Palolo Chinese Home

In the surveyor’s words

From the most serious findings on record at Palolo Chinese Home, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 5, 2025

  Based on interviews and record review, the facility failed to identify and intervene for an acute change in a resident's condition related to a stroke for one (Resident (R) 4) of three residents sampled, resulting in the family telling the facility to transport the resident to the hospital.Care plan did not address the resident's stroke or include interventions for the prevention of aspirationStaff did not identify R4's occasional moist cough when eating as an early symptom of aspirationStaff did not communicate to the physician that the resident's cough had occurred while eating Staff did not follow the physician's orders for treatment of symptoms of R4's coughConflicting information in the documentation, which did not relay the resident's distress when positioned on his backAs a result… […]

• Actual harm, isolatedF689Feb 26, 2021

  Based on observation, interview and record review, three residents (R) 34, R59 and R77 had one or more falls in the facility. The three residents are diagnosed with severe cognitive impairment and dependent on staff to assist with mobility. two residents are taking [CONDITION(S)] medication which may cause unsteady gait and falls and have poor safety awareness and impulsiveness. The deficient practice places the residents at an increased risk for harm, requiring a higher level of staff supervision. Findings include: 1) An initial observation of R77 was made on 02/22/21 at 12:16 PM in her room. R77 was lying in bed with the radio on, bed in the lowest position, floor mats on both sides of the bed on the floor and side rails on both sides of the bed were lowered. […]

• Actual harm, isolatedF656Jan 12, 2021

  Based on closed record review (RR) and staff interviews, the facility failed to develop a comprehensive care plan (CP) for one of three residents (Resident (R) 1) in the survey sample. As a result of this deficient practice, the facility also failed to ensure comprehensive, individualized CPs were developed for: 1) the spinal wound and two separate pressure ulcers R1 was admitted with, and 2) the five facility acquired pressure ulcers which developed during R1's stay at the facility. […]

• Actual harm, isolatedF686Jan 12, 2021

  Based on closed record review (RR) and staff interview, the facility failed to prevent the development of pressure ulcers for one of three residents (Resident (R) 1) in the survey sample. As a result of this deficient practice, R1 developed five new facility acquired deep tissue injuries (DTIs) to her feet. These were pressure ulcers (also known as pressure injuries), which she did not have on admission. As a result, the potential for harm existed as the facility failed to ensure the resident received care and services to prevent pressure ulcers from developing and failed to develop resident-centered plans of care incorporating necessary treatment/services consistent with professional practice to prevent new ulcers from developing. […]

• Actual harm, isolatedF726Jan 12, 2021

  Based on record review (RR) and interviews, the nursing staff failed to recognize that a change of condition was a medical emergency in one resident (R)2 of a sample size of two. When R2's pulse (P) increased and blood pressure (BP) dropped, the Registered Nurse (RN)4 did not notify the physician (MD) immediately to report the major change of vital signs so interventions could be done to prevent further deterioration. Low BP can be a life threatening condition and is consider a medical emergency. R2's BP and condition continued to decline and she was subsequently transferred to the hospital over two hours later where she was admitted to the Intensive Care Unit with the diagnosis (Dx) of septic shock. […]