Inspection Report Summary
The most recent inspection on January 28, 2025, identified multiple deficiencies related to documentation, medication management, and some unsecured items. Earlier inspections also noted similar issues with personnel documentation, medication orders, nutrition records, and certification requirements. Prior reports did not list any enforcement actions or fines in the available records, and no complaint investigations were reported. The main themes across inspections involved missing or incomplete background checks, physical exams, tuberculosis clearances, medication labeling, and inconsistent resident weight records. The pattern of deficiencies has remained fairly consistent over time, with no clear improvement or worsening trend evident.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Jan 28, 2025
Visit Reason
Annual inspection conducted to assess compliance with licensing requirements for Lanihale, Inc., including verification of documentation for primary care givers, substitute care givers, personnel physicals, diet orders, medication administration, food sanitation, record keeping, and resident care.
Findings
Multiple deficiencies were identified related to missing or misplaced documentation such as background checks, physical examinations, diet orders, medication orders, and record keeping. Several physical items such as thermometers and cleaning supplies were found misplaced or unsecured. Plans of correction were submitted with specific actions and future plans to address each deficiency.
Deficiencies (16)
Primary Care Giver (PCG) – No documented evidence care giver meets Fieldprint background check requirements (2 consecutive years of APS, CAN and fingerprint registries).
Substitute Care Giver (SCG) #1 and #2 – No current annual physical examination.
SCG #1 and #2 – No current annual tuberculosis clearance.
Resident #2 – No annual diet order available.
No metal stem thermometer available to check hot and cold food temperatures.
Comet cleaner unsecured in residents’ bathroom.
Resident #1 – Medication order for Famotidine changed on 12/4/2024 to routine; however, medication label still says as needed.
Resident #1 – Dulcolax liquid available for resident; however, no documented evidence of order for it. Dulcolax liquid bottle does not have a label with the resident’s name or order directions on it.
Resident #1 – Dulcolax liquid and antibiotic cream found in medication bin for administration; however, no documented evidence of an order for either.
Resident #1 – Acetaminophen bottle with a resident’s name who was discharged in August 2024 still available.
Resident #1 – No initials on medication administration record for 1/23/2025 and 1/24/2025 Famotidine administrations at 7:00 pm.
Resident #1 – Emergency information sheet does not include a current list of the resident’s medications.
Resident #1 – No weight available on PCG’s admission assessment, August weight record, nor August progress note.
Multiple residents’ recorded weights included big fluctuations of gains and losses of more than 5 lbs in one month, multiple times throughout the year.
Garbage receptacle in residents’ bathroom does not have a tight-fitting lid.
Resident #1 – No documented evidence of current influenza vaccine.
Report Facts
Completion Date: Mar 4, 2025
Completion Date: Jul 8, 2025
Completion Date: Apr 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benah Christy Hussey | Licensee/Administrator | Signed plan of correction and statement of deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Jan 11, 2024
Visit Reason
Annual inspection conducted to assess compliance with licensing requirements for Lanihale, Inc., including verification of personnel background checks, physical examinations, tuberculosis clearances, certifications, training, nutrition, medication management, records, and fire safety.
Findings
Multiple deficiencies were identified including missing background checks, physical exams, tuberculosis clearances, first aid and CPR certifications, medication order issues, nutrition documentation, incomplete records, and fire drill documentation. Plans of correction were submitted with completion dates ranging from March to May 2024.
Deficiencies (15)
Primary Care Giver (PCG), Substitute Care Giver (SCG) #3, #4, and #5 – No current Fieldprint background check.
SCG #3 and #5 – No current annual physical examination.
PCG, SCG #1, #3, and #5 – No current annual tuberculosis clearance. SCG #2 and #5 – No initial/2-step tuberculosis clearance.
PCG, SCG #1, #2, #3, #4 and #5 – No current first aid certification.
SCG #2, #3, #4, and #5 – No current cardiopulmonary resuscitation (CPR) certification.
No evidence that menus meet the nutritional needs of residents as menus do not include portion sizes.
No menu substitutions available for residents who refuse food served.
Resident #4 – Diet ordered 5/19/2023 was chopped solids and thin liquids; diet type not specified.
Resident #1 – Medication order for Fexofenadine HCL 60 mg changed from original order but not accurately reflected on medication label.
Resident #1 – Acetaminophen 325 mg appeared on September 2023 MAR; no medication order available prior to January 8, 2024.
Resident #1 – Calamine Plus spray on signed medication orders from 1/8/2024; spray not on MAR or available for administration; no order to discontinue.
Resident #1, #2, and #3 – No annual tuberculosis clearance available.
Multiple residents’ recorded weights included big fluctuations of gains and losses of more than 5%, multiple times throughout the year; new scale may have caused fluctuations.
SCG #1, #2, #3, #4 and #5 – 0 out of 12 continuing education hours completed within last year.
Fire drills not conducted monthly since becoming expanded.
Report Facts
Deficiencies cited: 15
Completion dates: Mar 9, 2024
Completion dates: May 3, 2024
Continuing education hours: 12
Medication reevaluation interval: 4
Weight fluctuation threshold: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benah Christy Hussey | Licensee/Administrator | Signed the plan of correction documents on multiple dates. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 25, 2023
Visit Reason
Annual inspection conducted to evaluate compliance with licensing requirements for Lanihale, Inc., including verification of documentation for substitute care givers and personnel certifications.
Findings
Deficiencies were found related to missing documented evidence for substitute care givers regarding prior felony or abuse convictions, lack of current physical examination assessments for certain care givers, and absence of current First Aid certification for substitute care givers. Plans of correction include scheduling fingerprint appointments, physical examinations, and First Aid certification for the affected care givers.
Deficiencies (3)
No current documented evidence stating substitute care givers have no prior felony or abuse convictions in a court of law.
No current physical examination assessment done by physician or advanced practice registered nurse (APRN) for certain substitute care givers.
No current First Aid certification for substitute care givers providing coverage for less than four hours.
Report Facts
Number of Substitute Care Givers cited: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 18, 2022
Visit Reason
Annual inspection conducted to assess compliance with state licensing regulations.
Findings
No deficiencies were identified during the inspection; the facility was found to be in compliance with all applicable rules.
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