Inspection Report Summary
The most recent inspection on August 1, 2024, identified multiple deficiencies related to staff background checks, physical exams, tuberculosis clearances, first-aid and CPR certifications, medication labeling and orders, care plans, documentation, and fire drills. Earlier inspections showed similar issues with staff certifications, medication management, and care planning, indicating recurring themes in personnel qualifications and resident care documentation. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. Complaint investigations were not noted in any of the reports. The pattern of deficiencies has remained consistent over time without a clear trend of improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
122% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 23
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as the annual survey of the facility Hale O Meleana to assess compliance with licensing and regulatory requirements.
Findings
The report identifies multiple deficiencies related to incomplete background checks, missing annual physical exams, tuberculosis clearances, first-aid and CPR certifications, admission policies, medication labeling and orders, care plans, documentation, fire drills, and other regulatory requirements. Plans of correction with specific completion dates and future prevention strategies are provided for each deficiency.
Deficiencies (23)
Substitute Care Giver (SCG) #4 and #5 background check requirements incomplete.
SCG #1,4,5 current annual physical exam unavailable.
SCG #2,4,5 current annual tuberculosis clearance unavailable.
SCG #3,8 valid first-aid certification unavailable; online certification not accepted. SCG #2,6,7 current first-aid certification unavailable.
SCG #3,8 valid cardiopulmonary resuscitation (CPR) certification unavailable; online certification not accepted. SCG #2 current CPR certification unavailable.
Resident #1 level of care dated 7/28/23 marked as both ARCH and ICF; no clarification on level of care with physician documented.
Resident #5 inventory of possessions upon admission (1/15/24) unavailable.
Bedroom 203 Lysol disinfecting spray stored on bathroom counter unsecured.
Resident #5 physician's order medication label does not reflect physician's orders.
Resident #1 label on lidocaine box does not include portion of physician's order to remove after 12 hours.
Resident #1,2,4 admission assessment unavailable for specified dates.
Resident #1 monthly progress notes unavailable for 1/2024, 2/2024, 4/2024-6/2024; Resident #2 monthly progress notes unavailable for 4/2024-6/2024.
Resident #1 fax to physician dated 1/29/24 stated edema to left hand after injury on 1/22/24; no documented evidence injury was monitored; current status unknown. Resident #5 incident report unavailable for unwitnessed falls on 2/16/24 and 4/9/24.
Resident #4 monthly weight unavailable for 4/2024.
Bedroom #341 oxygen tank stored in bedroom; no 'oxygen in use' sign posted on front door of unit.
No documented evidence caregiver training was provided by resident's case manager on daily personal care for Resident #1.
No documented evidence caregiver training was provided by resident's case manager on daily and specialized care for Resident #2.
No documented evidence caregiver training was provided by resident's case manager regarding use of Hoyer Lift for Resident #4.
Resident #1,2,4 current medication orders not reflected on care plan.
Resident #2 no nutrition care plan developed for renal, NCS diet.
Resident #3,4 medications not reevaluated by physician every four months.
Resident #1 care plan does not include risk for constipation or nutrition deficit as evidenced by physician's orders.
Monthly fire drills performed do not include a duration of time taken to complete.
Report Facts
Completion date: Sep 12, 2024
Completion date: Sep 9, 2024
Completion date: Aug 1, 2024
Completion date: Aug 13, 2024
Completion date: Aug 14, 2024
Completion date: Aug 15, 2024
Completion date: Aug 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jan Shishido | Licensee/Administrator | Signed the plan of correction on 09/09/2024 |
| Community Case Manager | RN and MSN-Ed | Provided training on daily personal care and specialized care for Residents #1 and #2; training on use of Hoyer Lift for Resident #4 |
| Case Manager | Developed revised care plans for multiple residents including medication orders, nutrition, and health concerns | |
| Human Resources Designee and Administrator | Set monthly meetings to verify background checks, physical exams, tuberculosis clearances, first-aid, and CPR certifications | |
| Resident Care Coordinator/Manager | Responsible for verifying level of care, completing monthly progress notes, and updating care plans |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Aug 9, 2023
Visit Reason
Annual inspection conducted from August 9 to 11, 2023, to assess compliance with state licensing regulations for the facility Hale O Meleana.
Findings
Multiple deficiencies were identified including lack of initial tuberculosis clearance for an employee, missing or invalid first aid and CPR certifications for substitute caregivers, medication order errors and delays in administration, incomplete or inaccurate resident care plans, failure to notify physicians of significant resident health changes, and missing comprehensive reassessments by case managers.
Deficiencies (12)
Employee #1 – No initial tuberculosis clearance available.
