Every finding on record at Kalakaua Gardens

Based on observation, interview, and record review the facility failed to assure the kitchen followed dishwasher manufacturers guidelines for sanitizing their dishware and utensils, failed to label beverages with the opened-on date once they were opened, failed to label prepared vegetables and grated cheese with the prepared-on date and failed to throw away meats by the facility's discard by date. The deficient practice puts all residents who eat their meals at the facility at risk for foodborne illness. On 02/17/26 at 09:20 AM initial tour of the kitchen started with [NAME] (C) 9. Inquired about the facility dishwasher logs which C9 was able to provide. Reviewed the dishwashing/warewashing machine temperature log which states For High Temperature Machine: (Refer to machine data plate for temperature requirements). Review of the temperatures logged by facility staff for Final Rinse Temp ranged from 110-185 degrees Fahrenheit from 02/09/26 - 02/17/26. Observation of the dishwasher at this time revealed it was a Model ADC-44, Multi-tank, rack conveyor dishmachine manufactured by American Dish Service Corporation. Review of the thermometers on this dishwasher found the final rinse thermometer had a sticker that stated, Final Rinse 180 degrees Fahrenheit. The NSF Data Plate on the dishwasher states NSF Operational Requirements for Model ADC-44, Multi-tank, rack conveyor dishmachine manufactured by American Dish Service Corporation:Hot water sanitizing Final sanitizing rinse minimum temperature: 180 degrees FPumped rinse tank minimum temperature: 160 degrees FWash tank minimum temperature 159 degrees FFinal rinse minimum pressure: 20 psi Maximum conveyor speed: 6.7 ft./min.Interviewed Dishwasher (DW) 11 in the kitchen. Inquired how he can tell the temperature of the dishwasher that he logs, and he stated he writes the temperature from the thermometers on the dishwasher. Inquired about test strips that are run through the dishwasher, and DW11 stated they do not do use those. At this time the Dining Services Director (DSD) was asked when the logs are reviewed and he stated the end of the month. Inquired if they use test strips to check the water temperature of the dishwasher and he stated, It's a new machine. Inquired if the vendor had explained how to use the temperature strips to assure the dishwasher was reaching the temperatures needed to sanitize the dishes and utensils and DSD said no. Reviewed with the DSD the final rinse temperatures that were logged and showed most of the temperatures logged did not reach the 180 degrees needed to sanitize the dishware. Inquired if he had been notified of the temperatures not reaching 180 degrees for the final rinse and he said no. Continuation of the initial kitchen tour found food items (sliced mushrooms, loose spinach, grated cheese, chopped red bell peppers, chopped tomatoes and chopped onions) uncovered in the refrigerator that was not labeled with the date the food was prepped. Found two large containers of meat (chopped Portuguese sausage and chopped ham) dated 2/9. Inquired of DSD how long they can keep meat like this and he said one week. DSD stated these should have been thrown away. Found a container of orange juice and soy milk that was opened and not labeled with a date when these were opened. Inquired of DSD how long these items can be kept once opened and he stated the vendor told him till the expiration date. Reviewed the soymilk container and shared the following that was printed on the container Shake Well. Refrigeration not needed before opening. Once opened, refrigerate 7-10 days. On 02/19/26 at 10:45 AM went to observe trayline. Requested to review temperature logs and DSD stated they test the temperature of the food but do not log this information. Interviewed a dietary aide and inquired what the temperature of the food has to be on the trayline and he stated 160 degrees. On 02/19/26 at 11:30 AM interviewed the Administrator in his office. Inquired if he would expect the kitchen staff to log the temperature of the foods on the trayline and he confirmed he would expect the kitchen to have logs of the temperature checks for the trayline for all the meals. Requested facility policy on food safety and Administrator was able to provide this.Review of facility policy titled, Food Safety Requirements states .Policy Explanation and Compliance Guidelines: .3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/ receipt and ensure timely and proper storage.c. Refrigerated storage - foods that require refrigeration shall be immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: .iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; andv. Keeping food covered or in air tight containers.

Based on observation and interview, the facility failed to ensure that 2 of 2 ice and water machines for the residents were kept in clean and sanitary conditions in accordance with professional standards for food service safety. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents receiving ice or water on the affected resident units. Findings include:On 02/17/26 at 10:35 AM, observed a buildup of hardened dark brown sediment/material around the bottom edges of the plastic chute dispensing ice and water from the ice/water machine located on the 4th floor dining room. On 02/18/26 at 08:33 AM, observed the same ice/water machine in the 4th floor dining area with the same buildup of hardened dark brown sediment/material around the bottom edges of the plastic chute. On 02/18/26 at 08:37 AM, interviewed the Director of Nursing at the ice/water machine located on the 4th floor dining area. The DON stated that the ice/water machine is used by residents, staff, and visitors. The DON confirmed the presence of hardened dark brown sediment/material around the bottom edges of the plastic chute and stated that it was not clean. The DON also stated that the Maintenance was responsible for cleaning the ice/water machine.On 02/18/26 at 08:44 AM, met with the Environmental Services Manager (EVSM) and DON at the ice/water machine located in the 4th floor dining room area. The EVSM stated that the housekeepers cleans the drip tray and front portion of the ice/water machine but not way inside. On 02/18/26 at 08:53 AM, observed hardened dark brown sediment/material around the bottom edge of the plastic chute dispensing ice and water from the ice/water machine located on the 5th floor dining room.On 02/19/26 at 06:40 AM, the EVSM confirmed the presence of hardened dark brown sediment/material around the bottom edges of the plastic chute dispensing ice and water from the ice/water machines located on the 4th and 5th floor dining rooms. The EVSM also stated there was no cleaning log for both the 4th and 5th floor ice/water machines.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was maintained within professional standards of practice for 4 of 4 Residents (Resident (R) 12, R24, R26, and R45) sampled for Respiratory/Tracheostomy care and suctioning. The facility failed to label and properly store oxygen, nebulizer, and suction equipment. The deficient practice placed the residents at risk of infections and illness. Findings include:1) On 02/17/26 at 10:03 AM and 02/18/26 at 08:21 AM, the following was observed in R12's room: -Undated humidifier bottle with undated tubing connected to an oxygen concentrator. -Uncovered oxygen tubing connected to an oxygen tank located on the side of R12's bed. -Uncovered yankauer suction tip catheter attached to suction tubing and connected to the suction machine was hanging down from the suction machine and leaning against R12's bedside dresser drawer. On 02/19/26 at 01:32 PM, a review of R12's physician orders noted active orders stating, Suction orally prn [as needed] for increased secretions and O2 [Oxygen] 1-4 L [Liters] per NC [Nasal Cannula] for SOB [Shortness of Breath]. 2) On 02/17/26 at 07:52 AM and 02/18/26 at 08:27 AM, observed an uncovered mask with attached medication chamber and undated tubing connected to the nebulizer machine located on the top of R45's bedside dresser. On 02/19/26 at 01:45 PM, a review of R45's physician orders noted an active order stating, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliters]. 3 ml inhale orally every 4 hours as needed for SOB [shortness of breath] or Wheezing. Administer for 10-15 minutes via nebulizer. Rinse after administration. 3) On 02/17/26 at 10:57 AM and 02/18/26 at 08:29 AM, observed an uncovered and dry nebulizer mask with medication chamber on a paper towel next to the nebulizer machine with uncovered tubing attached on R24's bedside dresser. On 02/19/26 at 01:49 PM, a review of R24's physician orders noted actives orders stating, Sodium Chloride Inhalation Nebulization solution 7% 1 ml inhale orally via nebulizer one time a day for Asthma, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml.1 vial inhale orally every 4 hours prn for SOB. On 02/18/26 starting at 02:07 PM a walkthrough of R12, R24, and R45's room was done with the DON who stated: -For R12: The humidifier bottle should have been discarded. The humidifier connection tubing should have been dated. The humidifier connection tubing, oxygen tubing and mask, and yankauer suction tip catheter and tubing should have been stored in a plastic bag. -For R24 and R45: The nebulizer equipment (mask and medication chamber) should be washed after use and air dried. Once the equipment is dry, it should be stored in a plastic bag. A facility policy titled, Respiratory: Nebulizer Therapy with a review date of January 2026 stated, Care of the Equipment.4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water.6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a ziplock bag. 8. Change nebulizer tubing weekly. Another facility policy titled, Oxygen Administration with a review date of January 2026 stated, Policy Explanation and Compliance Guidelines.5. Staff shall.a. Change oxygen tubing and mask/cannula weekly.c. Change humidifier tubing and delivery devices weekly.d. Keep delivery devices covered in plastic bag when not in use. 4) Observation in R26's room on 02/17/2026 at 09:47 AM. R26 was asleep in bed. On the left side of the bed on the nightstand, observed a suction cannister with clear secretions inside with tubing connected to a yankauer (small device used to suction the mouth). The yankauer was placed in a wrapper inside of the nightstand drawer. There was no label with a date when it was placed. Interview with Registered Nurse (RN) 17 on 02/20/2026 at 09:25 AM in the nurse's station. Asked RN17 if R26 requires the use of the suction machine. RN17 said the certified nurse aides (CNAs) use the yankauer to suction her mouth when they are providing oral care. Asked her when the tubing is changed and whether they label it with the date when they change it. She said she would change it on Monday, and yes, they should be putting a label on it when it is changed. Observation in R26's room on 02/202/26 at 09:45AM. Inspected the suction equipment with RN17 and verified that there wasn't a label placed on the tubing or on the yankauer wrapper with a date.

