The Care Center Of Honolulu

F-F609)

Resident R31 is a [AGE] year-old resident, who was admitted to the facility on [DATE REDACTED] for physical and occupational therapy to improve the resident's level of functioning. Resident R31's diagnoses include sepsis, cellulitis (skin infection that appears red and swollen) of upper limb, hypertension, a history of falling, and a need for assistance with personal care, weakness, and unsteadiness on feet.

Review of Resident R31's Electronic Health Records (EHR) documented a Minimum Data Set (MDS) admission assessment with an Assessment Refence Date (ARD) of 07/18/24, Section C. Cognitive Patterns the resident scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition is intact, and that he is a reliable source of information. Section GG- Functional Abilities and Goals documented

the resident is dependent (helper does ALL the effort) on staff for oral hygiene, toileting, upper and lower body dressing, putting on footwear, and personal hygiene (combing hair, shaving, washing and drying face and hands).

After filing a complaint with the facility regarding the Alleged Perpetrator's (AP) treatment of Resident R31, AP was informed not to have any form of contact with the resident. Resident R31 reported AP verbally confronted and intimidated the resident causing the resident to be fearful of staff, feel afraid and anxious, and started having violent nightmares of physically defending himself from AP.

During an interview on 08/14/24 at 11:10 AM with the Administrator and AADM, the Administrator confirmed

she was not informed that Resident R31 reported to AADM that AP confronted and intimidated the resident after the resident complained to the facility's management of the staff. AADM confirmed he did not identify AP confronting the resident about his complaints as having the potential for abuse. As a result of not conducting and following up with Resident R31, the facility was unaware of Resident R31's nightmares and new feeling of anxiousness and feeling unsafe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0610 On 08/14/24 at 01:48 PM, conducted an interview with Social Service Director (SSD) regarding Resident R31's allegations. SSD stated she normally handles the resident's complaints and grievances; however, she was Level of Harm - Minimal harm or on leave during this time and had not been informed of Resident R31's allegations. SSD confirmed no investigation potential for actual harm was conducted into the resident's report of AP confronting the resident after complaining about staff's treatment of the resident and it was not reported to the state agencies. SSD stated at the time of the incident, Residents Affected - Few AADM was acting as the Grievance Officer. After SSD was informed of Resident R31's allegations, she confirmed AP should have been placed on leave after Resident R31 reported he confronted the resident while a formal investigation was completed to ensure the resident's safety. At 03:00 PM, SSD reported Resident R31 was interviewed regarding

the incident and her interview with the resident was consistent with this surveyor's resident interview and would be conducting a formal investigation of Resident R31's allegation of verbal abuse and intimidation by AP.

Review of a progress note written by SSD on 08/14/24 at 03:14 PM, Social Service Assistant (SSA)5 and SSD met resident in the social service office, Resident R3 1 verbalized I am not feeling safe unless you transfer me to another facility or let him (AP) go. Resident agreed to a lateral transfer.

Review of SA's Aspen Complaints/Incidents Tracking System did not include a report from the facility of AP confronting Resident R31 after the resident filed a complaint of AP's treatment of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38870 potential for actual harm Based on record review and interview, the facility failed to correctly document the presence of a stage three Residents Affected - Few pressure ulcer in the Resident Assessment Instrument (RAI) for one Resident (R) 56 of 32 in the sample. As

a result of this deficient practice, Resident R56 was not properly coded which could affect the resident's care plan and potential outcomes. All residents have the potential to be affected.

Findings include:

Resident R56 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] with a diagnoses that include anoxic brain damage, muscle weakness, contractures of left and right forearm muscle, stage three pressure injury to the sacrum . per record review (RR) of face sheet.

RR of a skin & wound evaluation, dated 08/12/2024, noted the following documentation:

Stage three to sacrum. present on admission. 0.3 centimeters (cm) long 0.2 cm wide no undermining or depth. No tunneling. Wound healing is slow or stalled but stable, little/no deterioration. Generic wound cleanser with foam dressing .

