Nursing home inspection form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
(X1) PROVIDER / SUPPLIER
/ CLIA
IDENNTIFICATION
NUMBER
125051
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
NAME OF PROVIDER OF SUPPLIER
KA PUNAWAI OLA
STREET ADDRESS, CITY, STATE, ZIP
91-575 FARRINGTON HIGHWAY
KAPOLEI, HI 96707
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0159
Level of harm - Minimal
harm or potential for actual
harm
Residents Affected - Some
Properly hold, secure and manage each resident's personal money which is deposited
with the nursing home.
Based upon staff interview and review of resident's personal funds, the facility failed to manage personal funds for
residents that utilized salon services arranged by the facility. Findings include: On 5/22/13 at 12:45 P.M. review of
residents' personal funds was done with the Receptionist and Business Office staff member. Inquired what is the process for
residents to request money from their personal funds account. The Receptionist reported that the resident will fill out a
slip and sign for receipt of the petty cash. A review of Resident #135's account found that the facility withdrew funds to
pay for a haircut on 4/5/13 for $12.50. A request was made to review the documentation that accompanied the withdrawal to
pay for the resident's haircut. At this time the Business Office staff member provided assistance. The staff members
provided an invoice from the stylist requesting payment for services for Resident #135 and other residents of the facility.
There was no documentation by the resident that she approved of the payment to the stylist. Inquired how does the facility
ensure that the resident approved the payment and received the service. The staff members reported that this stylist did
not follow the process of acquiring the resident's signature on the request slip for haircuts. The stylist was submitting
an invoice for all the residents who received services for remittance. The Receptionist reported that this stylist is no
longer contracted through the facility. Inquired how long was this stylist on contract. The Receptionist replied, he was on
contract from January 2012 through April 2013. Interview with the Business Office Manager (BOM) was done 5/28/13 at 8:30
A.M. The BOM reported that when a resident/family member requests a haircut, a slip is completed and signed by the resident
or nurse/aide to confirm the service was provided. However, the slips are not being attached to the residents' account
information. A policy and procedure related to paying contractors for services provided was requested. On 5/28/13 at 9:30
A.M., the BOM reported that the facility does not have policy and procedures for paying contractors (i.e. haircuts). The
facility did not have a system in place to ensure that salon services were provided to residents with personal funds before
remittance.
F 0160
harm
Residents Affected - Few
Follow policies and procedures to convey the resident's personal funds to the
appropriate party responsible after the resident's death.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of personal fund accounts and staff interview, the facility failed to ensure upon the death of a resident
with a personal funds account, the facility conveyed within 30 days a final accounting of those funds to be provided to the
appropriate individual for 1 of 3 accounts reviewed. Findings include: Resident A expired on [DATE]. The resident's
personal fund account was closed on [DATE] and the balance was provided to the representative on [DATE]. The facility did
not ensure the personal funds account for Resident A was conveyed within 30 days to the individual managing the resident's
estate. On [DATE] at 12:45 P.M. a review of personal fund accounts and interview with Receptionist and Business Office
staff member was done. A request was made to review the account of a deceased resident who had an account managed by the
facility. The staff members provided documentation for Resident A. Resident A expired on [DATE] and the account was closed
on [DATE] with a check payable to a family member of $476.53. Inquired how many days does the facility have to convey the
funds. The staff members replied that the facility has 30 days to reconcile the account and release any remaining funds to
the appropriate recipient. Inquired what happened with this account, the staff members replied that the BOM was on
maternity leave at that time and the person assisting them did not come in frequently enough to reconcile the resident's
account for closing. On [DATE] at 8:30 A.M. an interview and concurrent review of the account was done with the BOM. The
BOM explained that the resident received automatic direct deposit subsequent to his expiration. The ledger notes a deposit
was made on [DATE] and these monies had to be returned, which was done on [DATE]. The cost share for March also had to be
refunded to the account which was done on [DATE]. On [DATE] the approval to close the account was made and the refund check
was dated [DATE].
F 0224
Level of harm - Actual
harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and
theft of residents' property.
Based on observation, record review, resident, family and staff interviews, and a review of the facility's policy and
procedure, there was a failure to provide services necessary to avoid mental anguish and a potential for a decline in
health status for 1 of 32 residents included in the Stage 2 sample. Findings include: Cross-reference to additional and
related findings at F226, F241, F242, F309, F312 and F323. During an interview with Resident #161 on 5/20/13 at 10:55 A.M.,
the resident stated she felt afraid because of the way she and/or other residents were treated. The resident conversed both
in Japanese and English and said she was admitted to the facility for short term rehabilitation following a surgical
procedure. She said, I have asthma and that there was an incident with her breathing which made her fearful and afraid
since. The resident said one night she had chest pain/discomfort and could not breathe good. The night nurse just gave her
some pain medication and told her, Good night, you can go sleep and never came back to check on her. The resident said her
chest felt painful, but said it was because of the asthma. She said in Japanese, Tasukete, iki dekinai kara or Help me,
because I cannot breathe and said she had to plead to a male nurse aide who came into the room. She told him, I need
inhaler, something, I cannot takey my breath. She said the pain killer did not do anything because it was not the problem.
She felt the nurse just wanted her to sleep. The resident said, How can be a nurse? and shook her head during the
interview. The resident also said the male aide did tell the nurse and only then did that nurse return after 35-45 mins
later to give her a breathing treatment. The resident said she felt really, really afraid because she could not breathe.
The resident also stated during the interview that some staff have no feeling towards her. She said at night after
toileting, when she has to lay back down, the staff do not assist or help her back to bed. She said they just leave her at
the bedside and it was mostly the female staff. The resident said there were some staff who cared, but others were not and
rude in their manners. She said her roommate was a new admission and about 4-5 nights ago around 3:00 A.M., her roommate
started crying out for help. She said they both used their call lights, but the staff who came into the room said, Wow,
wow! The resident said she told the staff her roommate needed help, but was told, No, she's okay, although her roommate
could not sleep. The resident said she felt sorry for her and because she was also coughing, she called the nurse again.
She asked the nurse if she could give her neighbor something for the cough, and this made her think how bad it was when the
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99)
Previous Versions Obsolete
Event ID: YL1O11 Facility ID: 125051 If continuation sheet
Page 1 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0224
harm
(continued... from page 1)
staff did not seem to care. She said, patient so new--they don't even take care. I cannot sleep too--I worry for her, but
cannot speak to her (language barrier). In addition, the resident said even though her family member meets with the staff
about the issues related to her care, the communication was not good and did not feel clear answers were being provided.
She stated she did not even know how she was doing with her illness and felt saddened by it. She stated, I just likey go
home already and dabbed her eyes with tissue. Clinical record review on 5/22/13 found the resident was admitted on [DATE]
with [DIAGNOSES REDACTED]. The resident's 14 day MDS assessment with an ARD of 5/8/13 noted her BIMS was not done in
Section C, but Section B coded the resident as having clear speech, made self understood, able to usually understand and
had adequate vision. The resident was also capable of hearing and responded appropriately to surveyor's questions during
the 5/20/13 interview with her. On 5/24/13 at 2:10 P.M., during an interview with the resident's family member, the family
member stated one problem was the Administration. He/she stated, there's no communication--it's the little things that's
not being reported. There's no communication. The family member also gave an example regarding a shower incident involving
the resident and said, (resident) didn't even have a chance to clean up well after the shampoo was dumped on her head.
Another instance the aide didn't wipe her down well. And the staff says to her, 'I'm doing my best!' in a heightened tone
of voice. Different nurses come in and say what can she do? What?! So, they don't even know her level of care? It's just
the communication, lots of improvement needed. And a lot of staff are rude, grouchy, but this is their job, their
profession they chose. It shouldn't be like this.
F 0226
harm
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of
resident property.
Based on interview with staff and review of facility's documents, the facility failed to implement policies and procedure
to identify, investigate and report allegations of mistreatment, neglect, and abuse of residents and misappropriation of
resident property. Findings include: 1) During the abuse prohibition review, a request was made of the facility's listing
of incident reports from the previous certification survey. The facility produced two incidents related to falls. A review
of the resident council minutes found documentation of the Help Us To.Serve You Better Concern & Comment Form reports which
is utilized to document residents' concerns/complaints. On 1/31/13, Resident B reported to the Activities Director that a
male associate took his watch and was rough during care. The facility investigation and response was that the resident
could not recall any concerns with staff, resident was not fearful and per resident's daughter, the resident did not have a
watch. The action taken was the DON educated staff about proper care of resident with activities for daily living. Another
report noted Resident C informed the Activities Director on 1/31/13 that (name) C.N.A. requested money from the resident to
buy lunch and a C.N.A. was rough during care. The facility interviewed the resident and spoke with the resident's son. Both
the resident and her son wanted the facility to follow up on the concern. The action taken was the DON educated staff and
spoke with them about inappropriateness of requesting things (money) from residents and gentle care during activities of
daily living. Upon request of specific reports related to Stage 2 sample residents, there was also a report of roommates,
Residents #162 and #172 got into a screaming match on 2/4/13 resulting in Resident #172 feeling uncomfortable being in the
same room. The follow up by facility included interviewing the residents and residents admitting that they do not like each
other and would not meet to talk about the situation. Subsequently, Resident #172 moved to another room on 3/22/13. During
the Quality Assessment and Assurance meeting on 5/28/13 at 1:35 P.M., the aforementioned concern and comment forms were
reviewed with the team. Administrator #1 reported that if concerns related to abuse were identified the process for
investigating concern and comment forms would go beyond what is required to process the facility's concern and comment
forms. The administrator also acknowledge that this is a system that needs to be worked on. On 5/29/13 at 8:45 A.M. an
interview was conducted with Administrator #2. Inquired whether the information shared from the Help Us To.Serve You Better
Concern & Comment Form cards during the QA&A interview regarding rough handling by Certified Nurse Aides required further
investigation. Administrator #2 replied, moving forward these are issues that should have been investigated further then
what was required to process the concern and comment form. The facility failed to identify and investigate allegations of
abuse as identified in the Help Us To.Serve You Better Concern & Comment form submitted by residents and family members.
