Ka Punawai Ola

F-F641 Accuracy of Assessment)

On 03/31/25 at 11:10 AM, conducted a review of Resident R42's Electronic Health Record (EHR). Review of the resident's vitals documented on 02/08/25, the resident weighed 154 lbs. On 03/07/2025 and 03/09/25, Resident R42 weighed 143.2 pounds which is a -7.01 % loss. Review of Resident R42's progress notes did not contain documentation addressing the resident's significant weight loss of more than 5% in a month. Review the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25, Section K. Swallowing and Nutritional Status K0300. Weight Loss documented No or Unknown to

a loss of 5% or more in the last month.

On 04/02/25 at 12:12 PM, conducted a concurrent review of Resident R42's EHR and interview with the Dietician (D)1. D1 reviewed Resident R42's weights on 02/08/25, 03/07/25, and 03/09/25 then confirmed Resident R42 lost more than 5% in one month. D1 stated he/she was aware that Resident R42 was losing weight, but did not identify the weight loss as being more than 5% in one month. D1 reported adding supplemental nutrition to Resident R42's meals and confirmed he/she may have given the resident more calories and monitored the resident more closely had he/she identified Resident R42 loss more than 5% in one month.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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 51868

Residents Affected - Few Based on interviews and record review, the facility failed to provide competent nursing services for two residents (Resident (R)249 and Resident R246) in the sample. Staff did not report to the Registered Nurse (RN) when Resident R249 refused to be repositioned and Resident R246 was given a higher dose of pain medication for the pain level reported by the resident. As a result of the deficient practice, the two residents were placed at risk for avoidable injuries and adverse health conditions.

Findings include:

Cross-reference to

F-F686. (Treatment to Prevent/Heal Pressure Ulcers)

1) Reviewed of Resident R294's Electronic Health Record (EHR), Task records performed from 03/19/25 through 04/02/25 for bed mobility, noted check marks indicating the resident was repositioned every two hours three times a day. On 04/01/25, the task was checked only twice and there was no documentation in the progress notes of Resident R294 refusing to be repositioned every two hours.

On 04/03/25 at 10:00 AM, conducted an interview with Certified Nurse Aide (CNA)9. When asked how often CNA9 assist Resident R294 with repositioning, she said, We try to reposition resident every two hours, but she always refuses to be moved or repositioned. CNA9 also stated that she is supposed to report to the nurse when the residents refuse care, but did not report anything to the nurses until she noticed the open area on Resident R294's coccyx on 03/31/25, 12 days after the resident was admitted .

Conducted an interview with the Director of Nursing (DON) on 04/03/25 at 10:17 AM, in her office. Asked if CNAs should report the resident's refusal to be turned or repositioned, DON confirmed it should be reported to the nurses.

47783

2) On 04/02/25 at 07:57 AM, observed RN7 during medication administration. RN7 asked Resident R246 what her pain level was. Resident R246 said, Six out of 10. RN7 opened the computer on the cart, logged Resident R246's pain level and checked the medication to be given. RN7 then prepared Hydrocodone-Acetaminophen (opioid pain medication) 10-325 mg (milligrams) tablet and administered it to Resident R246. After giving the medication, RN7 documented on the computer.

Review of Resident R246's Electronic Health Record (EHR) was conducted. The following orders for pain were noted: Hydrocodone-Acetaminophen Oral Tablet 10-325 mg every 6 hours as needed for severe pain and Hydrocodone-Acetaminophen Oral Tablet 5-325 mg every 6 hours as needed for moderate pain.

On 04/02/25 at 10:11 AM, a concurrent interview and record review was conducted with RN7 just outside Resident R246's room. Asked RN7 what numeric pain level is considered severe. RN7 said, Seven to 10 is considered severe. Asked RN7 if the pain medication dose given to Resident R246 earlier in the morning was correct. RN7 checked in the computer and said Resident R246 should have been given Hydrocodone-Acetaminophen 5-325 mg since her pain level was only at six and considered moderate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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 On 04/02/25 at 10:20 AM, an interview with Unit Manager (UM)3 was conducted at the nurse's station. UM3 confirmed that a pain level of six out of ten is considered moderate. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 47783 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals are stored in a locked compartment for one of six medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications.

