Inspection Reports for
Hale Malamalama
6163 Summer St, Honolulu, HI 96821, HI, 96821
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
33% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 31, 2025
Visit Reason
The inspection was conducted in response to anonymous reports and allegations of physical and psychological abuse, neglect, and failure to provide necessary care to residents, including specific complaints about mistreatment and neglect of toileting assistance.
Complaint Details
The complaint investigation was triggered by anonymous reports of physical and psychological abuse and neglect involving two residents. The investigation found verbal abuse and neglect substantiated for one resident, failure to report allegations timely, inadequate investigations, and failure to provide proper incontinence care to two residents.
Findings
The facility failed to protect a resident from verbal abuse and neglect, failed to timely report abuse allegations to authorities, failed to conduct thorough investigations, and failed to update care plans timely. Additionally, the facility did not provide adequate incontinence care to two residents, failing to check and document incontinence care every two hours as required.
Deficiencies (5)
F 0600: The facility failed to protect one resident from verbal abuse and neglect by staff, resulting in mental anguish and emotional harm.
F 0609: The facility failed to timely report suspected abuse and neglect allegations to the Office of Healthcare Assurance and failed to notify the Administrator promptly.
F 0610: The facility failed to conduct thorough investigations of abuse and neglect allegations and failed to immediately remove alleged perpetrators.
F 0657: The facility failed to timely update a resident's care plan to reflect increased assistance needs for toileting and transfers, risking unsafe care.
F 0684: The facility failed to provide appropriate incontinence care and failed to check and document incontinence care every two hours for two residents, risking skin breakdown and other complications.
Report Facts
Residents affected: 2
Staff suspended: 3
BIMS score: 14
Care plan revision dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA2 | Certified Nursing Assistant | Named in verbal abuse and neglect findings for resident R1. |
| SW1 | Social Worker | Conducted interviews and investigation related to abuse allegations. |
| DON | Director of Nursing | Involved in investigation and reporting of abuse allegations. |
| ADM | Administrator | Notified late about abuse allegations and relied on SW1 for investigation findings. |
| RN3 | Registered Nurse | Provided nursing behavior notes related to resident R1. |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, medication storage, housekeeping, and quality assurance at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during feeding assistance, inadequate maintenance of resident care equipment, failure to revise care plans after falls, unlocked medication carts, lack of an annual performance improvement project, and unsafe housekeeping practices involving chemical use around residents.
Deficiencies (6)
F 0550: The facility failed to treat one resident with respect and dignity during meal assistance by allowing a CNA to sit on the resident's bed instead of at eye level.
F 0584: Resident care equipment was not maintained and stored properly, staff noise at night disrupted residents' sleep, and the dining room temperature was too cold at night.
F 0657: The facility failed to revise a resident's care plan after a fall with injury, placing the resident at risk for future falls.
F 0761: Medication carts were left unattended and unlocked, risking unsafe medication administration and diversion.
F 0867: The facility failed to create an annual Performance Improvement Project focusing on high risk areas identified through data analysis.
F 0921: Housekeeping staff sprayed toxic chemical disinfectants on dining tables while residents were seated, risking chemical exposure and illness.
Report Facts
Residents sampled: 13
Residents in facility: 34
Fall date: Jul 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding feeding assistance, equipment maintenance, care plan revision, medication cart security, and resident complaints |
| RN4 | Registered Nurse | Observed administering medications and confirmed medication cart should be locked |
| RN5 | Registered Nurse | Observed near medication cart during medication administration |
| HKS | Housekeeping Supervisor | Interviewed about chemical use and staff monitoring in dining area |
| CNA7 | Certified Nurse Aid | Observed assisting resident with feeding improperly by sitting on bed |
| CNA15 | Certified Nurse Aid | Observed assisting resident with feeding while standing |
Inspection Report
Routine
Deficiencies: 22
Date: Sep 15, 2023
Visit Reason
Routine inspection of Hale Malamalama nursing home to assess compliance with regulatory requirements including resident rights, care planning, medication management, environment safety, infection control, and facility administration.
Findings
The facility had multiple deficiencies including failure to inform residents about psychotropic medication risks, lack of resident council and grievance system, incomplete care plans, inadequate discharge planning and documentation, improper pain management, unsafe environment conditions, ineffective infection control practices, and lack of staff competency evaluations.
Deficiencies (22)
F 0552: The facility failed to inform three residents or their representatives about the risks and benefits of psychotropic medications and alternative treatments prior to administration.
F 0565: The facility failed to ensure residents exercised their right to organize and participate in a resident group due to lack of resident council president and no formal meetings.
