Oahu Care Facility

F-F655 Baseline Care Plan

Resident R4 was a [AGE] year old female admitted to the facility for skilled nursing services on 03/19/2025 for short term rehabilitation after being hospitalized for two unwitnessed falls at home. She had a sacral Stage 2 PU present on admission that was not identified on her baseline care plan. Record review revealed no documentation the Resident R4 had been turned or repositioned until after the treatment administration record (TAR) was initatiated on 03/25/2025.

2) Record review of Resident R1's Minimum Data Set (MDS), noted Resident R1 was admitted on [DATE REDACTED] with an unstageable wound ulcer to his coccyx and required substantial/maximal assistance with rolling left to right in bed, sitting to lying position, and with transfers. Review of Wound Care Nurse (WCN) notes, dated 05/13/2024, indicated, wound on coccyx is necrotic and malodorous with large, purulent drainage. Resident R1's care plan for unstageable ulcer, initiated on 05/16/2024, included tasks to assist Resident R1 to turn/reposition at least every 2 hours. There was no documentation in Resident R1's TAR that repositioning/turning every 2 hours was completed.

3) Record review of R2s MDS noted that Resident R2 was admitted to the facility on [DATE REDACTED] with multiple PUs. Resident R2 had

a Stage 3 PU on the right buttocks, unstageable wound left buttocks, Stage 2 coccyx, and left ankle ulcers.

Review of WCN notes dated 03/21/2025, indicated wounds located on bilateral buttocks and left posterior thigh are smaller in size while the right posterior thigh is healed. Resident R2's care plan initiated on 02/28/2025, included tasks that Resident R2 needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. There was no documentation in Resident R2's TAR that repositioning/turning every 2 hours was completed.

4) On 03/25/2025 at 10:25 AM, interview with Certified Nurse Assistant (CNA)1 inquired how often they would check on the residents with PUs. CNA1 stated, We check up on them every time they have bowel movement, at least three times a day, in the morning after breakfast, again at lunch, and after dinner. When asked about peri care and repositioning, CNA1 replied, We clean them and would report any findings to the charge nurse. We change their position every two hours and document that in the I-pad, under Activities of Daily Living (ADLs), repositioning and sign our name. At 10:30 AM, CNA1 showed surveyor, where in the I-pad, they would document repositioning was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 125042 Department of Health & Human Services Printed: 09/04/2025 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 125042 B. Wing 03/25/2025

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

Oahu Care Facility 1808 South Beretania Street Honolulu, HI 96826

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 On 03/03/2025 at 10:40 AM, interviewed CNA2, who confirmed that they check residents with PUs every two hours for bowel and bladder elimination and reposition them every two hours. CNA2 verified that they Level of Harm - Minimal harm or document these tasks in the ADLs section in the I-pad. Surveyor asked CNA2, to open up Resident R2's chart to see if potential for actual harm documentation was noted for repositioning. Documentation showed repositioning on 03/25/2025. CNA2 was asked to show if documentation for repositioning was completed on 03/24/2025, and she confirmed that Residents Affected - Some there was none as she wasn't assigned to Resident R2 yesterday. CNA2 checked another date, 03/11/2025 to see if documentation on repositioning was done by another CNA, but record showed none were documented. It was confirmed that the documentation for positioning started on 03/24/2025. CNA2 went on to note that the CNAs should be documenting every day.

On 03/25/2025 at 01:30 PM, interview with Director of Nursing (DON) confirmed the importance of every two hours repositioning for residents with PUs and agreed there should be documentation of the task being done. DON also confirmed that there were no tasks triggered for the repositioning for both Resident R1 and Resident R2 upon admission but will do so to improve the process moving forward.