Based on interview and record review the facility failed to inform 1 of 5 residents (Resident (R) 2), of the risk and benefits of taking an antidepressant medication for his insomnia. The deficient practice could affect all residents in the facility who are not informed in advance of starting an antidepressant of the risks and benefits and offered other treatment alternatives or options. On 02/19/26 at 09:12 AM during record review of R2's Electronic Health Record (EHR) found R2 was ordered Trazodone HCL 50 mg one tablet by mouth at bedtime for insomnia. Review of R2's consents and progress notes did not reveal documentation that R2 or his representative was informed in advance of the risks and benefits of this medication or treatment alternatives that he could choose.On 02/19/26 at 10:00 AM requested of Director of Nursing (DON) documentation that the facility reviewed the risk and benefits of Trazodone with R2 or his representative.On 02/19/26 at 04:30 PM DON confirmed she could not find any documentation that facility staff reviewed the risks and benefits with R2 or his representative of taking Trazodone and this should have been done.

Based on observation and interview, the facility failed to provide clean personal care equipment and living space for 1 of 13 residents (Resident (R) 26) sampled for a clean environment. The deficient practice placed the resident at risk for discomfort and illness. Findings include: Resident (R) 26's room was observed on 02/17/26 at 09:47 AM. R26 was asleep in her bed and observed an Oxygen (O2) concentrator that was not being used in the corner next to the bed. Upon closer inspection observed dust on the top of the unit. In the same area, thick dust was observed on the wall behind the resident's headboard. On the left side of the bed on the nightstand, observed a suction cannister with clear secretions inside and tubing connected to a yankauer (small device used to suction the mouth) without a date or label. No date or time written on the wrap or the tubing. Registered Nurse (RN) 17 was interviewed on 02/20/2026 at 09:25 AM in the nurse's station and was asked if the O2 concentrator is for R26. RN17 said, Yes, she's receiving Hospice care. Asked if R26 uses it and she said, No she hasn't ever used it. The Hospice ordered the concentrator, and the medical supplier brought it to the resident's room. Asked RN17 who is responsible for cleaning the machine and providing the maintenance. She said, We can clean it if it's dusty and the medical supplier will provide necessary maintenance. Observation with RN17 in R26's room. Inspected the care equipment and wall behind the headboard and verified there was heavy dust.

Based on interview and record review, the facility failed to ensure 1 of 5 residents (Resident (R) 3) sampled for unnecessary psychotropic medication was not prescribed as needed (PRN) anti-psychotic medication for greater than 14 days. The deficient practice placed the resident at risk for an adverse event. Findings include:Electronic Medical Record (EMR) reviewed on 02/19/26. Resident (R) 3 is an [AGE] year-old male admitted to the facility on [DATE]. Resident is taking Quetiapine (an anti-psychotic medication) for his diagnosis of Parkinsons and non-Alzheimer's dementia. Reviewed the Medication Regimen Review (MRR) dated 01/31/26. Note to attending physician/ prescriber with recommendations to order PRN for no more than 14 days and then reassess. The physician (MD) agreed and wrote the order for 30 days. It was signed and dated 02/05/26.Physician orders reviewed. Quetiapine Fumarate oral tablet 25 milligrams (MG); Give 0.5 tablet by mouth every 12 hours as needed for mild hallucinations for one month and give 1 tablet by mouth every 12 hours as needed for moderate to severe hallucination for one month.Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/04/26 reviewed. R3 is severely cognitively impaired and did not have any delusions, hallucinations or behaviors that were coded on the assessment. R3 was coded as behavior was improved since the last assessment. Care Plan Reviewed, revised 01/13/2026. R3 is receiving anti-psychotic medication as ordered thus is at risk for experiencing possible complications. Director of Nursing (DON) interviewed on 02/19/2026 at 03:51 PM in the conference room.Asked the DON what is the process for the medication regimen review. The DON explained the pharmacy consultant reviews the Drug regimen every month. If there is a recommendation, he sends a copy of it out via email to medical records, the DON and the Medical Director. If there are recommendations for nursing or the practitioner, the DON carries it out and puts it in the binder for that resident's Physician. The physician reviews the recommendation in the binder and writes the order. The order for the prn use of quetiapine for 30 days was discussed with the DON who stated the provider was adamant about re-evaluating the effectiveness of the antipsychotic medication after 30 days. Telephone call to the Pharmacy Consultant (PC) on 02/19/2026 at 03:59 PM. Asked the PC if the order for 30 days was correct. The PC said the recommendation to the physician was to order the prn quetiapine for no more than 14 days and re-evaluate the need for the prn medication. Explained to the PC that the DON reviewed the recommendation written by the physician and carried out the order in the Residents record. Psychotropic Medications policy with a review date of 12/2025 stated, Page 3. b. PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Based on observation, interview, and record review, the facility failed to implement resident centered activities based on the resident's interests for 1 of 2 residents (Resident (R) 44) sampled for activities. This deficient practice failed to enhance the Resident's sense of well-being of watching news and sporting events on the television. Findings include: Observed Resident (R) 44 in her room in bed on 02/17/2026 at 10:35 AM. The television (TV) was off and the room was quiet. R44 was non-verbal and smiled. Random observations made on 02/17/26 and 02/18/26, observed R44 in her room in bed with the TV off and the room quiet while awake. Family member (FM) 10 was sitting at the bedside and interviewed on 02/19/2026 at 10:33 AM. Asked how often she visits R44. FM10 said, My husband visits her more often. When asked how R44 is doing, she answered, Ok, but I wish we could turn the TV on for her. I think there is something wrong with the remote. I asked the nurse and she said she would ask for maintenance to look at it. She [R44] really does seem to engage with the TV.Minimum data set (MDS) with an assessment reference date (ARD) of 05/30/25 reviewed. R44 is cognitively impaired and dependent on staff for her care. It is very important to R44 to keep up with the news and somewhat important to listen to music that she likes. Care plan dated 04/15/25 reviewed which listed that R44 enjoys one to one (1:1) room visit from staff to talk. She enjoys independent activities like listening to music and watching TV.Social services note dated 02/13/26 reviewed. Nephew asked to put in a work order for resident's TV because he notices she seems to enjoy watching sports and follows along with the TV, but not always able to work it. Medical Social Worker (MSW) followed up with maintenance to check on the status of her TV. MSW to follow up as needed. Observation and interview with Registered Nurse (RN) 17 on 02/20/26 at 07:45 AM in R44's room during a medication administration observation. RN17 looked up at the TV that was off and asked R44 if she would like to watch TV. RN17 went to the TV and reached behind it to turn it on. The channel was on the sports channel with a Volleyball match and R44 smiled at RN17. RN17 said that R44 likes to watch sports channels. Interview with the Activity Director (AD) on 02/20/2026 at 02:15 PM in the conference room. Asked the AD what type of activities does R44 like to do. The AD said, Most of the time she just stays in her room. She doesn't really talk. When asked if she ever comes out of her room she replied, Sometimes, she comes out when the certified nurse aides (CNA's) change her bedding. Mostly she just listens to music, and I talk to her and keep her company. She gets excited when someone comes into her room. When asked if R44 likes to watch TV, the AD responded, She likes sports. Explained to the AD that the niece was visiting and said that she likes to watch TV and it has not been working. The AD said, The TVs are wonky sometimes. Asked her what the process is to put in a work order to fix the TV. The AD said, It's probably faster to call maintenance.Reviewed the Activity Participation 1:1 task flow sheet dated 01/22/26 to 02/17/26. Music and TV/ Video were listed on the form, but talking & repositioning was the only column checked on each day. Quality of life activities policy revised 12/2025 was reviewed and stated, Guidelines: 2. Activities will enhance the physical, cognitive and emotional health of the residents. 4. The activity program consists of individual and may include the following: Music .

