Ann Pearl Nursing Facility

F-F699 TIC for Resident R41. The facility failed to develop a TIC plan of care to address the trauma triggers and specific needs of Resident R41 with a diagnosis of PTSD.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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** 48351

Residents Affected - Few Based on record review and interview, the facility failed to revise the care plan for one of one sampled resident (Resident (R) 42) for elopement. This deficient practice has the potential to place Resident R42 at risk for future elopements.

Findings include:

Resident R42 is a [AGE] year-old male, admitted to the facility on [DATE REDACTED]. Resident R42 has medical diagnoses that include, but not limited to schizophrenia and dementia.

A review of Resident R42's Electronic Health Record (EHR) was conducted on 02/26/25. Resident R42's EHR noted a progress note that on 10/11/24, Resident R42 had walked out of the front door of the facility because he was needing money for cigarettes. A review of Resident R42's current care plan noted that on 07/10/24, the facility had created a plan of care for Resident R42's wandering and exit seeking behaviors. Since 07/10/24, there was no revision done for this plan of care.

Interview was conducted with Director of Nursing (DON) on 02/27/25 at 10:22 AM in her office. DON confirmed that the facility would normally address the root cause of his elopement, which was seeking money for cigarettes, and update the resident's care plan. She added that a revision of Resident R42's care plan should have been done after he walked out of the facility door on 10/11/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. 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 observations, interviews, and record reviews, the facility failed to ensure one of two residents (Resident (R)12) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM in her left hand and elbow, as evidenced by inconsistent application of orthotic devices and ROM exercises. As a result of this deficient practice, Resident R12 was placed at risk of a decline in ROM and a loss of function.

Findings include:

Resident R12 is a [AGE] year-old female admitted to the facility on [DATE REDACTED] for long-term care. A review of Resident R12's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 12/01/24 noted that her diagnoses include, but are not limited to, left-sided weakness and paralysis following a stroke, chronic pain, and heart failure. The Annual Assessment also documents Resident R12 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that she is cognitively intact.

On 02/25/25 at 09:16 AM, observations and interview were done with Resident R12 at her bedside. Observed that Resident R12 was not moving her left arm. When asked, Resident R12 stated that she had a stroke in 2015 and has not been able to move her left arm too much since. No braces or splints were visible at the bedside at this time.

On 02/25/25 at 01:07 PM, observations and interview were done with Resident R12 at her bedside. Observed an elbow splint and wrist splint sitting on the nightstand behind her bed. Resident R12 stated that they were for her left arm because of her stroke and resulting paralysis and weakness, and that facility staff helped her put them

on every day. Resident R12 confirmed that they had not been applied yet that day.

Review of physician/provider orders revealed the following orders related to Resident R12's splints:

01/10/25 Splint: Apply left elbow splint for 1-2.5 hours during day shift (06:00 AM - 02:00 PM), once a day.

01/10/25 Splint: Apply left palm protector splint with finger separators for 1-2.5 hours during day shift, once a day.

01/10/25 Splint: Apply left wrist, hand, finger, orthosis for 1 - 2.5 hours during evening shift (02:00 PM - 10:00 PM), once a day.

On 02/26/25 at 08:00 AM, a review of Resident R12's electronic health record (EHR) revealed that Point-of-Care (POC) responses for splints and passive range of motion (PROM), which is ROM that is achieved when an outside force (such as a therapist) exclusively causes movement of a joint, did not reflect the application or offer of application of her splints or PROM, on any shift, since 02/23/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 On 02/26/25 at 09:05 AM, an interview was done with Certified Nurse Aide (CNA) 52, who was also the Restorative Nurse Aide (RNA), out in the activities area. When asked, CNA52 stated that she documents Level of Harm - Minimal harm or individual therapies as soon as possible but definitely gets all charting in by the end of day. For Resident R12, CNA52 potential for actual harm stated that she does PROM first, then applies her splints, daily after her morning medications (per resident preference). Residents Affected - Few Further review of POC responses for RNA services in the last thirty (30) days revealed PROM was done, and splints were documented as applied, for half that number of days.

