Inspection Reports for Care Homes By Hale Makua
472 Kaulana St, Kahului, HI 96732, HI, 96732
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 2, 2024, identified deficiencies related to medication orders and administration, including conflicting orders and documentation issues. Earlier inspections showed a pattern of deficiencies involving caregiver qualifications, medication management, and documentation of resident health changes, particularly weight monitoring. Prior reports noted issues such as unclear fitness determinations for substitute caregivers, missing nutritional assessments, and incomplete progress notes. No fines, enforcement actions, or substantiated complaints were listed in the available reports. The facility’s inspection history reflects recurring challenges with medication and documentation, with no clear indication of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
163% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 11, 2025
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to treat residents with respect and dignity, including delayed response to call lights and inadequate care related to incontinence management.
Complaint Details
The complaint investigation found substantiated issues including delayed response to call lights, inadequate assistance with incontinence care, and failure to maintain resident dignity and privacy.
Findings
The facility failed to treat two residents with respect and dignity, including delayed response to call lights, lack of privacy during care, failure to wash hands before feeding, and leaving a resident in a soiled diaper for over 40 minutes, risking urinary tract infection and skin breakdown.
Deficiencies (5)
Failure to respond promptly to call lights and provide assistance regardless of staff assignment.
Failure to maintain resident privacy after bathing.
Staff did not wash hands before feeding residents.
Resident left in soiled incontinent brief for more than 40 minutes, risking urinary tract infection and skin breakdown.
Staff speaking in native language during care, causing resident to feel excluded.
Report Facts
Time delay: 40
Residents sampled: 6
Residents affected: 2
Date of survey completion: Apr 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding facility policy on call light response and incontinence care |
| Neighborhood Supervisor 1 | Neighborhood Supervisor | Interviewed regarding delegation of incontinence care tasks |
| Director of Nursing | Director of Nursing | Confirmed staff responsibilities and discussed the situation regarding delayed assistance |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 13, 2025
Visit Reason
The inspection was conducted based on complaints and observations related to resident wandering, elopement risk, and failure to implement or revise care plans to address these behaviors in a nursing home setting.
Complaint Details
The investigation was complaint-driven, focusing on wandering and elopement risks for residents. The facility was found to have failed in developing, revising, and implementing care plans for wandering and elopement behaviors, and in monitoring the effectiveness of interventions. The complaint included observations of residents wandering into other residents' rooms, elopement incidents, and inconsistent documentation and monitoring of behaviors.
Findings
The facility failed to ensure residents' rights to a safe and clean environment, did not develop or revise comprehensive care plans for residents at risk of wandering and elopement, and failed to monitor and document wandering behaviors and the functioning of WanderGuard devices consistently. Several residents exhibited wandering and elopement behaviors without adequate interventions or care plan updates, resulting in potential safety risks.
Deficiencies (4)
Facility did not execute a resident's right to reside in a clean home environment.
Failed to develop a person-centered comprehensive care plan for wandering/elopement behavior for Resident 2.
Did not ensure a person-centered comprehensive care plan was reviewed and revised following an actual incident of elopement for Resident 1.
Failed to implement residents' care plans to eliminate risk of accidents related to wandering and elopement and monitor effectiveness for Residents 1, 2, and 3.
Report Facts
Deficiencies cited: 4
WanderGuard missing entries: 13
WanderGuard missing entries: 5
Wandering behavior documentation: 17
Wandering behavior monitoring opportunities: 63
Wandering behavior documented: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reported missed audits for Resident 2, discussed inconsistent documentation, and provided information on care plan development and medication adjustments. | |
| Certified Nurse Aide 1 | CNA | Observed assisting Resident 1 and reported lack of knowledge on approaches for wandering behavior. |
| Licensed Nurse 1 | LN | Confirmed linen needed to be changed and would have someone change it. |
| Infection Preventionist | IP | Interviewed regarding hygiene concern of Resident 1 lying in Resident 6's bed. |
| Unit Nurse | UN | Interviewed about care plan revisions and wandering incidents for Resident 1. |
| Administrator in Training | AIT | Reported inability to find elopement risk assessment for Resident 2 and discussed care plan issues. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation into allegations of abuse and failure to implement a comprehensive care plan related to resident behaviors and safety risks.
