Pearl City Post Acute

In the surveyor’s words

From the most serious findings on record at Pearl City Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 17, 2022

  Based on record review, observations, and interviews, the facility failed to provide treatment and care of Moisture-Associated Skin Damage (MASD) for Resident (R) 12 in accordance with professional standards of practice and comprehensive care plan, resulting in the progressive worsening of R12's sacrum wound. Findings Include: Cross reference to F656. A record review on 06/15/22 of R12's Discharge Summary dated 05/10/22, documented that R12 was discharged from the hospital and readmitted to the facility on [DATE]. R12 was readmitted to the facility after being hospitalized for a [CONDITION(S)] sustained during an offsite hemodialysis session on 04/26/22. R12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689May 7, 2021

  Based on record reviews and interviews, the facility failed to provide Resident (R)234 more interventions to ensure a safe environment to prevent her from falling. This deficient practice caused R234 to sustain a right [CONDITION(S)] and needing care in an acute facility. This can potentially affect residents who are at a high risk for falls placed into quarantine. Findings include: A record review was done on 05/05/21 at 2:25 PM of R234's completed facility reported incident (FRI). R234 sustained a fall on 11/30/20 at 1:35 PM and was admitted to a local hospital on 12/02/20 for a right [CONDITION(S)]. R234 was an [AGE] year-old female admitted to the facility on [DATE] for rehabilitation services. […]

• No harm, potential for more than minimal, widespreadF755May 12, 2023

  Based on observations, interviews, and record reviews (RR), the facility failed to ensure safe and secure storage of medications to minimize loss or diversion. Findings include: On [DATE] at 09:08 AM, inspected a medication cart with Registered Nurse (RN)55. While reconciling controlled medications, when asked how many residents currently use Fentanyl patches stored in this specific cart, RN55 stated that Residents (R)39 and R48 had patches in the cart with current physician orders. When asked how she disposes of used fentanyl patches, RN55 stated that she disposes of used fentanyl patches by removing the patch from the resident, rolling the patch up in a glove, and throwing the glove in the unsecured trash bin on the side of the medication cart. […]

• No harm, potential for more than minimal, widespreadF838Jun 17, 2022

  Based on review of the current Facility Assessment, interview with the Director of Nursing (DON), and review of policy, the facility failed to review and update that Facility Assessment on an annual basis. As a result of this deficiency, the facility did not update their determination for resources necessary to care for its residents. Findings include: On 06/16/22 at 09:00 AM, a review of the Facility Assessment Tool revealed the following: date of last update was 10/27/20, date assessment last reviewed with QAA/QAPI committee was 01/21/21. During an interview on 06/17/22 at 01:00 PM, DON acknowledged that the Facility Assessment was not updated on an annual basis. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2026

  Based on observations, interviews and record reviews, the facility failed to follow proper food handling and storage practices in accordance with professional standards for food service safety. Specifically, the facility failed to keep bulk food items off the floor in the storage room and did not label two containers of food brought in by family/visitors in one of three unit refrigerators sampled. 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. […]