Inspection Reports for Aloha Nursing and Rehab Center
45-545 Kamehameha Hwy, Kaneohe, HI 96744, HI, 96744
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Aug 1, 2025
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements and ensure resident safety and quality of care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal assistance, delayed baseline care plan development, inadequate care for residents with limited range of motion, insufficient fall prevention measures, failure to prevent dehydration, lack of trauma-informed care protocols, improper medication and wound care supply storage and labeling, food safety violations, incomplete hospice documentation, and lapses in infection prevention and control practices.
Deficiencies (10)
Failed to promote care that maintains dignity for residents requiring meal assistance, including not sitting while feeding and rushing the resident.
Failed to discuss and complete baseline care plan within 48 hours of admission for a resident.
Failed to provide appropriate care to maintain or improve range of motion for a resident, including missing left knee splint and incomplete documentation.
Failed to implement interventions to prevent avoidable falls for a resident with multiple falls and injury.
Failed to provide adequate fluids to prevent dehydration for a resident at risk.
Failed to have protocol to identify past trauma for residents with PTSD, hindering trauma-informed care.
Failed to ensure medications and wound care supplies were properly labeled and stored in locked compartments.
Failed to monitor dishwasher sanitizing temperatures consistently, label open food items properly, and discard food past use-by dates.
Failed to maintain current hospice certification and interdisciplinary group assessment in resident's hospice records.
Failed to implement infection prevention and control measures including improper PPE use, failure to perform hand hygiene and glove changes during wound care, and improper urinary catheter bag placement.
Report Facts
Fall incidents: 5
Fluid intake range: 1615
Fluid intake range: 1940
BIMS score: 99
BIMS score: 3
BIMS score: 1
Medication doses: 2
Medication doses: 2
Dishwasher temperature checks missed: 15
Food use-by dates missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA41 | Certified Nurse Aide | Named in meal assistance deficiency for not sitting while feeding Resident R57. |
| RN66 | Registered Nurse | Confirmed proper meal assistance procedures and PPE requirements. |
| DON | Director of Nursing | Provided multiple confirmations regarding care plan delays, hospice documentation, PPE use, and food safety. |
| CNA80 | Certified Nurse Aide | Involved in care for Resident R2 with missing knee splint and positioning device. |
| PT1 | Physical Therapist | Confirmed missing left knee splint for Resident R2. |
| CNA18 | Certified Nurse Aide | Assigned to Resident R2, unsure how to apply positioning cushion. |
| RCC2 | Resident Care Coordinator | Confirmed missing equipment and improper documentation for Resident R2. |
| RN75 | Registered Nurse | Observed leaving medication cup unattended and confirmed labeling/storage issues. |
| RN15 | Registered Nurse | Observed missing discard dates on eye drops and expired glucometer control solutions. |
| KS1 | Kitchen Staff | Confirmed missed dishwasher sanitizing temperature documentation. |
| KS2 | Kitchen Staff | Confirmed missed dishwasher sanitizing temperature documentation. |
| DM | Dietary Manager | Confirmed food safety and dishwasher sanitizing deficiencies. |
| RN127 | Registered Nurse | Observed not changing gloves or performing hand hygiene during wound care. |
| UM2 | Unit Manager | Confirmed hand hygiene requirements during wound care. |
| IP nurse | Infection Preventionist | Confirmed infection control deficiencies and PPE requirements. |
| CNA57 | Certified Nurse Aide | Observed not wearing N95 mask exiting COVID positive resident room. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly identify and plan for a resident's predictable condition decline and to make timely revisions to comprehensive care plans for multiple residents.
Complaint Details
The complaint involved concerns about nursing care and failure to update care plans to reflect resident needs and preferences. The investigation found deficiencies in care planning and communication regarding condition changes.
Findings
The facility failed to timely notify the physician and plan for a resident's significant condition change, resulting in potential delay in transfer to higher care. Additionally, the facility did not revise care plans to reflect current orders and interventions for four residents, including inaccurate documentation of feeding needs, oxygen orders, fall prevention, and wound care.
Deficiencies (2)
Failure to identify and plan in advance for a resident's predictable condition decline and timely notify physician of condition changes.
Failure to make timely revisions to comprehensive person-centered care plans for four residents to reflect current orders and interventions.
Report Facts
Residents sampled: 6
Residents affected: 4
Date of resident R4 hospital transfer: Mar 3, 2025
Date of resident R4 death: Apr 7, 2025
Oxygen liters per minute: 3
Fall report number: 1160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD1 | Physician | Provided medical orders and discussed care decisions with resident R4's POA |
| RN1 | Registered Nurse | Provided care to resident R4 and communicated with POA and EMS |
| House Supervisor | Assessed resident R4 and coordinated emergency response | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan revisions and facility response |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 3, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding residents being fully informed and understanding their health status, care, and treatments, specifically focusing on psychotropic medication education and consent.
