Palolo Chinese Home
Palolo Chinese Home in HONOLULU, HI — inspection on September 5, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
before this interview) for 08/13/25 at 10:40 PM documenting the physician was notified of 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 R4. P1 recalled receiving a phone call from RN13who reported R4 was wheezing and coughing and ordered Duoneb and Robitussin as a plan of care.
Inquired if P1 was informed that R4 had coughing while eating or oral intake.
Reviewed a progress note written by RN13 which documented 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 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 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 R4's care plan with the Director of Nursing (DON)1. DON1 confirmed that R4's diagnosis of a stroke should have been addressed upon admission to prevent the potential for aspiration.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Palolo Chinese Home
2459 10th Avenue Honolulu, HI 96816
SUMMARY STATEMENT OF DEFICIENCIES
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 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 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 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 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 R4's decreased coughing and wheezing.
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