Based on observation, interview, and record review the facility did not correctly transcribe the physician orders for the splints/braces to the Medication/Treatment Administration record (MAR/TAR), did not ensure staff were trained on the application of physician ordered splints/braces, and did not follow-up on therapy recommendations for a palm splint for 1 of 3 residents (Resident (R) 37) sampled for limited range of motion (ROM). This deficient practice hindered R37's ability to maintain the highest practicable well-being and has the potential to affect all residents at the facility who have limited ROM. Findings include:Resident (R) 37 is a is a [AGE] year-old male with a diagnosis of left hemiplegia following cerebral infarction. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 noted R37 requires dependent care (resident does none of the effort to complete the activity) for his activities of daily living (ADL).On 02/17/26 at 10:10 AM, observed R37 sleeping in bed with left arm and leg bent. Two braces were seen on the top of R37's shelf near the bedside.1) On 02/19/26 At 03:42 PM, a review of R37's physician's orders and February 2026 MAR/TAR were done. The following active orders were noted:-04/28/23 order and start date: Knee brace. Apply brace to left knee for 2 hours every shift for contractures. Remove brace after 2 hours. This order was transcribed to the February 2026 MAR/TAR and being signed off by the Licensed Nurses.-04/28/23 order and start date: Apply brace to left elbow for 2 hours every shift for contractures. Remove after 2 hours. This order was transcribed to the February 2026 MAR/TAR and signed off by the Licensed Nurses.-03/05/24 order date and 03/07/24 start date: Apply elbow orthosis splint on left upper extremity every day shift, every Tuesday, Thursday, Saturday for contracture of left arm. This order was transcribed to the February 2026 MAR/TAR and signed off by the Licensed Nurses.-03/05/24 order date and 03/07/24 start date: Remove elbow orthosis splint on left upper extremity after 3.5 hours every day shift, every Tuesday, Thursday, Saturday for contracture of left arm. This order was transcribed to the February 2026 MAR/TAR and signed off by the Licensed Nurses.-03/08/24 order date: Patient to wear left knee contracture splint 3 times a week for total of 4 hours (2 hours on/2 hours off/repeat). Can be worn on same schedule as left upper extremity splint. This order was not transcribed to the February 2026 MAR/TAR.On 02/20/26 at 08:06 AM, Registered Nurse (RN) 16 was interviewed on the 4th floor at medication cart B. RN16 stated that the left elbow and knee splint for R37 are both applied daily in the daytime for 2 hours and that the splint and brace are the same equipment.On 02/20/26 at 09:54 AM, the Director of Nursing (DON) was interviewed in her office with a concurrent review of R37's Order Summary report and MAR/TAR. The DON confirmed that the 03/05/24 order for the left elbow splint and 03/08/24 for left knee splint were the current orders and should have replaced the 04/28/23 left elbow and left knee brace orders on the MAR/TAR. 2) On 02/20/26 at 08:24 AM, the Therapy Director (TD) was interviewed in her office. The TD stated that training on recommended equipment by therapy is done by therapy staff with the Restorative Nurse Assistant (RNA) or Nurse on duty that is in charge at the time if the RNA is not available. TD also stated that the DON would be the one to ask about training of additional nursing staff.On 02/20/26 at 09:54 AM, the DON was interviewed in her office. The DON stated that the splint recommendations for R37 would have been trained by therapy staff with the RNA or Nurse on duty at the time. Training with additional nursing staff would be done utilizing a train the trainer method. However, documentation of splint training with additional staff could not be provided.3) On 02/20/26 at 08:24 AM, the Therapy Director was interviewed in her office. The TD stated that R37 received occupational therapy starting on 01/12/26 and ending on 02/06/26. A Therapy to Restorative Nursing Communication form dated 02/16/26 was prepared by Occupational Therapist (OT) 1 which listed recommendations for a left palm splint to be put on for up to 8 hours daily. The form was signed off by RN11 on 02/16/26 as receiving instructions. On 02/20/26 at 09:54 AM, the DON was interviewed in her office with a concurrent review of R37's 02/16/26 Therapy to Restorative Nursing Communication form, order summary report and MAR/TAR. The DON stated that follow-up regarding the left palm splint recommendation was not done with R37's physician and nursing documentation regarding the left palm splint and physician orders to use it was not able to be found.

Based on observation and interview, the facility failed to ensure that medications in 2 of 4 medication carts were stored and locked in accordance with professional standards. Proper storage of medications and locking of the medication cabinet is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications.Findings include:1) On 02/19/26 at 07:43 AM, the 4th floor medication cart B was inspected with Registered Nurse (RN) 16 present. In the first drawer of the medication cart: -Three individually sealed capsules of Vancomycin Hydrochloride 125mg and one individually sealed capsule of Cephalexin 250mg was found in a container that also contained sealed Acetaminophen and Bisacodyl suppositories. The individually sealed capsules were not stored in a bag/packaging containing the following minimum information: Medication name (generic and/or brand), prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration. RN16 stated he did not know which resident(s) the Vancomycin and Cephalexin capsules were prescribed for, why is what stored individually in the container, and stated that the medications should have been discarded. -In another compartment of the first drawer of the 4th floor medication cart B, two individually sealed capsules of Midodrine 2.5mg was found in a medication cup. RN16 stated that on the evening shift of 02/18/26 an order was received to start Midodrine 2.5mg 1 tab three times a day for Resident (R) 54. On 02/18/26, RN16 pulled 3 doses from the automated medication dispensing cabinet and stated one dose was administered the for the scheduled evening dose on 02/18/26. The other 2 doses were pulled for the morning and afternoon doses on 02/19/26 because delivery of the medication was not going to occur until the evening of 02/19/26. RN16 acknowledged that it was not good practice to pull multiple doses from the automated medication dispensing cabinet and store it in the medication cart because there was no labeling for which resident it was for and no labeled instructions regarding administration of the medication. On 02/19/26 at 10:17 AM, the Director of Nursing (DON) was interviewed in her office. The DON stated that the individually sealed Vancomycin and Cephalexin capsules found in the medication cart should have been discarded. The DON also stated that the amount of medication pulled from the automated medication dispensing cabinet should only be for the dosage that is due at the time and extra doses should not be pulled and stored in the medication cart. 2) On 02/17/26 at 01:07 PM observed a medication cart on the 4th floor was left unlocked. Registered Nurse (RN) 7 was asked if the medication cart is supposed to be locked and RN7 confirmed it was left unlocked and it should have been locked before she left it. On 02/20/2026 at 10:51 AM interviewed the Director of Nursing (DON) in the conference room and inquired if medication carts are to be locked before nurses leave them. DON confirmed the nurses are to lock the medication cart before leaving the medication cart.

Based on interview and record review, therapy services failed to follow physician ordered restrictions for 1 of 3 residents (Resident (R) 7) sampled for limited range of motion. This deficient practice had the potential to lead to worsening injury to R7.Findings include: On 02/19/26 at 02:32 PM, R7's records in the Electronic Health Record (EHR) were reviewed. R7 re-entered the facility from the hospital on [DATE] with a diagnosis of unspecified fracture of left femur with non-operative management. A physician's order dated 02/26/25 stated non-weight bearing (NWB) and no range of motion (ROM) every shift for left distal femur fracture. On 02/20/26 at 08:43 AM, an interview was conducted with the Therapy Director (TD) in her office. The TD stated that R7 received physical therapy that spanned from 04/29/25-06/27/25 and ROM was being done to R7's bilateral lower extremities (ankle, knee, and hip). The TD confirmed that during the span of therapy, no new order was received since the 02/26/25 initial order for NWB and no ROM for R7. After therapy ended on 06/27/25, recommendations from therapy were written on the Therapy to Restorative Nursing Communication, dated 06/27/25, for Everyday ROM. The TD confirmed that the recommendation should have included more specific information on which extremities ROM was to be done.On 02/20/26 at 11:34 AM, the TD was interviewed in her office with concurrent review of R7's physical therapy treatment encounter notes printed from the electronic health record. The TD again confirmed that the current physician order stating NWB and no ROM to R7's left was 02/18/25. The TD also stated that the physician orders should have been checked for any restrictions before therapy was initiated and that the physical therapy notes from 04/29/25 -06/27/25 had charting of movement performed to R7's left leg in the form of stretches and active and passive ROM.