5) On 03/25/2025 at 01:45 PM, record review of the facility's Repositioning policy, with a revised date of May 2013, documented under General guidelines, states, 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief.3. Repositioning is critical for

a resident who is immobile or dependent upon staff for repositioning.5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Also noted in the same policy under the Documentation section, notes, The following should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet. 2. The name of the individual who gave the care.7. The signature and title of the person recording the data. These policy statements were not followed by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 125042 Department of Health & Human Services Printed: 09/04/2025 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 125042 B. Wing 03/25/2025

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

Oahu Care Facility 1808 South Beretania Street Honolulu, HI 96826

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39853 Residents Affected - Few Based on interviews, medical record review and document review, the facility failed to provide adequate supervision of one Resident (R)3 of three residents sampled that were high risk of elopement. Resident R3 eloped on 02/09/2025 and suffered harm. When she was found, she was taken to the hospital where she was treated for abrasions from a fall and discharged back to the facility. The facility met the following three criteria for past non-compliance 1) Not in compliance with the regulatory requirement at the time the situation occurred; 2) The noncompliance occurred after the exit date of the last recertification and 3) There is evidence that the facility corrected the noncompliance and is in substantial compliant at the time of this survey.

Findings include:

1) The Office of Healthcare Assurance received an initial facility reported incident (ACTS # 11488) on 02/10/2025 regarding an elopement. The report included the following information:

-Resident R3 initially admitted to facility on 01/10/2025 for skilled nursing facility services after a hospital admission following an unwitnessed fall with acute traumatic injury of CSpine (C3-C4), Unsteady gait, Multilevel degenerative changes of C-spine, Stage 5 Chronic Kidney Disease and dementia. Resident R3 is pleasant, alert, oriented to self, forgetful of place/situation, able to verbalize needs and understands others, and able to walk with a front wheel walker with supervision. Resident R3 had nondirectable exit seeking behavior on 1/12/2025 and a wanderguard bracelet was determined to be the least restrictive device.

-On 2/9/2025 at 4pm [sic] Resident R3 was unable to be found on the facility property and staff initiated the missing resident procedure. The resident was found by a good Samaritan on [NAME] Avenue (several blocks away in high traffic area) and had taken Resident R3 to .ER for evaluation. Resident R3 sustained a minor skin injury on bilateral knees, right elbow, and palm. She returned to the facility accompanied by facility Administrator on 2/9/2025 at 9:22Pm .

-Resident R3's wanderguard bracelet was noted in good working condition by day shift RN. On evening shift, RN noted Resident R3's wanderguard triggered by elevator, staff escorted her away, and RN administered medications at 3:26pm. CNA (Certified Nurse Assistant) then escorted her to the dining room to participate in activities. Activity staff were aware resident was in the dining room, but did not observe Resident R3 walking out of the dining room. At 4:00pm, RN started looking for resident to give her next scheduled medication. He looked in the dining room and her room, and resident was not found. Staff began missing resident procedure at approximately 4:10pm. Staff contacted the administrator soon after and called 911.

-Upon Resident R3's return to the facility, the facility Administrator and Nursing Supervisor tested the wanderguard bracelet on Resident R3's right ankle and found that the wanderguard bracelet is faulty. The wander guard bracelet did not trigger the elevator door until the Administrator was right in front of the elevator door and called for the elevator. A new wanderguard bracelet was immediately tested and .placed on resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 125042 Department of Health & Human Services Printed: 09/04/2025 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 125042 B. Wing 03/25/2025

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

Oahu Care Facility 1808 South Beretania Street Honolulu, HI 96826

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 0689 The completed report was received on 02/14/2025 and included the following:

Level of Harm - Actual harm -Upon incident on 02/09/2025, RF Technologies (RFT) Senior Service Technician was dispatched (urgent request was submitted immediately) and arrived on 2/12/2025. Technician assessed resident's transmitter Residents Affected - Few bracelet (the one on at the time of elopement) and verified that the equipment was faulty. The hardware (elevator and exit door system) for the WanderGuard transmitter bracelet was tested multiple times, and all devices were found to be working in good condition-please see attached report. 15 minute checks were done immediately upon incident on 2/9/2025, on resident and all other residents wearing the WanderGuard transmitter bracelets until the technician confirmed the system was in good condition.

-Additional education was done on 2/10/2025 regarding Wandering and Elopements and Missing Resident policies and procedures.