On 02/28/25 at 11:13 AM, an interview was done with Director of Nursing (DON) in her office. During a concurrent review of MDS Quarterly Assessment with ARD of 12/19/24 revealed PROM and Splint application was documented as being performed 2 days out of the 7-day observation period. DON explained that the data is compiled through observation and review of POC responses. DON agreed that if splints are ordered for daily application, the expectation is that the assessment result should be 7 of 7 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51869

Residents Affected - Few Based on observations, record reviews, and interviews, the facility failed to ensure residents remain as free of accident hazards as possible for two of six residents (Resident (R) 35 and Resident R42) sampled for accidents.

The facility failed to identify and eliminate a known and foreseeable accident hazard in the resident environment (wet floor); failed to lock up Resident R35's cigarettes and lighter; and failed to ensure Resident R42's seizure pads were in place. The deficient practices have the potential for ambulatory residents on the unit to sustain a preventable injury; the potential of a fire accident in the facility that has residents who are on oxygen; and the potential for Resident R42 sustaining injuries in bed when having a seizure.

Findings include:

1) On 02/26/25 at 07:38 AM, clear colored wetness was noted on the hallway floor outside of rooms 111-118 and extended to the floor inside resident room [ROOM NUMBER]. From the initial observation at 07:38 AM until 08:02 AM, multiple staff were observed walking on and around the wetness observed on the floor in the hallway and resident room [ROOM NUMBER], taking no action to wipe it up. There were no wet floor caution signs observed on the areas of wetness.

On 02/26/25 at 08:28 AM, Director of Nursing (DON) was interviewed and stated that a cone with a wet floor sign should typically be placed. Housekeeping should be notified if staff cannot get to it in time to clean it up. DON confirmed the wetness in the hallway and in resident room [ROOM NUMBER] remained, and agreed that it should have been wiped up.

43414

2) On 02/25/25 at 09:36 AM, observed Resident R35 smoking in the designated smoking area. Review of the list of residents who smoke in the facility, Resident R35 was not included on the list.

On 02/25/25 at 10:12 AM, an interview and observation of Resident R35 was done in his room. Observed in his left breast pocket on his shirt a green box. Resident R35 confirmed that the green box was his cigarettes, and he also had his lighter. Resident R35 reported a staff member is usually with him when he smokes and helps him light his cigarettes except when he gets back from dialysis in the evening. Before coming in the building, he will smoke, they give him his cigarettes and lighter when he leaves for dialysis. Resident R35 further reported he is blind and only smokes half of his cigarette, so he does not burn himself. Resident R35 admitted he was supposed to forfeit his cigarette and lighter to the nurse, but he forgot to.

On 02/26/25 at 08:09 AM, observed Resident R35 in the common dining room tapping his green cigarette box on the dining room table. His lighter was observed to be on his left side visibly on top of the table. Other residents and staff members were around and the tapping sound he was making was audibly loud. When asking for

the nurse, two staff members approached him, cigarettes and lighter visibly on the table.

On 02/26/25 at 09:09 AM, a staff member was observed to take Resident R35 outside, cigarette pack and lighter was visibly outlined in left breast pocket on his shirt. At 09:12 AM, Resident R35 was observed smoking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 On 02/27/25 at 08:59 AM, observed Resident R35's cigarettes and lighter on the table in the dining room while he was eating breakfast. Level of Harm - Minimal harm or potential for actual harm On 02/27/25 at 01:44 PM, a concurrent observation and interview was done with Resident Care Manager (RCM) 21 and Infection Preventionist (IP). Inquired about the facility's smoking policy on locking residents' Residents Affected - Few cigarettes and lighter, RCM21 reported the facility locks up residents' cigarettes and lighter, and when a resident wants to smoke, they can request it from the nurse. There are no situations where a resident is allowed to hold on to their cigarettes or lighter in the facility. Concurrent observation of Resident R35 in the dining room with his cigarettes and lighter on the table with RCM21 and IP. Inquired with Resident R35 if the cigarettes and lighter was his on the table, Resident R35 stated it was. IP confirmed the resident should not have had his cigarettes and lighter with him in the facility and reported it was for safety because the facility would not know if a resident smoked inside their room or somewhere in the facility, and there are residents that use flammable oxygen.