Complaint Details
The complaint investigation found substantiated abuse where Resident R106 hit Resident R141 with a wheelchair causing bruising and fear. The facility also failed to implement a care plan for Resident R98 related to smoking behaviors, leading to safety risks and altercations.
Findings
The facility failed to protect one resident from abuse when another resident hit her with a wheelchair causing bruising and fear. Additionally, the facility failed to consistently implement a person-centered care plan for a resident with smoking-related behaviors, placing him at risk for altercations. The facility took corrective actions including revising care plans and relocating the aggressive resident.
Deficiencies (2)
Failed to ensure one resident's right to be free from abuse; resident was hit with a wheelchair causing bruising and fear.
Failed to implement a person-centered comprehensive care plan for a resident with smoking-related behaviors, leading to risk of altercations.
Report Facts
Facility Reported Incident (FRI) number: 11157
Facility Reported Incident (FRI) number: 10878
Size of bruise: 10
Size of red mark: 0.5
Date of survey completion: Oct 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Interviewed regarding monitoring of Resident R98 in smoking area |
| HK1 | Housekeeper | Interviewed about cleaning and ashtray condition in designated smoking area |
| UM4 | Unit Manager | Interviewed about resident behaviors related to smoking and ashtray use |
| LPN1 | Licensed Practical Nurse | Interviewed about Resident R98's smoking behavior and cigarette possession |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, safety, and infection control at Hale Makua - Kahului nursing home.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications for residents, inadequate accommodation of resident needs such as appropriate shower chairs and accessible call lights, failure to prevent resident abuse, incomplete and inconsistent care plans, improper catheter care, inadequate pain management during wound care, medication management issues including narcotic counts and medication storage, and failure to follow infection control procedures for shared equipment.
Deficiencies (10)
Failed to ensure residents were fully informed and consented to psychotropic medication use, specifically duplicate antidepressant therapy for two residents.
Failed to reasonably accommodate resident needs by not providing a suitable shower chair and ensuring call lights were within reach.
Failed to protect a resident from abuse when another resident hit her with a wheelchair causing bruising.
Failed to implement a complete care plan addressing safety risks related to smoking behaviors for one resident.
Failed to revise care plan to provide support for a resident who leaned over in his wheelchair.
Failed to provide appropriate treatment and care for a resident with a stage 4 pressure ulcer, including pain management during dressing changes.
Failed to ensure accurate reconciliation and accounting for controlled medications on a medication cart, with incomplete narcotic count signatures.
Failed to label blood glucose test strips with opened dates, store insulin properly, discard expired medications, and ensure medications were stored according to manufacturer recommendations.
Failed to ensure proper cleaning of shared equipment, specifically blood pressure cuffs, between resident uses.
Failed to secure a storage room containing cleaning wipes, posing a risk for accident hazards.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts inspected: 16
Blood glucose test strip bottles: 6
Medication expiration date: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RR4 | Resident Representative | Named in deficiency related to lack of informed consent for psychotropic medication |
| UM4 | Unit Manager | Interviewed regarding lack of informed consent documentation and medication administration |
| DON | Director of Nursing | Interviewed regarding call light accessibility, catheter care, infection control, and storage room security |
| RN30 | Unit Manager | Interviewed regarding pain management and wound care for resident with stage 4 pressure ulcer |
| RN26 | Registered Nurse | Observed performing wound care and dressing change with inadequate pain management |
| RN3 | Registered Nurse | Observed medication cart narcotic count and insulin storage |
| LPN2 | Licensed Practical Nurse | Observed failing to clean blood pressure cuff between residents |
| LN35 | Licensed Nurse | Interviewed regarding care plan for resident leaning in wheelchair and behaviors |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 2, 2024
Visit Reason
Annual inspection conducted for regulatory compliance and licensing review of Care Homes By Hale Makua.
Findings
Multiple deficiencies related to medication orders and administration were identified, including conflicting medication orders, lack of discontinued orders, and documentation issues. Plans of correction and future monitoring plans were submitted for each deficiency.