Minimum Data Set (MDS) quarterly assessment, dated 07/18/24, reviewed. Resident R56 was not coded with an unhealed pressure ulcer.

Prior discharge assessment, dated 04/24/24, reviewed. Resident R56 was coded with a stage three pressure ulcer which was not present on admission.

Interview with Minimum Data Set Coordinator (MDSC)1 in the MDS office on 08/15/24 at 12:30 PM. The surveyor confirmed with MDSC1 that Resident R56 was not coded with a stage 3 pressure ulcer on the 07/18/24 quarterly assessment and that Resident R56 was diagnosed with a stage 3 pressure ulcer at the time of the look back period. MDSC2 joined the interview stating, we will correct the error on the MDS assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38870

Residents Affected - Few Based on observation and record review, the facility failed to implement the care plan for two Residents, (R)126 and Resident R218, of 32 residents in the sample. Resident R126 was not repositioned at least every two hours to promote healing of his pressure ulcer and Resident R218 was not routinely repositioned or transferred to a wheelchair.

The deficient practice placed the residents at risk for a decline in their functional and physical health status. All residents who are dependent on staff have the potential to be affected.

Findings include:

Cross reference to

F-F610)

Resident R31 is a [AGE] year-old resident, who was admitted to the facility on [DATE REDACTED] for physical and occupational therapy to improve his level of functioning. Resident R31's diagnoses include sepsis, cellulitis (skin infection that appears red and swollen) of upper limb, hypertension, a history of falling, and a need for assistance with personal care, weakness, and unsteadiness on feet.

Review of Resident R31's Electronic Health Records (EHR) documented a Minimum Data Set (MDS) admission assessment with an Assessment Refence Date (ARD) of 07/18/24, Section C. Cognitive Patterns the resident scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition is intact, and that he is a reliable source of information. Section GG- Functional Abilities and Goals documented

the resident is dependent (helper does ALL the effort) on staff for oral hygiene, toileting, upper and lower body dressing, putting on footwear, and personal hygiene (combing hair, shaving, washing and drying face and hands).

During an interview on 08/12/24 at 10:06 AM, Resident R31 reported he made a complaint to the facility regarding how AP treated him when he requested assistance with the temperature of the air conditioner. After filing the initial complaint with the facility, Resident R31 was assured that AP had been instructed not to have any form of contact with him. Following this assurance, Resident R31 reported AP verbally confronted and intimidated him while

he was alone in his room, causing him to be fearful of staff, feel afraid and anxious, and he began having violent nightmares of physically defending himself from AP. Resident R31 stated he informed AADM that AP came into his room and confronted him for making the initial complaint.

During an interview on 08/14/24 at 11:10 AM with the Administrator and AADM, the Administrator confirmed

she was not informed that Resident R31 reported to AADM that AP had confronted and intimidated him following the initial complaint. AADM confirmed although he was informed, he did not identify AP confronting Resident R31 about

the initial complaint as having the potential for abuse. As a result of not conducting an investigation and following up with Resident R31, the facility was unaware of Resident R31's nightmares and new feelings of anxiousness and feeling unsafe.

Review of SA's Aspen Complaints/Incidents Tracking System did not include a report from the facility of AP confronting Resident R31 after the resident filed a complaint of AP's treatment of him.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42160 potential for actual harm Based on interview and record review, the facility failed to thoroughly investigate an allegation of potential Residents Affected - Few abuse for one resident (Resident (R)31) sampled. Resident R31 reported to the Assistant Administrator (AADM) that a staff member confronted and intimidated him about a complaint he made about the staff member. AADM confirmed the incident was not identified as potential abuse and an investigation into the incident was not initiated.

Findings include:

(Cross reference to

F-F656.

RR of physician orders: Up to wheelchair daily at 10:30 am and have patient up in wheelchair until lunch time use HOYER (a mechanical lift to assist with transfer) one time a day 4/4/2024.

RR of plan of care (POC) dated 08/02/24 to 08/14/24. Turn and reposition (right side, left side, back, chair. Resident R218 was documented up in the chair on 08/03/24 at 2:13 PM and 08/10/24 at 12:19 PM. The rest of the days document Resident R218 was laying in bed.