Employees #2, #3, #4, and #5 – No current first aid certification as certification was completed online; Employee #6 – No first aid certification available.
Employees #3, #4, and #5 – No current cardiopulmonary resuscitation certification available as certification was completed online.
Resident #1 – Medication order for Amlodipine written incorrectly and held daily because systolic blood pressure was greater than 110; order not clarified until 7/6/2023.
Resident #1 – Dulcolax suppository medication not administered timely according to bowel movement logs, with delays of up to five days.
Resident #1 – Sorbitol 70% solution medication not given despite resident not having bowel movements for more than four days on multiple occasions.
Resident #2 – Plavix order change not noted until physician clarification on 2/3/23; medication given daily starting 2/9/23.
Resident #1 – Nursing care plan intervention instructs to administer Divalproex 125 mg, but no documented evidence of medication order.
Resident #1 – No documented evidence that primary care physician was notified when resident had no bowel movement for multiple periods as instructed.
Resident #4 – Nutrition care plan not updated to reflect current nutritional needs; care plan included tube feeding goals but resident was not administered tube feedings.
Resident #1 – No documented evidence physician was notified when resident had no bowel movement for 3 days or more as instructed in care plan.
Resident #2 – No documented evidence of six-month comprehensive reassessment completed by case manager (due February 2023).
Report Facts
Inspection duration days: 3
Medication order date: Jun 16, 2023
Medication order clarification date: Jul 6, 2023
Bowel movement no occurrence days: 4
Bowel movement no occurrence days: 4
Medication order change date: Dec 27, 2022
Medication clarification date: Feb 3, 2023
Medication administration start date: Feb 9, 2023
Six-month reassessment due date: 202302
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Aug 24, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the facility Hale O Meleana, following an inspection conducted on August 24, 25, and 29, 2022. The purpose is to identify deficiencies found during the inspection and outline corrective actions.
Findings
Multiple deficiencies were identified related to personnel physical exams, tuberculosis clearance, first aid certification, cardiopulmonary resuscitation certification, medication orders and administration, records and reports, case management, and personal care services. The facility submitted plans of correction addressing each deficiency with completion dates mostly by October 30, 2022.
Deficiencies (19)
No documented evidence of a current annual physical examination clearance for employees #3, #4, and #8.
No documented evidence of a current annual tuberculosis clearance for employees #2, #3, #4, #6, and #8.
No documented evidence of a current first aid certification for employee #8.
No documented evidence of a current cardiopulmonary resuscitation (CPR) certification for employee #8.
Admission medication orders for Resident #1 did not include a route or dose for Calcium Carbonate with Vitamin D.
Medication orders for Resident #1 were not signed by a physician or APRN.
Medication not reevaluated and signed every four months for Resident #3.
No documented evidence of completion of twelve continuing education hours within past twelve months for employees #1, #2, #3, #4, #7, #8, #10, and #11.
Progress notes for Resident #2 did not include observations on response to diet and medications.
Aspiration risk care plan was not reviewed for Resident #2 with special diet and significant weight changes.
Resident #1 exhibited physical aggression; progress notes did not document medication tolerance or effects.
Nutrition care plan was not developed for Resident #2 with special diet and significant weight changes.
Aspiration risk care plan was not reviewed by case manager for Resident #2 for August 2022.
Resident #2 monthly progress notes missing observations of response to medications.
Resident #1 nutrition care plan was not reviewed by case manager.
Resident #2 aspiration risk care plan was not reviewed by case manager for August 2022.
Resident #2 monthly progress notes did not include observations of response to medications.
Resident #1 admission medication orders from 1/17/2022 not signed by physician or APRN.
Resident #3 refused pneumovax vaccine; no documented evidence that arrangements were made to obtain vaccine or confirmation from physician.
Report Facts
Completion date: Oct 30, 2022
Continuing education hours: 12
Medication orders: 2
Medication reevaluation interval: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in deficiencies related to lack of physical exam and tuberculosis clearance. | |
| Employee #4 | Named in deficiencies related to lack of physical exam and tuberculosis clearance. | |
| Employee #8 | Named in deficiencies related to lack of physical exam, tuberculosis clearance, first aid certification, and CPR certification; noted as no longer employed. | |
| Employee #2 | Named in deficiencies related to tuberculosis clearance. | |
| Employee #6 | Named in deficiencies related to tuberculosis clearance. | |
| Employee #1 | Named in deficiencies related to continuing education hours. | |
| Employee #7 | Named in deficiencies related to continuing education hours. | |
| Employee #10 | Named in deficiencies related to continuing education hours. | |
| Employee #11 | Named in deficiencies related to continuing education hours. |
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