Review of the facility's policy and procedure Smoking effective 04/02/22, documented Residents regardless of smoking privileges are not permitted to keep cigarettes, e-cigarettes/vaping devices, pipes, tobacco, and other smoking articles in their possession. Those grandfathered in prior to the date of this policy and assessed as safe to smoke on their own may keep their supplies in a locked box in their room when not in use, which will be audited regularly for safety. If resident is non-compliant, supplies will be removed from room .Smoking materials must be checked out and in with the nurse and stored by the nurse .

48351

3) Resident R42 is a [AGE] year-old male, admitted to the facility on [DATE REDACTED]. Resident R42 has medical diagnosis include, but not limited to epilepsy.

Multiple observations were conducted from 02/25/25 to 02/27/28 of Resident R42's bed rails. The right side of Resident R42's bed rail was covered with a blue padding. The left side bed rail did not have a blue padding.

Record review of Resident R42's Electronic Health Record (EHR) was conducted on 02/27/25. Resident R42's EHR noted a progress note that on 02/26/25, Resident R42 was witnessed having a tonic seizure during the evening.

Interview was conducted with RCM54 in Resident R42's room on 02/27/25 at 09:33 AM. RCM54 was shown Resident R42's bed, which had the blue padding only on the right-side rail. RCM54 confirmed that seizure pads should have been placed on the left-side rail as well for Resident R42's safety since he is on seizure precaution.

A review of the facility document titled, Seizure management, with an effective date of 06/19/23 was conducted. The document noted, EQUIPMENT .Padding for side rails and bed headboard.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 51869 potential for actual harm Based on observation, interview, and record review the facility failed to provide the physician ordered oxygen Residents Affected - Few therapy during assistance with a meal for one of two residents (Resident (R) 2) sampled for oxygen use. This deficient practice has the potential for Resident R2 to encounter difficulty breathing and discomfort.

Findings include:

On 02/27/25 at 07:58 AM, Certified Nurse Aide (CNA) 7 was observed removing Resident R2's oxygen mask and replacing it with a nasal cannula. The flow rate of oxygen was observed to be set at five liters per minute via oxygen concentrator. CNA7 stated that she was informed by the nurse that the resident must always have oxygen on, and it was okay to replace the face mask with the nasal cannula.

A review of the physician orders for Resident R2 noted the following 06/05/21 oxygen order: Difficulty breathing: Oxygen 5-10 (five to ten) LPM (liters per minute) via face mask for SOB (shortness of breath) or SpO2 (oxygen saturation) < 90%. Special Instructions: Notify MD (physician) if O2 (oxygen) is applied or increased as needed.

On 02/27/25 at 08:07 AM, Registered Nurse (RN) 4 was interviewed. She stated that when the resident eats,

the face mask is switched to the nasal cannula and the certified nurse aides are aware to do that. She also confirmed that there was no order for that.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51869 potential for actual harm Based on interviews and record reviews, the facility failed to adequately assess for and identify past trauma Residents Affected - Few experienced by one of one residents (Resident (R) 41) sampled for trauma-informed care (TIC). As a result of this deficient practice, Resident R41 did not have her trauma triggers identified, placing her at increased risk of re-traumatization, and was hindered from attaining her highest practicable mental and psychosocial well-being.

Findings include:

Resident R41 is a [AGE] year-old female admitted to the facility on [DATE REDACTED]. A review of Resident R41's electronic health record (EHR) noted that she was admitted with diagnoses that include cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD). The initial physician (MD) 2 note for Resident R41, dated 10/26/24, noted a psychiatric history of post-traumatic stress disorder with avoidant behavior.

On 02/25/25 at 02:00 PM, Resident R41 was interviewed in an unoccupied resident room (resident requested privacy) and stated that she is unable to sleep because of hearing other residents and past roommates having personal emergencies like falling out of bed and coughing all night. Resident R41 also stated that loud disruptive noises and staff talking loud in the hallway keep her awake at night.

On 02/27/25 at 09:33 AM, an interview with Director of Nursing (DON) was conducted. DON stated that Social Services Director (SSD) 46 meets with the resident on admission. If the resident has a history of trauma or PTSD then a TIC care plan should be initiated.

