Inspection Report
Annual Inspection
Deficiencies: 17
May 1, 2025
Visit Reason
Annual inspection of Aiea Heights Senior Living facility conducted to assess compliance with state licensing regulations and standards.
Findings
Multiple deficiencies were identified including incomplete resident inventories, medication labeling and storage issues, incomplete medication orders, missing documentation such as current inventories and progress notes, lack of documented notifications to physicians, missing annual dental exams, incomplete care plans, and missing resident rights documentation. Several deficiencies require future plans of correction.
Deficiencies (17)
| Description |
|---|
| Resident #2 – Geri-Chair was not recorded at readmission on inventory log |
| Resident #1 – Unlabeled tube of triple antibiotic stored in bedroom closet |
| Resident #2 – Tube of triple antibiotic and bottle of nystatin powder stored unsecured in bedroom closet |
| Resident #1 – Physician’s order dated 2/14/25 incomplete; PRN indication unavailable |
| Resident #1 – Medication unavailable for administration as ordered |
| Resident #1 – Medication orders renewed and discontinued on same day without clarification |
| Resident #1 – Current inventory of possessions unavailable; last completed 4/2024 |
| Resident #1 – Monthly summary for 7/2024 lacked observations related to diet intolerance |
| Resident #1 – Progress notes for 8/2024 and 11/2024 lacked response to medications |
| Resident #1 – Progress notes lacked observations on response to Glucerna supplement and fluid restriction; Resident #2 lacked observations on tolerance to Boost supplement |
| Resident #1 – White out used on faxed physician order sheet dated 3/20/25 |
| Resident #1 – Physician’s order to notify MD if SBP >150 not documented as notified for multiple elevated readings |
| Resident #1 – Annual dental exam unavailable |
| Resident #2 – No documented evidence resident was informed verbally and in writing of services and charges at admission |
| Resident #1, Bedrooms #9 & #10 – Protective pillow cases or initials on pillows unavailable |
| Resident #1 – Evidence of current pneumococcal vaccination unavailable |
| Resident #1 – Nutritional management care plan did not specify measurable goals and outcomes for weight |
Report Facts
Elevated systolic blood pressure readings: 15
Plan of correction submission timeframe: 10
Inspection Report
Annual Inspection
Deficiencies: 11
May 3, 2024
Visit Reason
The inspection was conducted as the facility's annual survey to assess compliance with state licensing regulations.
Findings
Multiple deficiencies were identified related to medication storage, medication administration, record keeping, fire drill documentation, and case management. The facility submitted plans of correction with future plans to address each deficiency.
Deficiencies (11)
| Description |
|---|
| Medications stored unsecured in refrigerated medication box |
| Resident #1 medications scheduled for administration were not administered per medication administration record (MAR) |
| Physician's order for catheter site care not followed on specified dates |
| Monthly progress notes did not include resident's response to medications |
| No documented evidence of follow-up with resident's physician regarding dietitian's advisement |
| White out used on resident's urine output log |
| Fire drills performed did not include duration of time |
| No documented evidence personalized and specialized training was provided by case manager |
| Resident #1 care plan did not reflect physician's orders for restraints |
| Resident #1 current medication orders not reflected in care plan for specific medications |
| Case management services not provided as required for Resident #2 |
Report Facts
Deficiency completion dates: May 9, 2024
Future plan completion dates: Jun 25, 2024
Inspection Report
Annual Inspection
Deficiencies: 23
May 30, 2023
Visit Reason
Annual inspection of Aiea Heights Senior Living facility conducted from May 30 to June 1, 2023 to assess compliance with state licensing regulations.
Findings
Multiple deficiencies were identified related to personnel certifications, medication orders and administration, resident records, care plans, and staff training. Several medication orders and medication administration records did not match, care plans lacked measurable goals and updates, and required staff certifications and training were incomplete or undocumented.
Deficiencies (23)
| Description |
|---|
| Substitute Care Giver (SCG) #1 had no annual tuberculosis clearance. |
| SCG #2 had no current first aid certification. |
| SCG #2 had no current cardiopulmonary resuscitation certification; certification was obtained online only. |
| Medication order and medication administration record (MAR) for Refresh eye drops did not match for Resident #2. |
| No documented evidence of medication order for skin protectants applied to Resident #2. |
| Medication order and MAR for Milk of Magnesia did not match for Resident #2. |
| Refresh eye drops ordered for Resident #2 did not appear on August 2022 MAR. |
| Medications for Resident #2 were not reevaluated and signed every four months as required. |
| Medication administration record for Desitin was not initialed timely for Resident #2. |
| Admission assessment for Resident #2 was completed 10 days after admission. |
| Progress notes did not include observations on residents' responses to nutritional supplements for Residents #1 and #2. |
| Progress notes did not include observations on Resident #1's response to fluid restrictions. |
| No documented evidence that fluid restriction orders were followed for Resident #2. |
| No documented evidence that facility followed up on diet liberalization advisement for Resident #1. |
| Standing orders for Acetaminophen, Dulcolax, and Fleets Enema were not included on MARs for Resident #2. |
| Care plan for Resident #1 was inaccurate regarding April 2023 weight. |
| No documented evidence that Consultant Registered Dietitian provided special diet training for food preparation staff. |
| SCG #1 completed only 10.5 of 12 required continuing education hours in the last year. |
| No comprehensive signed list of medications available upon admission for Resident #1. |
| No documented evidence of annual flu vaccine for Resident #1. |
| Alteration in Nutrition and Hydration care plan for Resident #1 did not include measurable goals and outcomes for weight. |
| Alteration in Nutrition and Hydration care plan for Resident #1 was not updated to reflect current diet order. |
| At Risk for Aspiration care plan for Resident #1 was not updated to reflect current diet order; texture of food solids not included. |
Report Facts
Continuing education hours completed: 10.5
Medication order date: Jul 19, 2022
Admission date: Jul 19, 2022
Admission assessment date: Jul 29, 2022
Weight: 115
Weight: 133
Inspection Report
Annual Inspection
Deficiencies: 10
Jun 15, 2022
Visit Reason
The inspection was conducted as the facility's annual survey to assess compliance with regulatory requirements for personnel, staffing, medications, records, and other care standards.
Findings
The inspection identified multiple deficiencies including lack of documentation for annual physical exams and tuberculosis clearances, medication labeling and administration issues, incomplete progress notes, unavailable medication orders for review, and insufficient continuing education hours for staff.
Deficiencies (10)
| Description |
|---|
| No documentation of current annual physical exam. |
| No initial tuberculosis clearance; only 2nd step skin test result available. |
| No annual tuberculosis clearance; last available skin test from 4/14/2021. |
| Medication label did not include 'as needed' status for Furosemide; 'Directions Changed' sticker placed on blister pack during inspection. |
| Medication order for Metoprolol Succinate ER 25 mg discontinued on 7/13/2021 but appeared on medication lists after that date without documented physician clarification. |
| Medications not reevaluated and signed by a physician or APRN every four months as required. |
| No annual tuberculosis clearance for Resident #2; last documented skin test from April 2021. |
| Monthly progress notes do not include observations of the resident’s response to medications. |
| Medication orders not readily available for review. |
| Primary and substitute care givers completed only 3 of 12 required hours of continuing education within the last year. |
Report Facts
Continuing education hours completed: 3
Medication reevaluation interval: 4
Date of last tuberculosis skin test: Apr 14, 2021
Medication discontinuation date: Jul 13, 2021
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