The facility also failed to report allegations to the State Agency.
2) Cross-reference to additional and related findings at F224, F241, F242, F309, and F323. Clinical record review on
5/22/13 found Resident #161 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's 14 day MDS assessment
with an
ARD of 5/8/13 noted her BIMS was not done in Section C, but Section B coded the resident as having clear speech, made self
understood, able to usually understand and had adequate vision. The resident was also capable of hearing and responded
appropriately to surveyor's questions during the 5/20/13 interview with her. During a follow-up interview with the resident
on 5/21/13, she stated there was a problem with one of the CNAs (CNA #5). The resident said she was on a different unit
when she was admitted and argued with CNA #5 about how cold the shower felt. She also said when she requested a shampoo,
the CNA put shampoo just to one side of her head and did not help her shampoo. She ended up with the shampoo all over her
body and felt like she had taken a shower with shampoo. The resident said she was upset because of this, and reported it to
a nurse. The resident said CNA #5 came to tell her sorry but she (CNA #5) did it right. The resident said all CNA #5 did
was control the shower head and spray her. She did not give her enough time to wash herself with soap and said, no more
soap, only shampoo. The resident reiterated that CNA #5 told her, Sorry, I do my best and walked out. The resident said,
She say I'm sorry, but she not sorry--the way she say it! I know. The resident stated she felt more upset afterward and no
one really took care of the problem. This was also told to the surveyor by the resident's family member. On 5/23/13 at 2:35
P.M., an interview of CNA #5 was conducted. She has worked almost three years at the facility this June and started working
morning shifts from November 2012. She was familiar with Resident #161. CNA #5 recalled the last time she showered the
resident, she told me I did not help her do everything. She said just like rinsing everything, face towel, rub on her body
and she told me I did not help her. But for me, I help her, I give her 2 towel and I use the other towel for her back and
eveything. CNA #5 was asked how capable the resident was in doing her ADLs and she replied the resident was limited
assistance but still needed help. She said she shampooed the resident's hair and the shower took about 10-15 minutes. She
said the resident also liked hot water, and you can only make it only so hot and told the resident that. She said the
family member was okay, but the resident is the one who making trouble. The nurse told me after break the resident said I
didn't help her so I went with her to say I'm sorry, I did everything to help you. (Resident) told me, 'Oh no you don't
even help me', but the (family member) said 'no, she help you', but (resident) said, 'no she don't help.' CNA #5 said she
did not work with the resident thereafter because the resident moved to a different room and did not request for any more
showers either. CNA #5 said there was no incident report written up, but a licensed nurse (LN #5) asked her questions about
it. CNA #5 said, Only now someone is complaining. On 5/23/13 at 2:58 P.M., an interview with LN #7 revealed the resident
told her CNA #5, she just put shampoo on her hair and then only on this side (top of head), and she wanted it all around,
but CNA only showered in front. LN #7 said CNA #5 denied showering the resident as the resident claimed. LN #7 told the
resident she would find out and wrote it on a blue form and told the charge nurse (LN #3) about what happened, but did not
know anything more. LN #7 said she was concerned about the way CNA #5 shampooed the resident. That's why right away I have
to investigate it. As long as I done talking with (CNA #5), I talk to my charge nurse. LN #7 said she apologized to the
resident and told her she would talk to the CNA about it as well. On 5/24/13 at 1:25 P.M., during an interview with the
DON, she stated she was away when the shower incident occurred between Resident #161 and CNA #5. She said a family member
also brought it to her attention upon her return and asked that CNA #5 not shower the resident anymore. The family member
did not like the action of the CNA squirting shampoo on her hair. The DON asked if the resident was hurt and the family
member said no. However, the DON said she did not ask the resident about it and only asked LN #7 about what happened. The
DON stated she did not have documentation on it as well. She said her expectation was there should be documentation about
the incident, such as a concern and comment card, but there was none. On 5/24/13 at 3:42 P.M., the DON said she talked to
LN #7 about the shower incident again. She reconfirmed the details and included that the shampoo they use was a shampoo and
body wash combination. The DON stated she did not think the resident was informed of this and said she should have inquired
more into this. At 3:53 P.M. the Registered Dietitian (RD) said she would be going to see the resident to explain that it
was an all in one type of body wash/shampoo they used. Per interview with MDSC #1 on the morning of 5/24/13, she said if a
situation involved a staff to resident issue, such as a concern or lack of an appropriate shower the resident received,
FORM CMS-2567(02-99)
Page 2 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0226
harm
there would be an incident report generated. MDSC #1 said staff would also be addressed, and she would remove the staff
from the unit until the investigation was completed. Per the guidelines at ?483.13(c) of Appendix PP of the State
Operations Manual: Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or
mental illness. (42 CFR 488.301). The facility's policy and procedure regarding the Protection of Residents: Reducing the
Threat of Abuse & Neglect (Rev. 2/09), stated, All personnel will promptly report any incident or suspected incident or
resident abuse and/or neglect, including injuries or unknown origin.10. Following the report of suspected abuse and/or
neglect, the administrator will designate a resident advocate (i.e., social services), to support the resident through
his/her feelings about the incident and his/her reaction to their involvement in the investigation. The designated resident
advocate will coordinate development of care planned interventions as necessary to assist the resident in successfully
dealing with the occurrence of abuse and/or neglect. There was no documentation or evidence that the facility followed
their own policy and procedure nor further investigated the resident's concerns related to the shower incident with the
CNA, despite being aware of it.
F 0241
harm
Provide care for residents in a way that keeps or builds each resident's dignity and
respect of individuality.
Based on observations, resident and staff interviews, the facility failed to maintain the dignity and respect for 15 of 24
residents. Findings include: Interviews and observations were made during both Stages 1 and 2 of the Quality Indicators
Survey (QIS) and revealed a multitude of issues/concerns related to dignity and respect. 1) Interview of a Resident, R
#333, on the morning of 5/21/13 revealed that a Certified Nurses Aide, CNA #7, treated the resident roughly and was rude to
her. During the interview on 5/21/13, R #333 was alert and oriented to person, place, and time. The R #333 was admitted to
the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident stated, When I first came, I couldn't walk. I couldn't
even move off the chair. The CNA was so rough, she pushed me around to make me move. I couldn't. She forced me to go to
bed. She's short tempered. She complained that I was too demanding. I didn't demand anything. She's just mean and nasty.
The resident further explained that this occurred every night that CNA #7 was on duty. The R #333 stated that she would use
her call light to go to the bathroom and would wait long periods of time before the CNA would tend to her. The R #333
stated she was in the Day Room on the Keolamau unit one evening when she wanted to return to her room to go to bed. The
resident stated the CNA #7 was sitting at the nurse's station, drinking water, and took her sweet time. The R #333 stated
she waited approximately 30 minutes before the CNA #7 got up to assist her back to her room. The R #333 stated the CNA #7
was caring for her when she stated (in Filipino), You're a pain in the neck. Every time I come here you make more work for
me. The resident was upset and stated to the surveyor, I don't want her near me. I don't want her taking care of me
anymore. The R #333 stated that she was planning on talking to someone about this. As of 5/21/13, the resident did not
share these concerns with any other staff members. The resident stated the CNA #7 hadn't worked over the past 2 evenings.
The R #333 reasoned that the CNA #7 was likely to return that night (5/21/13) since she had been off the past 2 nights. She
stated, I think she's coming back tonight and I refuse to let her touch me. I don't want her near me. The R #333 stated she
wasn't afraid of the CNA and that she would tell her to leave her alone. The resident was able to describe what the CNA
looked like: Body frame, Ethnicity, height. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of
5/21/13 during the afternoon of 5/21/13 found R #333 had a Brief Interview for Mental Status (BIMS) score of 15/15. The
resident was able to tell the surveyor where she was (facility), the city where her home was located, the reason for
admission to the facility (rehabilitation), and how long she had been in the facility (7 days). Interview of the
Administrator and Director of Nursing (DON) on the afternoon of 5/21/13 revealed the Administrator recently started working
at the facility and had only been on the job for one week. The DON and Administrator both stated they were unaware of R
#333's allegations of abuse. The DON and Administrator stated they would immediately investigate the allegations. The
Administrator and DON interviewed R #333 on the afternoon of 5/21/13, during which the resident spotted the alleged
perpetrator and was able to verbalize, You stay away from me. I don't want you touching me. The Administrator and DON
stated she was pointing to CNA #7. The CNA #7 was immediately suspended pending investigation. Interview of the
Adminstrator, Interim Administrator, DON, Chief Nurse Executive (CNE) on the afternoon of 5/22/13 revealed they were almost
done with their abuse investigation. They had to interview the alleged perpetrator, CNA #7, and a rehab therapist was
writing a statement. The DON expressed her shock at the fact that CNA #7 was being accused, as the CNA was recommended by a
family member for outstanding performance. The Adminstrator further expressed that the resident, needed re-education on
appropriate transfer techniques. The Administrator consulted the Physical Therapist, who informed her that the resident
needed frequent reminders about proper transfer technique. The CNA #7 was interviewed by the DON on evening of 5/22/13,
when the CNA denied the allegations. According to the DON, the CNA #7 was inconsistent with her stories. The facility
substantiated abuse. The CNA #7 submitted a letter of resignation on the morning of 5/23/13. 2) Interview of R #333 on the
morning of 5/21/13 revealed that she was admitted on [DATE] and still hadn't received a shower. Record review confirmed
that R #333 did not receive a shower since her admission. The Montly Flow Report revealed R #333 received sponge baths on
the evening and night shifts on 5/14/13; Day, evening and night shifts on 5/15/13; Day, evening and night shifts on
5/16/13; Evening and night shifts on 5/17/13; Day, evening and night shifts on 5/18/13; Day and Night shifts on 5/19/13 and
5/20/13; and Night shift on 5/21/13. Interview of the Assistant Director of Nursing, ADON, on the afternoon of 5/23/13
revealed that showers were usually given shortly after breakfast or soon after the evening shift began. Unless a resident
requested, the night shift usually didn't provide showers. Their night shift was from 11 P.M. to 7 A.M. The ADON explained
that sponge baths included a head to toe wipe down in bed. When asked whether the night shift provided sponge baths to
residents, the ADON responded, Yes, probably. The DON and MDS-Coordinator (MDS-C #1) were notified on the afternoon of
5/21/13 that R #333 had not received a shower since her admission. The DON stated she would look into it. On 5/22/13 at
12:45 P.M., R #333 stated she still hadn't received a shower. She stated, I feel dirty. I want to take a shower. The
resident didn't receive a shower until the late afternoon on 5/22/13, 8 days after she was admitted to the facility. The
facility had a Bath List for Keolamau which indicated R #333 was supposed to receive showers on Wednesdays and Saturdays.