Interview with Restorative Nurse Aide (RNA) 4 on 08/15/24 at 12:29 PM the surveyor asked RNA4 if Resident R218 was receiving restorative care. RNA4 stated that Resident R218 is working with an outside rehabilitation agency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 42160

Residents Affected - Few Based on observation and interview, the facility failed to ensure that staff implemented specific competencies necessary for resident safety. This deficient practice has the potential for harm.

Findings include:

On 08/14/24 at 09:00 AM, while waiting to check a medication cart on Unit 4, observed Registered Nurse (RN)10 dispose of a medication tablet in the trash bin (unlocked, unsecure) located on the side of the medication cart. The medication landed on the top of other trash which was visible and accessible to anyone passing the medication cart. Inquired if it was okay to dispose of the medication tablet in the trash bin at the side of the medication cart which was unsecured and unable to be locked. RN10 stated she would have to check on how she was supposed to dispose of that medication. RN10 confirmed she disposed of a tablet of Aspirin 81 mg (milligrams) on the side of the medication cart and remained unsure of how to properly dispose of the medication. As RN10 and this surveyor were discussing RN10 disposing of the medication in

an unsecure/unlocked trash bin, and the potential opportunity for a resident to retrieve the medication from

the cart, Resident (R)140 independently and unsupervised, wheeled himself past the medication cart with the Aspirin 81 mg tablet exposed.

On 08/15/24 at 12:20 PM, conducted an interview with Unit Manager (UM)8 and informed her of an

observation of staff disposing a tablet of Aspirin 81 mg in the trash bin on the medication cart. UM8 confirmed disposal of non-controlled medication should be in the sharps or another closed system and should have not been disposed of in the trash on the medication cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42160 potential for actual harm Based on observations and interviews, the facility failed to ensure posted nurse staffing information was in Residents Affected - Some clear and in an identifiable and prominent place. As a result of this deficient practice, residents and resident representatives are not informed of the number of staff available for resident care.

Findings include:

1) On 08/13/24 at 10:55 AM, conducted observations of daily staff posting at the entrance of the building and

on all four (4) units. Near the entrance of the building, after the screener's station, Daily Staff Posting is posted on a bulletin board along with the employee clock in/out system, a Stay up to Date with your Covid Vaccine poster, Cover your Cough poster, August 2024 Employee Calendar, Mandatory CNA (Certified Nurse Aide) Meeting, and a list of employees who need to see the Director of Nursing (DON) prior to starting

the shift. The 24-hour-Daily Staff Posting form was printed on what appeared to be an 11-inch (in) x 13 in paper. The print was small, and this surveyor was unable to clearly read the form until standing approximately two (2) feet away from the form. There was no larger sign clearly indicating the form was the 24-Hour-Daily Staff Posting. A visitor approached the main exit doors and this surveyor inquired if she knew where the daily staff posting was located. The visitor confirmed she did not know where it was despite standing approximately 3-4 feet away from the posted form.

On each of the four units, the names of the staff working are written on a dry erase board which is set in the back of the nurses' station, over 10 feet from the entrance to the nurses' station. The entrance of the nurses' station is noted by a high counter/desktop, which is where any resident or visitor would be stopped prior to entering the nurses' station. The dry erase board was difficult to identify the location the units were listing, or

the individual staffing census.

On 08/14/24 at approximately 02:10 PM, inquired with the Director of nursing where the daily staffing information was posted. DON confirmed daily staffing is written on the whiteboards on each unit and at the entrance of the building. Informed DON on initial observation, the listing was not identifiable or highly visible when entering into the building due to the form being posted on the employee notification board, it appears like information for staff.

On 08/15/24 at 11:37 AM, observed Resident (R)315 and multiple family members (FM), walk past the nursing station at a slow rate, then into the resident's room. Inquired with FM99, who was a young adult male (25-[AGE] years old), confirmed he does not need or use glasses and has great eyesight, if he was aware where the daily staffing was posted for the unit and for the facility. FM99 confirmed he has never seen any daily staffing form or information, and stated, Nope, I don't know where it is, and staff never told me where it was at.