On 02/27/25 at 09:42 PM, an interview and concurrent review of Resident R41's care plan was conducted with SSD46. During the interview, SSD46 confirmed that there was no TIC care plan addressing Resident R41's specific trauma triggers and needs. During concurrent review of the facility's TIC policy with SSD46, the following was noted: A resident will be screened for trauma upon admission, quarterly, annually, and as needed using

the tool in the electronic medical record. SSD46 stated the quarterly screen was not done.

On 02/28/25 at 07:19 AM, a review of Resident R41's Comprehensive Care Plan and facility TIC policy was conducted. The TIC policy noted that trauma events and triggers identified through screening will be used to develop a care plan. Review of Resident R41's Mood State care plan noted some resident triggers in the Problem area of that care plan. However, there were no interventions listed to address them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245

Residents Affected - Few Based on interview and record review, the facility failed to ensure that medication regimen irregularities/recommendations were addressed by the physician for one of five residents (Resident (R) 7) sampled for unnecessary medications. As a result of this deficient practice, Resident R7 was placed at risk of avoidable complications related to continuing an as needed psychotropic (a drug taken to exert an effect on

the chemical makeup of the brain and nervous system) past 14 days without a clinical rationale.

Findings include:

Resident R7 is a [AGE] year-old female admitted to the facility on [DATE REDACTED] for long-term care. A review of Resident R7's Minimum Data Set (MDS) Quarterly Review Assessment with an Assessment Reference Date (ARD) of 12/03/24 noted that her diagnoses include, but are not limited to, dementia with behavioral disturbance-aggression, and left-sided weakness and paralysis following a stroke.

A review of Resident R7's electronic health record (EHR) noted the following open-ended physician order on 08/26/24:

Lorazepam 0.5 mg [milligrams] PO [by mouth] or dissolve in water and place under tongue every 4 hours as needed for Anxiety.

Review of Resident R7's Medication Regimen Reviews (MRRs) revealed the following recommendation made by the pharmacist on 08/31/24:

This resident is currently receiving the PRN [as needed] psychotropic medication lorazepam . Please provide

a specific stop date or time period (e.g [sic] six months) AND a clinical rationale to continue PRN psychotropic medication past 14 days:

The physician made the following response and signed the MRR form on 09/10/24:

Nonpharmacological interventions are either ineffective or not practical for this resident's situation .

Further review of the MRRs noted the pharmacist made the same recommendation the following month, on 09/30/24, however, this recommendation had no documented physician response.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 On 02/27/25 at 09:13 AM, an interview was done with Director of Nursing (DON) in her office. When asked about the MRR process, DON explained that the facility gives themselves thirty (30) days to receive and print Level of Harm - Minimal harm or the recommendations from the pharmacy, place it in the appropriate provider/physician binder, receive a potential for actual harm response from the provider/physician, and make the appropriate changes to close it out. During a concurrent

review of the 08/31/24 MRR recommendation, DON agreed that the physician response did not align with or Residents Affected - Few address the pharmacist's recommendations, specifically, provide a specific stop date or time period . AND a clinical rationale to continue PRN psychotropic medication past 14 days. DON stated that either the Resident Care Manager (RCM) or DON should catch it when the provider/physician response does not match the pharmacist's request/recommendation. DON agreed that the inappropriate response should have been noticed and addressed with the physician prior to the receipt of the same recommendation being made the following month.

Review of the facility policy and procedure Medication Regimen Review and Reporting, last revised 01/24, revealed the following:

A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format . within 48 hours of completion.

The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43245 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a medication error rate of Residents Affected - Some less than 5%, as evidenced by five medication errors observed out of 31 opportunities for errors, for an error rate of 16%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, three residents (Residents (R) 37, Resident R7, and Resident R52) were placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff.

Findings include:

1) On 02/27/25 at 07:46 AM, observations were done of Registered Nurse (RN) 1 preparing medications for Resident R37 at a medication cart outside of room [ROOM NUMBER]. Review of Resident R37's Medication Administration

Record (MAR) and medication orders noted there was an Amlodipine 2.5 mg (milligrams) due at 08:00 AM that RN1 was not observed preparing or administering, and that she had documented on the MAR as Not Administered: Drug/Item Unavailable. Further review of the MAR revealed the medication had been documented as Not Administered: Drug/Item Unavailable since 02/22/25, with the last time it was administered documented as 02/21/25.