Based on observations, interviews, and record review, the facility failed to implement the facility's infection prevention and control measures for Legionnaire's Disease by not monitoring and testing for concentration of hydrogen in a solution (pH) levels in five sinks and showers per floor once a month, not monitoring and testing for presence of Legionella from decorative water fountain in front of facility, and not performing ice machine preventative maintenance once a month. This deficient practice placed everyone at risk for growing and spreading Legionella or other opportunistic waterborne pathogens and other adverse health complications.Findings include: On 12/16/25 at 1:26 PM, concurrent interview, observation, and record review was done with Maintenance. Observed maintenance check water sample from first floor bathroom sink for pH, and chlorine level using a test strip and thermometer to check for water temperature. Monthly Potable Waterlog dated, 08/29/24 to 11/26/25 indicated that testing and monitoring for pH, chlorine, and temperature was only done from the first floor. Water Temperature Log indicated that water temperature was checked and monitored from all floors once a day. When asked Maintenance if facility needed to be tested and monitored for pH and chlorine level in five sinks and showers on all floors, he concurred that all floors should also be tested, monitored, and documented. On 12/16/25 at 02:02 PM, a tour of the decorative water fountain and an interview was conducted with Maintenance. He explained that water pump was turned off on 12/14/25 and when asked if facility is supposed to test water fountain for Legionella once a year, he stated, Yes, that should be tested on ce a year as stated in facility's Water Management Program. On 12/18/25 at 10:05 AM, an interview was conducted with Infection Nurse and Director of Facilities. When asked if testing and monitoring should have been done on all floors for pH, chorine and water temperature, and testing decorative water fountain where Legionella and other opportunistic waterborne pathogens can grow and spread, both answered, Yes, that should have been done. Review of the facility's policy and guidelines for implementation was reviewed on 12/18/25 titled, Infection Prevention & Control Legionnaires' Disease directed the staff to complete the following, .Table 22: Potable Water System Monitoring Frequency.pH Monitoring.Test pH [NAME] in 5 sinks/showers per floor.Frequency.Monthly.Legionella Testing.Potable water log.Frequency.Annually.Table 51:Decorative Water Feature Maintenance Protocols.Frequency of cleaning and disinfecting.Daily.Table 52: Decorative Water Feature Legionella Testing.Will Legionella culture testing be performed.Yes.Responsible party for Legionella sample collection.Maintenance.Table 55: Machine Maintenance Protocols.How often ice machines cleaned?.Description.Monthly.

Based on interviews and record review, the facility failed to provide adequate supervision to prevent a second fall which could have been avoided for one (Resident (R)22) of 14 residents sampled. As a result of this deficient practice, the resident had a second fall which could have been avoided and sustained physical injuries. Findings include: On 11/17/24 at 08:57 AM, conducted a record review of R22's Electronic Health Record (EHR). Review of progress notes documented on 9/5/24 at 03:28 AM, a Certified Nurse Aide (CNA)65 answered R22's light at 12:45 AM and assisted R22 onto the toilet. CNA65 left R22 unattended, then heard a loud noise and the resident calling for help. CNA65 and Registered Nurse (RN)41 went into the bathroom and found the resident on the floor. R22 was lying on the right side, with her right arm under and behind the resident's back; the resident's head was against the wall (adjacent to the toilet), with wet briefs around her ankles and urine on the floor. R22 reported to staff that she hit her head hard against the wall, but she doesn't remember how or why she fell . A progress note on 09/09/24 at 03:20 PM, documented the resident returned to the facility with a diagnosis of a right superior and inferior ramus fracture and skin tears to her right arm/forearm and right leg as a result of the fall on 09/05/24. Review of the facility's Fall Scene Investigation Tool form documented R22's loss of balance while getting off the toilet as the root cause of the fall. Staff's recommended interventions to prevent future falls documented R22 should be accompanied to the restroom and to not leave the resident unattended. (Cross Reference to F657: Review/Revise Care Plan) Review of comprehensive care plan documented R22 is at risk for falls related to gait/balance problems and a history of multiple falls. After the fall on 09/05/24, where R22 sustained a pelvis fracture, the comprehensive care plan was not revised or updated. No interventions identified in the root cause or staff's recommendations to not leave the resident unattended in the bathroom were added to prevent a similar accident. On 11/26/24 at 08:57 AM, R22 was escorted to the toilet and assisted with pulling down the resident's brief. Staff left R22 unattended, then heard a loud noise and groaning. The registered nurse and staff entered R22's bathroom, saw the resident sitting on her right side in a puddle of blood which was coming from the resident's head. R22 had a skin tear to right knee, multiple bruises to the right arm, and a bruise forming on the right temple/cheekbone. Resident states she doesn't remember what happened, she thought she was just going to sit on the toile, then ended up on the floor. R22 was sent out to the acute hospital and returned with three sutures above the right eye. On 01/17/24 at 09:55 AM, conducted a concurrent record review and interview with the Director of Nursing (DON) regarding R22's falls and care plan revision. DON reviewed R22's comprehensive care plan and confirmed the resident's care plan was not updated to prevent a similar fall from occurring. DON also confirmed if R22 was not left unattended, the second fall could have been avoided.

Based on observation, interview and record review, the facility failed to follow food handling and storage practices in accordance with professional standards for food service safety. Unsafe and/or unsanitary food handling and storage practices have the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness as a result of their compromised health status. Findings include: 1) On 01/14/25 at 08:58 AM, an initial tour of the facility's kitchen and interview with the Dietary Director (DD) were done. Observed six boxes of various food items including spam, apple juice, garbanzos, and mayonnaise on the floor of the dry storage area. DD confirmed the boxes of food items should not be on the floor. 2) On 01/14/25 at 09:05 AM, continued observation and interview of the facility's kitchen with the DD. Observed five boxes of various food items including imitation crab meat, potato roll, bread, and vegetables on the floor of the walk-in freezer. There was also an open plastic bag with food item DD identified as chicken nuggets on one of the shelves. DD confirmed delivery person did not properly store the boxes of food on the shelves. He stated, They were just delivered early this morning right before you guys (surveyors) came, and not supposed to be on the floor. DD immediately transferred the boxes of food into the appropriate shelves. 3) On 01/14/25 at 09:18 AM, observed a large metal pan with food items partially covered with plastic wrap stored in the upper shelf inside the refrigerator. Dietary Aide (DA)1 identified the contents as cooked noodles and that it should not have been partially covered. DD stated, It was still hot when we placed it inside the refrigerator, so we left it partially covered. Review of the facility's policy and procedure on 01/14/25 titled Storing Food directed the staff to, . 3. Keep all food items on shelves that are at least 6 above the floor . 8. Store food in original container if the container is clean, dry, and intact. If necessary, repackage food in clean, dry, and airtight containers . 4) On 01/14/25 at 09:20 AM, while inspecting the refrigerator close to the food preparation area with DD, observed a container labeled tuna salad and dated 01/08/25. At 09:55 AM, observed Dietary Aide (DA)2 with two small plates and four slices of bread in the food preparation area. Queried DA2 what she was about to prepare. DA2 said I'm going to make tuna sandwiches. Asked DA2 if she was using the tuna salad that was observed in the refrigerator earlier. DA2 said, We prepared the tuna salad on 01/08/25 and will be using it to prepare the sandwiches. Asked DA2 how long is the tuna salad good for, from the time it was prepared. DA2 said 6 days. Review of document posted on another refrigerator on 01/14/25, titled, Holding for Opened Food Items directed staff, . Tuna, Eggs & (and) Potato Salad - 4 (four) days . 47783 5) On 01/14/25 from 08:58 AM to 09:24 AM, initial tour of the kitchen area was conducted. Observed DD and DA1 not wearing required hair restraints. DD accompanied surveyors around the food preparation areas, food storages and dish washing area without any hair restraint. DA1 was working in the food preparation area and washing pots and pans in the sink close to the stove and oven. After the initial tour, shared observations with DD and he acknowledged that they should all be wearing hair restraints while in the kitchen area, and immediately proceeded to get a hairnet to cover his head.

Based on observation, interviews and record review, the facility failed to ensure a comprehensive care plan was person-centered to maintain the resident's highest practicable physical well-being and the person-centered care plan was implemented for one resident (Resident (R)348) of 14 residents sampled. As a result of this deficient practice, dependent resident is at risk of more than minimal harm. Findings include: On 01/14/25 at 12:05 PM, conducted an observation of R348 in the resident's assigned room. R348 was lying in bed with a wedge partially under the resident's right hip area. Certified Nurse Aide (CNA)32 entered the room and provided peri-care to R348. R348 was dependent on CNA32 to move from side-to-side (left to right). After CNA32 rolled R348 onto the left side, observed an open area of skin with pink and white in the open wound-bed area on the right buttock. CNA32 reported that this is the first time she was aware that R348 had an open wound. Inquired with CNA32 what type of intervention were being implemented to prevent R348 from developing a pressure ulcer. CNA32 replied, It appears that we are placing a wedge under the resident's hip to off load the resident's weight. R348's Family Member (FM)1, also in the resident's room, R348 did not have an open wound or pressure ulcer on admission to the facility. On 01/15/24 at 10:05 AM, conducted a review of R348's Electronic Health Record (EHR). R348 was admitted to the facility on [DATE]. Diagnosis which include hemiplegia and hemiparesis following a cerebral infarction which affected the left side, pneumonitis due to inhalation of food, dysphagia, and atrial fibrillation. Review of R348's baseline care plan documented the resident requires two-person assistance while providing peri-care, and an observation was made of CNA32 changing the resident without the assistance of another staff. Review of R348's comprehensive care plan did not include the resident's functional abilities and amount of assistance needed from staff. The comprehensive care plan documented, R348 has potential for impairment to skin integrity related to fragile skin Moisture Associated Skin Damage (MASD) noted to Intergluteal Cleft with four interventions, Keep skin clean and dry. Use lotion on dry skin (Date Initiated: 01/14/25); Perform and document weekly skin checks. Notify MD/NP if skin integrity becomes compromised PRN (Date Initiated: 01/14/25); PT/OT to evaluate and treat as indicated, per MD order (Date Initiated: 01/14/25); and Treatment to be completed as ordered (Date Initiated: 01/14/25). The comprehensive care plan did not include interventions to prevent the open area from worsening or preventing R348 from developing a pressure ulcer in another area. Review of an assessment documented, on 01/13/25 at 01:28 PM, a Moisture Associated Skin Damage (MASD) Incontinence Associated Dermatitis (IAD) on the Intergluteal Cleft, in-house acquired; new 2.5-centimeter (cm) x 4.3 cm x 0.8 cm. On 01/17/25 at 10:20 AM, conducted a concurrent record review of R348's EHR and interview with the Director of Nursing (DON) with the Infection Preventionist (IP) in the DON's office. Informed DON of an observation of CNA348 providing care without assistance from another staff. Reviewed R348's care plan which documented the resident requires two-person assistance. Also, F348's functional abilities were not included in the care plan. DON reviewed R348's care plan and confirmed the comprehensive care plan was not person-centered to prevent the resident from acquiring MASD or a pressure ulcer. Also, DON confirmed the care plan did not include the functional abilities of the resident but should have.