Findings include:

On 04/02/25 at 08:02 AM, observed Registered Nurse (RN)7 as she was administering medications. RN7 walked to the medication cart to log into the computer to check the orders. After checking the orders, RN7 took the medications from the other cart that was being used by RN5 and brought it to her cart. RN7 then prepared the medications and placed the blister packs back in RN5's cart. As RN7 walked to the resident's room, observed the medication cart was not locked, and three other staff members were walking around the hallway. After giving the medications to the resident, RN7 went back to the cart, signed off on the medications on the computer and walked back to the other section of the unit. The medication cart remained unlocked.

On 04/02/25 at 10:11 AM, shared observation of the cart not being locked and left unattended with RN7. RN7 said she did not notice it since she did not open the cart, only used it to prepare the medications and document on the computer. RN7 added that the cart was being used by two other RNs helping to pass medications for day shift.

On 04/02/25 at 10:20 AM, an interview was conducted with Unit Manager (UM)3 at the nurse's station. Shared observation of the unlocked medication cart with UM3. UM3 confirmed that medication carts should always be locked and secured when not in use.

A review of the facility policy titled, Medication Storage stated, . Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm 51868

Residents Affected - Few Based on interview and record review, the facility failed to provide food that accommodates the food allergies for one of the two residents in the sample. Resident (R)294 is allergic to eggs and was served eggs for breakfast more than once. As a result of this deficient practice, residents are at risk for more than minimal physical harm.

Findings include:

During breakfast meal observation on 04/02/25 at 08:52 AM, inside Resident R294's room, Family Member (FM) reported on two separate occasions (03/202025 and 03/29/2025), Resident R249 was served breakfast with scrambled eggs. FM stated that she notified the Food Service Director (FSD) about the incidents and Resident R249's food allergy included eggs.

Reviewed Resident R294's Electronic Health Record (EHR) on 04/02/25. Resident R294's clinical resident profile included list of allergies, created on 03/19/25, documented, Allergies: Aspirin, metronidazole, Eggs . Nutrition Assessment, dated 03/20/25 at 04:47 PM, also identified eggs as a food allergy.

Conducted an interview with the FSD on 04/02/25 at 10:32 AM, FSD verified Resident R294's food allergies included eggs, but the resident was served eggs on 03/20/25 and 03/29/25. The FSD said it should not have been given to resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39754

Residents Affected - Few Based on observation, resident interview, staff interview and record review, the facility failed to maintain a functioning clock for one Resident (R)143 out of three residents sampled. As a result of this deficiency, Resident R143 did not know the time of day when referring to that non-functioning clock.

Findings include:

Review of Electronic Health Record (EHR) showed Resident R143 was admitted on [DATE REDACTED] with diagnosis including Stroke, Aphasia (language disorder that affects the ability to communicate), Urinary Tract Infection.

During observation of Resident R143's room on 04/01/25 at 10:30 AM, a wall clock showed the time as 08:25 and was not functioning.

Observation of Resident R143's room wall clock on 04/02/25 at 08:45 AM showed the same time 08:25 as previously mentioned and still not functioning.

Resident interview on 04/02/25 at 08:50 AM, Resident R143 said he wished the wall clock worked because it was located on the wall right in front of him. Resident R143 said he told the staff about the clock not working a day ago.

Staff interview on 04/03/25 at 09:15 AM, Unit Manager (UM)1 acknowledged that the clock was not functioning and said they will have someone come and fix it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 125051

F-F692: Nutrition Status Maintenance)

On 03/31/25 at 11:10 AM, conducted a review of Resident R42's Electronic Health Record (EHR). Review of the resident's vitals documented on 02/08/25, the resident weighed 154 pounds (lbs). On 03/07/25 and 03/09/25, Resident R42 weighed 143.2 lbs, which is a -7.01 % loss in one month. Review of Resident R42's progress notes did not contain documentation addressing the resident's significant weight loss of more than 5% in a month. Reviewed the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25, Section K. Swallowing and Nutritional Status K0300. Weight Loss documented No or Unknown to a loss of 5% or more in the last month, indicating Resident R42 did not have a significant weight change.