Deficiencies (8)
Resident #2 had conflicting physician orders for Tylenol with no documented clarification.
Resident #2 medication administration record showed Atorvastatin order discontinued but no discontinued order observed.
Resident #2 had unclear dosage orders for Atorvastatin with no documented discontinued order.
Resident #1 continued to take Aspirin despite physician orders to avoid NSAIDs.
Resident #1 medication order for eye drops was incorrect and required clarification.
Resident #1 incident report for ED visit on 2/16/24 was unavailable.
Resident #2 had blue ink observed on daily activity records for multiple months.
Resident #2 had white out observed on leave sign out sheet where name was written over.
Report Facts
Completion date for correction: 2024
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 12, 2024
Visit Reason
The inspection was conducted in response to complaints regarding the facility's failure to honor Resident 3's right to receive visitors and telephone calls of her choosing, concerns about care plan revisions for Residents 1 and 2, inadequate personal hygiene and diabetic foot care for Resident 3, and an elopement incident involving Resident 1.
Complaint Details
The complaint investigation was initiated after the State Agency received complaints from the Long-Term Care Ombudsman and Resident 3's family member regarding visitation restrictions, care plan deficiencies, inadequate hygiene and diabetic foot care, and an elopement incident involving Resident 1. The investigation confirmed these issues and found the facility failed to comply with regulatory requirements.
Findings
The facility failed to honor Resident 3's visitation rights, delayed revising care plans for Residents 1 and 2 to address high-risk behaviors, inadequately provided personal hygiene and diabetic foot care for Resident 3, and failed to prevent an elopement by Resident 1, resulting in actual harm. The facility did not follow its own elopement risk program and lacked proper investigation and monitoring.
Deficiencies (5)
Failed to honor Resident 3's right to receive visitors and telephone calls of her choosing, resulting in denial of visits and calls from family members.
Failed to timely revise comprehensive care plans for Residents 1 and 2 to include high-risk behaviors such as exit seeking and medication swallowing issues.
Failed to provide necessary care and assistance for activities of daily living, including personal hygiene, for Resident 3, resulting in inadequate bathing and hygiene.
Failed to provide adequate diabetic foot care for Resident 3, including monitoring and care of overgrown toenails, despite history of podiatric consultations.
Failed to provide appropriate supervision and interventions to prevent elopement of Resident 1 with moderate cognitive impairment, resulting in actual harm after Resident 1 left the facility and drove his vehicle unsupervised.
Report Facts
Deficiencies cited: 5
Length of Resident 3's overgrown toenail: 2.5
Distance Resident 1 drove during elopement: 2.6
Distance Resident 1 was found from Walgreens: 0.4
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Cared for Resident 1 during exit seeking behavior, applied WanderGuard but did not complete incident report or revise care plan |
| UM3 | Unit Manager | Interviewed regarding visitation policy changes and diabetic foot care for Resident 3 |
| SSA1 | Social Service Assistant | Observed Resident 1 during exit seeking behavior and interacted with him regarding parking |
| DON | Director of Nursing | Interviewed about diabetic foot care and elopement procedures |
| UM2 | Unit Manager | Investigated Resident 1's elopement incident |
| CNA8 | Lead Certified Nurse Aide | Interviewed about bathing schedule and procedures for Resident 3 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 12, 2024
Visit Reason
The inspection was conducted following a complaint received on 02/29/2024 regarding alleged failure to provide appropriate incontinence care to two residents (R1 and R2) during the day shift on 02/24/2024.
Complaint Details
The complaint was substantiated as the facility confirmed that CNA2 failed to provide timely incontinence care to residents R1 and R2 on 02/24/2024. CNA2 was suspended pending investigation, and Adult Protective Services and OHCA were notified. The facility conducted a thorough investigation including interviews and skin assessments, and corrective actions were taken.
Findings
The facility failed to provide appropriate incontinence care to two residents, resulting in increased risk of adverse outcomes such as discomfort, skin breakdown, and infection. The issue was identified, investigated promptly, and corrected prior to the survey. CNA2 was suspended pending investigation and received additional training. No current deficient practice was identified at the time of the survey.
Deficiencies (1)
Failure to provide appropriate incontinence care to two residents according to professional standards and individual care plans.