At 11:40 AM, inquired with Resident R138's FM if she knew where the facility's daily staffing information for Resident R138's unit and for the entire facility was located. FM confirmed she did not know where that information was and has never seen the form.

43414

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0732 2) On 08/12/24 at 08:24 AM, during an initial observation of Unit 3, the daily nursing staffing posting with total number and actual hours worked per shift for nursing staff responsible for resident care was not found. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 48351

Residents Affected - Few Based on observation, interview, and record review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled on 1 of 4 units in the facility.

This deficient practice increases the risk for diversion of resident medications.

Findings include:

Observation was conducted on 08/14/24 at 07:38 AM at the nurses' station on the second floor. Registered Nurse (RN)24 was observed preparing medications for a resident. The medication cart she was using was unlocked and RN24 was accessing the medications contained in the medication cart.

A review of the facility's document titled, Controlled Item Checklist, dated August, was conducted on 08/14/24 at 07:49 AM. The sheet did not contain the outgoing night shift nurse and the incoming day shift nurses' signatures for August 14, 2024, in the 07:00 AM boxes. RN24 was informed of the missing signatures. RN24 stated that it should have been signed earlier with the outgoing night shift nurse.

On 08/14/24 at 07:57 AM, RN24 and RN20 were both observed signing the facility's, Controlled Item Checklist, form.

Interview was conducted with RN20 on 08/14/24 at approximately 08:20 AM. RN20 stated that she was the only nurse on the unit on night shift and after performing the narcotic count with RN24, she did not sign off on

the controlled item sheet. Instead, RN20 stated that she did her final rounds and used the restroom. She didn't want RN24 to wait on her to start her morning medication administration, so she handed off the medication cart prior to signing the narcotic count sheet. RN20 confirmed that the normal process is to count

the narcotics and once verified, the outgoing and incoming nurses sign the sheet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 43414

Residents Affected - Few Based on record review and interview, the facility failed to ensure the physician, the facility's medical director, and/or director of nursing acted upon irregularities the pharmacist reported during the monthly medication regimen review (MRR) for two of five residents sampled (Resident (R) 67 and Resident R110). The attending physician did not document in the medical record that the identified irregularities had been reviewed, nor did he/she document the rationale for the no change in medications.

Findings include:

Review of the facility's policy and procedure Medication Regimen Reviews, revised in May 2019, documented The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record.

1) During review of Resident R67's Electronic Health Record (EHR), under the pharmacist note in progress notes, the pharmacist documented for MRR 07/31/24 to see report. Review of documented MRRs uploaded in the resident's EHR found the MRR for 07/31/24 was not uploaded in the EHR. Review of hard chart at the nurse's station found the MRR 07/31/24 was not in the file.

On 08/14/24 at 08:57 AM, an interview with Director of Medical Records (DMR) was done. Inquired where

the facility keeps residents' MRRs. DMR reported it would be uploaded in the EHR or put in a binder. DMR was observed to look for the binder at the nurses' station but was not able to locate it. DMR further stated

she will have to look for it in the medical records office.

On 08/15/24 at 09:25 AM, an interview and concurrent record review was done with DMR. Review of Resident R67's MRR dated 07/31/24 from the pharmacist to the attending physician documented: To help optimize pain management for this resident, please consider adding: . For severe pain not managed by PRN [as needed] APAP [Acetaminophen] to the PRN oxycodone order. Under physician's response, a handwritten note on the signature line documented: No new order. The note was dated 07/31/24, and was not signed. The bottom of

the MRR form was noted to have a print date of 08/05/24. Inquired why the physician did not sign the document. DMR reported the physician was called, and the response was not to change the order. Requested for DMR to provide documentation the physician was called and notified, as well as documentation of the physician's rationale for not making the recommended change in the order.

Review of Resident R67's progress notes found no documentation the physician was notified of the recommendation and the physician's response or rationale. The documentation requested on 08/15/24 was not provided by

the facility or DMR.