On 02/27/25 at 01:49 PM, an interview was done with RN1 outside of room [ROOM NUMBER]. RN1 confirmed that she did not administer Resident R37's Amlodipine as it was out of stock in the medication cart. When asked what is usually done when a medication is out of stock, RN1 stated that the nurse should call the pharmacy and find out when it was being delivered. RN1 acknowledged that she had not done this.

On 02/27/25 at 02:01 PM, an interview was done with Director of Nursing (DON) in her office. When asked about the process that should be followed when a medication is found to be out of stock, DON stated first,

the nurse should check the RX NOW system (electronic medication storage) to see if the medication is in the machine. If it is, and the medication is overdue, the nurse calls the provider to get a one-time order to administer the medication late. Whether the medication is in the machine or not, the pharmacy is called to find out when the medication will be delivered. This information is documented in a progress note and passed off in shift report to the oncoming nurse. DON checked the RX NOW system and confirmed that the medication is available and should have been given.

2) On 02/27/25 at 08:05 AM, observations were done of RN1 preparing medications for Resident R7 at a medication cart outside of room [ROOM NUMBER]. Observed RN1 crush all the prepared tablets together then mix them into one (1) teaspoonful of applesauce. RN1 then opened an Omeprazole DR (delayed release) 20 mg capsule, emptied its contents on top of the same spoonful of applesauce, and mixed it in.

Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following:

Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 0759 On 02/27/25 at 01:54 PM, an interview was done with DON in her office. DON confirmed that the Omeprazole DR capsule should not be opened and mixed in with applesauce. During a concurrent review of Level of Harm - Minimal harm or the medication orders, DON stated that the Omeprazole DR had a 'Do Not Crush' special instruction. potential for actual harm 3) On 02/27/25 at 08:05 AM, observations were done of RN1 preparing medications for Resident R7 at a medication Residents Affected - Some cart outside of room [ROOM NUMBER].

Review of Resident R7's MAR and medication orders noted there was Polyethylene Glycol (a laxative) 17 gm (grams) due at 08:00 AM that RN1 was not observed preparing or administering, and that she had documented on

the MAR at 10:22 AM as Charted late . given on time.

On 02/27/25 at 12:18 PM, an interview was done with RN1 outside of room [ROOM NUMBER]. RN1 stated that she gave Resident R7 the Polyethylene Glycol with her other medications that morning. State Agency Surveyor (SA) reminded her that she did not take any medication that was not in the spoonful of applesauce into the room that morning. At 12:24 PM, RN1 prepared and administered the Polyethylene Glycol, mixed in approximately 60 ml (milliliters) of fluid to Resident R7. Resident R7 drank a little more than half the fluid, then handed the cup back to RN1. RN1 placed the remaining fluid (with medication) on Resident R7's bedside table and left the room.

Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following:

The resident is always observed after administration to ensure that the dose was completely ingested.

The individual who administered the medication dose, records the administration on the resident's MAR immediately following the medication being given.

On 02/27/25 at 01:54 PM, an interview was done with DON in her office. DON confirmed that no medication should be left at the bedside to finish unless the resident has orders to self-administer. DON also confirmed that a medication should not be documented as given until after it is administered. Review of Resident R7's provider/physician orders noted that she did not have an order to self-administer.

4) On 02/27/25 at 08:19 AM, observations were done of RN1 preparing medications for Resident R52 at a medication cart outside of room [ROOM NUMBER]. Amongst other medications, observed preparation of the following:

Sennosides-Docusate Sodium 8.6-50 mg (a stimulant laxative with stool softener combination)

At 08:23 AM, observed RN1 administering a total of six (6) tablets/medication to Resident R52. At this time, observed RN1 ask Resident R52 if he wanted his stool softener, which he refused. RN1 did not inform Resident R52 at any time that one of the medications she had given him contained a stool softener.

