Inspection Reports for Acedo, Melba
2501 Kinoole St, Hilo, HI 96720, USA, HI, 96720
Back to Facility ProfileDeficiencies per Year
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Unclassified
Inspection Report
Plan of Correction
Deficiencies: 5
Dec 19, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility Acedo, Melba (ARCH) following an inspection conducted on December 19, 2024.
Findings
The report identifies multiple deficiencies related to medication labeling discrepancies, lack of documented physician orders for medications, incomplete records and reports including missing explanations for abbreviations on MARs, incomplete Plan of Care documentation, and improper use of white out on resident records. Each deficiency includes a plan of correction with future prevention strategies.
Deficiencies (5)
| Description |
|---|
| Physician order and medication label for Mycophenolate Mofetil 500 mg PO BID do not match. |
| No documented evidence of a physician order for Amoxicillin-Clav 875-125 mg 1 tab every 12 hours for 10 days; medication label was placed in the November 2024 MAR but no physician order was available. |
| Legend was not provided to explain the symbols and abbreviations on MARs from October 2024 to December 2024; repeat deficiency from 2023 annual inspection. |
| Primary care giver (PCG) Plan of Care was incomplete and not readily available for review by the department. |
| White out was used on pages 9 and 10 in the Signed Policy and Procedure/Rights and in the October 2024 MAR; repeat deficiency from 2023 annual inspection. |
Report Facts
Completion Date: Mar 10, 2025
Medication Dosage: 500
Medication Dosage: 875
Medication Dosage: 125
Medication Frequency: 12
Medication Duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dr. Tran | Mentioned in relation to correcting medication label discrepancy for Mycophenolate Mofetil. | |
| Melba Suero Daak | Licensee/Administrator | Signed the plan of correction document dated March 10, 2025. |
Inspection Report
Annual Inspection
Deficiencies: 4
Dec 21, 2023
Visit Reason
The inspection was conducted as an annual licensing inspection to ensure the facility meets all regulatory requirements under Chapter 100.1.
Findings
The inspection identified deficiencies related to licensing documentation for substitute caregivers, progress notes not reflecting medication response, missing legend for symbols on medication administration records, and improper use of white-out in resident records. Plans of correction were submitted addressing these issues.
Deficiencies (4)
| Description |
|---|
| Substitute Caregiver (SCG) - No current documented evidence stating caregiver has no prior felony or abuse convictions in a court of law. |
| Resident #1 - Progress note did not reflect the need and response to Colace 100 mg PRN given daily as reflected on medication administration records (MAR) from December 2022 to December 2023. |
| Resident #1 - Legend was not provided to explain the symbols and abbreviations on MARs from December 2022 to December 2023. |
| Resident #1 and Resident #2 - White out was used in January, February, and March 2023 progress notes and Plan of Activities sheet. |
Report Facts
Medication administration records timeframe: 12
Progress notes timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melba Acedo | Licensee/Administrator | Signed plan of correction and responses to deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 5, 2022
Visit Reason
The inspection was conducted as an annual licensing inspection to verify compliance with licensing requirements for the facility.
Findings
The inspection found deficiencies related to the lack of fingerprint background checks for substitute care givers and medication documentation errors for Resident #1, including incorrect medication labeling and incomplete medication record initials.
Deficiencies (2)
| Description |
|---|
| Substitute care giver (SCG) #1 and SCG #2 had no fingerprint background check. |
| Resident #1 medication order discrepancy: physician order indicated PRN for stool softener but medication record read BID; also, medication record for Metoprolol was not initialed for several days. |
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