The Bath List noted, Please don't make any changes unless approved by (DON) or (staff nurse). On the afternoon of 5/23/13,
the ADON stated that residents had the ability to choose the frequency of their showers. If they wanted daily showers, they
would try to accomodate them. 3) A Unit Clerk, #1, wheeled R #333 out to the lanai on the morning of 5/21/13 to meet with
the surveyor. While being wheeled out, R #333 asked the Unit Clerk #1 if she could get a newspaper to read. The Unit Clerk
#1 informed the resident that the Activities staff went over the current events with residents in the Day Room and she
could get the paper after they were done with it. Interview of R #333 revealed that she was purchasing her own newspaper
over the past week since she was admitted but the resident has since run out of money. The R #333 stated she had loose
change in her bedside table but ran out so she now had to wait for her daughter to buy her a newspaper. Interview of the
MDS-C #1 on the afternoon of 5/21/13 revealed that the resident was entitled to receiving a newspaper if she requested one.
The MDS-C #1 stated the staff should have provided the R #333 with a newspaper. 4) On the morning of 5/21/13 interview of R
#328 found that she was disrespected and felt her dignity was compromised. The resident explained that she previously went
to the dining room for meals but stopped because of the way she was treated. The resident explained that while in the
dining room, the staff would provide her with her food tray after everyone else got served. The resident stated the staff
would bring the trays to persons who required assistance with eating, and uncover all their food items then walk back to
the food cart to pass out the remainder trays without feeding them first. The R #328 stated she and another resident were
the last to receive their trays. She stated that she asked to get served earlier but was ignored. By the time she received
her tray, the hot food had already cooled off and the cold items weren't cold. The R #328 stated that she asked for toast
one day and was told, No. She stated that she didn't have any dietary restrictions that would prevent her from a liberal
diet. She stated, Now I stay in my room. I don't want to make a scene. I feel more comfortable and my TV is on. Record
review for R #328 revealed a physician order [REDACTED]. Interview of the ADON on the afternoon of 5/23/13 found that
residents were able to receive additional food items per their requests if within their dietary restrictions. 5) Interview
of Resident, R #334, on the morning of 5/21/13 revealed she experienced long wait times for the call light to get answered.
She stated that she looked at her clock and she often waited 15-20 minutes for assistance. The R #334 stated that 15-20
minutes is really long when you have to go the bathroom. The resident stated that she told the facility staff that they're
slow. The R #334 told facility staff, We paying big money. They tell us they have other patients. They take so long to
FORM CMS-2567(02-99)
Page 3 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0241
harm
come. Sometimes they're outside laughing. Sometimes you don't know what they're saying because they're talking Filipino.
The R #334 stated that during the late morning one day last week they had something (ex. movies or other activity) in the
Day Room on Keolamau. The R #334 and 3 other residents were waiting in the Day Room for approximately 30 minutes for the
staff to take the resident back to her room. The resident observed one staff member walking back and forth. The R #334 went
to the nurse's station and said something to the staff about ignoring the residents in the day room and making them wait
for long periods of time. The resident stated that one resident was sleeping in the Day Room. One of the CNAs just stood
there and looked at her. It wasn't in an intimidating way. Another staff member took them back to their rooms. The resident
stated she often had to use her call light to assist her roommate, who was not alert and oriented. Record review for R #334
on the afternoon of 5/22/13 revealed a Brief Interview of Mental Status score of 15/15, indicating she was alert and
oriented. The resident was admitted for rehabilitation and was being discharged on [DATE].
6) During an interview with Resident #161 on 5/20/13 11:33 A.M., she stated when the staff approached her, they don't tell
who and what going to do. She said for instance, CNA #4 who came to take her to bathroom, just started to comb her hair
while she was sitting on the toilet. Resident #161 also stated when she used her call light, the staff failed to answer in
a timely manner, but when they did, her sense was that staff were uncaring or unfriendly and did not properly introduce
themselves. Resident #161 also stated she had a problem with one of the CNAs about her showers. Cross-reference to findings
at F226 and F224. 7) Observation of Resident #326 on 5/21/13 at 9:36 A.M. found the resident sitting in his wheelchair
(W/C) with head in his hands. He was situated by the foot of his bed with the privacy curtain drawn. The resident declined
to be interviewed, but said, I like go home, I like go home, and teared up. It was also observed his call light was not
within his reach. It was hung on an IV pole at the head of his bed. A social worker (SW) consultant passing by was asked to
come see the resident and when she did, the SW failed to fully assess the resident's condition/needs when he sat there with
his hands to his face, stating he wanted to go home. Instead the SW consultant told the resident that the therapist, who
had walked in to talk with the resident's roommate, was going to schedule the resident's next therapy appointment. The
resident acknowledged that; however, as the SW was going to leave his side, surveyor asked about his call light. The SW
said, oh yeah, saw the call light hanging on the IV pole, obtained it and told the resident she was going to clip it to his
shirt. CNA #4 walked in then and the SW told her the call light had been hung on the pole and then left the room. The SW
did not tell CNA #4 anything about how she found the resident. CNA #4 kneeled down next to the resident and asked him in
his native dialogue, Who put you here? and the resident replied he did not know. CNA #4 said, We usually don't put him here
by himself. She said the resident tries to get up by himself and was not supposed to have been placed there with no call
light within reach. After a few more questions, the resident said he wanted to go to bed and the CNA assisted him to bed.
8) During multiple random observations of Resident #329, the resident was found dressed in a white tee shirt and blue adult
briefs. On 5/24/13 at 8:28 A.M., the resident was observed from the doorway laying in bed wearing blue adult briefs and a
white tee shirt. The resident's right hand was in his brief and did not have a blanket or sheet covering him. The resident
was in full public view from the doorway. Interview with CNA #6 revealed the therapist had just finished working with the
resident. CNA #6 said, oh no, he no like sheet. Surveyor explained the resident was visible to the public, but then CNA #6
opened up the folded white bedsheet and immediately covered him and said, Someone maybe don't like, and drew the privacy
curtain around the bed. At 9:00 A.M., therapist #2 said CNA #6 told him he did not cover the resident after working with
him. Therapist #2 acknowledged with the resident being in blue adult briefs and visible to public view was not dignified.
He was asked if there were shorts that the resident could wear, and he said, Oh yeah. However, in the afternoon, the
resident still had the blue adult briefs and his thighs and legs were fully exposed. He did not have any shorts or other
type of undergarment to cover the adult blue briefs.
9) Cross Reference to F353. Interview with residents during the survey found residents' reporting that they did not receive
the assistance they require for toileting and managing pain. A) Interview with Resident #172 was done on 5/21/13 at 9:50
A.M. The resident reported that there has been times when she uses the call light for assistance to use the restroom and
will have to wait a long time for assistance. Inquired how long she has to wait, the resident responded sometimes an hour
or she has to wait so long that she forgets what kind of assistance she needs. She also reported that sometimes she waits
so long that she loses the urge to use the toilet. The resident also shared that the staff will tell her that its okay if
she wets the bed/urinate in her personal brief; however, the resident stated that after 3 to 4 times it gets uncomfortable.
Record review done on 5/24/13 at 2:00 P.M. found an Initial Data Collection Tool/Nursing Service dated 12/19/12 documenting
the resident is continent of bowel and bladder and occasionally incontinent. Review of the quarterly Minimum Data Set with
assessment reference date notes the resident is frequently incontinent of urine and always continent of bowel. Resident
#172 requires extensive assistance with one person physical assist for toileting and is not steady and only able to
stabilize with staff assistance for moving on and off the toilet. B) Resident #44 was interviewed on the morning of
5/21/13. When asked whether the staff treats him with respect and dignity, he replied no. He reported that there is not
enough staff available to assist him when he wants to use the toilet and he has to yell for help. Review of the resident's
annual MDS with assessment reference date of 1/21/13 notes he requires extensive assistance with one person physical assist
to use the toilet. The resident was also noted to be always incontinent of urine and frequently incontinent of bowel. The
subsequent quarterly evaluation with assessment reference date of 4/8/13 notes the resident is always incontinent of urine
and bowel. Resident #44 scored 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). C) Resident #292
was interviewed on 5/21/13 at 10:15 A.M. The resident reported that when his legs are sore and he asks for help, the staff
doesn't come right away. He stated he is told there's plenty patients beside me, so they come when they get a break. They
say, yeah, yeah we coming, we coming. But when they say they gonna come back, by the time they come, I'm suffering already.
