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PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 679 Continued From page 4PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 679Findings Include:1) An interview was done with R334 in his roomon W1 on 02/23/21 at 09:37 AM. Upon enteringhis room, R334 was observed sitting in hiswheelchair staring out the window with the TVand radio off. During a discussion on how he wasfeeling, R334 said he feels like if he does not callfor help, nobody bothers, and he does not haveanyone to talk to. R334 went on to say that hefeels it is disrespectful [for staff] not to check onhim, that he would like to have someone to talkto, but he does not want "to grumble".2) An interview was done in the W1 Dining Roomwith Recreation Aide (RA)1 on 02/25/21 at 11:03AM . When asked what activities he does toengage new residents isolated in their rooms,RA1 stated, "I offer them crossword puzzles,newspapers, magazines and books. I teach themhow to turn on the TV, or I turn on the radio forthem."3) Record review of R334's baseline care plan foractivities notes an activities assessment wasdone on 02/21/21, and interventions plannedbased on the resident's preferences, including to"offer magazines as needed." A review of R334'sActivity Participation Record notes the care planwas not implemented until two days later on02/23/21. Further review of the ActivityParticipation Record notes that between 02/23/21through 02/25/21, magazines were never offered,and the activities the resident spent the most timedoing were watching the TV and listening tomusic in his room.F 689 Free of Accident Hazards/Supervision/DevicesSS G CFR(s): 483.25(d)(1)(2)FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11F 689Facility ID: HI02LTC5054If continuation sheet Page 5 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 5PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 689§483.25(d) Accidents.The facility must ensure that §483.25(d)(1) The resident environment remainsas free of accident hazards as is possible; and§483.25(d)(2)Each resident receives adequatesupervision and assistance devices to preventaccidents.This REQUIREMENT is not met as evidencedby:Based on observation, interview and recordreview, three residents (R) 34, R59 and R77 hadone or more falls in the facility. The threeresidents are diagnosed with severe cognitiveimpairment and dependent on staff to assist withmobility. two residents are taking psychotropicmedication which may cause unsteady gait andfalls and have poor safety awareness andimpulsiveness. The deficient practice places theresidents at an increased risk for harm, requiringa higher level of staff supervision.Findings include:1) An initial observation of R77 was made on02/22/21 at 12:16 PM in her room. R77 was lyingin bed with the radio on, bed in the lowestposition, floor mats on both sides of the bed onthe floor and side rails on both sides of the bedwere lowered. Surveyor asked her if she was ableto reach her call light and she made avocalization that sounded like "yes." Anotherobservation of R77 on 02/23/21 at 07:54 AM inher room, revealed that R77 was sitting high up inbed with both side rails lowered being assistedwith breakfast by the certified nurse assistant(CNA)73. The CNA73 stated that R77 liked tolisten to Hawaiian music on the radio.FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11Facility ID: HI02LTC5054If continuation sheet Page 6 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 6PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 689R77's electronic health record (EHR) wasreviewed on 02/22/21 at 1:17 PM. R77 is a 65year old female resident with epilepsy (a centralnervous system disorder causing seizures) andfunctional quadriplegia (complete inability to movedue to a severe disability). R77's Minimum DataSet (MDS) annual assessment of 05/01/20revealed that R77 was total dependent on onestaff member to provide toileting care. A review ofR77's MDS quarterly assessment of 10/30/20revealed that R77 had declined to totaldependence on two staff members to provide hertoileting care. R77's care plan problem wasreviewed for "Current Functional Performance has impaired mobility due to malignant melanoma(skin cancer), quadriplegia (paralysis of all fourlimbs) and contracture (shortening of muscles inthe limbs) to right and left legs and Alzheimer'sdisease." Intervention initiated for 10/30/20stated, "Resident performance: Toilet use - Totalassist/two-person physical assist."The facility's completed Office of Health CareAssurance (OHCA) Event Report of 11/02/20 wasreviewed on 02/25/21 at 11:00 AM. It stated thatR77 sustained a cut to her right forehead and hernose bridge was bruised and swollen aftersustaining an unwitnessed fall on 10/31/20 at07:30 AM. R77 was lying on her left side,centered on her bed, the bed was at CNA73'swaist level and both side rails were down. CNA73turned away from R77 to obtain supplies toprovide toileting care. CNA73 then heard