-In conclusion, resident's transmitter bracelet was effective and noted to be working by licensed staff an hour prior to the incident. The transmission bracelet resident had on was later identified to be faulty and malfunctioned .and tested by RFT technician; and thus the technical glitch was determined to have caused

the incident. Facility did not identify any problem with the WanderGuard system, and noted to be working properly, also verified and confirmed by technician.

-Resident R3 .was discharged as planned on 2/13/2025 .after successful rehabilitation and was transferred to a lower-level of care.

2) Reviewed Resident R3's Hospital Emergency Department Provider record dated 02/09/2025, time seen 06:14 PM.

The record included: Chief Complaint: Fall. Location of injuries-right elbow, right wrist and right knee and left knee. The injury occurred just prior to arrival. Occurred on a street. (Apparently a patient at .rehab and eloped undetected. Found on [NAME] Ave with wounds to extremities. Unwitnessed fall. Patient does not recall what happened.She complains of pain in right elbow and wrist).

Skin: (Multiple large skin tears involving right elbow and bilateral knees).

Neuro: Altered mental status: disoriented to place and time.

Course of Care:Wounds were thoroughly irrigated and dressed .

Resident R3 was discharged back to the facility with the nursing home manager.

3) Reviewed the facility policy titled WanderGuard Device, which included but not limited to the following:

1. Residents will be assessed for the need of WanderGuard bracelet at the time of admission and as needed.

3. The Director of Nursing or designee will be notified of any residents assessed for the need of the WanderGuard bracelet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 125042 Department of Health & Human Services Printed: 09/04/2025 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 125042 B. Wing 03/25/2025

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

Oahu Care Facility 1808 South Beretania Street Honolulu, HI 96826

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 0689 4. The Director of Nursing or designee will ensure that an order has been received from the attending physician and immediately facilitate the placement of the WanderGuard bracelet on the resident. Resident Level of Harm - Actual harm family will be notified in a timely manner.

Residents Affected - Few 5. Nurses will obtain an order on TAR (treatment administration record) for WanderGuard check every shift.

6. Environmental Services will be notified of resident receiving WanderGuard service and will issue the WanderGuard bracelet to the Nursing department.

7. An interdisciplinary team will develop a care plan for all residents wearing a WanderGuard bracelet

4) The facility is a three story building located on a busy street. There is one entrance/exit to the street and another to the parking garage. The first floor has a very small lobby with one elevator. All Residents live on

the second and third floor. The only exits from the Resident floors are the elevator and the fire exit doors/stairs.

On 03/25/2025 at approximately 10:30 AM, conducted a facility tour with maintenance staff (MS) and the Administrator (ADM). At that time, interviewed MS, who described their audit process for ensuring the equipment is working. Observed that all exits had the WanderGuard System in place, which was tested by maintenance with surveyor present.

At the time of survey, there were eight residents that had been assessed to be at risk of elopement, who had

the WanderGuard bracelets on. A random sample of three Residents were selected and maintenance staff accompanied surveyor and demonstrated and checked the bracelets with a handheld device. All three bracelets were functioning. Reviewed the Maintenance Audit tools completed once/week from February to current and confirmed Resident R4 had been on the list and the new Resident had been added the day the WanderGuard was put on. The tool included: Resident Room, date of expiration, did the elevator alarm activate, did the elevator door lock, did the exit door alarm activate, did the exit door lock, keypad working and alarm cleared, and any alarm delay less than 2-4 ft of the elevator or door noted.

Reviewed all Resident's with WanderGuard to confirm there was a Provider order. Some orders were specific to monitor the bracelet six times a day. This is a shared task between the Nurses and CNA's. Record

Review revealed compliance with monitoring on all Resident's. The monitoring includes Wanderguard Monitor placement and quality of device. Monitor skin integrity of resident.

Confirmed education on Wandering and Elopement, Resident Safety, and Policy had been completed for all staff

In summary, there was sufficient evidence of compliance at the time of survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 125042