Honoka'a Hospital & Skilled Nursing

Based on observation and staff interview, the facility failed to record hot water temperatures for manual washing of dishes/pots/pans and failed to completely record hot water temperatures for the dishwashing machine. Findings include: During observation of the kitchen on 11/19/24 at 10:25 AM, there were two different dishwashing sections; manual washing and dishwashing with machine. Review of hot water temperature logs showed no recording log for the manual washing, and missing temperature logs for the dishwashing machine. During staff interview on 11/21/24 at 08:20 AM, Kitchen Staff 1 revealed that the facility did not have temperature logs for manual washing and acknowledged that there were missing temperature logs for the dishwashing machine. The facility did not provide a related policy but said that they follow Hazard Analysis Critical Control Points (HACCP) which states temperature test logs should be maintained for each hot water sanitation dishwasher in the facility in order to follow HACCP-based record keeping standards.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interview, the facility failed to protect a resident (Resident 310) from physical abuse. The facility did not de-escalate the situation between two roommates, resulting in Resident (R)50 going over and punching R310. This deficient practice has the potential to affect the residents' optimal physical and psychosocial well-being. Findings include: On 06/17/24, the facility submitted an Event Report regarding an allegation of abuse, resident to resident. On 05/18/24 at approximately 02:50 AM, Resident (R)310 alleged he was punched by his roommate, R50. The report documents at approximately 02:00 AM, Certified Nurse Aide (CNA)1 heard the residents yelling. R310 reportedly turned on the television and had the volume turned up, waking his roommate. R50 was heard telling R310 to go to sleep and turn off the television. Registered Nurse (RN)1 provided R310 with headphones to connect to his TV. After this, Licensed Practical Nurse (LPN)1 heard the television playing loudly again…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to monitor vital signs; blood pressure for one Resident (R) 57 of fourteen residents sampled. As a result of this deficiency, the facility put R57 at risk for further health complications. Findings include: Review of Electronic Health Record (EHR), on 11/21/24 at 08:25 AM, showed R57 admitted on [DATE] with diagnosis including recent Hip Fracture, Chronic Kidney Disease, Lymphedema, Paroxysmal Atrial Fibrillation, Hypertension, High Cholesterol, Venous Stasis. There was an active doctor order to take vital signs; blood pressure routine (monthly for this resident). Blood pressures were documented on the following dates: 11/12/24, 09/26/24, 09/13/24. During staff interview on 11/21/24 at 09:20 AM, Director of Nursing acknowledged that vital signs; blood pressures were not taken monthly as ordered. On 11/21/24 at 10:45 AM, review of policy for Extended Care Facility Vital Signs read Purpose, to assist in assessing resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 14 residents sampled (Resident 11) was free from accident hazards. Resident 11 was transferred using a mechanical lift transfer in a manner that placed her at risk for an avoidable fall and/or injury. This deficient practice has the potential to affect all the residents at the facility who are dependent on mechanical lift transfers. Findings include: Resident (R)11 is an [AGE] year-old female admitted to the facility on [DATE]. On 11/19/24 at 12:02 PM, observations were made at the bedside of R11. Certified Nurse Aide (CNA)2 and CNA3 were transferring R11 from her bed to a standard wheelchair via a mechanical lift. Observed CNA3 positioned behind the wheelchair, tilting it up onto its back two wheels, leaving the front two wheels approximately a foot off the ground, while CNA2 operated the mechanical lift, lowering R11 into the tilted wheelchair. Interviewed both CNAs at the bedside as soon as the wheelchair with R11 in it had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview with staff members, the facility failed to provide education regarding the benefits, risks, and potential side effects associated with COVID-19 immunization before offering the vaccine to staff member(s). Findings include: On 11/21/24 at 11:30 AM an interview was conducted with the Infection Preventionist (IPC). IPC reported the facility offered staff members the COVID-19 vaccination in October. A staff member, Kitchen Staff (KS)1 was randomly selected to verify the requirements for education and offering of COVID-19 immunization. IPC reviewed the spread sheet and reported the immunization was refused. Further queried if KS1 was provided with education on risks and benefits of the immunization. IPC reported the facility will provide a Vaccine Information Sheet (VIS) which includes education when vaccines are offered and administered, however, as the COVID-19 immunization is no longer required for staff members, the facility had not been providing the VIS. On 11/21/24 at 12:15 PM, KS1 was interviewed in the kitchen. KS1 was not sure whether the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Facility Reported Incident (ACTS 10975), record review, staff interview and review of policy, the facility failed to implement the comprehensive care plan for Resident (R)2. As a result of this deficiency, R2 was found in another resident's room showing inappropriate sexual behaviors. Findings include: Review of ACTS 10975 mentioned that R2 was found in another resident's room on 05/16/24 at approximately 03:20 AM displaying inappropriate sexual behaviors. R2 was directed back to room and placed on 1:1 supervision. Prior to this incident, R2 had a report of entering another resident's room on 11/22/22, and then on 12/02/22 there was another report of R2 exposing self in the room doorway. There were no other incidents thereafter until this current incident. Review of the Electronic Health Record showed that R2 was admitted on [DATE] with a diagnosis including Subarachnoid Hemorrhage, High Blood Pressure, Emphysema, High Cholesterol, Alcohol Abuse with Seizure. On 05/17/24 after the incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. Facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to two residents (Resident (R) 41 and 12) on Transmission Based Precautions (TBP). This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: 1) On 12/06/23 at 08:56 AM, observed signage next to R41's door indicating she was on Droplet Plus Precautions. R41 was sitting in a wheelchair with her breakfast tray on a table in front of her. R41 was not wearing a mask and was telling the staff that she wanted to come out of her room. Certified Nurse Aide (CNA) 3 entered the room to check on R41 without any PPE other than a surgical mask. CNA3 explained to R41 that she needed to stay in her room for now and asked her if she was done with her meal. R41 said she was done eating and CNA3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with a resident and record review, the facility failed to provide treatment and care in a manner that promoted his or her quality of life for one of 17 residents (Resident (R) 25) in the active case sample. This deficient practice has the potential to affect the resident's psychosocial well-being. Findings include: Record review noted R25 was admitted to the facility on [DATE]. A review of her quarterly Minimum Data Set with an assessment reference date of 10/13/23 documents R25 is cognitively intact. R25 also requires substantial assistance to roll from left and right and is dependent on helper to transfer to and from a bed to a chair (or wheelchair). On 12/06/23 at approximately 11:30 AM an interview was conducted with R25. R25 reported sometimes staff members are rough during care, specifically while providing incontinence care and during transfer via mechanical lift. R25 explained staff members push or pull her side to side while cleaning her. She also explained during transfer, staff will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview with the resident council, the facility failed to ensure residents were provided ongoing communication regarding where to find the State Agency (SA) report with survey results and the facility's plans of correction, and information on how to file a complaint with the SA and Long-Term Care Ombudsman (LTCO) should they want to exercise these rights. Findings include: On 12/06/23 at 11:00 AM an interview was conducted with four resident council representatives. Asked the residents if the State inspection was available to read. The representatives were not aware of the location of the survey results, and that the report was available for them to review. Upon query, the representatives were not aware of where the LTCO's contact information was posted. Also, the representatives could not recall being provided with information on how to formally file a complaint with the SA. A review of the facility's hospitality book does not include information for reviewing the survey results, LTCO information, and how to file a complaint with the SA.