2) During review of Resident R110's EHR under the pharmacist note in progress notes, the pharmacist documented for MRR between 09/01/23 and 09/30/23 to see report. Review of documented MRRs uploaded in the resident's EHR found the MRR was not uploaded in the EHR. Review of hard chart at the nurse's station found the MRR was not in the file.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0756 The facility provided a copy of Resident R110's MRR between 09/01/23 and 09/30/23 after it was not found in a binder of residents' MRRs provided by the DMR. The MRR documented on 09/11/23, the pharmacist's Level of Harm - Minimal harm or recommendation to nursing staff, Please clarify medication administration directions for this resident using a potential for actual harm feeding tube (APAP sorbitol Instaglucose Iron see MAR [Medication Administration Record]. There was no documentation found for either the physician or nursing staff regarding the recommendation and their Residents Affected - Few response.

On 08/15/24 at 11:48 AM, an interview and concurrent record review with License Practical Nurse (LPN) 2 was done. Inquired if Resident R110 had a feeding tube, LPN2 confirmed she did, and that medications would be administered through the feeding tube. Concurrent review of the MAR for APAP, sorbitol, insta-glucose, and iron found the order for APAP: Give 650 mg by mouth .; insta-glucose (discontinued on 08/14/24, 11 months

after the recommendation): Give 24 gram by mouth .; and for iron: Give 1 tablet by mouth . LPN2 reported

the medication orders should not say by mouth and should have been changed to administer via G-Tube.

The orders for APAP, insta-glucose, and iron routes of administration were not changed to feeding tube or by G-Tube despite the pharmacist recommending the facility clarify the administration directions on 09/11/23.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 43414

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure a resident's food preference/request was followed for one of four residents sampled (Resident (R) 106). Resident R106 requested white bread for every meal and did not get white bread for every meal.

Findings include:

On 08/12/24 at 10:45 AM, during an interview with Resident R106 at the bedside, resident reported she spoke with the facility's dietician and requested to have milk every morning and plain white bread every meal but has not been getting her request. Resident R106 did not understand why she needed to ask for milk and white bread every day.

On 08/12/24 at 12:36 PM, observed Resident R106's lunch tray to not have plain white bread. Resident R106 stated no bread again and brought out a half a slice of white bread from the top of her nightstand kept in a cup that she saved from the morning and said, good thing I kept one. Reviewed Resident R106's meal card for lunch on her meal tray which documented + 2 SLICES BREAD DAILY (untoasted).

On 08/13/24 at 08:24 AM and 08/14/24 at 08:44 AM, observed Resident R106 eating breakfast with bread and milk on her plate, she reported she received them without asking for breakfast but did not receive white bread for lunch and dinner on 08/12/24 and 08/13/24.

On 08/15/24 at 10:12 AM, an interview with Dietary Director (DD) was done. DD reported if the meal card documented a specific preference for that mealtime, whether it be breakfast, lunch, or dinner the resident should be getting their request despite the word daily for that mealtime.

Reviewed Resident R106's meal card for breakfast, lunch, and dinner, all meal cards document + 2 SLICES BREAD DAILY (untoasted).

Review of the facility's policy and procedure, Food and Nutrition Services revised in October 2017 documented Meals and/or nutritional supplements will be provided per scheduled meal time or by request, and in accordance with the resident's medication requirements .Reasonable efforts will be made to accommodate resident choices and preferences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48351

Residents Affected - Some Based on observations, interview, and record review, the facility failed to store and serve food in accordance with professional standard for food service safety. This deficient practice has the potential to place facility residents at risk for food-borne illness.

Findings include:

1) A concurrent observation and interview were conducted on 08/12/24 at 08:27 AM in the facility kitchen. One of the refrigerators contained a container of rice porridge with a discard date of 08/11/24. Dietary Director (DD) stated that it should have been discarded since the kitchen staff performs audits twice a day.

Review of the facility policy titled, Food Receiving and Storage, with a revised date of 10/2017, was conducted. The facility policy documented, Food shall be received and stored in a manner that complies with safe food handling practices.