Report Facts
Resident sample size: 7
Additional incontinent residents reviewed: 5
BIMS score: 8
Date of incident report: Feb 29, 2024
Date of incident: Feb 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA2 | Certified Nurse Assistant | Accused of failing to provide incontinent care to residents R1 and R2 |
| CNA1 | Certified Nurse Assistant | Reported the failure to provide incontinence care and found soaked briefs |
| LN1 | Licensed Nurse | Investigated and confirmed soaked briefs, notified supervisor |
| Director of Nursing | Director of Nursing | Confirmed expectations for care and oversaw investigation |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as the facility's annual licensing survey to assess compliance with state licensing requirements for Care Homes by Hale Makua.
Findings
The inspection identified deficiencies including inability to determine fitness of substitute care givers from background checks, failure to notify the physician of a resident's significant weight gain, and lack of documented nutritional assessment by a registered dietitian for the resident with weight gain.
Deficiencies (3)
Substitute Care Giver #1 and #2 – Unable to determine fitness determination on printed Fieldprint background check result.
Resident #2 – No documented evidence that the facility notified the physician of 19 lb. weight gain (18.5% weight change) in one year.
Resident #2 – No documented evidence that the facility utilized the Consultant Registered Dietitian to provide nutritional assessment for resident with 19 lb. weight gain (18.5% weight change) in one year and taking Boost 1 bottle PO q AM.
Report Facts
Weight gain: 19
Weight change percentage: 18.5
Boost intake: 1
Inspection Report
Routine
Deficiencies: 7
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, environmental conditions, care planning, treatment and care, accident hazards, and medical record maintenance at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to uphold resident privacy during care, inadequate environmental conditions such as temperature control and pest management, failure to develop and implement comprehensive care plans for residents, improper treatment and documentation of bowel protocols, failure to prevent accidents including resident-to-resident aggression and falls, and failure to maintain accurate and timely medical records.
Deficiencies (7)
Failed to uphold a resident's right to privacy during showering, exposing the resident to potential psychosocial harm.
Failed to ensure a safe, clean, comfortable, and homelike environment, including temperature control, pest control, and maintenance of resident rooms.
Failed to develop and implement complete care plans for residents' needs including trauma-informed care, infection precautions, medication monitoring, and oxygen therapy.
Failed to review and revise residents' comprehensive care plans to address changes in condition and prevent further complications.
Failed to provide appropriate treatment and care according to orders, including bowel protocol implementation, root cause analysis for skin conditions, and medication availability.
Failed to ensure residents were free from accident hazards and provided adequate supervision to prevent accidents, including failure to protect a resident from being grabbed by another resident, delayed falls care planning, and unsafe possession of smoking materials.
Failed to maintain accurate and timely medical records, including delayed care plan revisions following behavioral incidents.
Report Facts
Residents in sample: 36
Residents affected: 6
Residents affected: 3
Residents affected: 1
Residents affected: 8
Bowel movement days: 5
Fall Risk Score: 25
Fall Risk Score: 14
Bruise size: 3
Bruise size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA15 | Certified Nursing Assistant | Named in privacy violation during resident shower |
| NS1 | Neighborhood Supervisor | Acknowledged privacy violation incident |
| CNA66 | Certified Nurse Aide | Witnessed resident grabbing incident |
| RN15 | Registered Nurse | Confirmed lack of monitoring for bleeding in resident 114 |
| LPN15 | Licensed Practical Nurse | Spoke with family representative about resident safety |
| NS2 | Neighborhood Supervisor | Provided information on environmental and wound care issues |
| RN27 | Registered Nurse | Reported resident grabbing behavior |
| LPN7 | Licensed Practical Nurse | Reported resident grabbing behavior |
| RN4 | Registered Nurse | Confirmed smoking materials policy and practice |
| SSD | Social Services Director | Provided information on appointment rescheduling and medication issues |
| FM3 | Family Member | Reported concerns about appointment and medication |
| Administrator | Provided documentation and interviews related to medication and care plans |
Inspection Report
Routine
Deficiencies: 19
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, environment, and infection control at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights and dignity, inadequate accommodation of resident needs, failure to provide timely notifications, privacy violations, environmental concerns, improper use of restraints, incomplete care plans, unsafe medication administration, inadequate infection control practices, and failure to provide trauma-informed care. An Immediate Jeopardy was identified related to unsafe food handling and dishwashing practices.
