Ka Punawai Ola

In the surveyor’s words

From the most serious findings on record at Ka Punawai Ola, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 24, 2026

  Based on record review and interview, the facility failed to identify and intervene for an acute change in a resident's condition related to infection for one Resident (R) 10 resulting in R10's family member initiating the transfer to the Emergency Department. The resident was admitted to the hospital with respiratory distress, pulmonary edema, and septic shock. There was no documentation of the resident's vital signs or notification of the change in condition to the physician which preceded the transfer to the Emergency Department, cross reference to F580. The deficient practice caused harm to the resident related to complications of sepsis. Findings include: Intake #2968720 reviewed on 04/21/26. […]

• Actual harm, isolatedF689Apr 24, 2026

  Based on interviews, and record review, the facility failed to implement and develop interventions to prevent avoidable falls for one of three residents (Resident (R), 30) investigated for falls. R30 had four fall incidents ([DATE], [DATE], [DATE], [DATE]) and one near fall incident ([DATE]) from the time he was admitted to the facility on [DATE]. This deficient practice has the potential to affect residents with balance deficits and strength impairments.Findings Include:Cross reference to F656On [DATE] at 08:00 AM, the Department of Health, Office of Health Care Assurance (OHCA) received a complaint from R30's Family Member (FM) 2 that R30 sustained three falls at the facility. […]

• No harm, potential for more than minimal, widespreadF812Apr 26, 2024

  Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Findings include: On 04/23/24 at 08:06 AM, during the initial tour of the facility's kitchen with Food Service Director (FSD), inquired with FSD if the facility labels food items when the arrive at the facility, FSD reported they label food items when they arrive and when they open them. Observed in the small prep-refrigerator, juice refills of apple juice, orange juice, cranberry juice, and passion orange guava juice for a juice dispenser without a label when the juice arrived. Inquired if the juice had a use-by date, FSD was not able to locate the date on the juice refills. […]

• No harm, potential for more than minimal, widespreadF880May 5, 2023

  Based on observations, interviews with staff, and review of the facility's infection control policy, procedures, and protocols 1) the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections were implemented, 2) the facility failed to ensure measure to prevent the spread and transmission of communicable diseases were followed. Facility staff did not perform hand hygiene between glove use and did not disinfect shared equipment after use. This deficient practice has the potential to affect all residents, staff and visitors at the facility. Findings include: (Cross-Reference to F713 Availability of Physicians for Emergency Care) 1) On 05/02/23 at 09:18 AM, observed Resident(R)37 with an indwelling urinary catheter. […]

• No harm, potential for more than minimal, patternF684Apr 26, 2024

  Based on observations, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the resident's choices, for 5 of 21 Residents (R32, R231, R22, R2, and R47) sampled. As a result of this deficient practice, the residents were placed at an increased risk for avoidable declines and/or injuries. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation (rehab) following a fall with resulting fractures. […]