2) Concurrent observation and interview were conducted with the Dietary Aide (DA) 1 on 08/12/24 at 08:53 AM. DA1 was observed checking the dishwasher sanitizer with a quality assurance strip. When asked if she logs the results, DA1 stated that kitchen staff only logs the temperature for the dishwasher and there was no log for checking the dishwasher sanitizer.

Interview was conducted on 08/12/24 at 01:28 PM with DD. DD confirmed that the facility did not have a log for the dishwasher sanitizer quality assurance checks.

A review of the facility policy titled, Dishwashing Machine Use, with a revised date of 03/2010, was conducted. The facility policy documented, A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245

Residents Affected - Few Based on interview and record review, the facility failed to maintain medical records on 1 of 32 residents sampled, that were accurately documented. As a result of this deficient practice, Resident (R)313 was placed at risk for a decrease in quality and competency of care. In addition, based on observation, interview, and

record review, the facility failed to keep a resident's Electronic Health Record (EHR) confidential. This deficient practice places residents' EHRs at risk for violations of the Health Insurance Portability and Accountability Act (HIPAA).

Findings include:

1) Resident (R)313 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] for short-term rehabilitation. Resident R313's admitting diagnoses include, but are not limited to, acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), epilepsy, and esophageal (tube that runs from

the throat to the stomach) obstruction. As a result of his admitting diagnoses, Resident R313 was admitted with a tracheostomy (a surgically created hole in your windpipe (trachea) that provides an alternative airway for breathing) and a gastrostomy tube (feeding tube). A review of Resident R313's electronic health record (EHR) on 08/13/24 noted the following active provider order:

NPO diet, NPO texture, to mean nothing by mouth.

On 08/15/24, further review of Resident R313's EHR noted the following in the nurse progress notes, documented word-for-word, on 08/12/24 10:28 AM; 08/11/24 06:17 PM; 08/11/24 10:13 AM; 08/10/24 10:40 PM; 08/10/24 03:40 PM; and 08/10/24 05:05 AM:

Nutrition: Taking nutrition and hydration orally. No complaints of thirst. No signs/symptoms of a swallowing disorder. Mucous membranes moist.

On 08/15/24 at 11:40 AM, an interview was done with Unit Manager (UM)8 in her office. After a concurrent

review of the nurse progress notes/skilled nursing assessments listed above, UM8 agreed there should not be any documentation indicating that Resident R313 was taking any food or liquids by mouth as that would be incorrect. UM8 also agreed that the documentation appeared repeatedly copied and pasted. UM8 stated that copying and pasting of assessments or portions of assessments should not happen. UM8 stated that she was surprised and disappointed to see incorrect documentation happening even once, but repeatedly over

the course of two days was unacceptable. UM8 agreed that accurate assessments were important for appropriateness and quality of care.

48351

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0842 2) Concurrent observation and interview were conducted on 08/14/24 at 01:20 PM near the 1st floor nurse's station. A medication cart was parked in front of the nurse's station with the computer screen facing the Level of Harm - Minimal harm or hallway and the tv/dining room. The screen displayed one of the resident's EHR. The tv/dining room had five potential for actual harm residents sitting at the tables. The hallway had a newly admitted resident in a wheelchair that was being pushed by a visitor. The visitor paused in front of the medication cart waiting for staff to acknowledge him Residents Affected - Few and the new resident. As they both waited, the visitor was observed looking at the computer screen with a resident's EHR displayed. Registered Nurse (RN) 24 was nearby and the State Agency (SA) informed RN24 of the opened computer screen. RN24 stated the computer did not belong to her and that it belonged to RN10. RN24 quickly closed the resident's EHR and confirmed that it should not have been left open. RN10 was informed of the opened EHR; she agreed that she should have logged off prior to leaving the computer unattended.

A review of the facility policy titled, Computer Terminals/Workstations, with a revised date of 04/2014, was conducted. The policy documented, A user may not leave his/her workstation or terminal unattended unless

the terminal screen is cleared, and the user is logged off. Each user must log off at the end of his/her work shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 potential for actual harm Based on interview and record review, the facility failed to ensure the Binding Arbitration Agreements Residents Affected - Few ([NAME]) they asked the residents (or their representatives) to enter into, were explained in a form and manner that they could understand. This is evidenced by 1 of 3 residents or resident representatives (of Resident 63) sampled stating she did not have the BAA explained to her in a way that she understood what it meant.