Based on interviews and record review, the facility failed to ensure a resident's (R)22 comprehensive care plan was revised with person-centered interventions after a significant change of condition assessment. As a result of this deficient practice, R22 was physically harmed, twice while left unsupervised in the bathroom and on the toilet. Findings include: (Cross Reference to F689 Accident/Hazards) On 11/17/24 at 08:57 AM, conducted a record review of R22's Electronic Health Record (EHR). Review of progress notes documented on 9/5/2024 at 12:45 AM, R22 was assisted to the bathroom by Certified Nurse Aide (CNA)65 who assisted the resident to the bathroom and onto the toilet. CNA65 left R22 unattended, and the resident fell from the toilet. CNA65 and Registered Nurse (RN)41 found the resident on the bathroom floor with her head against the adjacent wall. R22 reported to the staff that she hit her head hard and does not remember how or why she fell . Another progress note on 09/09/24 at 03:20 PM, documented the resident returned to the facility with a diagnosis of a right superior and inferior ramus fracture and skin tears to her right arm/forearm and right leg as a result of the fall on 09/05/24. Review of the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/24, Section C. functional Abilities, C. Toileting Hygiene (the ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal) R22 requires partial/moderate assistance (helper does less than half the effort); Mobility Sit to stand: R22 requires partial/moderate assistance; F Toilet transfer (ability to get on and off the commode) R22 requires partial/moderate assistance. Review of the facility's Fall Scene Investigation Tool form dated 09/05/24 documented R22's loss of balance while getting off the toilet as the root cause of the fall. Staff's recommended interventions to prevent future falls documented R22 should be accompanied to the restroom and to not leave the resident unattended. Review of comprehensive care plan documented R22 is at risk for falls related to gait/balance problems and a history of multiple falls. After the fall on 09/05/24, where R22 sustained a pelvis fracture, the comprehensive care plan was not revised or updated. No interventions identified in the root cause or staff's recommendations to not leave the resident unattended in the bathroom were added to prevent a similar accident. Review of progress notes documented on 11/25/524 at 11:40 PM, R22 had a second fall in the bathroom. Again, R22 was assisted to the toilet, left unattended and had an unwitnessed fall. R22was found in a pool of blood which was coming from a cut on the resident's head. R22 also had a skin tear and multiple bruises. R22 reported she does not remember what happened. R22 was sent out to the acute hospital and returned with three sutures above the right eye. On 01/17/24 at 09:55 AM, conducted a concurrent record review and interview with the Director of Nursing (DON) regarding R22's falls and care plan revision. DON reviewed R22's comprehensive care plan and confirmed the resident's care plan was not updated to prevent a similar fall from occurring. DON also confirmed if R22 was not left unattended, the second fall could have been avoided.

Based on observation, interview, and record review, the facility failed to ensure the supplies used for Quality Control (QC) testing of the blood glucose meter (device used for testing blood sugar) were not expired or beyond their discard date. This deficient practice has the potential to affect all residents that need glucose testing. Findings include: On [DATE] at 09:04 PM, medication cart was inspected with Registered Nurse (RN)12. A pouch that contained the glucose meter, test strips and two QC solutions was on the top drawer of the cart. Noted a green sticker on the QC solutions that stated an open date of [DATE] and use by date of [DATE]. Asked RN12 how often the staff perform QC testing for the glucose meter. RN12 said QC testing is done daily by the night shift nurse. Showed RN12 the two QC solutions that was in the pouch with the glucose meter, RN12 acknowledged that both QC solutions were beyond their stated use by date and will be discarded. When asked if the staff used the QC solutions that were in the pouch with the glucose meter, RN12 reviewed the QC log and said Yes, it matches the lot number on the log. On [DATE] at 11:15 AM, Director of Nursing (DON) provided a document titled EvenCare G2 Glucose Control Solution that stated, . Discard any unused control solution 90 days after first opening or after expiration date .

Based on observations, staff interview and review of policy, the facility failed to follow up on an out-of-range temperature recording for one medication refrigerator out of one sampled. As a result of this deficiency, there was risk of decreasing the effectiveness for the stored medications. Findings include: During an observation of the Medication Refrigerator, on 01/16/25 at 08:50 AM, several medications were being stored under temperature control. Review of the refrigerator temperature log showed an out-of-range recording that was not followed up and not reported. Staff interview on 01/16/25 at 10:00 AM, Director of Nursing (DON) acknowledged the out-of-range temperature recording and that follow up should be done. DON also said the out-of-range temperature may have been recorded in error. Review of facility policy on Storage of Medication read; Policy, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications . Procedures . Medications requiring refrigeration or temperatures between 2'C (36'F) and 8'C (46'F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label . A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits . Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken.

Based on record review and interviews, the facility failed to maintain a complete and accurate medical records for one of the residents (Resident (R)4) in the sample. This deficient practice has the potential to affect all the residents admitted to the facility. Findings include: R4 is a [AGE] year-old resident admitted to the facility on [DATE] for hospice care. During the review of R4's Electronic Health Record (EHR), noted baseline care plan under the Documents tab had a date of 10/15/24. Review of the document titled Baseline Care Plan revealed that it did not include the name of the staff who completed it and the date it was completed. On 01/15/25 at 02:40 PM, a concurrent interview and record review was conducted with Medical Records Specialist (MRS) at the third floor sitting area. Asked MRS what the facility's practice was when completing baseline care plans for newly admitted residents. MRS said the form used is part of the admission packet and is completed by the licensed staff on the day of admission. After completion of the form, it is scanned into the EHR by the MRS. Asked MRS if she was able to tell if R4's baseline care plan was completed within 48 hours of her admission. MRS looked in R4's EHR and was not able to find the completion date of the baseline care plan. MRS added that she leaves the facility at 04:30 PM so if the admission happens in the afternoon and the baseline care plan is not yet completed, it would be scanned into the EHR when she returns to work the next day. MRS confirmed that R4's baseline care plan was scanned into the EHR on 10/15/24, four days after admission. On 01/17/24 at 10:44 AM, a concurrent interview and record review was conducted with Registered Nurse (RN)12 at the nurses' station. Asked RN12 if she was able to tell when the baseline care plan for R4 was completed. RN12 opened R4's EHR and said it was completed on the admitted since she was the one that admitted the resident. Asked RN12 if there was documentation in the EHR that it was completed on 10/11/24. RN12 was not able to find any documentation on the form or in the progress notes that the baseline care plan was completed within 48 hours of admission. RN12 acknowledged that there was no documentation of who completed the form and when it was done.