On 04/02/25 at 12:12 PM, conducted a concurrent review of Resident R42's EHR and interview with Dietician (D)1. D1 reviewed Resident R42's weights on 02/08/25, 03/07/25, and 03/09/25, then confirmed Resident R42 did lose more than 5% in one month. D1 confirmed he/she did was not aware that Resident R42's weight loss was significant. D1 reviewed Resident R42's quarterly MDS with an ARD of 03/27/25, Section K. and confirmed the MDS should have coded Resident R42 for a weight loss of 5% or more, but did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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** 51868 potential for actual harm Based on observation, interview, and record review, the facility failed to prevent the development of pressure Residents Affected - Few ulcers for one of three residents (Resident (R)294) sampled for pressure ulcers. Staff failed to report Resident R294's refusal to be turned every two hours which delayed the implementation of new interventions to prevent the development of a new pressure ulcer. As a result of this deficient practice, Resident R294 developed a Stage 2 pressure ulcer to her coccyx area and has the potential to affect other residents who are high risk for developing pressure ulcers.

Findings include:

Cross-reference to

F-F726. (Competent Nursing Staff)

Resident R294 is an [AGE] year-old female who was admitted to the facility on [DATE REDACTED] for short-term rehabilitation services. Diagnoses included but not limited to muscle weakness, unspecified protein-calorie malnutrition, and depression.

During an interview with her Family Member (FM) at the bedside on 03/31/25 at 12:40 PM, FM stated that Resident R294 had no skin problem or pressure ulcer prior to her admission. FM explained that Resident R294 is now complaining of pain to her coccyx. FM stated that she visits every day and stays in the facility for up to six hours, and did not observe the staff repositioning Resident R294 every two hours. FM stated most of the time Resident R294 refuses to be moved.

On 04/02/25 at 10:29 AM, review of Resident R294's Electronic Health Record (EHR) was conducted. Care Plan Report dated 03/19/25, stated Resident R294 was . at risk for break in skin integrity . Skin assessment upon admission done on 03/19/25 documented skin condition as, . coccyx - brown discoloration . admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/25, Section M, documented Resident R294 is at risk of developing pressure ulcers/injuries.

Resident R294's Braden Scale assessment with a completion date of 03/26/25, noted a score of 12, which identified Resident R294 as high risk for developing pressure ulcer and mobility as Very Limited.

Physical Therapy treatment encounter notes for 03/25/25 to 04/01/25, documented the resident's resistance to care. On 03/26/25, . Resistive to sitting edge of bed . Documentation for 03/27/25 stated . Attempted to have the patient stand but she was combative . Documentation for both 03/28/25 and 03/29/25 stated . exhibits heightened anxiety w/ activity . Documentation for 04/01/25 stated . She was agreeable for therapist to assist with mobility but then would resist movement or want to return to bed.

On 04/03/25 at 10:00 AM, conducted an interview with Certified Nurse Aide (CNA)9. Asked how often CNA9 assist Resident R294 with repositioning, she said, We try to reposition resident every two hours, but she always refuses to be moved or repositioned. When asked what should staff do if Resident R294 refuses to be turned, CNA9 stated that she is supposed to report to the nurse. Then asked CNA9 if Resident R294's refusal to be repositioned was reported to the nurse. CNA9 confirmed the resident's refusals was not reported until the open area was noticed on Resident R294'c coccyx on 03/31/25, which is 12 days after the resident was admitted .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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 Conducted a concurrent interview and record review with the Director of Nursing (DON) on 04/03/25 at 10:17 AM in her office. DON confirmed there was no documentation about resident being repositioned every two Level of Harm - Minimal harm or hours or the resident's refusals. DON confirmed that CNAs should have repositioned the resident every two potential for actual harm hours but did not.

Residents Affected - Few Review of the facility's policy and procedure manual on 04/03/25, titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management stated, . 3. A skin assessment/inspection should be performed weekly by a licensed nurse . a. Skin observations . Any changes or open areas are reported to the Nurse . a. reposition at least every 2-4 hours .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 125051 Department of Health & Human Services Printed: 08/31/2025 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 125051 B. Wing 04/03/2025

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

Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or 42160 potential for actual harm Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional Residents Affected - Few status for one resident (Resident (R)42) sampled. As a result of this deficient practice, there is the potential for more than minimal physical harm to the resident.

Findings include:

(Cross reference to