Findings include:

On 08/13/24 at 12:00 PM, an interview was done with the resident representative/family member (FM3) for Resident (R)63 at his bedside. During a concurrent review of a copy of the signed BAA and being asked if

she recognized it, FM3 reported that she believed it was a form in a bunch of forms that had been sent to her to sign once when Resident R63 was being readmitted from the acute care hospital. FM3 also reported that she could not recall the form being explained to her and stated that she wasn't sure what it was for. After the state agency (SA) explained the BAA form to her, FM3 stated that she was sure the form had not been explained to her before, because if it had, she would not have signed it. When shown the Voluntary Arbitration Program Information Sheet and asked if it had been read to her by a facility representative, FM3 responded that she did not recall seeing the Information Sheet before, nor did she remember it being read to her. FM3 stated that she did receive a phone call about the Admission Packet forms but was only asked if there were any changes. When she responded that there were no changes, FM3 stated that she was asked to review and sign the forms.

On 08/14/24 at 02:19 PM, an interview was done with the Director of Medical Records (DMR) outside of the Administrator's Office. The DMR confirmed that the BAA would have been sent to FM3 for e-signatures with about 27 [other] forms in the Admission Packet [all requiring signatures]. The DMR also confirmed that the social services representative that had signed off as reviewing the BAA information with FM3 no longer worked for the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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** 43414 potential for actual harm Based on observation and interview, the facility failed to provide a safe, sanitary, and comfortable Residents Affected - Few environment to prevent the development and transmission of communicable diseases and infections for two of six residents sampled for infection control (Resident (R) 126 and Resident R85). Resident R85's humidifier bottle was not properly secured to the oxygen concentrator. During Resident R126 sacral wound dressing change, the nurse didn't sanitize hands after removing dirty gloves and before putting on clean gloves. This failure could place the resident at risk for infection.

Findings include:

1) On 08/12/24 at 08:38 AM, during an observation of Resident R85's room, observed Resident R85 on oxygen, oxygen contractor running, and the humidifier bottle had broken off tape around it and was taped on the bottom sticking to the ground. The rubber band that secured the humidifier bottle to the concentrator was broken and there was tape around the concentrator. Resident R85 reported the humidifier bottle was taped to the concentrator this morning but it fell off and he had issues with his oxygen tube soon after, .there was a kink in the machine and the tubing was changed right after. Resident R85 reported the rubber band holding the humidifier bottle had been broken for a while but could not provide how long or the date when he first noticed it broken.

On 08/15/24 at 10:39 AM, an interview with Infection Preventionist (IP) was done. Inquired if an oxygen humidifier bottle on the floor would be acceptable. IP stated no because the floor is not sanitary with possible germs, bile, and infectious diseases on the floor. IP admitted this could put the resident at risk of infection.

38870

2) Resident R126 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] with primary diagnoses that includes heart failure; septicemia; wound infection and an unhealed stage four pressure ulcer of the sacral region, per

Record Review (RR) of the face sheet.

Wound care team observed on 08/14/24 at 08:45 AM. Licensed Practice Nurse (LPN) 3 and Registered Nurse (RN) 22 started the dressing change on Resident R126's stage four sacral wound.

During the dressing change, observed LPN3 clean the wound and remove her dirty gloves then put clean gloves on without sanitizing her hands. The surveyor asked LPN3 if she should sanitize her hands after removing the dirty gloves and before putting on the clean gloves. LPN3 said yes and proceeded to remove

the gloves, apply the hand sanitizer, and replaced with the clean gloves.

Wound Care policy and procedure, 2001 MED-PASS, Inc. (Revised October 2010) reviewed. 7. Cleanse wound with ordered wound cleanser . 8. Pull glove over and discard into appropriate receptacle. Wash and dry your hands thoroughly or may use alcohol-based sanitizer as an alternative . 9. DON new gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 125019

F-F686.