On 5/22/13 at 10:30 A.M., Resident #292 reported that he sometimes has to wait for medicine a long time and he gets mad
when staff tell him they will be right back and two hours later they come back. He shared that he has burning and needs
help to reposition himself or no longer wants to sit and staff tell him to take a deep breath. The resident commented that
this is bull[***]. While interviewing the resident, the resident's wife arrived and requested to add her comments to the
interview. The resident's wife reported that although her husband presses the red button nobody comes, it takes a very long
time. The resident's wife also reported that her husband had to ring the call light for his roommate when he fell . D)
During resident interview done on 5/21/13 at 8:00 A.M., Resident #162 responded that she has to wait a long time for staff
to receive care and assistance that she needs. The resident clarified that sometimes she has to wait so long for staff to
assist her with toileting that she will pee in her pampers. Record review found a quarterly MDS with assessment reference
date of 3/11/13 noting Resident #162 scored a 13 (cognitively intact) on the BIMS. She was noted to require extensive
assist with two plus person physical assist for toileting. She was also noted to be occasionally incontinent of urine and
frequently incontinent of bowel. E) During interview with Resident #135 on 5/20/13 at 11:00 A.M. the resident reported that
she sometimes has to wait two hours for assistance. She reported that at night it is really bad and the facility is short
of staff and the people out there don't want to work and say they are very busy. Resident #135 reported that her bed gets
wet. Record review done on the afternoon of 5/24/13 found an annual MDS with assessment reference date of 4/2/13
documenting the resident scored a 15 (cognitively intact) on the BIMS. Resident #135 requires extensive assist with one
person physical assist to use the toilet. She was also noted to be frequently incontinent of urine and always incontinent
of bowel. 10) On 5/21/13 at 7:30 A.M. observed Residents #12, #186 and #162 seated on their unit with bath towels wrapped
around their upper body, covering their chest and back. Interview with Resident #162 found that she wears the towel because
she is cold. Inquired whether she has a sweater, she responded that she has a sweater; however, it is in the laundry.
Observation on 5/22/13 during breakfast found the three residents having breakfast in the dining room with the bath towels
wrapped around their upper body. On the morning of 5/28/13 Licensed Nurse #5 was asked why the residents have towels draped
on their upper body. LN #5 replied it is because they are cold. Inquired whether these residents have sweaters. The
licensed nurse responded that they have sweaters and would look into why they are not wearing their sweaters.
11) On 05/21/13 at 8:04 AM during Stage 1 of the survey, R#165 was interviewed. When asked the QIS question, Has staff
yelled or been rude to you? The resident answered, Yes. The resident further elaborated that staff are impolite sometimes,
and that he/she felt hurt when staff said, This is your medicine, you supposed to take it. The resident stated that he/she
is educated and not a moron that doesn't know things. Med record review on 5/22/13 at 8:45 AM revealed that R#165 was
admitted to the facility on [DATE] for a short-term course of physical and occupational therapy, to improve functional
FORM CMS-2567(02-99)
Page 4 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0241
harm
status. The resident's previous lifetime career was in insurance sales. R#165 was prescribed an anti-depressant with
behavior monitoring for, sad mood, and sad face, and in the Month of May 2013, a 0 was written each day to document that
the resident did not display signs and symptoms of depression. On 05/22/13 a facility, Concern and Comment, card was
completed by LN#3, due to R#165 becoming upset that LN#3 wanted to provide insulin by subcutaneous injection while he/she
was eating breakfast. The outcome of the facility investigation concluded that LN#3 would no longer provide services to
R#165, as resident requested, (He does not understand me.); and, LN#3 was provided education on appropriate treatment
times. 12) On 5/21/2013 at 8:00 AM during Stage 1 of the survey, interviewed R#327 for QIS interview. The resident stated
that the staff cleans his/her dentures daily, but not if he/she was to ask as needed. The resident related that on 05/20/13
in the evening, he/she wanted to rinse dentures in the bathroom sink, and requested assistance from the CNA that delivered
the dinner tray. The CNA's reply to R#327 was that he/she was too busy with the dinner meal service. The resident resorted
to rinsing his/her dentures in hot miso soup that was on the dinner tray and gargled with water to rinse. The resident
stated that had to do whatever could be done for him/her self; because There are a lot of, ' Schwarzenegger ' s, ' that
work here. When asked to clarify, R#327 stated that whenever he/she requests help from staff their reply is, I'll be back.
The resident was a quadriplegic and admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R#327 required
extensive assistance for all activities of daily living, (ADL), due to generalized weakness. The resident's May 2013
monthly flow sheet for daily care documented under the Dentures Cleaned, section, that there were no check marks between
and on the days of 5/18-20/2013.
F 0242
harm
Make sure each resident has the right to have a choice over activities, their
schedules and health care according to his or her interests, assessment, and plan of
care.
Based on resident interviews, record reviews, and staff interviews, the facility failed to provide 5 of 40 residents the
ability to choose their preferred shower schedules. Findings include: 1) Interview of Resident #333, R #333, on the morning
of 5/21/13 at approximately 9:00 A.M., revealed the resident had not received a shower since she was admitted to the
facility on [DATE]. Interview of the resident on 5/22/13 at 12:45 P.M. revealed the R #333 still hadn't received a shower.
She stated, I feel dirty, I want to take a shower. The resident finally received a shower in the late afternoon of 5/22/13.
Record review on the afternoon of 5/22/13 found that R #333 was admitted to the facility on [DATE]. The facility was in the
process of completing the Minimum Data Set (MDS) and the completed portions were reviewed. The Brief Interview for Mental
Status (BIMS) revealed that R #333 had a score of 15/15, indicating her ability to appropriately recall items, colors, and
numbers after a brief period of time. The MDS further indicated the resident was not experiencing problems with her mood
and did not have problems with behavior. On the afternoon of 5/22/13, a review of R #333's Activities of Daily Living (ADL)
flow sheets revealed the resident did not receive a shower since her admission on 5/14/13. The ADL flow sheets revealed the
resident received a sponge bath on various shifts on these dates: 5/14/13 (evening & night); 5/15/13 (day, evening, &
night); 5/16/13 (day, evening, & night); 5/17/13 (evening & night); 5/18/13 (day, evening, & night); 5/19/13 (day & night);
5/20/13 (day & night); and 5/21/13 (night). Review of the Bath List For Keolamau, Evening Shift on the afternoon of 5/22/13
found that R #333 was supposed to have received showers on Wednesdays and Saturdays, twice per week. The Bath List For
Keolamau, Evening Shift also noted, Please don't make changes unless approved by (DON) or (staff name), Thank you.
Interview of the Assistant Director of Nursing (ADON) on the afternoon of 5/23/13 at approximately 1:30 P.M. revealed that
residents were given the ability to choose when/if they shower. If the resident wanted daily showers, the facility would
try to accomodate them. The ADON explained that a sponge bath included a head to toe cleansing with a washcloth. The ADON
was asked whether the night shift (11:00 P.M. to 7:00 A.M.) were actually providing residents with sponge baths. The ADON
responded, Yes, probably. The ADON stated that aside from the nurses' quarterly review of CNA records, the nurses were not
providing oversight of CNA documentation. 2) Interview of R #328 on the morning of 5/21/13 found that she wasn't given a
choice for her shower days. She stated she would prefer showers every other day, not only Tuesdays and Fridays (her current
schedule). The R #328 was alert and oriented to person, place and time. Record review for R #328 on the afternoon of
5/22/13 found documentation of the resident refusal for showers on: 5/7/13 night shift; 5/12/13 night shift; 5/14/13 night
shift; 5/15/13 night shift. Interview of R #328 on the afternoon of 5/23/13 found that she never refused a shower.
Interview of the Minimum Data Set-Coordinator #1, MDS-C #1, on the afternoon of 5/23/13 revealed that residents were
allowed to choose their shower preferences and the facility would accomodate them. The MDS-C #1 was informed that R #328
preferred showers every other day. The MDS-C #1 stated she would note the changes and begin providing showers every other
day for the resident. Observation on the morning of 5/24/13 found R #328 in the hallway with her hair wet. The resident
stated she just received a shower and, It feels good.
3) During an interview with Resident #161 on 05/20/13 at 10:43 A.M., she said she did not have a choice in how many times a
week she had a shower, but it was once every 4 days. She recalled once she was sweating a lot and asked for a shower, but
was told by a staff that her scheduled shower days were once every 4 days. She was not offered a shower, but said she had
really wanted a shower then. Review of ADL flowsheets showed the day, evening and NOC shift CNAs marked the May 2013
monthly flow sheet as having given the resident sponge baths and/or refused bathing. In addition, the resident's shower
days documented a span of 7 days from one shower day to the next (5/10 and 5/17). During that period, it was marked that
the resident also received up to 2 sponge baths daily. On 5/22/13, during a follow-up interview with the resident, she said
when she counted her shower days, in my head--one time every 4 days. At 2:42 P.M., during an observation of an interview
conducted by MDSC #1 with the resident, the resident stated she showered every 4 days and a sponge bath was given 50-50.