Review of Resident R52's MAR and medication orders noted there was Polyethylene Glycol (a laxative) 17 gm (grams) due at 08:00 AM that RN1 was not observed preparing or administering, and that she had documented on the MAR at 08:28 AM as Not Administered: Refused.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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 0759 On 02/27/25 at 12:27 PM, interviewed RN1 outside room [ROOM NUMBER]. RN1 confirmed that Resident R52 refused the stool softener and after prompting by the SA, acknowledged that she did give a stool softener to Level of Harm - Minimal harm or him at that time. RN1 explained that Resident R52 doesn't like the powder [Polyethylene Glycol] because he thinks it potential for actual harm makes him go more. RN1 also stated that (the Polyethylene Glycol) is what she meant when she asked Resident R52 if he wanted the stool softener. RN1 did not seem aware that Polyethylene Glycol is a laxative and not a Residents Affected - Some stool softener.

Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following:

Explain to resident the type of medication being administered .

On 02/27/25 at 02:01 PM, an interview was done with DON in her office. DON agreed that if Resident R52 refused a stool softener, he either should not have been given the Sennosides-Docusate Sodium, or he should have been informed that there was a stool softener component in the medication he was given and been allowed

the opportunity to refuse it.

5) On 02/27/25 at 08:19 AM, observations were done of RN1 preparing medications for Resident R52 at a medication cart outside of room [ROOM NUMBER]. At 08:23 AM, observed RN1 administering a total of six (6) tablets/medication to Resident R52. At this time, observed RN1 telling Resident R52, I didn't bring your . [Acetaminophen], is that OK?

Review of Resident R52's MAR and medication orders noted there was Acetaminophen 1000 mg due at 07:00 AM that RN1 was not observed preparing or administering, and that she had documented on the MAR at 08:20 AM as Not Administered: Refused.

Review of the facility's Medication Administration General Guidelines, last revised, 01/25, revealed the following:

Medications are administered within 60 minutes of scheduled time .

On 02/27/25 at 02:01 PM, an interview was done with DON in her office. DON agreed that medication cannot be marked as refused before it is offered and should be offered and/or administered within one hour of its scheduled time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 125048 Department of Health & Human Services Printed: 09/07/2025 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 125048 B. Wing 02/28/2025

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

Ann Pearl Nursing Facility 45-181 Waikalua Road Kaneohe, HI 96744

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, interview, and record review, the facility failed to implement the facility's infection Residents Affected - Few prevention and control measures for one of two residents (Resident (R) 35) sampled for Transmission Based Precautions (TBP). The facility did not ensure nursing staff hand hygiene between glove use while providing wound care for Resident R35. This deficient practice has the potential to put residents at risk of spreading infections and communicable diseases.

Findings include:

Resident R35 was admitted to the facility on [DATE REDACTED] with diagnoses of acute osteomyelitis on right ankle and foot, stage 4 pressure ulcer of right heel, non-pressure chronic ulcer of right lower left with fat layer exposure and left lower left limited to breakdown of skin, local infection of the skin and subcutaneous tissue, and pseudomonas.

Review of Resident R35's Electronic Health Record (EHR) found Resident R35 started contact precautions on 02/22/25 due to lab results of methicillin-resistant Staphylococcus aureus (MRSA) infection (a bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infection) to leg wound.

On 02/25/25 at 11:47 AM, observation of Resident Care Manager (RCM) 21 and Director of Nursing (DON) cleaning and changing the wound dressing to Resident R35's leg wounds was done. DON was observed to hold Resident R35's right leg up, take off the old wound dressing and helped direct RCM21 with cleaning and redressing the wounds. DON and RCM21 ran out of the dressing and the DON directed RCM21 to ask for more silver alginate wound dressing. RCM21 took off her gloves, radioed for someone to bring more silver alginate, threw her gloves in the trash, walk to the entrance door to Resident R35's room, grabbed a pair of gloves and donned them without hand hygiene between glove use. RCM21 proceeded to dress the wounds after receiving the silver alginate wound dressing.

At 12:09 PM, after NM21 completed Resident R35's wound dressing with DON, an interview with RCM21 was done. Inquired if she hand-sanitized before donning the new pair of gloves while providing wound dressing care for Resident R35, NM21 confirmed she did not and stated she was supposed to hand-sanitize between gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 125048