Findings
The facility failed to ensure that two of three sampled residents (R4 and R11) were informed in advance of the risks and benefits of psychotropic medication therapy. Documentation and education regarding the use and risks of prescribed medications Lexapro, Ativan, and Citalopram were not present in the residents' records.
Deficiencies (1)
Failure to ensure residents were informed in advance of the risks and benefits of psychotropic medication therapy for residents R4 and R11.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed the facility did not inform residents or their representatives of the risks versus benefits of psychotropic medications. |
Inspection Report
Routine
Capacity: 141
Deficiencies: 13
Date: Aug 9, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing homes, including resident rights, care planning, medication management, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, incomplete and untimely care plans, late submission of Minimum Data Set (MDS) data, inadequate discharge planning, improper medication administration practices, failure to prevent urinary tract infections, improper food storage and handling, incomplete pharmacist medication regimen reviews, and inadequate infection prevention and control practices.
Deficiencies (13)
Failed to ensure residents' right to formulate an Advanced Health Care Directive (AHCD) for three residents.
Failed to electronically transmit and complete the Minimum Data Set (MDS) data within 14 days for one resident.
Failed to develop and implement a comprehensive person-centered care plan for three residents, including monitoring blood thinner effects, PICC line care, and skin condition.
Failed to revise the comprehensive person-centered care plan within 7 days of assessment for one resident.
Failed to ensure one resident was free of accidents and failed to develop a discharge plan ensuring safe discharge; resident had multiple falls and was discharged without adequate supervision.
Failed to provide appropriate services to prevent urinary tract infections for one resident with a urinary catheter; catheter tubing was observed dragging on the floor.
Failed to ensure staff implemented competencies necessary for resident safety; resident left unattended with medications and medication administration record marked prior to administration.
Failed to maintain accurate and reconciled controlled substance drug records; missing nurse signature on controlled substance count.
Failed to accommodate a resident's vegetarian diet preference; resident was served meat-containing foods multiple times.
Failed to store food safely and maintain sanitary cooking area; nourishment refrigerators had unsafe temperatures above 41 degrees and opened foods were not labeled with discard dates.
Failed to review and act upon pharmacist's recommendations on monthly Medication Regimen Review for one resident; lab tests recommended were not completed.
Failed to include staffing levels required to meet resident needs in the facility-wide assessment.
Failed to implement infection prevention and control measures; staff did not wear gowns, failed hand hygiene between glove changes, and placed clean supplies on unclean surfaces during IV medication administration.
Report Facts
Licensed capacity: 141
Resident falls: 4
MDS late submission days: 14
Medication tablets: 10
Temperature: 58
Temperature: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Manager (SSM)8 | Social Services Manager | Interviewed regarding AHCD and care planning for residents R151, R87, and R97 |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding care plans, MDS submission, medication administration, and staffing |
| Registered Nurse (RN)39 | Registered Nurse | Observed leaving resident R34 unattended with medications and marking MAR prior to administration |
| Registered Nurse (RN)17 | Registered Nurse | Observed administering IV antibiotic to resident R250 without proper PPE and hand hygiene |
| Physical Therapist (PT)15 | Physical Therapist | Interviewed regarding resident R150's functional status at discharge |
| Registered Nurse (RN)7 | Registered Nurse | Observed signing controlled substance count late |
| Social Services Assistant (SSA)2 | Social Services Assistant | Involved in discharge planning and family communication for resident R150 |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed regarding infection control practices |
| Executive Director (ED) | Executive Director | Interviewed regarding resident R300's diet preference and kitchen errors |
| Minimum Data Set Coordinator (MDSC)1 | MDS Coordinator | Interviewed regarding MDS submission for resident R87 |
| Maintenance (M)5 | Maintenance Staff | Interviewed regarding refrigerator temperatures and logs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 9, 2024
Visit Reason
The inspection was conducted following a complaint (Aspen Complaint Tracking System intake #10993) regarding multiple falls of resident R150 during her stay and concerns about an unsafe discharge plan that did not ensure adequate home supervision.
Complaint Details
The complaint documented multiple falls of resident R150 and discharge home without supervision or family support in an unsafe environment. The family reported lack of assistance with Medicaid paperwork and withheld information about appeal rights. The Administrator threatened to call adult protective services when the family refused to take the resident home due to safety concerns.
Findings
The facility failed to ensure resident R150 was free from accidents, as she experienced multiple falls during her stay. The discharge plan was inadequate, resulting in the resident being discharged home without proper supervision or family support, increasing her risk of injury. The care plan was not timely updated after falls, and discharge planning did not consider the resident's safety needs.
Deficiencies (1)
Failed to ensure resident R150 was free of accidents during stay and failed to develop a discharge plan ensuring safe discharge.