The resident also said she never had gotten a shower at night and the staff also never wiped her down at night. The
resident stated she perspired a lot and the most staff would do was to take off her shift and just wipe off her back, just
change clothes, sometimes no even wipe off, towel? No, I don't think so. At 2:55 P.M., with the RD as the interpreter, the
resident stated she had never received a head to toe sponge bath in her bed and did not even know what it was until it was
explained to her by the RD. The resident also restated she had never been asked nor given a sponge bath by the night shift
(NOC). Per an interview with MDSC #1 on 5/28/13, she said the documentation regarding the NOC shift was inaccurate. Per
MDSC #1, she confirmed the NOC CNA never asked the resident about a sponge bath or that the resident refused a bath. MDSC
#1 said the CNA marked off that it was done when it was not. MDSC #1 stated, I will be looking into how we are going to
investigate about the CNAs not providing the service. She said given the number of sponge baths documented in the
flowsheet, the staff should have offered more showers instead of those sponge baths, which the resident stated she never
received. During a re-interview with Resident #161 on 5/23/13 at 9:15 A.M., she said regarding all the questions asked of
her about the sponge baths and bathing, she did not even know what a sponge bath was until they explained it to her. The
resident reiterated, Here, don't know what, who--they come in, no say nothing. The resident also said on the evening on
5/22/13, after all the discussion about the sponge bath, a social worker came to see her. Why all of sudden asking all
kinds questions? I don't know. I likey go home already.
4) Cross Reference to F353. A family interview was done on 5/20/13 at 11:30 A.M. The family member reported that Resident
#179 does not receive the same number of baths or showers in a week based on past preference. The family member shared that
at home, Resident #179 received a bath daily and at the facility receives a bath twice a week. The family member reported
although Resident #179 received a bath/shower daily at home, the preference would be for a bath/shower three times a week.
A review of the resident's care plan for Activities of Daily Living notes to assist with bath or shower 2 times weekly,
more often as desired. The Monthly Flow Sheet noted for the month of March 2013, the facility missed two showers and
received a total of seven showers and for the month of April 2013, the facility missed five showers and received a total of
four showers for the month.
5) On 05/21/13 at 7:53 AM on Stage 1 of the survey, R#165 was interviewed. When the resident was asked whether he/she could
choose how many times a week to take a bath or shower, R#165 answered, No. The resident further elaborated that he/she used
to take a shower 1-2 times a day at home, but at the facility, he/she was on a schedule and given a shower every 4-5 days.
FORM CMS-2567(02-99)
Page 5 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0242
harm
The resident stated that he/she would want to bathe more often. The resident further stated that no one ever asked him/her
how many times he would like to bathe, and didn't think of asking because facility had a schedule for baths. ON 05/22/13 at
5:23 AM reviewed R#165's Monthly Flow Report for the month of May 2013, that the CNA staff would check off for each day an
ADL task was performed. The Daily Care Monthly flow sheet for May 2013 had a check mark under the shower section on 5/4,
5/8, 5/11, 5/16, and 5/18 in the evening shift row. Sponge baths were checked off from 5/01-5/21 if provided during the
day, evening or night shift, and on some days R#165 received a sponge bath each shift. The Bathing Refused section had
check marks during the night shift for May 2013, with the exception of 7 days left blank. On 5/22/13 at 7:44 AM interviewed
R#165, who stated that a shower was provided only once a week, and his/her last shower was 8 days ago. According to R#165,
the facility staff provided no explanation on why cannot shower more often but instead informed him/her that baths are
scheduled. Reviewed R#165's care plan (CP), dated 4/27/13 for, ADL Self-care deficit: Requires asst w/ADL care, due to
resident's inability to perform test for balance while standing without physical support. The CP approaches included: Asst
with bath or shower 2 times a week or more often as desired; Explain all procedures and purpose prior to performing task
and encourage self performance.
F 0247
harm
Give notice to the resident before a room or roommate change.
Based on interview with resident and staff member and record review, the facility failed to ensure a resident received
notice before the resident's roommate in the facility is changed. Findings include: Interview with Resident #135 was done
on 5/20/25 at 11:00 A.M. The resident reported that she was not notified of receiving a new roommate. Resident #135
explained that new roommates are just brought into the room, introduced to her and then they just stay there. Interview
with the Ward Clerk was done on the morning of 5/22/13. The clerk reported that Resident #135 had a new roommate in April;
however, this resident has been discharged . Review of the new roommate's record noted that she was admitted on [DATE].
Review of Resident #135's record could not find documentation that the resident was notified of the new roommate. Interview
and concurrent record review was done with the Assistant Director of Nursing (ADON) on 5/22/13 at 2:27 P.M. The ADON
reported that social services usually document and notify residents of roommate change. Documentation could not be found in
the record and the ADON was agreeable to follow up. At 2:45 P.M. the ADON returned and reported that the resident should
have been provided documentation Room Transfer Notification by social services. The ADON confirmed that notification was
not provided to Resident #135.
F 0250
harm
Provide medically-related social services to help each resident achieve the highest
possible quality of life.
Based on interview with family and staff and record review, the facility failed to: provide medically-related social
services to attain the highest practicable psychosocial well-being for and discharge planning for 2 of 32 sampled residents
in Stage 2. Findings include: 1) Cross Reference to F329 and F319. Resident #292 was admitted to the facility on [DATE]
from an acute hospital. The resident presented with signs and symptoms of depression as indicated in the Social Service
Assessment and administration of the Geriatric Depression Scale related to decline in activities of daily living and
overwhelmed by the stress caused by his illness. Resident #292 also reported to social services that it would be better if
he wasn't around. Record review and interview with Administrator #1 could not find documentation that social services were
provided to address the resident's depression and the problems the resident was experiencing related to adapting to changes
in his life's circumstances.
2) During an interview with Resident #329's family member on 5/22/13 at 9:30 A.M., the family member stated they have not
been informed about any discharge plans for the resident and feared mentioning anything during the initial care plan
conference for fear of being kicked out too soon. The family member was unaware the facility was a long term care facility
and thought the resident was only here for rehab. The family member believed the resident was going to be discharged
sometime soon, but did not know what was going to happen. The family member began to cry and stated the adjustment has been
great stress. The family member stated at the care conference they discussed the resident's current situation/condition,
but nothing about what was going to happen in the near future. The family member cried during the interview and stated the
anxiety of not knowing was difficult to deal with. On 5/23/13 at 1:00 P.M., a discussion with MDSC #2 revealed that
discharge (d/c) planning started when residents were admitted . LN #1 stated however, that d/c planning usually was done
two weeks before discharge. She said the post-discharge plan was not done until the resident was closer to d/c when the
type of services the resident needed was determined. LN #1 said the social worker would follow up with the family and for
Resident #329, they already completed the initial intake. Per the Interim Administrator (IA), he stated there were weekly
discharge planning progress notes. He also said a staff in payroll/billing was currently helping with the intake questions
for social services as the facility recently lost their SW and two social service designees. Interview with the business
account staff (AR #1) stated on 5/13/13 found she spoke to the resident's family members. She noted one family member would
leave their job in the event the resident was discharged . However, AR #1 confirmed she left a section regarding the
anticipated discharge/transfer blank and that should have filled it out. In addition, AR #1 marked Unknown about whether
the resident had family capable of and willing to provide assistance post-discharge. There was no further documentation
that the IDT reviewed progress toward discharge during weekly discharge meetings.assist with referrals to community
resources prior to discharge, assist with paperwork process, as stated in the discharge care plan. In addition, the IA was
asked to produce documentation regarding the weekly discharge meeting as outlined in the resident's discharge care plan of
5/7/13. The Interim Administrator stated it was too early to know. The IA later confirmed he did not have any additional
documentation about the resident's discharge planning, except for what the therapist noted on 5/14/13. On 5/24/13 at 10:40
P.M., during a reinterview with a family member, the family member said he/she had not been informed about any discharge
process and reiterated he/she wanted to know, What's going to happen? He's a human. I don't know who to ask. I don't even
know what's really happening to him. The doctor told me he has a stroke, but I already know that. That's not what I want to
know. What's going to happen to him? The family member said no resources have been provided to them and that no social
service representative has met with them to go over things. Review of the facility's policy and procedure, Discharge Plan
(Rev. 6/17/08), it stated, Social Services staff, as members of the interdisciplinary care plan (ICP) team, participate in
developing a discharge plan for residents with potential for discharge to a private residence.and care home. The discharge
plan is used to assist the resident in preparing for discharge and to address continuing care needs after discharge. When
the ICP team determines that a resident has potential for discharge in the next quarter, Social Services staff address the
following. Necessary supportive relationship in the community to meet emotional needs, The cost of needed services and
financial resources necessary to pay for services, Education needed by the resident and/or family about available community
resources and how to access those services, Needs for emotional support to assist in adjustment to the new living
environment. The need for a discharge plan is assessed upon admission. The discharge plan is incorporated into the
resident's ICP. The interviews with the resident's family members revealed this was not implemented for the resident in
accordance with the facility's policy on discharge planning. On 5/28/13, the Regional Chief Nurse Executive (CNE) met with
the family as per the family member's request, and because the resident had a recent change in his condition. The CNE
informed the surveyor that, from now on, there will be ongoing discussions with family about the discharge planning process.
F 0253
harm
Provide housekeeping and maintenance services.
Based on observation and interview with staff member, the facility failed to provide housekeeping services necessary to
maintain a sanitary interior. Findings include: On 5/20/13 during the initial tour of Wailani, observation in the men's
shower across Room 202 found a bucket with black substance scattered on the inside of the bucket. Interview and concurrent
observation was done at 8:25 A.M. with C.N.A. #1. The aide identified the bucket as the catchment for the commode and when
asked what the black substance was in the bucket, the aide replied probably poop and apologized.
F 0280
harm
Allow the resident the right to participate in the planning or revision of the
resident's care plan.
Allow the resident the right to participate in the planning or revision of the
resident's care plan.
FORM CMS-2567(02-99)
Page 6 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0280
harm
Based on observations, record reviews, and interviews, the facility failed to ensure the residents' care plans were revised
and/or updated to reflect the residents' current status for 2 of 32 residents in the Stage 2 sample. Findings include: 1)
Cross-reference to findings at F312. For Resident #329, the facility failed to update the plan of care related to the
resident's oral health and failed to ensure the staff delivered the oral care/hygiene regimen in a consistent manner.
Cross-reference to findings at F312 for additional details. Resident #329 was admitted on [DATE] with [DIAGNOSES
REDACTED].
The resident's BIMS score coded on the 5 day PPS MDS assessment was 5. The resident also required extensive assistance in
his activities of daily living (ADLs). A care plan for ADL self-care deficit as evidenced by a need for extensive to total
dependence due to his medical condition had been developed. On 5/24/13, although LN #1 reported the ST made a clarification
to the order, she acknowledged the resident's care plan had not been updated nor revised to reflect the ST's oral care
regimen of 5/14/13. LN #1 confirmed it had not been communicated to the nursing staff nor the physician. Thus, as it was
not implemented in the care plan, the staff failed to follow and deliver the treatment/services to maintain the resident's
optimum oral health and hygiene.
2) Resident #292 did not have a history of falls before his admission to the facility. On 4/14/13 he fell from his
wheelchair. Based on an assessment to address the identification of causal factors, the resident's care plan was not
revised to prevent subsequent falls. Interview with licensed nurse was done on 5/20/13 at 12:30 P.M. The licensed nurse
reported that Resident #292 fell on [DATE]. Interview and concurrent record review was done with MDSC #1 on 5/22/13. A
progress note documents that on 4/14/13 at 12:25 P.M., an alarm was heard and Resident #292 was found on the floor. The
resident fell from his wheelchair while seated in front of the television by the nurses station. He sustained a skin tear
on the right forearm. The ADON interviewed the resident and he stated that he was trying to reposition himself while seated
on the wheelchair. On 5/22/13 at 10:45 A.M., the resident's wife commented that her husband fell out of the wheelchair
while in the activity area and can't see how that would happen when there are people around him. Record review found a care
plan for falls (onset date of 3/28/13) related to limitations in mobility, unable to perform test for balance while
standing without physical support and admission [DIAGNOSES REDACTED]. times; assess for participation in the falling star
program as needed, apply hip protector at all times as needed, except during showers; and assess for pain and offer pain
medication as ordered. Also noted on the care plan was a handwritten note 4/14/13 Actual Fall. Under the approaches column
a handwritten note was added for hip protector. Interview was done with LN #1 on 5/23/13 at 10:30 A.M. Inquired who updates
the resident's care plan after a fall, the nurses or MDSC? LN #1 reported she would check with MDSC #1. On 5/23/13 at 10:40
A.M. LN #3 was interviewed. Inquired who updates the resident's care plan after a fall. LN #3 responded the person who
found the resident or the nurse in charge of the resident. The LN #3 clarified that a hip protector will protect the
resident's hip if he should fall again. At 10:47 A.M., MDSC #1 joined the interview. The MDSC reported that the clip alarm
has been added, concurrent review of the care plan found that this was not added to the care plan. Also, informed her that
he already had a clip alarm at the time of the fall as the staff member reported to hear the alarm, responded and found the
resident on the floor. Also of note was that the hip protector was already included in the resident's care plan. Inquired
what causal factors were identified that contributed to the fall with a reminder that the resident reported he was
repositioning himself when he fell out of the wheelchair. The MDSC #1 updated the resident's care plan to include the clip
alarm. On 5/23/13 at 11:00 A.M., the ADON was interviewed and concurrent review of the resident's record was done. The ADON
reported that the resident is not able to position himself in the wheelchair related to left sided weakness. The ADON was
not sure whether positioning in the wheelchair was addressed in rehab and would have to follow up with them. The ADON
confirmed that the care plan was not revised to include evaluation by rehab for positioning. On 5/23/13 at 11:15 A.M., the
facility provided a copy of the Rehabilitation Services, Post-Fall Screening Tool. The document notes the resident reported
that he was attempting to reposition himself due to anal pain and fell out of the wheelchair. The Falls Committee
suggestions included: wheelchair pressure alarm and bed pressure alarm and resident to only be up in wheelchair for 2 hour
periods until wound heals.
F 0281
harm
Make sure services provided by the nursing facility meet professional standards of
quality.
Based on observations, record review, staff interview and review of the facility's policies and procedures, the facility
failed to ensure professional nursing standards of practice were followed for 4 of 32 residents in the Stage 2 sample.
Findings include: 1) During an observation of Resident #161 on [DATE] at approximately 7:52 A.M., she stated, I don't feel
too good and her legs were visibly shaking. LN #4 came in to assess the resident and proceeded to take the resident's blood
pressure (BP) and oxygen saturation level. She then told the resident, I'd encourage you to eat your breakfast. The
resident's legs were still shaking. Surveyor asked LN #4 if the resident's blood sugar was taken. LN #4 replied, around 5
minutes ago and it was 72. The resident told LN #4 she did drink some juice earlier. LN #4 however, proceeded to assess the
resident's lung status asked her if she wanted some cough syrup. Resident #161 restated she did not feel good. LN #4 did
not respond to the resident about that, and also failed to notice the resident did not have a meal tray either. LN #4 then
stepped out of the room and at 8:00 A.M., the RD came in. The RD asked the resident how she was and the resident said, I'm
shaking, nervous. Sugar low that's why. RD informed her she was going to check with her nurse right away. At 8:03 A.M., the
Medical Director (MD) came to assess Resident #161. He asked her to take some deep breaths, and the resident told him her
sugar was low. The MD stated they were going to take care of it. The resident also said she had some cramping, just went
shi-shi.go home, when? The MD stated, We gotta get you better first. We can't send you home like this. He said he would
talk with the nurse, to get your blood sugar and breathing better. Keep taking deep breaths through your nose. The MD
stepped out, spoke to the nurse and ordered a Mighty Shake to be given to the resident along with other orders. During a
discussion with the MD at 8:55 A.M., the MD acknowledged there was an issue with the way the licensed staff assessed
Resident #161 earlier. The MD affirmed a lot of had to do with the licensed nurse's assessment and critical thinking
skills. Surveyor expressed concern that despite the resident stating she did not feel good and visibly shaking, LN #4 just
encouraged the resident to eat something after assessing her, but failed to ensure the resident was provided with something
to eat and failed to monitor the resident. He affirmed it was basic nursing care that was missed in this instance, and
these issues were an on-going struggle with the licensed staff. In addition, review of the facility's policy and procedure
on Diabetic Care, (Rev ,[DATE]), for Hypoglycemic Reaction.The nurse must use good clinical judgment in the treatment of
[REDACTED]. The resident's care plan also included approaches to observe for signs and symptoms of unstable blood sugar
levels, which included tremors, shaking, and to offer substitutes, supplements or alternative choices PRN. 2) Resident #161
had a [DATE] treatment order date for oxygen (O2) at 2 liter/min via nasal cannual (NC) for respiratory distress as needed.
On [DATE] and [DATE], the resident was observed with O2 via a NC. During a review of Resident #161's treatment record (TAR)
for [DATE], it showed there was no documentation marked on [DATE] and [DATE] for the resident's O2 use. In addition, a new
entry on the TAR dated [DATE] noted, Change O2 tubing weekly with [DATE] marked as done. The next tubing change date was to
be [DATE]. During the initial interview with Resident #161, she stated her NC had not been changed for approximately three
weeks until an aide told her that was not right and changed it for her. In addition, on ,[DATE] and [DATE], during random
observations of the resident, it was noted the sterile water connected to the resident's oxygen concentrator was not
dated/initialed. On ,[DATE], the sterile water attached to the O2 concentrator was not dated/initialed. However, on [DATE],
it was dated. On [DATE], during an interview with the DON, she said the humidifier (sterile water) had to have a date on
it. She said however, the NC did not have to be dated. Yet, there was a new entry in the TAR dated [DATE] to change the O2
tubing weekly. Thus, it was not clear what the procedure was to ensure resident care items were monitored and replaced
consistently. Within the TAR, there was another entry, Monitor O2 sat q 4 h prn per (family member) request). On [DATE] at
8:17 A.M., per LN #1, she said there was no physician's order for this and there were no parameters for it, such as to call
the MD if the O2 sat was below a certain percentage. LN #1 confirmed with the missing documentation in the TAR, unlabeled
items, and no physician's order, this did not meet the nursing standard of care practices nor for clinical documentation.
