Inspection Reports for Aina Haina ARCH
237 E Hind Dr, Honolulu, HI 96821, HI, 96821
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 27, 2025, identified deficiencies related to personnel tuberculosis clearance documentation and medication labeling errors. Earlier inspections also noted issues with tuberculosis clearance documentation, medication management, dietary compliance, food safety, fire prevention, and staffing adequacy. No enforcement actions, fines, or license suspensions were listed in the available reports. Complaint investigations were not mentioned in any of the reports. The facility’s inspection history shows recurring documentation and medication-related deficiencies, with no clear pattern of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 27, 2025
Visit Reason
The inspection was conducted as the annual survey for the facility Aina Haina ARCH to assess compliance with state licensing requirements.
Findings
The report identifies deficiencies related to personnel tuberculosis clearance documentation and medication labeling errors, including discrepancies in melatonin and acetaminophen labels and missing PRN indications. Plans of correction and future prevention measures are documented for each deficiency.
Deficiencies (4)
Initial two-step TB clearance unavailable for review for personnel.
Bottle of melatonin label does not reflect physician’s current order.
Bottle of acetaminophen label states dosage but PRN indication not provided.
Medication Administration Record (MAR) does not contain PRN indication for acetaminophen.
Report Facts
Plan of correction completion date: Mar 13, 2025
Plan of correction completion date: Mar 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lan Chen | Licensee/Administrator | Signed plan of correction documents dated 03/13/2025 and 03/28/2025. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 10, 2024
Visit Reason
Annual inspection conducted to assess compliance with licensing requirements and regulatory standards for the facility Aina Haina ARCH.
Findings
Multiple deficiencies were identified related to licensing documentation, nutrition/dietary compliance, food sanitation, medication storage, fire prevention, physical environment, waste disposal, admission requirements, and personal care services. Plans of correction and future plans were provided for each deficiency.
Deficiencies (9)
Primary Caregiver (PCG), Substitute Caregiver (SCG) #1,2 – Two consecutive years of Fieldprint clearances unavailable.
Resident #2 – Diet order dated 12/22/23 states heart healthy; no added salt (preference: no pork/beef); however, licensee states resident is consuming a regular diet.
Resident #2 – Diet menu unavailable for special diet, heart healthy; no added salt (preference: no pork/beef), prescribed on 12/22/23.
Licensee/PCG reports cooking food prepared for residents to 100°F, below the minimally safe temperature of 165°F.
Resident #1 – Internal and external use medications stored in the same compartment together.
Fire drills performed on 5/7/23 and 6/12/23 do not include the time taken to safely evacuate residents from the building.
Bedroom and bathroom receptacles do not contain tight fitting covers.
Resident #1 – Resident admitted on 9/15/23 without documentation of a current influenza vaccination.
Resident #1 – Resident was expanded level of care between 9/15/23-11/27/23; no documented evidence that time sensitive tasks were performed or recorded.
Report Facts
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lan Chen | Licensee/Administrator | Signed the plan of correction document on 02/08/2024. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 19, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, specifically reviewing resident records and tuberculosis clearance documentation.
Findings
The inspection identified deficiencies related to incomplete or missing tuberculosis clearance documentation for residents, as well as incomplete monthly progress notes that did not always include the resident's response to medications.
Deficiencies (5)
Resident #2 – No initial (2-step) tuberculosis (TB) clearance available.
Resident #3 – Tuberculosis clearance not signed by a physician or APRN.
Resident #4 – No annual TB clearance; QuantiFERON-TB Gold test done in December 2021 negative, but no new test done in December 2022.
Resident #1 – Monthly progress notes do not always include the resident’s response to medications.
Resident #1 – Monthly progress notes list resident’s diet as 'regular, NAS 2GM;' however, last signed diet order is 'regular.'
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 4, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for the facility Aina Haina ARCH.
Findings
The report identifies deficiencies related to tuberculosis clearance documentation, staffing adequacy, and immunization records. Plans of correction were submitted addressing these deficiencies with specific corrective actions and future plans.
Deficiencies (3)
Tuberculosis clearance not signed by a physician or APRN.
Insufficient number of caregivers present at all times to meet resident needs.
No documented evidence of pneumococcal vaccine for a resident.
Report Facts
Completion Date: Jan 11, 2022
Completion Date: Feb 28, 2022
Completion Date: Jan 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lian Chen | Licensee/Administrator | Signed plan of correction documents. |
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