Resident R126 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] with a primary diagnosis that includes heart failure; septicemia; wound infection and an unhealed stage four pressure ulcer of the sacral region, per

Record Review (RR) of the face sheet.

During random observations of Resident (R)126 in his room on the following days and times:

08/12/24 at 09:07 AM and 2:00 PM;

08/13/24 at 09:15 AM; 11:30 AM; 2:00 PM and 3:45 PM;

08/14/24 at 08:45 AM, 11:38 AM, 1:45 PM, and 3:14 PM,

noted Resident R126 laying on his back with the head of the bed elevated, watching television.

Record Review (RR) of Resident R126's Care plan (CP), started 07/15/2023, noted the following:

Resident R126 has limited physical mobility related to pain, wounds, deconditioning secondary to sepsis. Stage four to sacrum. Will show signs of healing without complications through the next review date. The resident will not develop any further complications related to immobility .

2) Resident R218 is a [AGE] year-old female admitted to the facility on [DATE REDACTED] with a diagnosis that includes depression, hemiplegia, and hemiparesis (weakness) per Record Review (RR) of face sheet.

Cross reference to

F-F688. Care plan (CP) 02/19/24 reviewed:

The resident has impaired mobility related to (r/t) medical comorbidities. The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 The resident has impaired mobility r/t medical comorbidities. Date Initiated: 02/19/24 Resident to be up in wheelchair (w/c) at 1030. Revision on: 03/05/24 Restorative Nurse Aide (RNA) to Monitor/document/report Level of Harm - Minimal harm or as needed (PRN) signs and symptoms (s/sx) of immobility: contractures forming or worsening, thrombus potential for actual harm formation, skin-breakdown, fall related injury.

Residents Affected - Few RR of Plan Of Care (POC) dated 08/02/24 to 08/14/24. Turn and reposition (right side, left side, back, chair. Resident R218 was up in the chair on 08/03/24 at 2:13 PM and 08/10/24 at 12:19 PM. The rest of the days documented Resident R218 was laying in bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 29 125019 Department of Health & Human Services Printed: 09/13/2025 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 125019 B. Wing 08/15/2024

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

The Care Center of Honolulu 1900 Bachelot Street 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38870 potential for actual harm Based on observation, interview and record review, the facility failed to provide treatment consistent with Residents Affected - Few professional standards of practice to promote the healing and prevent infection of an existing stage four pressure ulcer for one Resident (R) 126. Resident R126 required maximum assistance and was not repositioned off of

the wound at least every two hours. The deficient practice places placed the resident at risk of worsening a stage four pressure injury. All residents who require maximum assistance from staff have the potential to be affected.

Findings include:

Resident R126 is a [AGE] year-old male admitted to the facility on [DATE REDACTED] with a primary diagnosis that includes heart failure; septicemia; wound infection and an unhealed stage four pressure ulcer of the sacral region, per

Record Review (RR) of the face sheet.

Observation and interview with Resident R126 in his room on 08/12/24 at 09:04 AM. Resident R126 was in his bed on his back with the head of bed up 45 degrees. Resident R126 said that he used to walk pretty well before but now I'm in bed all

the time. The surveyor asked Resident R126 if he is able to get the help he needs from the staff? Resident R126 said, I have a sore on my back that's infected and pretty deep. I'm supposed to be turned every two hours but there isn't always enough staff available. It takes two Certified Nurse Aides (CNA)'s to do it, and one CNA can't do it by themself. I take antibiotics because I have an infected sore. I wish I could turn or get a pillow. When they came in to change the bed, they moved the extra pillows and I didn't get them back, they must be in short supply.

Record Review (RR) of the Minimum Data Set (MDS) annual review 07/09/24. Resident R126 is cognitively intact. Dependent on staff for toileting, bathing and dressing and requires partial to moderate assistance to roll left and right and dependent on staff for bed to chair transfer. Resident R126 has a stage four pressure ulcer present on admission.

RR of Care plan 07/15/23 cross reference to