Ann Pearl Nursing Facility

F-F609 Reporting of Alleged Violations. The facility failed to report an allegation of abuse within 2 hours which resulted in the facility not implementing its policy and procedure to ensure the immediate safety of the alleged victim, timely reporting of an alleged crime, and a timely abuse investigation.

Resident R12 is a [AGE] year-old female admitted to the facility on [DATE REDACTED] with hospice services. Review of Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/25, revealed in Section C that Resident R12 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident R12 had severe cognitive impairment. Section GG (Functional Abilities) noted that Resident R12 required dependent assistance (requires full assistance from another person(s)) for self-care and bed mobility.

On 03/19/25 at 09:30 AM, a review of Resident R12's Resident Progress Notes was done. A progress note dated 02/01/25 at 11:24 AM, with a notation, Recorded as Late Entry on 02/04/25 at 11:40 AM, was inputted by Registered Nurse (RN) 10 and stated, resident screaming she raped last night, in front of husband. However, there was no documentation that the facility's Administrator or Director of Nursing (DON) was notified.

On 03/19/25 at approximately 11:45 AM, a form titled, [Provider] Alleged AMN (Abuse, Misappropriation, Neglect), with a submission date listed as 02/03/25, was reviewed. The form listed 02/01/25 at 05:00 PM as

the date and time of the alleged abuse event. The date and time the Administrator and DON was notified of

the alleged abuse event was listed as 02/03/25 at 09:00 AM.

On 03/19/25 at approximately 10:30 AM, a review of the facility policy titled, Abuse and Neglect, dated 03/03/21, documented in the section titled, Overview of the Seven Components included 5) Investigation: Abuse Policy Requirement: The facility's immediate response is to protect the alleged victim. To protect the alleged victim, the facility has clear delineated roles of those responsible for investigating and will respond to ensure protection of the alleged victim, identify any other alleged victims, ensure the safety of all other residents and the integrity of the investigation.

On 03/19/25 at 03:45 PM, interviewed the DON in her office. The DON confirmed that she was made aware of the allegation of abuse two days later (02/03/25) but should have been sooner so the investigation could start immediately. This would have provided immediate protection for the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 125048 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125048 B. Wing 03/20/2025

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 0610 On 03/19/25 at 03:20 PM, interviewed the Social Services Director (SSD) in her office. The SSD stated she does a Safe Survey form with the residents as part of any abuse investigation. The SSD stated she Level of Harm - Minimal harm or completes the form as soon as possible once she is made aware of an abuse incident. The SSD confirmed potential for actual harm that the Safe Survey forms were started on 02/03/25 when she was made aware of the allegation.

Residents Affected - Some On 03/20/25 at 07:55 AM, interviewed the Administrator and SSD together. The SSD stated the purpose of

the Safe Survey form is to ensure the residents feel safe and to check if they have any concerns. The Administrator stated the safe surveys should be initiated right away.

On 03/20/25 at 09:20 AM, an interview was conducted with the Regional Nurse Consultant (RNC). RNC stated staff interviews regarding the allegation are done as part of the abuse investigation. A concurrent

review of the Interview Statement forms conducted with staff reflected dates of 02/03/25 - 02/04/25. The RNC stated that if she was made aware of the allegation sooner, the staff interviews would have started sooner after the allegation. She also stated that is the normal process and that becomes priority.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 125048

F-F610 Investigate/Prevent/Correct Alleged Violation. The facility failed to prevent potential abuse for one of three residents sampled for abuse (Resident (R) 12) and other residents at risk due to delayed initiation of the investigation for Resident R12's allegation of abuse.

1) On 03/19/25 at 09:00 AM, a review of the [State Agency] Event Report regarding an allegation of abuse was noted to be submitted to the State Agency (SA) on 02/03/25 at 11:08 AM via email. The Initial Report section of the report was noted with a date and time of 02/03/25 at 11:06 AM. The date and time of the incident (abuse allegation) noted on the report was 02/01/25 at 05:00 PM.

On 03/19/25 at 09:30 AM, a review of Resident R12's Resident Progress Notes was done. A progress note dated 02/01/25 at 11:24 AM, with a notation, Recorded as Late Entry on 02/04/25 at 11:40 AM, was inputted by Registered Nurse (RN) 10 and stated, resident screaming she raped last night, in front of husband. However, there was no documentation that the facility's Administrator or Director of Nursing (DON) was notified.

On 03/19/25 at approximately 11:45 AM, a form titled, [Provider] Alleged AMN (Abuse, Misappropriation, Neglect), with a submission date listed as 02/03/25, was reviewed. The form listed 02/01/25 at 05:00 PM as

the date and time the allegation was made. The date and time the Administrator and DON was notified of the event was listed as 02/03/25 at 09:00 AM.

On 03/19/25 at 02:45 PM, interviewed the Administrator in her office. The Administrator stated for any allegations of abuse, floor staff will notify the clinical on call person, who will then notify the Administrator.

This is usually done by phone. She confirmed the incident occurred on 02/01/25, but was notified on 02/03/25, and she should have been notified right away.

On 03/19/25 at 03:45 PM, interviewed the DON in her office. The DON stated that anytime there is an allegation of abuse, staff should immediately call the Administrator and DON. She confirmed that she was notified on 02/03/25 and that was not immediate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 125048 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125048 B. Wing 03/20/2025

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 0609 On 03/20/25 at 11:25 AM, an interview with RN10 was conducted via telephone call. RN10 stated that she was the Nurse on duty when the resident voiced the allegation of sexual abuse (rape). RN10 stated that at Level of Harm - Minimal harm or approximately 4:00 PM, Resident R12's husband visited and Resident R12 started yelling that she wanted to go home and to potential for actual harm call the ambulance to take her home. She then stated that she was raped the previous night. RN10 stated that she knew it was a serious allegation and was previously educated that it should reported, but did not Residents Affected - Few report it because she was busy and forgot.

2) On 03/19/25 at approximately 10:30 AM, a review of the facility policy titled,Abuse and Neglect, dated 03/03/21, revealed the section titled, Overview of the Seven Components included 7) Reporting/Responding: .The Administrator/designee will ensure that that all alleged violations involving abuse, neglect, exploitation, or mistreatment .are reported no later than 2 hours after the allegation is made, if events that cause the allegation abuse or result in serious bodily injury; or not later than 24 hours if the events that caused the allegations do not involve abuse and do not result in serious bodily injury, to the state survey agency and others (police, APS, OIG, AG, etc.) .

On 03/19/25 at approximately 10:45 AM, a review of a document titled, Honolulu Police Department noted

the date initiated as 02/03/25 for the allegation of abuse by Resident R12 which occurred on 02/01/25.

On 03/19/25 at 02:45 PM, interviewed the Administrator in her office. A concurrent review of the [State Agency] Event Report was done. The Administrator confirmed 02/01/25 at 05:00 PM was listed as the date and time of the incident and 02/03/25 at 11:06 AM as the date and time the initial report was completed. The Administrator confirmed the report was not initiated within the time frame as stated in the facility policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 125048 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125048 B. Wing 03/20/2025

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 0610 Respond appropriately to all alleged violations.

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 review, the facility failed to prevent potential abuse for one of three residents Residents Affected - Some sampled for abuse (Resident (R) 12) and other residents at risk due to delayed initiation of the investigation for Resident R12's allegation of abuse. As a result of this deficient practice, the residents were placed at a potential risk for physical and psychosocial harm.

Findings include:

Cross Reference to