hand sanitize if not.

3) On 02/04/25 at 01:40 PM observed Registered Nurse (RN)12 do dressing change for resident (R)54. RN12 brought in supplies to the resident's room, used proper personal protective equipment (PPE) as resident is on contact precautions. RN12 was observed placing clean gauze on resident's bed side table. Bed side table was not wiped down prior to nurse placing dressing change supplies directly onto the table, such as the clean gauze. RN12 cleaned Resident R54's pressure ulcer (PU) as ordered by the physician. Afterwards RN12 took off her dirty gloves and put on clean gloves. No hand hygiene was observed prior to RN12 putting

on clean gloves. After dressing change interviewed RN12 and asked if it was ok to put clean gauze on resident's dirty bed side table. RN12 confirmed it was dirty and asked if surveyor had any recommendations. RN12 was also told she was seen putting on clean gloves after taking off dirty gloves. Asked her if she is supposed to do anything before putting on clean gloves and she stated wash hands. Inquired with RN12 if

she had training on hand hygiene and she said not in a while. Surveyor asked RN12 when she started working at facility and she said about six months ago. Asked if she had training at that time and she confirmed that she had.

On 02/04/25 at 02:03 PM interviewed DON who confirmed staff have had training on hand hygiene during orientation, as needed and annually and she reported they do audits. DON explained audits consist of watching to see if staff sanitize their hands before they go into the room or if hands are soiled. DON explained wound nurse or Infection Preventionist nurse does audits as well of wound dressing changes. DON stated she will look into getting small chux that nurses can use for barriers. DON also stated they have trays, I don't know why she didn't use it.

On 02/04/25 at 02:10 PM interviewed education nurse who confirmed they do training with staff on hand hygiene and dressing change during orientation and annually. She confirmed nurse should have sanitized hands after taking off dirty gloves before putting on clean gloves.

43414

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 02/04/25 at 08:10 AM, observed RN12 respond to Resident R68 when yelling for help because she made a bowel movement (BM). Prior to entering Resident R68's room, a sign outside the door indicated she was under EBP, Level of Harm - Minimal harm or gloves and gown are needed when providing contact care. RN12 observed at bedside wearing gloves and potential for actual harm wiping Resident R68's hands. RN12 was not wearing a gown. Resident R68 complained to RN12 that her stomach was sore and RN12 was observed to assess and touch Resident R68's stomach. RN12 then took off her gloves and grabbed a Residents Affected - Some new pair without hand washing in between glove use and adjusted Resident R68 oxygen tubing. RN12 informed Resident R68 someone will be coming to change and clean her BM. RN12 reported she was wiping Resident R68's hands because

she was touching the BM stains on her incontinence under pads. RN12 confirmed Resident R68 is under EBP and should have worn a gown when providing direct care and hand sanitize between gloves.

On 02/06/25 at 11:35 AM, an interview with Infection Preventionist (IP) was done. IP stated nursing staff are to wear gown and gloves while providing high contact care to residents with EBP to prevent infections or multidrug-resistant organism (MDRO). Residents with certain medical devices are prone to more infections. IP confirmed nursing staff should hand wash or sanitize between glove use.

5) On 02/04/25 at 08:36 AM, during an interview with Resident R54 observed an opened lancet on the foot of Resident R54's bed and the cover on Resident R54's bedside table.

On 02/04/25 at 08:41 AM, an interview with RN12 was done. RN12 confirmed the item on Resident R54's bed was an opened lancet and was used to puncture a finger to test blood sugar levels. RN12 reported used lancets are discarded in a sharps container (a container used to prevent injuries and spread of infections from sharp objects.)

On 02/06/25 at 11:35 AM, an interview with IP was done. IP confirmed lancets are to be discarded in a sharps container because it could potentially prick someone else and puts others at risk of blood-borne pathogen contamination.

51870

6) Resident R68 is a [AGE] year-old resident who was admitted to the facility on [DATE REDACTED] for hospice services. Review of the electronic health record (EHR) , Resident R68 has an indwelling catheter.

On 02/05/25 at 08:05 AM, observed Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 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 Level of Harm - Minimal harm or below bladder level, clear from the floor and will not be level with resident in while resident is in bed. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 125024

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 Resident R24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 7) Cross-reference to

F-F684 Quality of Care for Resident 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 Resident R32's itching.