Based on interviews and record review, the facility nursing staff failed to demonstrate the competency (knowledge and skill set) to meet the needs of one Resident (R)1 of a sample size of three. The Nursing Staff: 1) did not identify a change in R1's level of consciousness, 2) did not report the trend Rl's high blood pressure (BP) medication was held due to low blood pressure. 3) administered medication twice when it should have been held because BP was outside parameters, and 4) did not administer oxygen timely or notify the physician (MD)1 when R1's oxygen level (PO2) remained below. Due to these deficiencies, R1's changing condition was not recognized and reported to the MD, which did not allow for timely interventions, and she suffered harm. On [DATE], R1 was transferred to the hospital where she was admitted in critical condition with diagnosis of urosepsis (sepsis due to urinary tract infection) and fluid overload. She expired on [DATE]. This could affect any resident who has a change of condition that is not recognized by the nursing staff. Findings include: 1) R1 was a [AGE] year old female with past medical history for hyperlipidemia (disease related to conditions like heart attack, stroke, and peripheral artery disease), cognitive communication deficit, chronic kidney disease stage 3, dysphasia (difficulty swallowing), muscle weakness, atrial fibrillation and dementia. She presented to an ER with weakness in her right upper and lower extremities after a fall on [DATE]. R1 was admitted and diagnosed with acute CVA (Cerebral vascular accident/stroke). On [DATE], she was discharged to Kalakaua Gardens for short term rehabilitation. On [DATE], R1 was transferred to the hospital for shortness of breath and low oxygen saturation level, where she was admitted to ICU with sepsis (serious condition in which the body responds improperly to an infection) and fluid overload (too much fluid in your body). She expired on [DATE]. 2) Reviewed R1's transfer notes, used by the hospital to convey information about her medical care to the receiving health care providers. The Hospitalist (MD)2 Progress Note dated [DATE] 06:49 AM, included Patient now with hypotension (low blood pressure) and mild bradycardia (slow heart rate) and metoprolol (lowers BP and heart rate) decreased on [DATE] (2023) to have 12.5 mg (milligrams) p.o (oral) daily (was 12.5 mg PO BID (twice a day). MD2 also documented Much more sleepy today on exam. She even forgets her name upon awakening I informed nursing staff to notify me when family arrives and will reassess the patient. Given limited participation as well as patient's more somnolent state further subjective exam unable to be obtained. R1's baseline was documented to be oriented only to self due to the dementia, but her level of consciousness had not been somnolent until [DATE], the day before transfer to Kalakaua Gardens. 3) Reviewed R1's orders, which included, but not limited to: Order date [DATE]: Order Summary: Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG. Give 0.5 tablet by mouth one time a day for HTN (hypertension/high BP) Hold for SBP (systolic/first number) less than 120 and HR (heart rate) 60. Scheduled administration time was 08:00 AM. Order date [DATE]: Order Summary Midodine HCL Oral Tablet 5 MG. Give 1(one) tablet by mouth as needed for hypotension (low BP) give meds if BP <100. Review of the Medication Administration Record (MAR) for metoprolol revealed a pattern the medication was held several times due to BP outside of parameter (<120 SBP). [DATE]th-31, 2023: Metoprolol dose held 11 of 20 days. [DATE]: BP ,d+[DATE] P 58 [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: Part of BP cut off of photocopy, but was out of range. Metoprolol given twice when it should have been held. [DATE] ,d+[DATE] [DATE] ,d+[DATE] February ,d+[DATE] (date of transfer), 2023 Metoprolol dose held seven of 19 days [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] [DATE]: ,d+[DATE] Midodine for low BP not administered per order. Additional BP's recorded in Vitals Summary included: [DATE] 11:12 PM ,d+[DATE] [DATE] 10:57 PM ,d+[DATE] [DATE] 11:11 PM ,d+[DATE] [DATE] 11:14 PM ,d+[DATE] Midodine not administered as ordered. 5) Review of facility Nursing progress notes included the following: [DATE] (admission note) 05:52 PM: .res (resident/R1) appeared tired . [DATE] 10:27 PM: .Affect lethargic (decreased level of consciousness)/tired this shift. [DATE] 09:38 AM: Resident noted with intermittent pain behaviors-grimacing, yelling out. MD made aware with new orders received, as follows: Gabapentin 200 mg TID (three times a day) PO for pain, and PRN (as needed) Tramadol 50 mg QID (four times a day) for pain. (side effect of both gabapentin and tramadol include sleepy and tired). [DATE] 10:49 PM: .she struggled with whole pills. Gave them crushed in pudding; . [DATE] 10:17 PM: .Affect is tired/lethargic [DATE] 07:42 AM: .Affect is tired/lethargic [DATE] 10:22 PM: BP ,d+[DATE] .Very lethargic; asleep most of the time but, she is arousable. Appears to have difficulty swallowing due to lethargy. Might be safer to crush meds; . [DATE] 11:11 PM BP ,d+[DATE] .Very lethargic; asleep most of the time but, she is arousable. [DATE] 12:12 PM: Resident family concerned about resident sleepiness. Explained that resident is at baseline with behaviors that have been present since admission. Resident has normal assessment with no change in condition noted. Family requested to have MD1 call them to discuss issue. Message left in MD binder. [DATE] 10:11 PM: BP ,d+[DATE] .Affect lethargic, baseline for resident at nighttime. [DATE] 11:29 PM . Lethargic.UA (urinalysis) done, pending results. [DATE] 05:56 PM: lab result came in .bacteria many . Updated MD and ordered D5 (Dextrose) NS (Normal Saline) 500 cc/hr for Dx of dehydration, .family updated regarding the new order (antibiotic) and they have request to d/c (discontinue) tramadol and gabapentin. MD called back at 05:45 PM and .start Ciprofloxacin 250 mg PO BID x 7 days, and d/c tramadol and gabapentin. [DATE] 11:40 PM BP ,d+[DATE] .Lethargic. [DATE] 09:36 PM: .Weak in appearance. [DATE] 10:19 PM: . Becoming more verbal, . [DATE] 10:17 PM: .Very lethargic, but arousable.Resident has a reddened, systemic appearing, itchy rash to her trunk and arms. Unknown etiology. [DATE] 02:41 AM: .Very lethargic, but arousable. Resident has a reddened, systemic appearing, itchy rash to her trunk and arms. Unknown etiology. [DATE] 00:45 AM: Very lethargic, but arousable. Resident has a reddened, systemic appearing, itchy rash to her trunk and arms. Unknown etiology. [DATE] 07:29 PM: CNA(Certified Nurse Assistant) alerted this RN this morning around Lunchtime resident has blood clot on the [sic] and tea colored urine, tried to reach MD1 and just called back around 7 PM, with new order to hold Eliquis (anticoagulant) for 2 days and monitor resident. [DATE]: O2 (Saturation) 92% . Affect lethargic but able to be aroused.Facial grimacing and calling out noted with movement, resolves with reset. Pain managed with scheduled Tylenol. [DATE] 10:17 PM: BP ,d+[DATE] O2 92.0%: Affect lethargic but able to be aroused.Facial grimacing and calling out noted with movement, resolves with reset. Pain managed with scheduled Tylenol. [DATE] 11:35 PM: BP ,d+[DATE] O2 91% : .Affect lethargic.Facial grimacing and calling out noted with movement, resolves with rest. Pain managed with scheduled Tylenol. [DATE] 10:03 PM: O2 91% .Lethargic but able to arouses easily; .Facial grimacing and calling out noted with movement, resolves with reset. Pain managed with scheduled Tylenol. [DATE] 02:34 PM: .Per night shift resident has oxygen sat of 90% and no crackles noted, recheck her oxygen sat and went up to 93% room air.Around 10:10 AM this RN went to check resident and noticed she is having slight SOB (shortness of breath), up HOB (head if bed) .RR 22 O2 sat ,d+[DATE]% with coarse lung sound on bilateral [sic] lungs. Initiated oxygen inhalation at 4LPM (liters per minute) via nasal cannula, called MD and he ordered to hold IV.maintain O2 at 92% or above.While doing nebulization resident's daughter came in and explained to her what's happening. Resident oxygen cannula changed to oxygen mask and boost up to 8 LPM, however resident O2 sat is not getting higher and went down to 80%. Called MD and informed him family wants to sent [sic] resident to ER for further evaluation. Called 911 and came here around 11AM. [DATE] 04:00 PM: . resident admitted in the ICU with initial Dx of Sepsis. 6) Reviewed the Vitals Summary O2 sats (saturation), which revealed R1's O2 sat was recorded to be 91% (target 92%) on [DATE] at 09:44 PM and then again, 91% at 11:36 PM. It was not recorded again during the night. Next recorded 90% on [DATE] at 07:00 AM. R1 should have been administered oxygen when O2 Sat dropped below 92% the evening of [DATE]. The standard of care would be to monitor the O2 sat frequently throughout the night. MD1 should have been notified if it did not maintain at 92%. 7) R1's level of consciousness changed. The day she was transferred from the hospital ([DATE]), the Hospitalist documented she was much more sleepy today on exam. She even forgets her name upon awakening. Her baseline had not been lethargic or very lethargic. The changing level of consciousness was not recognized by the nursing staff. 8) On [DATE] at 03:30 PM, during an interview with RN2, said if a resident had a 91% O2 sat, she would wait and repeat the vital and if still low, would then put oxygen on. On nights, they would not notify the MD if the resident maintained over 92% after the oxygen was applied. RN2 said the MD would be notified by the day shift and informed the resident required oxygen during the night. If it did not maintain 92% during the night, she said she would notify the MD. RN2 said if they are unable to reach any MD they have a back up on call. On [DATE] at 10:30 AM, during a telephone interview with RN3, she said the general practice for notification of the MD is when something is unusual or if there is a change in level of consciousness. R1 acknowledged she held R1's metoprolol several times due to low blood pressure. When inquired what the practice was for notifying the MD if SBP was outside parameters (below 120), she said she checks the BP again, holds the medication, but would not necessarily notify the MD unless it was very low. If it was close, I would not notify. RN1 said she had not informed MD1 when she held the medication, and said the MD comes in a couple times a week and should see the documented BPs. On [DATE] at 09:00 AM during an interview with the Assistant Director of Nursing (ADON), inquired what the practice was and expectation to notify MD if BP medication is held. She said there is not a policy, but if parameters are listed, it would depend on how low it is. If it is ,d+[DATE], I'm calling, but if it is ,d+[DATE], I'd put a note in the binder (physical binder staff make notes to communicate with MD), or tell the MD when came in. The ADON said she would expect the MD to be notified if a resident continued to be lethargic or increased lethargy, as well as if a resident developed a new rash as it may be an allergic reaction to the antibiotic. On [DATE] at 10:15 AM, during an interview with RN1, he said his practice is if a BP is <120, he would repeat it in 30 minutes, and if the still remained below 120 and the medication needed to be held, he would notify the MD each time. 9) Progress notes (above) dated [DATE] indicated medications were crushed as the R1 was having difficulty with whole pills. The note on [DATE] documented Appears to have difficulty swallowing due to lethargy. Might be safer to crush meds; . Crushing medication requires an order by the physician. Neither RN notified the MD or followed through appropriately to have R1 reevaluated for swallowing difficulty.