Deficiencies (19)
Failed to honor residents' right to a dignified existence, self-determination, communication, and to exercise rights, including respect and timely assistance with call lights.
Failed to reasonably accommodate the needs and preferences of residents, including ensuring call lights were within reach.
Failed to promote and facilitate resident self-determination through support of resident choice, including accommodating smoking preferences.
Failed to ensure residents were informed of their right to file complaints and how to contact the State Survey Agency.
Failed to keep residents' personal and medical records private and confidential, including failure to provide privacy during showering.
Failed to maintain a safe, clean, comfortable, and homelike environment, including pest control, temperature control, and maintenance of rooms and equipment.
Failed to ensure residents were free from physical restraints imposed for convenience, including improper use of pillows under fitted sheets restricting movement.
Failed to provide timely notification of transfer or discharge to resident, representative, and ombudsman.
Failed to develop and implement comprehensive care plans that meet all residents' needs, including trauma-informed care, medication monitoring, and care for communicable diseases.
Failed to provide appropriate treatment and care according to orders, resident preferences, and goals, including bowel protocols, skin care, and medication availability.
Failed to provide appropriate care to maintain or improve range of motion and mobility, including inconsistent application of orthotic devices and failure to address refusals.
Failed to ensure residents were free from accident hazards and provided adequate supervision, including failure to protect residents from aggressive behavior and falls.
Failed to provide appropriate care for residents with indwelling urinary catheters, including catheter bags touching the floor.
Failed to provide enough food and fluids to maintain residents' health, including failure to prevent significant weight loss and implement nutritional interventions.
Failed to ensure feeding tubes were labeled with resident's name, date/time of preparation, rate of feeding, and resident's room number.
Failed to provide safe and appropriate respiratory care, including lack of suction machines and bag valve masks at bedside for residents with tracheostomies.
Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including failure to maintain proper dishwasher temperatures and discard expired food.
Failed to safeguard resident-identifiable information and maintain accurate medical records, including delayed care plan revisions after behavioral incidents.
Failed to provide and implement an infection prevention and control program, including failure to wear appropriate PPE during high-contact care and maintain sanitary equipment.
Report Facts
Deficiencies cited: 20
Weight loss percentage: 11.96
Weight loss percentage: 9.92
Fall Risk Score: 25
Dishwasher temperature: 113
Dishwasher temperature: 118
Weight: 70.2
Weight: 71.8
Weight: 73.6
Weight: 74.2
Weight: 75
Weight: 77
Weight: 80.2
Weight: 81.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA66 | Certified Nurse Aide | Witnessed and reported incident of resident grabbing another resident |
| RN15 | Registered Nurse | Provided care without proper PPE and failed to ensure medication administration timeliness |
| RN26 | Registered Nurse | Interviewed regarding medication administration and resident care |
| NS2 | Neighborhood Supervisor | Interviewed regarding environmental and care concerns |
| RN4 | Registered Nurse | Interviewed regarding restraint use and medication administration |
| RN1 | Registered Nurse | Interviewed regarding respiratory care and suction equipment |
| IP | Infection Preventionist | Interviewed regarding infection control practices and PPE use |
| RD2 | Registered Dietitian | Interviewed regarding nutritional assessments and weight loss |
| FR1 | Family Representative | Interviewed regarding resident care and observations |
| FR4 | Family Representative | Interviewed regarding resident safety concerns |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 12, 2023
Visit Reason
The inspection was conducted following allegations of abuse reported by residents against certified nurse aides, including failure to promote resident self-determination, physical abuse during care, and failure to timely report suspected abuse.
Complaint Details
The complaint investigation involved allegations of abuse by two certified nurse aides (CNA1 and CNA2) against Resident 1. The allegations included rough handling during care and forcing a resident to go to bed against her wishes. The facility failed to report one allegation involving CNA2 within the required two-hour timeframe. CNA1 was suspended and no longer assigned to the resident's unit. Resident 1 expressed fear of retaliation but later stated she was not afraid.
