Ka Punawai Ola
KA PUNAWAI OLA in KAPOLEI, HI — inspection on April 24, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor asked the DON to review the documentation in the EHR to find the notes about R10's change in health status when she declined on 02/28/26.
The DON looked in the EHR and confirmed there was no documentation that stated R10 declined, the doctor was notified of R10's condition, or that R10 was sent to the ER.An Interview with the Advanced Practice Registered Nurse (APRN) 5 on 04/24/26 at 11:00 AM at the [NAME] nurses station.
Asked him if the nurse called him to inform him of R10's decline and transfer to the and said they may have called the on-call practitioner since it was on the weekend.During a Telephone interview with Registered Nurse (RN) 24 on 04/24/26 at 12:30 PM to discuss R10, asked RN24 if she called the doctor or APRN on 02/28/26 when R10 wasn't feeling well to report R10's change in condition. RN24 said she couldn't remember.
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
125051 04/24/2026
Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707
acknowledged that R30's care plan could have been more comprehensive and individualized to
moderate-protein calorie malnutrition, muscle weakness, dysphagia and cognitive communication
02/01/26-04/22/26 noted that R20 had two unwitnessed falls, 04/15/26 at 12:15 PM and 04/18/26 at 12:20 AM.On 04/21/26 at 10:00 AM, review of R20's care plan noted Focus: At risk for falls r/t (related to) deconditioning and functional dependence s/p hospitalization.
Goal: The resident will not sustain serious injury requiring hospitalization through review date.
Interventions: Bilateral fall mats when in bed, call light and frequently used items within easy reach, assist with ADLs (Activities of daily living) as needed, and completed fall risk assessment.On 04/24/26 at 10:30 AM, observed R20 asleep in bed with bed in low position, but with no fall mats on the bedside floor.
The fall mats were flushed against the wall in front of the entrance of R20's room. On 04/24/26 at 01:10 PM, interview with DON acknowledged that the floor mats were not in the right place and it does not do the resident any good having it flushed against the wall. On 04/24/26 at 02:00 PM, review of the facility's Comprehensive Care Plan and Revisions policy, with reviewed date of 08/29/25, in the Policy section, it reads, The facility will ensure that the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team who has the knowledge of the resident and his/her needs. In the Procedure section, it states 1.
The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered care plan.
125051 04/24/2026
Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707
Type: Nutrition/ Dietary Note Date: 2/25/2026 14:39:13 Note Text: Resident with 7.0% significant
Diet order: Reg, EC7 (easy to chew), Thin (liquids) with no added salt. ONS (on nutrition supplement):
Registered Dietician (RD) requested ST to determine if resident's texture can be upgraded to get the choice menu.
The RD increased 90 ml three times per day (TID) & added orders to offer snacks TID.
MD notified.
Dietary care plan reviewed.
Focus. At nutrition and hydration risk related to current health status including severe anemia.initiated 02/09/26.
Interventions.Weekly weights x 4 weeks.
Assistance with meals as needed.Weights reviewed: 02/05/26 13:30 138.0 lbs.
Hoyer lift. 02/18/26. 17:23 128.5 lbs.
Hoyer lift Resident had a significant weight loss of 7.2 % in 13 days.
Telephone interview on 04/28/26 at 10:32 AM with Dietary Manager (DM) 2 Asked what interventions were in place prior to R10's weight loss.
The DM2 said she was on a Liberalized (unrestricted) cardiac 2 Gram (GM) diet with no salt packets for fluid imbalance and edema.
Asked the DM2 when the weight loss was identified.
The DM2 said after she was admitted , the weekly weight didn't get done, there were weights done on 02/05/26 and 02/18/26.
The DM1 was on leave until the 16th, and I stopped covering R10 on the 13th. It was hard for her to get out of bed, and she required a Hoyer lift.
Once the DM1 discovered the weight loss, she added 2 Cal med Pass (a supplement) on the 16th and started the pro T gold 17 gm per 30 milliliters (ml), a supplement on the 27th when the pressure ulcer was identified.
125051 04/24/2026
Ka Punawai Ola 91-575 Farrington Highway Kapolei, HI 96707
means of communication with other departments is the daily grand rounds.
The daily grand rounds are
have with residents.
When asked if the R30's pain level and increased unsteadiness and episodes of
department, DON verbalized she did not remember it being presented in daily rounds. DON acknowledge that it should have been communicated right away so that appropriate nursing interventions could have been implemented and extra precautions made to prevent further falls.
When discussing the plan of care revisions after this incident, DON noted that R30 expired about two weeks ago.On [DATE] at 02:00 PM, review of the facility's Fall Management policy with a reviewed date of [DATE], it states in the Policy section, The facility will assess the resident upon admission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. In the Avoidable Accident section, it reads, 1.
Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. 3.
Implement interventions, including adequate supervision.consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident. 4.
Monitor the effectiveness of the interventions and modify the care plan as necessary in accordance with current professional standards of practice.
Risk-Refers to any external factor, facility characteristics (i.e. staffing or physical environment) or characteristics of an individual resident that influence the likelihood of an accident.
Supervision/Adequate supervision refers to an intervention and means of mitigating the risk of an accident.
Facilities are obligated to provide adequate supervision to prevent accidents.
Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of staff, and the frequency of supervision needed.
The determination is based on the individual resident's assessed needs. In the Procedure section, it states 4.
The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change.upon a fall event and as needed thereafter.6.
The interventions to reduce the risk of falls should be individualized based on the resident risk factors and fall history.
One of these interventions may include safety checks.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.