Based on interviews and record review, the facility failed to provide information to one Resident's (R)1 representative about the right to formulate an advanced health care directive (AHCD). The facility staff documented advanced directive information was provided to R1, and she agreed to the status of full code (resuscitation). R1 was not competent to make that decision or understand the information, and her representative was not involved. In addition, the physician wrote a conflicting order of do not resuscitate (DNR) on admission. As a result of this deficiency there was the potential the resident/representatives wishes were not taken into consideration during her treatment. Findings include: 1) R1 is a [AGE] year old female admitted from an acute care hospital for short term physical and occupational therapy after having a cerebral vascular accident (CVA/stroke) with right arm flaccidity. R1 has a cognitive deficit due to dementia. She wears a hearing aid on the left side and can only hear 2% on the right. There was a writing board in her room used for reminder cues and for communication. 2) R1's admission progress note 01/11/2023 at 08:23 PM by Registered Nurse (RN)1, included R1 was alert and orient 1-2x (knows who they are and where they are, but not what time it is or what is happening to them) on arrival. The Baseline Care Plan developed on admission by Registered Nurse (RN)1 included she was Confused. Record Review revealed an order written by R1's physician (MD)1 dated 01/12/2023, DNR (do not resuscitate) Review of Social Service (SS) note by SS1 dated 01/25/2023 at 05:06 PM, included: No POLST or AHCD on file, writer offered education and blank copies, resident does not wish to complete at this time and is okay with full code status. P1's record included a General Durable Power of Attorney (appoints someone to handle finances and make medical decisions if you're unable to) dated July 1, 2016, designating family members (FM)1, FM2 and FM3 in consecutive order to make her decisions if she was unable. 3) Reviewed the facility policy titles Resident Rights Advanced Directives dated 11/2017. The policy statement was The facility will have a process for determining and following the resident's advanced care planning decisions and informing residents of their right to formulate an advance directive. Policy Guidelines included: 1. Upon admission, staff will verify the formulating of an advance directive or the resident's wishes with regards to formulating an advance directive. Resident's wishes may be communicated through the resident representative. '2. The facility will provide information on advance directives in a manner easily understood by the resident or the resident representative about the right to refuse medical .treatment and to formulate an advance directive. 3.Documentation in the medical record will reflect the discussion of advance directives occurred, and that assistance has been offered to the resident, and the resident's acceptance or declination of assistance. 7. Facility staff will communicate the resident's wishes to the resident direct care staff and physician. 10. The facility identifies the primary decision maker. This includes assess the resident's decision-making capacity and identifying or arranging for an appropriate representative for the resident assessed as unable to make relevant health care decisions. 4) On 01/25/2024 at 01:40 PM, during an interview with SS1, she said there usually is a meet and greet with the resident and family three to five days from admission and they discuss advanced directives at that time. Reviewed the documentation of the IDT (interdisciplinary departmental team) Meeting dated 01/17/2023 at 11:14 AM. Documentation of that meeting was on a a form titled IDT Care Conference/Welcome Form-V4, signed by Social Services (SS)1. The form has a section Invitation and Attendance, which was left blank, indicating R1's representatives were not invited or notified of the meeting. The form did indicate the Resident (R)1 was in attendance, but she would not have been able to understand the content of such a meeting. SS1 said she did not have any recall of that meeting. Reviewed the SS note dated 01/25/2023 at 06:05 AM noted above, and SS1 confirmed it was her note.

Based on observations, record review, and interviews with staff member, the facility failed to implement the use of a gait belt consistent with the facility's standard of practice and the resident's needs, goals, and care plan to prevent an avoidable fall for 1 out of 2 residents (Resident (R) 11) sampled that resulted in sustaining a fracture to right rib. Findings Include: Review of R11's Event Report regarding an incident 04/26/22, R11 had a witnessed fall and sustained fracture to his right rib. The report documents R11 standing with two therapists at the elevator with his walker and .was attempting to place his face mask on. He fell forward and to the right hitting his right rib cage on the walker frame. The therapists caught him and lowered him to the floor. R11 was admitted to the facility on [DATE] with diagnosis of difficulty in walking not elsewhere classified, displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing, encounter for other orthopedic aftercare, muscle weakness, other lack of coordination, and unspecified fall subsequent encounter. Review of R11's Initial History & Physical dated 03/09/22, prior to admission to the facility, R11 was admitted to the hospital from 03/04/22 to 03/8/22 after losing balance at home and having a mechanical fall resulting in a displaced right femoral intertrochanteric fracture. The history and physical further documented R11 with history of chronic [CONDITION(S)]. Review of R11's admission minimum Data Set (MDS) with an assessment reference date of 03/13/22, R11's Brief Interview Mental Status (BIMS) scored him at 12 (moderate impaired cognition). In Section G. Functional Status, under Transfers (how resident moves between surface including to and from bed, chair, wheelchair, standing position), R11 requires extensive assistance with one-person physical assist. Walk in Corridor, R11 requires one-person physical assist. Locomotion on unit, R11 requires total dependence with one-person physical assist. Locomotion off unit, R11 requires extensive assistance with one-person physical assist. Under Balance During Transitions and Walking, R11 scored a 2 (not steady, only able to stabilize with human assistance) for walking (with assistive device if used) and turning around and facing the opposite direction while walking. On 05/25/22 at 10:22 AM interview with R11 was done. R11 stated he has a history of [CONDITION(S)] and broke his right rib at the facility after attempting to put his mask on in front of the facility elevators. R11 stated he lost his balance and fell forward onto his walker while with two therapy staff. R11 stated .they couldn't catch me. On 05/26/22 at 12:40 PM interview with Occupational Therapist Assistant (OTA) 1 and Physical Therapist Assistant (PTA) 2 was done. OTA reported she was one of the therapists with R11 when the incident happened on 04/26/22. OTA stated she was following R11 with his wheelchair and Physical Therapist (PT) 3 was standing next to R11. OTA1 further stated R11 was using his walker and before he walked into the facility elevator, he attempted to put his mask on, lost his balance and fell forward on to his walker. OTA1 reported R11 did not have his gait belt on that day but would usually have use a gait belt in case he loses his balance. On 05/26/22 at 04:41 PM interview with Director of Rehabilitation (DOR) was done. DOR confirmed R11 did not have a gait belt on when services was provided on 04/26/22 and stated there is .no documentation that he didn't need to use the gait belt anymore. DOR further stated it was the therapist .fault .didn't use safety device to prevent. DOR reported therapy services are contracted by the facility and it is their policy for all residents to wear gait belts. Review of therapy's Performance Corrective Action for PT3 dated 04/27/22 documents the description of the incident On 04-26-22, .PT3] .was working with a patient .who experienced a fall during a [CONDITION(S)] incident resulting in a rib fracture. At the time of the fall, the patient was not wearing a gait belt .policy states that all patients must wear a gait belt during therapy unless the patient refuses to wear one . On 05/26/22 at 03:39 PM interview with Director of Nursing (DON) and concurrent review of R11's Electronic Medical Record (EMR) was done. Concurrent review of R11's fall risk assessment dated [DATE] scored R11 at an 8. DON stated a score of 8 or higher in the fall risk assessment indicates R11 at a higher fall risk. Concurrent review of R11's diagnosis list and initial history and physical dated 03/09/22, DON confirmed the history and physical documented R11 with a history of chronic [CONDITION(S)] and it was not included in the facility diagnosis list. Inquired with DON if there is a reason for R11 not to use a gait belt when ambulating or during transfers with staff members, DON stated it is standard of practice for staff to use a gait belt anytime they are assisting the resident with ambulating or transfers. Review of Advance Practice Nurse progress note with an encounter date of 04/27/22 documents Patient with fall while working with therapy on 4/26/22. Nursing noted he fell down onto walker and noted to hit his right flank, .He complained of pain so Xray [X-ray] was ordered. Xray results showed possible nondisplaced fracture involving right 7th rib .He admitted to increased pain with deep breath, coughing, and movement. Review of physician progress note with an encounter date of 04/29/22 documents Therapists says has some difficulty with sit to stand due to right rib pain but still participating. Patient says has pain in right rib with coughing and movements. Sometimes it hurts even with swallowing or when has to bear down to have BM [Bowel Movement]. BM was small yesterday he couldn't bear down as much. On 05/27/22 the SA found the deficient practice Past Non-Compliance on 05/25/22 through observation , interviews and documentation provided from 05/24/22 to 05/26/22. On 05/24/22 at 09:26 AM observed R8 using a gait belt while receiving therapy services. On 05/24/22 at 09:35 AM observed R41 using a gait belt while receiving therapy services. On 05/26/22 at 08:42 AM observed R40 using a gait belt while receiving therapy services. On 05/26/22 at 04:41 PM interview with DOR was done. DOR stated after the incident a written performance corrective action was taken on PT3. DOR explained the performance corrective action included training PT3 and monitoring PT3 two weeks after the written performance corrective action was completed. Review of the Performance Corrective Action dated 04/27/22 documents verbal counseling and verbal warning was done with PT3 for the incident on 04/26/22 due to policy procedure violation, gait belt use. A two week follow up action was documented on 05/10/22, PT3 .has used gait belt with all patients. On 05/27/22 at 12:54 PM interview with DON was done. DON stated, The therapist was reeducated .and received disciplinary action. DON further stated that staff were in-serviced to use gait belts, the facility monitors for competency and monitors for gait belt use. Review of In-Service Training Report dated 04/27/22 documents training provided to all therapy providers All staff at Kalakaua Gardens are to make sure that a patient is using a gait belt during therapy at all times UNLESS the patients chooses not to use one AND if so, it must be documented thoroughly On 05/27/22 at 02:58 PM the facility provided documentation of monitoring gait belt use completed on 04/27/22, 04/28/22, 04/29/22, 05/02/22, 05/03/22, 05/04/22, 05/05/22, 05/06/22, 05/09/22, 05/10/22, 05/11/22, 05/18/22 and 05/25/22. The monitoring log included residents affected and therapy staff members providing the service.