6) Cross-reference to

F-F686. The facility failed to provide Resident R54 necessary treatment, consistent with professional standards of practice to promote healing of a stage 4 pressure injury. Level of Harm - Minimal harm or potential for actual harm Resident R54 was admitted to the facility on [DATE REDACTED]. Resident 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 Residents Affected - Some tissue, type 2 diabetes mellitus with other skin complications peripheral vascular disease, acquired absence 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 Resident R54's quarterly Minimum Data Set (MDS) with assessment reference date of 12/17/24 found Resident R54's Brief Interview for Mental Status (BIMS) scored a 15 (cognitively intact). In Section GG. Functional Abilities and Goals, under Mobility, Resident 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 Resident R54 was done. Resident 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. Resident 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. Resident 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 Resident R54, on 02/04/25 at 08:36 AM, Resident 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, Resident 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. Resident 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 Resident R54's EHR documented Resident 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 Resident R54 uses her arm to turn herself and has a wedge and pressure mattress but Resident 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 Resident R54's CP, UM1 confirmed the resident's CP was not updated to reflect Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 the facility's policy and procedure (P&P) Pressure Injury Prevention and Management reviewed/revised on 06/2023 documented under intervention for prevention and to promote healing of a Level of Harm - Minimal harm or pressure injury, The goals and preferences of the resident .will be included in the plan of care .Interventions potential for actual harm will be documented in the care plan and communicated to all relevant staff .Compliance with interventions will be documented in the weekly summary charting. The P&P included when modifications of interventions Residents Affected - Some are needed, Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include .Changes in resident's degree of risk for developing a pressure injury .Resident non-compliance.

Review of the facility's P&P Comprehensive Care Plans reviewed/revised 06/2023 documented the CP will describe, at a minimum, The services that are to be furnished to attain or maintain the residents highest practical physical, mental, and psychosocial well-being .Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse 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 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to provide the proper care and Residents Affected - Few treatment, including assistive devices/tools, to improve and promote the communication abilities of 3 of 3 residents (R) sampled for Language/Communication. Despite identifying upon admission that their primary language was not English, the facility failed to implement the use of alternative communication methods, such as a communication board, non-verbal pain assessment tools, or commonly used phrases in their primary language, or an interpreter for Residents (R)37, Resident R24 and Resident R55. As a result of this deficient practice,

the residents are at an increased risk of not having their needs met and experiencing a decline in their physical well-being, psychosocial well-being, and quality of life. This deficient practice has the potential to affect all residents at the facility with communication needs.

Findings include:

1) Cross Reference to

F-F688. The facility failed to ensure Resident 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.

Resident R56 was admitted to the facility on [DATE REDACTED] 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 Resident R56's quarterly admission Minimum Data Set (MDS) with assessment reference date of 01/06/25 found in Section GG. Functional Abilities and Goals, Resident R56 is dependent in self-care and has impairment on one side for upper and lower extremity range of motion.

Review of Resident R56's CP reviewed/revised on 01/25/25 documented Resident 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 Resident 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. Resident 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 Resident 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 Resident 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 Resident R56 was assessed to use hand rolls, if it was physician ordered, and care planned, DON stated she did not see the treatment in Resident R56's EHR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37954

Residents Affected - Some Based on observations, record reviews, and interviews, the facility failed to ensure the comprehensive person-centered care plan (CP) was reviewed and/or revised by the interdisciplinary team for four of 18 residents (Resident (R) 29, Resident R55, Resident R38, and Resident R54) sampled for care plans. As a result of this deficit practice, Resident R29's need for assistance with meals was not care planned for which was something new with the resident, Resident R55's range of motion (ROM) was not addressed as recommended by physical therapy to prevent further contractures, Resident R38's respiratory care was not person-centered and/or revised to appropriately reflect her status, and Resident R54's pressure ulcer status was not updated to a Stage 4 with person-centered interventions.

Findings include:

1) During record review of Resident R29's Electronic Health Record (EHR) found she was hospitalized on ce in December 2024 and she returned to the facility on [DATE REDACTED]. On 12/15/2024 at 14:37 the Minimum Data Set Coordinator (MDSC)1 documented Resident R29 had a significant change for The assessment was originally scheduled due to new indwelling Foley catheter. However, Foley catheter was discontinued and resident successfully completed voiding trial. On the other hand, IDT (Interdiisciplinary Team) reported that resident has declined in her ability to feed herself from setup help to dependent. For this reason, will continue to complete significant change assessment.