Findings
The facility was found to have failed in promoting resident self-determination, protecting residents from abuse, timely reporting suspected abuse, and completing annual performance reviews for nurse aides. Multiple allegations of abuse by certified nurse aides were substantiated, and deficiencies were noted in staff performance evaluations.
Deficiencies (4)
Failed to promote a resident's right for self-determination, affecting psychosocial and mental well-being.
Failed to protect a resident from abuse; CNA was rough during care, causing fear of retaliation.
Failed to timely report an allegation of abuse to the State Survey Agency within two hours.
Failed to complete annual performance reviews for nurse aides for two consecutive years.
Report Facts
Deficiencies cited: 4
Performance review dates: 2020
Date of hire: 2010
Date of hire: 1999
Cognitive score: 15
Wait time: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nurse Aide | Alleged perpetrator of abuse; suspended and no longer assigned to resident's unit. |
| CNA2 | Certified Nurse Aide | Alleged perpetrator of abuse; described as rushing residents and tightly bound to schedule. |
| Administrator | Interviewed regarding reporting failures and performance review processes. | |
| Human Resources Assistant | Provided personnel files and information on performance reviews. | |
| Activities Director | Reported hearing resident's statement about abuse. | |
| Social Services Assistant | Interviewed resident regarding abuse allegations. | |
| Director of Nursing | Former DON responsible for overseeing performance reviews. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 22, 2023
Visit Reason
The inspection was conducted following a complaint and incident involving Resident 1 (R1) who fell while unattended during transport, resulting in injury. The investigation focused on the facility's failure to implement fall risk assessments and provide adequate supervision to prevent accidents.
Complaint Details
The complaint investigation was triggered by an incident where Resident 1 fell from her wheelchair while unattended by the Transport Aide during transport to a medical appointment. The fall resulted in lacerations and a fractured hip. The facility failed to provide adequate supervision and did not conduct required fall risk assessments. The Transport Aide was counseled and educated following the incident.
Findings
The facility failed to implement required fall risk assessments for R1 and did not provide adequate supervision during transport, resulting in R1 falling from her wheelchair and sustaining injuries including lacerations and a fractured hip. The Transport Aide left R1 unattended with wheelchair brakes unlocked, and the facility lacked documentation of fall assessments. Staff interviews and record reviews confirmed these deficiencies.
Deficiencies (3)
Failed to implement Resident 1's care plan intervention to assess risk factors for falls at admission and throughout residence, resulting in a fall.
Failed to ensure adequate supervision to prevent accidents when Resident 1 was left alone during transport, resulting in a fall with injury (fractured left hip).
Failed to perform fall risk assessments for Resident 1 as required by policy and care plan.
Report Facts
Fall incident date: 2023
Report date: 2023
BIMS scores: 14
BIMS scores: 9
Pain rating: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Notified of fall incident and provided care instructions |
| DON | Director of Nursing | Interviewed regarding incident and supervision policies |
| ADON | Assistant Director of Nursing | Provided education to Transport Aide after incident |
| Transport Aide | Transport Aide (CNA) | Left resident unattended leading to fall; received counseling |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 8, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident (R1) who had symptoms of a urinary tract infection (UTI) that were not promptly addressed by nursing staff, resulting in delayed treatment.
Complaint Details
The complaint alleged that since the weekend prior to the survey, the resident had a UTI and requested staff action, but no response was given. The resident's symptoms worsened without timely physician notification or urine testing.
Findings
The nursing staff failed to identify and respond timely to R1's UTI symptoms, did not follow facility policy or standard of care, and inaccurately documented the urine sample collection method. This delay in treatment posed a risk of serious adverse outcomes for residents vulnerable to UTIs.
Deficiencies (3)
Nursing staff failed to provide timely care for a resident's UTI symptoms, delaying antibiotic treatment.
Inaccurate documentation of urine sample collection method, recorded as voided urine instead of catheterized specimen.
Failure to initiate the Suspected UTI SBAR form by nursing staff despite resident symptoms.