Based on observations, record review, policy review and interview with staff members, the facility failed to recognize and provide effective pain management to Resident (R)259 and R109. The deficient practice resulted in R259 yelling pain, making grimacing facial expressions, and irritability when repositioned during meals and medication administration. The deficient practice also resulted in R109's pain not managed, monitored or evaluated according to standards of practice. These deficient practices have the potential to affect other residents' pain management in the facility. As a result of this deficiency, residents have the potential for more than minimal harm. Findings Include: Cross Reference to 655 1) R259 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R259 is prescribed with routine Acetaminophen Liquid 160 milligrams (MG)/5 milliliters (ML), give 20 ML by mouth three times a day for pain, Acetaminophen Liquid 160 MG/5 ML, give 20 ML by mouth every 4 hours as needed for pain (not to exceed 3000 MG in 24 hours), [MEDICATION(S)] Patch 5% to be applied to right ribs and left hip topically every morning for pain management, and [MEDICATION(S)] 5 MG, give 2.5 MG by mouth every 6 hours as needed for severe pain. On 03/31/21 at 08:05 AM, observed R259 in bed facial grimacing and saying .owie . repeatedly. This surveyor used the call light for staff assistance and waited outside of R259's room. At 08:07 AM, the Activities Coordinator answered the call light, checked on R259, and sought assistance from nursing staff. This surveyor returned to R259's room and found Certified Nursing Assistance (CNA)25 and CNA26 repositioning R259 and changing her bed linens. R259 continued to facial grimace and repeatedly say .owie . CNA25 and CNA26 explained that R259 is in pain because earlier it took multiple attempts to reinsert the intravenous (IV). As R259 continuously expressed pain, CNA25 and CNA26 asked R259 where the pain is and R259 yelled .my leg . followed by .owie . A second observation on 03/31/21 at 02:24 PM, R259 was lying in bed and appeared upset with facial grimacing. In a loud voice, R259 yelled .owie, owie .I'm hurting! This surveyor left the room to look for assistance from nursing staff. When nursing staff was not seen this surveyor re-entered R259's room and R259 stated I am hurting, I am hurting!. This surveyor stepped out of the room again to look for nursing staff and found Certified Nursing Assistant (CNA) 27 making rounds to check vital signs. Surveyor informed CNA27 that R259 is yelling out in pain and if CNA27 can inform the nurse. CNA27 stated she will go check on R259. A few moments later CNA27 returned to this surveyor and reported R259 was okay. Concurrent review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On the day R259 was observed in pain and CNA27 reported R259 was okay, 03/31/21, R259 did not receive any PRN (as needed) medication, Acetaminophen or Oxycodone. On 04/01/21 at 06:59 AM observed R259 lying in bed and repeatedly loudly I want to stop the pain . During this time, a nursing staff was helping R259's roommate with care. On 04/01/21 at 07:22 AM, R259 could be heard from the fifth-floor dining area, R259 yelling stop the pain repeatedly from the room. At 07:25 AM, RN13 entered R259 ' s room and provided Oxycodone as needed for pain. As CNA28 attempted to adjust R259's bed for RN13 to safely administer R259 pain medication, R259 appeared to be facial grimacing, agitated, and repeatedly stated .ow . RN13 explained it will take about 30 minutes for the pain medication to start working. At 7:33 AM, CNA28 asked if R259 wanted to eat breakfast now or later. R259 continued to express pain through facial grimacing, verbal cues and agitation as CNA28 attempted to adjust R259's bed for breakfast. After multiple attempts with adjusting the bed CNA28 explained to R259 that she will come back in 15 minutes to assist with breakfast. 2) Interview on 03/30/21 at 09:28 AM with resident (R)109 who stated I have pain in my back and left lower back and I am taking [MEDICATION(S)] for it. It works to a point but three or four hours later, it wears off and I can only take four a day. They put the patch on two hours ago. R109 rated his pain 5/10 on the Wong-Baker FACES pain rating scale. Observation at 09:40 AM on 03/30/31 of R109 patch site revealed no patch on R109's back. Instead, the patch was stuck to the sheets. Interview on 03/30/21 at 09:50 with registered nurse (RN)8 who confirmed that the patch was not on R109's back. RN8 came back with a new patch and applied to R109's back. On 03/30/21 record review (RR) at 10:00 AM showed orders to question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident is not able to answer, use pain scale. RR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply patch to left lower back topically one time a day for compression fractures (12 hours on and 12 hours off. Another order to record non-pharmacological pain: 1=repositioning/limb, elevation 2=reassurance/emotional support 3=distraction/diversionary activities 4=ROM/ambulation/stretching 5=rest period/quiet environment 6=deep breathing/relaxation exercises 7=massage/therapeutic touch 8=application of ice/heat pack 9=laughter/socialization. 10=Aroma therapy 11=NO PAIN PRESENT EVALUATION OF PAIN IN VITALS, UNDER PAIN - Evaluation of pain, located in vitals under pain in the electronic medical records shows inconsistent documentation of pain in relation to administration and follow-up of pain medication as below: 3/30/2021 16:10 0 Numerical RN8 (Manual) 3/30/2021 14:19 0 Numerical RN8 (Manual) 3/30/2021 08:35 0 Numerical RN8 (Manual) RR of electronic administration record reveals that the first [MEDICATION(S)] patch was placed at 0800 AM and evaluated at 8:35 AM. The level of pain was recorded at 0. A replacement pain patch was placed on R56 at approximately 10:00 AM on 03/30/21. There was no pain evaluation done for the replacement patch. The next evaluation of pain was documented at 03/30/21 at 14:19 PM by RN8. Record review of policy and guidelines, dated 11/2017, on 03/31/21 at 1400 for Quality of Care for Pain Management was done. Policy for pain management states The resident will be monitored for the presence of pain and be evaluated when there is a change of condition and whenever there is new pain or exacerbation of pain is suspected. (d) Monitor appropriately for effectiveness and/or adverse consequences (e.g., constipation, sedation) including defining how and when to monitor the resident's symptoms and degree of pain relief; and modify the approaches as necessary.