a noiseand found R77 lying on the other side of the bedon her back. There was no other CNA assistingCNA73 with R77's toileting care.An interview was conducted with theFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11Facility ID: HI02LTC5054If continuation sheet Page 7 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 7PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 689Administrator on 02/26/21 at 1:33 PM in theoutdoor patio of the facility. He stated that R77has been a long time resident and that she hadregular staff members care for her. No harm wasmeant for the resident and the fall was notanticipated.2) Surveyor made observations on the Lehua unitin the activity/ dining room on 02/23/21 at 08:41AM and noted R59 sitting up in a wheelchair withtwo clips on her shirt. CNA29 verified that theyare fall alarms. She was noted to have a verydark purple colored lump on her right foreheadand her eyes were closed. When asked why R59had a bump on her forehead she verified withsurveyor that R59 had a fall the previous day. At09:51 AM R59's chair alarm sounded, and sheappeared to be leaning over in her chair, restlessputting her legs on the floor as if she were goingto stand up. CNA29 went to R59 to help her leanback into her chair she said "I want to go take ashower" in a very low voice. At 10:03 AM a highpitched whining sound was heard from R59.CNA29 went to check on R59 stating "why youcry? and adjusted her foot rest on her w/c,surveyor noted she had a facial grimace. TheCNA moved her next to the desk at the nursesstation.Surveyor reviewed the EMR for R59 on 02/23/21at 01:33 PM. R59 is a 96 year old femaleadmitted to facility on 10/20/20 for comfort careand Hospice, her primary diagnosis ofCerebrovascular disease and dementia. She isalert and oriented to her self only.Progress notes dated 02/22/21: Found on thefloor at 1357 by CNA, 4 x 5 centimeter (cm)hematoma to right forehead and 1.3 cm skin tearto right forearm.FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11Facility ID: HI02LTC5054If continuation sheet Page 8 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 8PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 689Surveyor reviewed Incident report dated 02/22/21on 02/24/21 at 3:45 PM: Unwitnessed fall.Oriented to person. predisposing physiologicalfactors; confused, gait imbalance and impairedmemory. Predisposing situation factors; does notuse call light. Root cause: is resident attemptingto toilet self without using call light or notifyingstaff.MDS quarterly review date 01/22/21: Briefinterview for mental status (BIMS) summaryscore 99, (resident was unable to completeinterview). Functional status: Bed mobility,transfer and toileting with extensive assistance,one person physical assist. Bladder/ Bowel:Incontinent/ continent. Fall history: one withoutinjury and one with injury since admission.Medications: Antipsychotic, antianxiety,antidepressant and opioid use.Care plan dated 10/20/20: Risk for falls; revisionon 02/11/21. History of fall prior to admission.Resident is not able to follow directions due todementia, resident is not calling for assistance fortoileting. Resident is at risk f fall due to possibleside effects from anti-depressant. Risk forimpaired communication. Has moderate difficultyof hearing. No hearing aids, moderate impairedvision, no eye glasses. The resident usespsychotropic medications (Lorazepam,Risperidione, Depakote) r/t behaviormanagement.Surveyor interviewed RN17 on 02/26/21 at 08:58AM. When surveyor asked her about R59's fallshe stated that she wasn't working on the day shefell. R59 had a telehealth appointment the nextday with her primary care physician (PCP). TheCNA found her sitting on the floor mattress in herFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11Facility ID: HI02LTC5054If continuation sheet Page 9 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 9PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 689room, we moved her to a room closer to thenurses station after the fall. RN17 explained thefollow up investigation after a resident has a falland the care plan is updated. The nursing staffshould be rounding on the resident every 2 hoursat the minimum; or more if they are a high risk.They should be toileting them every few hours.The resident should be on a toileting schedule.3) Surveyor made observations on Pikake unit on02/22/21 at 03:31 PM. R34 was sitting up in hiswheelchair in activity/ dining room at a table. Hewas non-verbal and wearing a mask. R34pushed his wheelchair back from the table,turned to the left and began to stand up in hischair. CNA83 went to assist R34 and asked if hewanted a snack, he said "chocolate pudding".CNA83 stated I will get that for you in just aminute and quickly left the room. A few minuteslater R34 was moving his chair and another staffapproached him to ask what he needed, CNA83proceeded to get a chocolate pudding out of therefrigerator for R34.Surveyor reviewed R34's hard chart on 02/23/21at 