She said, Yes, they (nurses and aides) need more education. LN #1 also confirmed for the use of pain medication, the
assessment should include documentation for the effect of the intervention and the administering nurse has to follow-up
with. 3) On [DATE] at 7:20 A.M., Resident #329 was observed in his room with two staff repositioning him. MDSC #3 confirmed
FORM CMS-2567(02-99)
Page 7 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0281
harm
the resident's tube feeding (TF) closed system had a manufacturer's label, but was not filled out with the resident's name,
type of enteral nutrition (EN) formula, start date and time and ordered rate. MDSC #3 said, it should have everything
written on it and verified it was not done. She also said the tubing expired in 48 hours and there was no date when it was
first used. She was unsure when the EN expired and thought it was to be used within 24 hours. However, with no start
date/time written on it, she stated it should be discarded. On [DATE], surveyor observed the resident's name on the EN
label with [MEDICATION NAME] 1.2 cal, room number, date, start time of 0500 and rate of 320 ml x 5 written on it. The
tubing was also dated ,[DATE] 12 am and initialed. The water flush bag was dated ,[DATE] 12 pm with the resident's name and
room number. On [DATE] at 9:55 A.M., LN #1 produced the facility's EN TF policy and procedure. She said it did not state
what the licensed staff's responsibility included for labeling the EN bottle. LN #1 said however, it should include the
resident's name and for all licensed staff, they are supposed to fill in the information on the label. LN #1 also said the
tubing was to be labeled. The American Society for [MEDICATION NAME] & Enteral Nutrition (ASPEN), Enteral Nutrition
Practice Recommendations, March/[DATE], Vol 33, No 2, ,[DATE], p. 129, noted for the labeling of enteral nutrition, To
avoid misinterpretation, a label should be affixed to all EN formula administration containers (bags, bottles,.). The label
should reflect the four elements of the order form and therefore contain the following: patient demographics, fomula type,
enteral access delivery site/access, administration method, individuals responsible for preparing and hanging the formula,
and time and date formula is prepared and hung.All EN labels in any healthcare environment shall express clearly and
accurately what the patient is receiving at any time. Having standard components on a label decreases potential confusion
when a patient is transferred to a different unit within a facility, or when a new staff member takes over a patient's
care.Clear labeling that the container is 'Not for IV Use' helps decrease the risk for an enteral misconnection. Proper
labeling also allows for a final check of that enteral formula against the prescriber's order. Care should be taken in
developing a label that is clear and concise and of a size that fits neatly on the container. 4) On [DATE] at 11:10 A.M.,
LN #4 was observed passing medications to Resident #336. She stated he was a newly admitted resident and was going to give
[MEDICATION NAME] for leg [MEDICAL CONDITIONS] and [MEDICATION NAME] for gout. After the resident took his
medication, LN
#4 asked the resident if he had any pain. Resident #336 replied yes and that his pain was 5 out of 10 on the pain scale
described to him. LN #4 said okay, and was going to walk out of the room without further assessing his pain. Surveyor asked
LN #4 if she was going to assess what the resident told her about his pain level, and LN #4 said, oh yeah. She went back to
ask questions, and the resident said he had sharp pain that radiated down his legs. The resident stated he would accept
Tylenol for pain relief. At the medication cart, LN #4 acknowledged she should have probed about the resident's pain
instead of walking out. She said 5 out of 10 was, moderate pain and should not be ignored. At 11:17 A.M., the resident
received Tylenol 325 mg, 2 tabs orally. It was also noted the resident had been transferred from an acute setting for which
he was admitted with left popliteal pain. Review of the facility's, Competency-Based Position Description and Performance
Review Registered Nurse (RN) (Rev [DATE]) produced by LN #1, stated, Specific Requirements - Must possess the ability to
make independent decisions when circumstances warrant such action, Must be knowledgeable of nursing practices and
procedures as well as the laws, regulations and guidelines governing nursing functions in the long-term care
facility.Essential Functions - Must be able to knowledgeably and competently deliver basic nursing care to residents, Must
be able to evaluate resident's needs through ongoing assessment and revised care plan based on changes in resident's
condition,.Must be able to concentrate and use reasoning skills and good judgment.
5) On [DATE] at 10:14 AM observed LN#9 administer medication to R#152. The resident requested [MEDICATION NAME] and
stated
that his/her head was sore. The LN#9 provided one tab of [MEDICATION NAME] to R#152, and stated that resident would not be
given routine [MEDICATION NAME] since provided [MEDICATION NAME]. The surveyor informed LN#3 that cannot provide
advice,
and that physician orders, (PO), should be followed. On [DATE] at 10 AM reviewed R#152's [MEDICATION NAME] prescription
as
written on the PO dated [DATE]; [MEDICATION NAME] 1 tab every 4 hours (hrs) for moderate pain and 2 tabs for severe pain.
Inquired of LN#3, how staff would determine pain severity. LN#3 showed the Medication Administration Record, [REDACTED].
Reviewed the MAR form for [MEDICATION NAME] with LN #3 and on [DATE] when R #152 received the [MEDICATION
NAME] tab for
headache, there was no documentation why prescription was provided. LN#3 later found documentation written on [DATE] by
LN#9 that [MEDICATION NAME] was provided to R #152 for bilateral lower extremity, (BLE), in the electronic medical record.
On [DATE] at approximately 10:30 AM verified with R #152, reason he/she asked for [MEDICATION NAME] on [DATE] during
the AM
med pass and resident stated that he/she has migraines. Inquired where else does R#152 have pain that would ask for
[MEDICATION NAME], and the resident stated, On my okole, (posterior), from the pressure ulcer, my back, and sometimes my
left shoulder. Inquired if he/she has pain in the legs or feet and resident replied, No. R#152 further stated that the
facility did not have [MEDICATION NAME] available, so asked for [MEDICATION NAME] instead. The resident further stated
that
he/she wants to talk to the Doctor to let him know that [MEDICATION NAME] does not help with the migraines. On [DATE] at
2:00 PM interviewed the Med Dir at the Keola Mau nursing unit regarding LN#9 not providing routine [MEDICATION NAME] due
to
the use of [MEDICATION NAME] for migraines. The Med Dir stated that the PO should be followed and LN#9 should not have
made
her own determination on use of pain med's. The DON listened in on the discussion, went to the med cart, and found the
[MEDICATION NAME] blister pack for R #152 in the narcotic drawer. The [MEDICATION NAME] blister pack was dated
[DATE] and
according to the DON would have been available from that date.

F 0309
harm
Provide necessary care and services to maintain the highest well being of each
resident
Based on observations, resident and staff interviews, and medical record reviews, the facility failed to ensure that 3 of
32 residents in the Stage 2 survey sample received the necessary care and services to help these residents attain or
maintain the highest practicable level of well-being by preventing or managing pain. Also for one resident, the facility
failed in managing the interchange of [MEDICAL TREATMENT] information. Findings include: Cross-reference to F 281 1) On
05/22/13 at 10:14 AM observed LN#9 administer medication to R#152. The resident requested [MEDICATION NAME] and stated
that
his/her head was sore. The LN#9 provided one tab of [MEDICATION NAME] to R#152, and stated to surveyor that resident would
not be given routine [MEDICATION NAME] since provided [MEDICATION NAME]. The surveyor informed LN#3 that cannot
provide
advice, and that he/she should just follow physician orders, (PO). On 05/23/13 at 10 AM reviewed R#152 PO for [MEDICATION
NAME] prescription as written on 05/17/13, [MEDICATION NAME] 1 tab every 4 hours (hrs) for moderate pain and 2 tabs for
severe pain. Inquired of LN#3, how staff would determine pain severity. LN#3 showed the Medication Administration Record,
[REDACTED]. Reviewed the MAR form for [MEDICATION NAME] with LN #3 and on 05/22/13 when R #152 received the
[MEDICATION
NAME] tab for headache, there was no documentation why prescription was provided. LN#3 later found documentation written on
05/22/13 by LN#9, that [MEDICATION NAME] was provided to R#152 for bilateral lower extremity, (BLE), in the electronic
medical record. On 05/23/13 at approximately 10:30 AM verified with R #152, reason he/she asked for [MEDICATION NAME] on
05/22/13 during the AM med pass and resident stated that he/she has migraines. Inquired where else does R#152 have pain
that would ask for [MEDICATION NAME], and the resident stated, On my okole, (posterior), from the pressure ulcer, my back,
and sometimes my left shoulder. Inquired if he/she has pain in the legs or feet and resident replied, No. R#152 further
stated that the facility did not have [MEDICATION NAME] available, so asked for [MEDICATION NAME] instead. The resident
further stated that he/she wants to talk to the Doctor to let him know that [MEDICATION NAME] does not help with the
migraines. On 05/23/13 at 2:00 PM interviewed the Med Dir at the Keolamau nursing unit regarding LN#9 not providing routine
[MEDICATION NAME] due to the use of [MEDICATION NAME] for migraines. The Med Dir stated that the PO should be
followed and
LN#9 should not have made her own determination on use of pain med's. The DON listened in on the discussion, went to the
med cart, and found the [MEDICATION NAME] blister pack for R #152 in the narcotic drawer. The [MEDICATION NAME] blister
pack was dated 05/21/13 and according to the DON would have been available from that date. 2) On 05/23/13 at 2:00 PM also
reviewed R152's medical record for the [MEDICAL TREATMENT] Communication form. The most current [MEDICAL
TREATMENT]
Communication form was dated 05/18/13, on which [MEDICAL TREATMENT] staff ordered that [MEDICATION NAME] be
increased to 60
mg effective with that evening meal. Reviewed R#152's PO and could not find prescription for [MEDICATION NAME] at 60 mg.
Interviewed the Med Dir on the [MEDICAL TREATMENT] communication process regarding the 05/18/13 prescription change of
[MEDICATION NAME] by R#152's Nephrologist. The Med Dir looked at the resident's PO, MAR, progress notes, and his
communication folder, and could not find documentation regarding the dosage increase for [MEDICATION NAME] on 05/18/13.
