Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 23, 2025
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with Medicare and Medicaid regulations and to evaluate the facility's adherence to resident care standards.
Findings
The facility was found deficient in providing timely Notice of Medicare Non-Coverage, preventing avoidable resident falls due to inadequate assistance, failure to communicate resident food preferences to kitchen staff, and improper infection control practices related to storage of oral care and incontinence supplies. The facility has taken corrective actions for the fall prevention deficiency.
Deficiencies (4)
F 0582: The facility failed to provide a written Notice of Medicare Non-Coverage at least two days before the end of services covered by Medicare for one resident, preventing timely appeal rights.
F 0689: The facility failed to ensure one resident received adequate assistance to prevent an avoidable fall, resulting in a laceration and displaced cervical fracture.
F 0806: The facility failed to communicate food preferences to all staff involved in meal preparation and service for one resident, resulting in the resident being served disliked foods.
F 0880: The facility placed oral care supplies with incontinent care supplies and food thickener packets with adult briefs in resident bedside drawers, increasing risk of cross-contamination.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Laceration size: 2.5
Bump size: 3.5
Bump size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW33 | Social Worker | Interviewed regarding Resident R22's Notice of Medicare Non-Coverage |
| RN3 | Registered Nurse | Provided statement regarding Resident R15's fall |
| CNA9 | Certified Nurse Aide | Assisted Resident R15 during fall incident and interviewed about fall |
| CNA8 | Certified Nurse Aide | Interviewed regarding Resident R15's functional abilities |
| CNAM14 | Certified Nurse Aide Manager | Interviewed regarding Resident R15's fall and facility corrective actions |
| RD23 | Registered Dietician | Interviewed about Resident R42's nutritional assessment and meal preparation |
| HSA2 | Health Services Assistant | Interviewed about meal tray preparation and resident food preferences |
| CNA14 | Certified Nurse Aide | Observed providing incontinence care and involved in infection control deficiency |
| IP | Infection Preventionist | Interviewed regarding infection control practices and observed bedside drawer storage |
| CNAM2 | Certified Nurse Aide Manager | Observed and corrected infection control storage deficiency |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 13, 2025
Visit Reason
Annual inspection of the facility 15 Craigside was conducted on March 13, 2025.
Findings
No deficiencies were found during the inspection; the facility was found to be in compliance with all applicable rules.
Inspection Report
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home inspection conducted by the Centers for Medicare & Medicaid Services.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
Annual inspection of the facility 15 Craigside was conducted on March 21, 2024.
Findings
No deficiencies were found during the inspection; the facility was found to be in compliance with all applicable regulations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the failure to use gait belts during resident transfers and ambulation, specifically concerning resident R38 who has a history of falls and unsteady gait.
Complaint Details
The complaint investigation focused on the failure to use gait belts during transfers and ambulation for resident R38. The complaint was substantiated as staff admitted not using a gait belt despite knowing the resident's unsteady gait and fall risk.
Findings
The facility failed to ensure that resident R38 was free from accident hazards by not using a gait belt during transfers and ambulation despite her history of falls and unsteady gait. Staff were observed assisting R38 without a gait belt, increasing her risk for falls and injury.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Resident R38 was ambulated without a gait belt despite her high fall risk and unsteady gait, placing her at risk for avoidable injury.
Report Facts
Fall score: 19
Date of last documented fall: Jun 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nurse Aide | Admitted not using gait belt with resident R38 despite unsteady gait |
| CNAM | CNA Manager | Reported gait belts are used at CNA discretion and expected for residents needing extensive assistance |
| PT1 | Physical Therapist | Reported gait belts are recommended during transfers and staff determine need |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 17, 2023
Visit Reason
The inspection was conducted as the annual survey of the assisted living facility 15 Craigside to assess compliance with state regulations.
Findings
Multiple deficiencies were identified related to medication administration, including mismatches between medication bottle labels and medication administration records (MAR) for several residents, unsecured medication bottles found on a resident's nightstand, and documentation issues regarding resident notification of charges and receipt of the resident handbook.
Deficiencies (7)
Resident #1 - Medication bottle prescription label and medication administration record (MAR) do not match for Escitalopram Oxalate Oral Tablet.
Resident #1 - Medication bottle prescription label and MAR do not match for Levothyroxine Sodium Oral Tablet.
Resident #1 - MAR does not match medication order for Ipratropium Bromide Nasal Solution.
Resident #5 - Medication bottles found unsecured on resident's nightstand.
Resident #4 - Documented evidence shows resident received notification of charges after admission on 8/7/20.
Resident #4 - Documented evidence shows resident received a copy of the resident handbook after admission on 8/7/20.
Resident #4 - Documented evidence shows resident received notification of rights and responsibilities after admission on 8/7/20.
Report Facts
Admission date: Aug 6, 2020
Admission notification date: Aug 7, 2020
Deficiency correction dates: Mar 17, 2023
Staff training date: Mar 28, 2023
Staff training date: Mar 28, 2023
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 14, 2022
Visit Reason
The inspection was conducted as the annual survey for the facility 15 Craigside to assess compliance with state regulations.
Findings
The inspection identified deficiencies related to the development and documentation of initial service plans for residents and the lack of documented evidence of an initial 2-step tuberculosis clearance for a resident. Plans of correction and future plans were provided to address these deficiencies.
Deficiencies (2)
No documented evidence the initial comprehensive assessment and service plan were completed and developed prior to admission for Resident #1 and Resident #2.
No documented evidence of an initial 2-step tuberculosis clearance for Resident #3.
Report Facts
Deficiency correction completion date: Mar 14, 2022
Future plan start date: Mar 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keleka Hovakawa | Licensee/Administrator | Signed the plan of correction documents |
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