On 02/06/25 at 09:59 AM interviewed Unit Manager (UM)1. Inquired if Resident R29 requires assistance with meals and UM1 confirmed this. Inquired about significant change Resident R29 had and UM1 confirmed Resident R29's significant change was for the decline with her Activities of Daily Living (ADLS) with requiring assistance with her meals. At this time reviewed Resident R29's Care Plan (CP) with UM1 and found there were no interventions to address resident's decline and the need for assisitance with her meals. Inquired of UM1 if Resident R29's CP should have been updated to reflect this significant change and UM1 confirmed it should have been updated with Resident R29's significant change for requiring assistance with her meals.

2) On 02/03/25 at 02:29 PM a family interview was conducted with Resident R55's family member. Inquired if Resident R55 had full range of motion (ROM) of his arms and family member stated he is able to lift up his cup to his mouth and

they were unsure if he has higher ROM with his arms.

During record review of Resident R55's Electronic Health Record (EHR) found resident has a CP that states [Name of Resident R55] is quadriplegic and contractures to bilateral legs related to this. His L (left) hand fingers, and R (right) index finger are contracted. Elbows and shoulders ROM are still WNL (within normal limits). R hand ROM slightly weak. with a Long Term Goal Target Date: 04/27/2025 Name of Resident R55 will participate in self care activities at highest level of independence. with an Approach Start Date: 02/15/2024 OT/PT to eval and treat per MD orders as needed for ROM.

On 02/06/25 at 10:28 AM interviewed Physical Therapy Assistant (PTA)1. Inquired if Resident R55 had Physical Therapy (PT) and PTA1 stated resident has finished with PT. PTA provided documentation that resident refused PT each time they asked. PTA1 provided a copy of the directions for ROM for Resident R55 and his preferences. Inquired if this was shared with nursing and PTA1 confirmed it was. PT's recommendation for facility staff was to perform passive range of motion (PROM) exercises in bed 2-3 times a week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 On 02/06/25 at 10:42 AM inquired of Director of Nursing (DON) if resident has recommendation listed on his CP from PT Continue PROM exercises in bed 2-3 times a week. DON confirmed it did not include the Level of Harm - Minimal harm or information provided by the PT department for Resident R55's PROM exercises. DON confirmed this should have potential for actual harm been included on resident's CP.

Residents Affected - Some 43414

3) Resident R38 was admitted to the facility on [DATE REDACTED] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hyperlipidemia, hypertension, and hypoxemia.

Review of Resident R38's physician orders for oxygen (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%.

Observations of Resident R38 in her room on 02/03/25 at 09:47 AM, 12:40 PM, and 02:26 PM, 02/04/25 at 08:25 AM, 02/05/25 at 08:01 AM and 11:06 AM and on 02/06/25 at 08:01 AM and 10:13 AM, found Resident R38's O2 face mask not covering her mouth or nose to provide continuous oxygen, but located on the side of her face. The O2 concentrator was running at two LPM.

On 02/03/25 at 09:47 AM, interview with Resident R38 was done. Resident R38 reported her O2 is on the whole day but she puts on her face mask herself when needed. Resident R38 stated she does not need to inform nursing staff when she used or needs O2.

A second interview with Resident R38 was done on 02/05/25 at 08:01 AM, Resident R38 reported when she needs O2 she will put the mask on herself and if she doesn't, she takes it off. When inquired how often does she need to utilize O2 she stated all day and all night. Resident R38 was not using her O2 mask at this time, and although the O2 concentrator was running, the tubing connecting the face mask to the concentrator was not connected.

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

On 02/06/25 at 10:37 AM, an interview and concurrent record review with Unit Manager (UM) 1 was done. UM1 reported Resident R38 does not use O2 all the time but likes to have it on continuously for comfort. Resident R38 takes on and off her face mask on her own. Inquired if Resident R38's CP reflected Resident R38's preference to have the O2 run continuously for comfort and was educated and assessed to independently remove and put on her mask on her own, UM1 confirmed it did not. Documentation for hand towels on both hands recommended and assessed by therapy, physician ordered, and in CP was not found by UM1.

Review of the facility's policy and procedure Oxygen Administration reviewed/revised on 06/2023 documented, The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 32 125024 Department of Health & Human Services Printed: 09/09/2025 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 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

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 4) Cross Reference to