Based on observation and interview with staff, the facility did not assure a resident was provided with personal privacy during incontinence care. Findings include: On 12/06/23 at 08:56 AM observed the curtain was drawn to block view into the residents' room. Knocked at the door, peered around the curtain, and observed R48 lying on his right side with his left lower extremity exposed from the waist down. Further observed the curtain between the roommates was not fully drawn, R36 was sitting up in bed and could view his exposed roommate. Interview with Certified Nurse Aide (CNA)5 was done. CNA5 reported that she closed the curtain between the residents, however, R36 opened it. CNA5 reportedly told the resident not to open the curtain. Inquired whether R36 does this all the time, initially CNA5 responded yes. CNA5 then clarified, this was the first time she observed this behavior. Upon further query, CNA5 stated she would speak to the nurse. Subsequent observations on 12/06/23 at 10:08 AM and 01:02 PM found the curtain between the residents was fully closed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff member, the facility did not ensure the notice of transfer/discharge contained the required contents; a copy of the notice is sent to the Long-Term Care Ombudsman (LTCO); and a resident transferred from the facility's long-term care/nursing to the critical access hospital was not provided written notice of transfer for 2 (Residents 54 and 55) of 2 residents in the sample. Findings include: 1) Resident (R)54 was admitted to the facility on [DATE] and discharged to an acute hospital on [DATE]. R54 was readmitted on [DATE] and discharged on 09/07/23 to an acute hospital. On 12/07/23 at 01:29 PM the facility provided fax confirmation of notification to the LTCO of R54's discharges. The facility sent notice of the discharge log to the LTCO. Review of the discharge log documented the resident's admission date, discharge date , name of resident, and discharge disposition (discharge location) At approximately 02:15 PM, the facility provided copies of the transfer/discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide appropriate services to prevent urinary tract infections for one of the two residents (Resident (R) 34) in the sample. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter. Findings include: On 12/05/23 at 02:38 PM, observed R34 sitting up in a wheelchair in his room. R34 had a urinary catheter tubing connected to a collection bag placed in a dignity cover that was hung under the wheelchair seat. Both the urinary catheter tubing and collection bag were touching the floor. On 12/06/23 at 11:19 AM, review of Electronic Health Record (EHR) for R34 conducted. R34 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis (paralysis and weakness on one side of the body), benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview with staff, and review of the policy and procedures, the facility did not assure drug records for controlled drugs were maintained. This deficient practice has the potential for possible drug diversion. Findings include: On 12/07/23 at 02:02 PM concurrent observation was done with Licensed Practical Nurse (LPN)8 and LPN9. A review of the Narcotic Count Medication Room/Lock Cabinet form found missing nurse signatures. Concurrent review of the log with LPN8 noted there were no nurse signatures for the off duty and on duty nurse for 12/06/23 at 11PM and no off duty signature for 12/07/23 at 7AM (the on duty nurse for this shift signed the log). Further review found missing signatures for 11/20/23 (off duty at 7AM); 11/10/23 (off duty at 3PM); 11/06/23 (on duty at 7AM and off duty 3PM); 10/28/23 (off duty at 7AM); 10/23/23 (off duty at 7AM); 10/22/23 (on duty at 11 PM); and 10/08/23 (off duty at 7AM). Inquired why is it important for the licensed nurses to sign the log for narcotic counts/reconciliation. LPN8 responded to show that the medications were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure planned fall prevention interventions were promptly and consistently implemented to minimize the risk of falls/fall-related injury for 1 (Resident #22) of 2 sampled residents reviewed for falls. Findings included: Review of a facility policy titled, Fall Prevention and Management, revised 03/2022, revealed the steps for post-fall management included, g. Complete post-fall huddle. h. First responder to complete First Responder Form. i. Clinical follow-up for care plan additions/changes as indicated through outcomes of daily stand-up and falls meetings discussions. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #22 was severely impaired in cognitive skills for daily decision-making, per a staff assessment for mental status. According to the MDS, the resident had active diagnoses including hypertension, Alzheimer's disease, and a history of falling. The MDS indicated the resident required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.