The
FORM CMS-2567(02-99)
Page 8 of 17

PRINTED:7/2/2014
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION
/ CLIA
IDENNTIFICATION
NUMBER
125051
A. BUILDING ______
B. WING _____
(X3) DATE SURVEY
COMPLETED
05/29/2013
KA PUNAWAI OLA
KAPOLEI, HI 96707
F 0309
harm
Med Dir conferred with LN#3, who stated that usually a copy of the [MEDICAL TREATMENT] Communication form would be
placed
in the Med Dir's communication folder when there are prescription changes. The Med Dir stated that he would review all
prescription changes from the [MEDICAL TREATMENT] facility and would communicate to the LN. The PO would be transcribed
to
the PO and/or signed if it was via telephone order to the LN. The Med Dir further stated that if he did not agree with
prescription changes would confer with the Nephrologist and document in progress notes. The Med Dir acknowledged that the
[MEDICAL TREATMENT] communication process needed to be corrected; and, asked LN#3 to call LN#10, that received the
[MEDICAL
TREATMENT] Communication form on 05/18/13 to find out why he was not informed of prescription change. On 5/24/13 at 8:45
AM
observed R#152 being transferred on a gurney for a MD appt., the resident stated that his/her catheter for [MEDICAL
TREATMENT] came out last night. Went to review R152's medical record for the [MEDICAL TREATMENT] communication form
and
progress notes in the electronic medical records about the resident's internal jugular, (IJ), perma catheter, (cath),
coming out and could not find documentation. Interviewed LN#1 at 10:14 AM who reported that she spoke with the RN that was
on duty the evening of 05/23/13, (Thurs), and found out that the computer was down that night but staff has 48 hrs to
document in progress notes. LN#1 stated that the [MEDICAL TREATMENT] facility had called the Med Dir the afternoon of
05/23/13, and informed him that the IJ Perma cath was still intact but coming loose. The Med Dir advised the [MEDICAL
TREATMENT] staff to tape down the IJ perma cath, and he was to look at it when the resident returned to the facility. There
was no [MEDICAL TREATMENT] Communication form in R#152's medical record and/or progress notes in the EMR pertaining to
the
resident's IJ Perma cath becoming loose. According to LN#1, the RN that was on duty the evening of 05/23/13, had planned to
document incident on the afternoon of 05/24/13, which is within the 48 hr timeframe to document. On 5/24/13, (Fri), at 3:51
PM reviewed the Med Dir progress notes dated 05/24/13 at 12:18 PM, that documented that R#152 was assessed by the Med Dir
upon return from [MEDICAL TREATMENT] on 05/23/13, and that the [MEDICAL TREATMENT] facility had already scheduled
the
05/24/13 MD appt. to replace the IJ perma cath. The Med Dir documented that the resident ' s IJ perma cath became loose
during [MEDICAL TREATMENT], was secured with tape but came out completely the evening of 05/23/13 when he/she returned to
the facility. The Med Dir Also assessed the resident's complaint of headaches and how pain med provided no relief. The Med
Dir diagnosed R#152 with cluster type headaches and prescribed a new medication that the resident was willing to try. On
05/28/13, (Tues), at 10:37 AM reviewed R152's medical record, and looked at the nursing notes dated 05/25/13, (Sat), at
8:47 PM that documented that the resident returned to the facility from [MEDICAL TREATMENT] at 5:30 PM with his/her perma
cath to the left chest intact and dry. The nursing note further documented that R#152 complained of a migraine and she was
given a tab of [MEDICATION NAME]. Interviewed LN#3 and asked how staff would be alerted of a prescription change by a
physician to treat migraines. According to LN#3, the MD would transcribe in the PO to alert LN of change. There was no PO
for the prescription change for migraines as noted in the Med Dir assessment done on 05/23/13. The resident was
administered [MEDICATION NAME] for complaints of headache throughout the 3 day Memorial Day weekend. On 05/29/13 at
7:45
AM, interviewed the Med Dir regarding prescription change for R#152 for migraines, and the Med Dir stated that the PO was
written on 05/28/13 at 10:45 AM because the resident returned to the facility at 5:30 PM on 05/24/13 (Friday). Also
discussed that there was no [MEDICAL TREATMENT] Communication form on 05/23/13 when the resident's IJ perma cath became
loose and late documentation for critical information regarding resident's lifeline. The Med Dir acquiesce that
communication and documentation between the facility and [MEDICAL TREATMENT] center could be improved. The DON
provided the
facility's policy and procedures, (P&P), for [MEDICAL TREATMENT] with the heading of Clinical Services Policies &
Procedures, Nursing Volume 1, Treatments, and Chapter 10. In this P&P, it is noted under the Procedure section for
Post-[MEDICAL TREATMENT], 3. Transcribe any diet, medication, and/or orders received with resident from the [MEDICAL
TREATMENT] facility; and, 7. Maintain [MEDICAL TREATMENT] transfer form in the resident's medical record - do not destroy.
Under the General Guidelines section, 6. Document in the clinical nursing record: [MEDICAL TREATMENT] treatment completed,
order changes, condition of shunt site, complaints from resident (if applicable), and whether physician was notified. The
P&P for physician's orders [REDACTED]. Receiving a written order: a. Physician or other licensed independent practitioners
must write order on order sheet.3. Transcribing the orders: a. Write order with black ballpoint pen on Medication
Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].5. When an order is changed, treat
old order as
if it has been discontinued. Write the change order in a new block and treat it as a new order. Never cross out or alter
any part of an order. Both P&P's did not provide a timeframe, (e.g. within 48 hrs), for transcribing changes to the PO from
the [MEDICAL TREATMENT] communication form, or when a physician changes a medication order.
3) On 5/22/13 at 7:23 A.M., LN #3 was observed taking Resident #161's O2 sat and it showed to be 97% on room air. The
resident was dressed in her night clothes, had a towel wrapped around her head and was conversant. She stated although her
chest felt tight, felt a little better after a rough night due to her breathing problems. LN #3 said the resident had been
complaining of being unable to breathe. A family member also present, then asked LN #3 if there was anything to relieve the
resident's complaints of knee pain. LN #3 said he would have to check and left the room. It was noted that LN #3 did not
ask nor assess the resident at that time for any complaints of knee pain. After he left, the resident said, Ahh, I likey go
home already, shook her head and then stated in Japanese, how tired she felt being here and uncertain of the care she was
receiving. At 7:35 A.M., the family member said LN #3 hasn't brought anything yet for the resident's knee pain. At 7:37
A.M., LN #3 was observed during the change of shift counting medications with the day nurse. At 8:05 A.M., LN #8 said LN #3
only endorsed that Resident #161 was given a medication at night to help with breathing, but did not receive any
endorsement related to pain. At 8:10 A.M., surveyor queried LN #3 what the status was about checking on the resident's knee
pain. He said he did not forget and personally was going to check, thus did not endorse it to the day nurse. He thought
there was an ointment and at that time, went to get her chart. After reviewing the resident's chart and 40 minutes later,
LN #3 said there was nothing ordered for knee pain. LN #3 acknowledged he did not assess the resident for the knee pain
after the family member requested something for it, and said he did not know if the resident actually had the knee pain
when he left her side at 7:23 A.M. LN #3 also confirmed this was something he should have done, but now it was now 45
minute later and the resident nor family had any response yet. At 8:17 A.M., LN #3 went to assess Resident #161, who told
him she has dull pain to her kneecap, and said, Oh I cannot tell you how high or low, I think weather change time, dull
pain. LN #3 said he would have to check with the doctor and at 8:28 A.M., LN #3 said the in-house physician was going to
see the resident. The facility's policy on Pain Management produced by LN #1 on 5/28/13 with Handout #2 attached, stated,
What do we do to care for resident's who cannot report pain, due to.or communications difficulties?.Always remember to
evaluate resident's by touching, moving and looking at our resident's in detail, to confirm that the signs and symptoms are
due to pain. Further review of the May 2013 MAR for Resident #161 noted for two entries on 5/7/13 and 5/10/13, the
follow-up assessment time and result of the pain medication administeration were not documented. 4) For Resident #336,
cross-reference findings to F281.

F 0312
harm
Assist those residents who need total help with eating/drinking, grooming and personal
and oral hygiene.
Based on observations, interviews with family members, residents and staff members, and record reviews, the facility failed
to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain
good personal and oral hygiene for 3 of 3 residents whom were sampled for ADL care in Stage 2. Findings include: 1)
Observation of Resident, R #272, on the afternoon of 5/21/13 found she was dependent on staff to provide her with personal
care to include showers and oral hygiene. On the morning of 5/22/13, a review of the May 2013 Monthly Flow Report noted the
resident received sponge baths on all 3 shifts: day, evening, and nights from 5/7/13 to 5/21/13. The R #272 was scheduled
to receive showers on Mondays and Thursdays. From 5/1/13 to 5/5/13, the resident did not receive any showers. A shower was
provided on 5/6/13 (Monday), 7 days later on 5/13/13 (Monday); and 8 days later on 5/21/13 (Tuesday). There was no
documentation to show the resident refused showers. A review of the Minimum Data Set (MDS) with an Assessment Reference
Date (ARD) of 3/20/13 found the resident was totally dependent on staff with bathing and required 2 person assistance. A
review of the MDS with ARD of 4/20/13 found the same, total dependence and required 2 person assistance. Interview of the
MDS-Coordinator, MDS-C #1, on the afternoon of 5/23/13 found that the resident should have received additional showers. The
FORM CMS-2567(02-99)
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