Palolo Chinese Home
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
before this interview) for 08/13/25 at 10:40 PM documenting the physician was notified of Resident R4's decreased coughing and congestion with respirations 24-26 breaths per minute (BPM), normal range 16-20 BPM, remains on 3 liters (L) of oxygen via nasal cannula with oxygen saturations of 96-97%. On 09/05/25 at 11:41 AM, conducted a telephone interview with Physician (P)1 regarding Resident R4. P1 recalled receiving a phone call from RN13who reported Resident R4 was wheezing and coughing and ordered Duoneb and Robitussin as a plan of care. Inquired if P1 was informed that Resident R4 had coughing while eating or oral intake. Reviewed a progress note written by RN13 which documented Resident R4 with an occasional moist cough noted when eating. and P1 confirmed he was not verbally informed of this by RN13 during their telephone call and it may have warranted a different course of care. Also reviewed RN13's late progress note entry on 09/04/25 at 02:46 PM (written immediately prior to this interview) if P1 recalled receiving a telephone call form RN13 reporting that the resident's condition had improved. P1 confirmed a follow-up telephone call was not received from RN13, reporting Resident R4's improved physical status, then stated it would be unusual to receive a call of a resident doing better that time of night, protocol dictates that staff would call back if the resident was not improving and required additional interventions or needed to be transferred out to the hospital. On 09/05/25 at 06:23 AM, conducted a concurrent telephone interview and record review with RN12 (08/13/25 night shift nurse). RN12 recalled Resident R4 being awake throughout the night and could not recall any significant incidents for
the resident. RN12 stated it was a while ago. On 09/05/25 at approximately 10:00 AM, conducted an
interview and review of Resident R4's care plan with the Director of Nursing (DON)1. DON1 confirmed that Resident R4's diagnosis of a stroke should have been addressed upon admission to prevent the potential for aspiration.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palolo Chinese Home
2459 10th Avenue Honolulu, HI 96816
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on interviews and record review, the facility failed to maintain accurate documentation in a medical
record for one (Resident (R) 4) of three residents sampled. Late entries affected the care the resident was provided and did not reflect an accurate presentation of the resident. Finding Include: (Cross Reference to F-F684- Quality of Care)1) Review of Resident R4's Electronic Health Record (EHR) documented Registered Nurse (RN) 12 wrote a late entry progress note on 08/15/25 at 02:13 AM for 08/14/25 at 05:58 AM, after the resident was discharged to the hospital. The progress note written documented, endorsed to CNAs (Certified Nurse Aide) and will endorse to morning shift that Resident R4's Head of Bed (HOB) needs to stay elevated. However, this progress note was entered into the resident's Electronic Health Record (EHR) late.
As a result of a late entry this information the resident's record was incomplete. This incident could be pertinent to other facility disciplines in assisting the resident to reach his/her highest attainable physical well-being. As a result of the late entry, instructions to elevate Resident R4's head of bed was not communicated to staff. 2) During an interview with RN13 on 09/04/25 at 02:56 PM, discovered a late progress note RN13 wrote on 09/04/25 at 02:46 PM (prior to the interview) for 08/13/25 at 10:40 PM. The progress note documented that RN13 notified Physician (P) 1 that Resident R4's coughing and wheezing had decreased. However,
during a telephone interview with P1 on 09/05/25 at 11:41 AM, P1 confirmed he did not receive a second phone call from RN13 reporting Resident R4's decreased coughing and wheezing.
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Palolo Chinese Home in HONOLULU, HI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HONOLULU, HI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Palolo Chinese Home or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.