Report Facts
Antibiotic dosage: 500
Colony count: 100000
Leukocyte esterase: 3
Blood: 3
Protein: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Noted resident's complaint of painful urination and communicated with charge nurse |
| CN | Charge Nurse | Received notification from RN1, responsible for communication with physician |
| NP1 | Nurse Practitioner | Notified of resident's symptoms, ordered urine tests and antibiotic treatment |
| RN3 | Registered Nurse | Administered initial dose of antibiotic ciprofloxacin |
| Infection Preventionist | Infection Preventionist | Reviewed infection surveillance program and resident's chart, confirmed criteria for suspected UTI |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 14, 2022
Visit Reason
Annual inspection of Care Homes by Hale Makua to assess compliance with personnel, medication, personal care services, records, and resident health care standards.
Findings
Multiple deficiencies were found including lack of documented first aid certification for a substitute caregiver, medication labeling issues, missing activity schedules for a resident, incomplete progress notes, and lack of documentation of significant weight changes for a resident.
Deficiencies (6)
Substitute Care Giver (SCG) #1 had no documented evidence of current first aid certification.
Medication order for Furosemide did not include 'as needed' status on the label.
Medication order for Mirtazapine not reflected on medication administration record (MAR) or medication label.
Resident #1 had no schedule of activities available.
Progress notes for Resident #1 did not include observations of the resident's response to Ensure supplement as ordered.
No documented evidence that significant weight changes for Resident #1 were reported to the physician.
Report Facts
Medication dosage: 20
Medication dosage: 15
Medication dosage: 7.5
Weight gain: 9.2
Weight loss: 5.3
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 22, 2022
Visit Reason
The inspection was conducted following a complaint alleging staff mistreatment of Resident #64 and concerns related to resident care including grooming, pressure ulcer care, oxygen administration, and diet consistency.
Complaint Details
The complaint involved an allegation that a CNA mistreated Resident #64 by placing her finger over the resident's mouth to quiet him/her. The facility investigated, interviewed involved parties including the resident, staff, and family, and suspended the CNA during the investigation. The resident was not fearful and wished to continue care from the CNA after education. The facility corrected the practice prior to the survey.
Findings
The facility was found to have past noncompliance for staff interaction that failed to maintain resident dignity involving Resident #64. Additional deficiencies included failure to provide regular nail care for Residents #95 and #189, failure to apply the correct dressing for a stage 4 pressure ulcer for Resident #95, failure to administer oxygen at the physician-ordered flow rate for Resident #198, and failure to provide food in the prescribed pureed consistency for Resident #33.
Deficiencies (5)
Staff failed to ensure interactions maintained Resident #64's dignity; a CNA placed her finger over the resident's mouth to quiet him/her.
Facility failed to regularly assist Residents #95 and #189 with nail care; nails were observed long and dirty.
Licensed nurse failed to apply the correct dressing (used collagen-based Puracol Plus instead of physician-ordered silver-calcium alginate Maxorb Extra Ag) for Resident #95's stage 4 pressure ulcer.
Oxygen was administered at 2.5 LPM instead of the physician-ordered 2 LPM for Resident #198.
Facility provided food that was not pureed as ordered for Resident #33; soft rice and rice pudding were not pureed.
Report Facts
Deficiencies cited: 5
Wound measurement: 3.2
Wound measurement: 1.8
Wound measurement: 0.7
Wound measurement: 2.1
Wound measurement: 1.5
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #15 | Certified Nursing Assistant | Named in dignity violation involving Resident #64; suspended during investigation and reassigned after education. |
| Director of Nursing | Provided statements regarding expectations for staff treatment, nail care, wound care, and oxygen administration. | |
| Administrator | Provided statements regarding staff expectations and facility policies on nail care, wound care, oxygen administration, and diet. | |
| Registered Nurse #1 | Registered Nurse | Performed wound care on Resident #95 and applied incorrect dressing. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed oxygen flow rate discrepancy for Resident #198. |
| Dietary Staff #1 | Acknowledged use of soft rice instead of pureed rice for Resident #33. | |
| Director of Nutrition Services | Explained facility practice of using soft rice rather than pureed rice. | |
| Speech Language Pathologist | Observed test tray and stated rice and rice pudding were not pureed as required. |
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