Report Facts
Falls: 4
Morse Fall Scale score: 80
Assessment Reference Date: Apr 9, 2024
Discharge date: May 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSA2 | Social Services Assistant | Involved in discharge planning and communication with family; failed to assist with Medicaid paperwork and discharge process. |
| PT15 | Physical Therapist | Provided discharge summary and stated resident needed supervision 24/7 at home. |
| Director of Nursing | Director of Nursing | Interviewed regarding number of falls and care plan updates; confirmed care plan was not timely updated. |
| SSM8 | Social Services Manager | Interviewed about discharge process and resident's insurance coverage; confirmed resident was covered under employer plan, not Medicare. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 6, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to immediately notify a physician of a resident's change in condition, failure to provide appropriate respiratory care, failure to ensure physician response to emergency calls, and failure of nursing staff competency in caring for residents.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to failure to notify the physician of a resident's change in condition, failure to provide appropriate respiratory care, failure to ensure physician availability for emergencies, and nursing staff competency issues. The resident (R1) suffered harm including a fall and subsequent death from a subdural hematoma. Another resident (R2) was at increased risk due to improper oxygen administration.
Findings
The facility failed to immediately notify the physician of a resident's significant change in condition, failed to provide complete and appropriate oxygen therapy orders, and failed to ensure physician response to emergency calls. Nursing staff lacked competency in monitoring and responding to residents' needs, resulting in harm to residents including a fall and subsequent death of one resident and increased risk to another due to improper oxygen administration.
Deficiencies (4)
Failure to immediately notify the resident's physician and family of a significant change in condition and subsequent hospital transfer.
Failure to provide safe and appropriate respiratory care, including incomplete oxygen therapy orders and oxygen administration outside physician orders.
Failure to ensure physician response to emergency calls and lack of a system to reach a physician 24/7.
Failure of nursing staff to demonstrate competency in caring for residents, including failure to notify physician timely, monitor condition, and follow oxygen weaning orders.
Report Facts
Oxygen saturation readings: 69
Blood pressure readings: 85
Oxygen flow rate: 1
Oxygen saturation readings: 88
Date of survey completion: Oct 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in findings for failure to notify physician timely, failure to monitor resident condition, and failure to follow nursing standards. |
| MD1 | Medical Director and Resident Physician | Named in findings for failure to respond to nursing staff calls regarding resident's change in condition. |
| RN2 | Registered Nurse | Interviewed regarding oxygen therapy orders and facility protocol. |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen therapy protocol and facility citations. |
Inspection Report
Routine
Deficiencies: 10
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication self-administration, care plan development, resident transfers, nutrition, respiratory care, medication regimen review, medication storage, food safety, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity, lack of documented interdisciplinary assessment for medication self-administration, failure to send comprehensive care plans during resident transfers, incomplete and non-personalized care plans, failure to provide diet texture as ordered, incomplete physician orders for oxygen therapy, failure to communicate pharmacist recommendations to physicians, unlocked medication carts, unlabeled opened food items, and incomplete COVID-19 visitor screening.
Deficiencies (10)
Failed to treat one resident with dignity and respect, leaving him partially undressed and exposed.
Failed to document interdisciplinary assessment and care plan for resident self-administration of medication.
Failed to provide comprehensive care plan goals to receiving providers during resident transfers.
Failed to develop and implement comprehensive, person-centered care plans for residents.
Failed to maintain nutrition status by not providing diet texture as ordered for a resident.
Failed to provide safe and appropriate respiratory care due to incomplete physician oxygen orders.
Failed to communicate pharmacist medication recommendations to attending physician.
Failed to ensure medication carts were locked, risking medication diversion.
Failed to label opened food items with dates to prevent serving expired items.
Failed to completely screen visitors, guests, and vendors for COVID-19 symptoms and enforce mask use.
Report Facts
Medication Regimen Review recommendations not communicated: 2
Resident meal consumption: 51
Oxygen flow rate: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN11 | Registered Nurse | Interviewed regarding resident R56's self-administration of eye drops. |
| RN12 | Registered Nurse | Interviewed about assessment process for resident self-administration of medications. |
| UM2 | Unit Manager | Confirmed lack of formal assessment and care plan for resident R56's medication self-administration. |
| CNA44 | Certified Nurse's Aide | Interviewed regarding resident R46's clothing during observations. |
| SW1 | Social Worker | Provided Notice of Transfer/Discharge documents and described document transmission process. |
| DON | Director of Nursing | Interviewed about transfer documentation, medication communication, and medication cart locking. |
| UM1 | Unit Manager | Interviewed about care plan for resident R34's contractures and oxygen therapy for resident R64. |
| RD | Registered Dietitian | Interviewed about diet texture requirements and nutritional risks for resident R26. |
| KM | Kitchen Manager | Interviewed about food preparation and labeling practices. |
| LPN1 | Licensed Practical Nurse | Interviewed after medication cart was found unlocked. |
| IP | Infection Preventionist | Interviewed about COVID-19 screening and mask policies. |
| COO | Chief Operations Officer | Acknowledged deficiencies in COVID-19 screening verification. |
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