2:42 PM and noted R34 had falls in the facilityon the following dates: 10/23/20; 11/27/20;02/01/21; 02/12/21.Surveyor reviewed the EMR on 02/24/21 at 11:44AM. "Res is an 88 year old male with diagnosisof urinary tract infection (UTI), chronic kidneydisease (CKD), Stage 3/dementia with dysphagia(difficulty swallowing) and aspiration pneumonia(PNA). Res is incontinent to both bowel andbladder. Res is total assist with bathing,dressing, grooming and toileting."Surveyor reviewed progress notes on 02/24/21 atFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11Facility ID: HI02LTC5054If continuation sheet Page 10 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 10PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 68903:05 PM.11/12/2020 at 06:46 AM. Skin tear to left lateralcalf. During rounds, staff noted resident to beincontinent of urine. Staff then attempted totransfer resident from bed to wheelchair via 1person extensive assist. Resident has difficultystanding and maintaining balance during transfer.2nd staff attempted to assist with transfer. Afterthe transfer was completed, staff noted thatresident sustained skin tear to left lateral calf.Resident sustained skin tear measuring 5.0 X 0.7cm.10/23/20 at 16:12. Status post (S/P) fall. At08:15 am, staff found resident lying down on hisside on the floor (end of the bed) , naked, andleaning his head on the bed' s foot board.Resident is incontinent to bladder and bowel.Resident' s brief and bedding are wet andresident did not sleep on their shift and that heremains with intermittent yelling. Surveyorreviewed the incident report on 02/24/21 at 3:50PM. 10/23/20: Root cause. Resident wasunsupervised during event.11/16/20 at 22:39. Resident with unwitnessed fallat 2200. Resident was put back to bed with bed inlowest position around 2000. Resident waslaying in bed with episodes of yelling. Residentwas last toileted by CNA at 2130. CNA reportshearing bed sensor alarm going off, when CNAgot to room resident was found laying parallel tobed with right side of body and head on floormatt. Resident unable to describe events beforefall. Resident alert and oriented x 1 at baseline.Resident denies pain, nausea, headache.Resident denies trying to get out of bed or reachfor any belongings. Surveyor reviewed theincident report on 02/24/21 at 2:50 PM.FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11Facility ID: HI02LTC5054If continuation sheet Page 11 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 11PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 68911/16/20. Root cause. Staff to pay more attentionto residents yelling as this may be the firstindication with alarm as the second indication thatresident is moving in bed or attempting to get outof bed.02/01/21 at 2215 S/P witnessed fall. Surveyorreviewed the incident report on 02/24/21 at 3:50PM. 02/01/21. Root cause. Resident has ahistory of pushing himself away from the table ineffort to achieve independence of ADL's andambulation which is his known behavior.2/12/2021 00:55. Unwitnessed fall. Res bedalarm alerting at 0000. Res found on floor in frontof cabinet laying on right side. Res with wet brief.Res with deep purple bruise to right trochanter.Deep purple bruise noted to right outer wrist, lightred bruising/ discoloration noted to spine and skintear (ST) noted to right elbow. Surveyorreviewed the incident report on 02/24/21 at 3:50PM. 02/12/21. Root cause: Resident is knownto have a behavior to not use his call light tomake his needs known. Resident does have acognitive deficit and lacks the awareness to makesafe decisions such as getting out of bed with theassistance of staff as evidence by current BIMSscore of 4/15. Resident unaware to call staff forassistance, found on floor with soiled brief.MDS quarterly assessment review date 12/24/20.Total BIMS score is 04. Functional assessment:Bed mobility, self performance is extensiveassist, Staff support is two person physical assist.Toileting use: Extensive assist. Staff support istwo person physical assist. Other behavioralsymptoms not directed toward others,verbal/vocal symptoms like screaming, disruptivesounds. R34 is frequently incontinent and notFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: 0E7P11Facility ID: HI02LTC5054If continuation sheet Page 12 of 29

PRINTED: 03/31/2021FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:125059OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDINGB. WINGNAME OF PROVIDER OR SUPPLIER02/26/2021STREET ADDRESS, CITY, STATE, ZIP CODE2459 10TH AVENUEPALOLO CHINESE HOME(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDHONOLULU, HI 96816SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 689 Continued From page 12PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 689participating in a toileting program.Primary medical condition

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 . PALOLO CHINESE HOME PROVIDER'S PLAN OF CORRECTION _ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS .