Inspection Reports for Aina Haina Quality Living
5304 Limu Pl, Honolulu, HI 96821, HI, 96821
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 7, 2024, identified multiple deficiencies related to caregiver qualifications, medication administration, food sanitation, physical environment, and safety. Earlier inspections also noted issues with documentation, nutrition care planning, medication orders, and environmental conditions, showing a pattern of challenges in record keeping and care management. Inspectors cited recurring themes such as incomplete caregiver certifications, medication documentation gaps, and food storage concerns. No fines, immediate jeopardy findings, license suspensions, or enforcement actions were listed in the available reports, and no complaint investigations were reported. The facility’s inspection history shows ongoing areas needing attention without a clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Aug 7, 2024
Visit Reason
The inspection was conducted as the annual survey for the facility to assess compliance with licensing requirements and regulations.
Findings
The report identifies multiple deficiencies related to licensing, caregiver qualifications, personnel requirements, medication administration, food sanitation, physical environment, and safety. Plans of correction were submitted with specific completion dates for each deficiency.
Deficiencies (17)
Primary Caregiver and Substitute Caregiver fieldprint clearance unavailable or incomplete.
No documented evidence of completed ARCH teaching modules for Primary Caregiver.
No documented evidence of one year full-time working experience for Primary Caregiver.
Current physical exam unavailable; last physical dated 3/30/23.
Annual tuberculosis clearance unavailable; last TB dated 3/30/23; initial TB clearance unavailable for review for some caregivers.
No documented evidence of current First Aid certification for substitute caregiver and expired certification for Primary Caregiver.
No documented evidence of current cardiopulmonary resuscitation (CPR) certification for caregivers; expired certifications noted.
Inventory of personal possessions unavailable for admission of resident #1 on 2/19/24.
Open boxes of Ensure, Boost, and protein shakes stored on floor in resident rooms; emergency food supply stored directly on garage floor.
Two refrigerator thermometers read above acceptable maximum temperature of 45°F.
Medication Administration Records for resident #2 lacked documentation for multiple medications on specified dates.
Physician orders for resident #1 not reflected in Medication Administration Records during admission/readmission.
Smoke alarm chirping in facility office room.
Two oxygen tanks stored in bedroom closet; tanks not properly stored in stands.
"Oxygen in use" warning sign not posted on exterior entrance despite oxygen tanks in use in bedroom #8.
Medication order for resident #2 not reevaluated every four months as required.
Medication order for resident #2 not transcribed into Medication Administration Record.
Report Facts
Deficiencies cited: 17
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 21, 2023
Visit Reason
Annual inspection conducted on August 21, 2023, to assess compliance with state licensing regulations for Aina Haina Quality Living facility.
Findings
Multiple deficiencies were identified related to record keeping, documentation, physical environment, nutrition and food sanitation, and case management. The facility submitted plans of correction addressing each deficiency with specific corrective actions and future prevention plans.
Deficiencies (8)
No documented evidence of initial/2-step tuberculosis clearance for Resident #1.
No documented evidence that the facility clarified with the physician about wound healing instructions regarding a high protein diet and daily multivitamin supplement for Resident #1.
Red ink used on resident's inventory of possessions.
Window screens bent/damaged in Bedrooms #1, #2, #3, #6, and window screen found on ground in backyard for Bedroom #8.
No documented evidence that the facility promptly utilized the Consultant Registered Dietitian to provide a nutritional assessment for Resident #1 with a pressure injury.
Nutrition-specific care plan was not developed for expanded ARCH resident with increased nutrient needs due to stage 4 pressure injury.
Nutrition-specific care plan was not developed for expanded ARCH resident with increased nutrient needs due to stage 4 pressure injury.
Nutrition-specific care plan was not developed for expanded ARCH resident with increased nutrient needs due to stage 4 pressure injury.
Report Facts
Completion date: Aug 22, 2023
Completion date: Oct 6, 2023
Completion date: Aug 1, 2023
Completion date: Aug 25, 2023
Completion date: Aug 22, 2023
Completion date: Aug 28, 2023
Completion date: Sep 10, 2023
Completion date: Oct 10, 2023
Completion date: Sep 27, 2023
Completion date: Sep 27, 2023
Completion date: Aug 26, 2023
Completion date: Aug 26, 2023
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 17, 2022
Visit Reason
The inspection was conducted as the annual survey of the Aina Haina Quality Living facility to assess compliance with regulatory requirements.
Findings
The report identified deficiencies related to the lack of documented annual diet orders, medication order discrepancies, medication orders not re-evaluated or signed within required timeframes, missing annual physical examinations, missing annual tuberculosis clearance, and physical environment issues such as strong urine odor in a resident's bedroom. Plans of correction were submitted with specific actions and completion dates to address each deficiency.
Deficiencies (6)
No annual diet order documented or signed by a physician or APRN for Resident #1.
Amlodipine Besylate medication order does not include hold and MD notification parameters as ordered for Resident #1.
Medication orders not re-evaluated or signed for over one year for Resident #1.
No annual physical examination for Resident #1.
No annual tuberculosis clearance for Resident #1.
Strong urine odor present in bedroom #7.
Report Facts
Completion date: Sep 23, 2022
Completion date: Dec 26, 2022
Completion date: Oct 19, 2022
Completion date: Aug 17, 2022
Completion date: Dec 29, 2022
Completion date: Dec 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Jabs | Licensee/Administrator | Signed the plan of correction documents |
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