F 0578: The facility failed to ensure one resident was able to fulfill her right to make choices about medical treatment by completing an Advance Health Care Directive.
F 0582: The facility failed to provide timely Notice of Medicare Non-Coverage to one resident and did not document notification to the resident's representative.
F 0584: The facility failed to provide a safe, clean, and comfortable environment as evidenced by a damaged closet shelf and inconsistent hot water temperature.
F 0585: The facility failed to implement a grievance system assuring residents' right to file grievances, lacking grievance officer and grievance documentation.
F 0622: The facility failed to ensure a complete medical summary was sent to receiving providers for one resident's transfer, omitting pertinent clinical information.
F 0655: The facility failed to develop and implement baseline care plans within 48 hours for two residents, omitting interventions for psychotropic medication use.
F 0657: The facility failed to involve and notify resident representatives of scheduled care plan meetings and failed to revise care plans after resident falls.
F 0660: The facility failed to assure discharge planning was done prior to one resident's discharge, lacking documentation of resident-initiated discharge and post-discharge needs assessment.
F 0661: The facility failed to ensure discharge summary included a recapitulation of the resident's stay and course of treatment for one discharged resident.
F 0684: The facility failed to provide appropriate care for a resident allergic to iodine by using alcohol pads for catheter insertion without an alternative cleansing order.
F 0689: The facility failed to ensure one resident was free from accidents by not performing root cause analysis or documenting fall prevention interventions after two falls.
F 0697: The facility failed to provide safe, appropriate pain management for one resident, lacking staff awareness of prn pain medication orders and inconsistent administration.
F 0730: The facility failed to observe nurse aide job performance and provide regular competency training or documented evaluations.
F 0812: The facility failed to provide safe food storage with unlabeled foods and lacked a process to ensure proper operation and monitoring of the dishwasher chemical sanitation system.
F 0835: The facility's nursing administration failed to develop and maintain systems supporting residents' rights, grievance processes, visitor policies, dishwashing monitoring, and nurse aide competency evaluations.
F 0837: The facility's governing body did not effectively oversee the Administrator's management and operations of the facility.
F 0865: The facility failed to develop and maintain an effective Quality Assurance and Performance Improvement program with data-driven monitoring and root cause analysis.
F 0880: The facility failed to maintain an infection prevention and control program including annual policy review, surveillance of hand hygiene and wound care, water management, and proper wound dressing technique.
F 0883: The facility failed to assure pneumococcal vaccination was provided or documented for two residents despite consent.
F 0919: The facility failed to provide accessible call light systems in resident bathrooms and shower rooms, risking resident safety in emergencies.
Report Facts
Falls: 2
Pain level: 9
Morse Fall Scale scores: 90
Morse Fall Scale scores: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in wound dressing technique deficiency. |
| LPN1 | Licensed Practical Nurse | Named in pain management deficiency. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including consent, care plans, pain management, and falls. |
| Social Worker | Social Worker | Interviewed regarding grievance system and resident council. |
| Administrator | Administrator | Interviewed regarding grievance system, governing body, and facility management. |
| Assistant Administrator | Assistant Administrator | Interviewed regarding grievance system and call light system. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding food storage and dishwasher system. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding dishwasher system. |
| Infection Control Coordinator | Infection Control Coordinator | Interviewed regarding infection control program and vaccination. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 15, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging the facility was not allowing visitors due to identification of COVID-19 cases.
Complaint Details
The complaint alleged the facility was not allowing visitors due to COVID-19 cases identified in the facility. The complaint was substantiated based on signage and interviews confirming visitor restrictions despite CMS waivers not being in effect.
Findings
The facility failed to ensure residents had the right to receive visitors during a COVID-19 outbreak period in late 2022. The Infection Control Coordinator confirmed the outbreak dates and that visitor restrictions were not officially mandated by CMS at that time.
Deficiencies (1)
F 0563: Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. The facility failed to ensure residents had the right to receive visitors during a COVID-19 outbreak in November-December 2022.
Report Facts
Date of outbreak start: Nov 10, 2022
Date of outbreak end: Dec 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Control Coordinator | Interviewed regarding visitor restrictions and outbreak dates |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 6, 2022
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident care, environment, staff competencies, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, improper use of resident rooms for storage, incomplete care plans for contractures, inadequate nursing care for positioning and post-fall neurological checks, failure to provide consistent passive range of motion exercises, employment of uncertified nursing assistants without proper training, improper use of feeding assistants, and lapses in infection control practices during meal preparation.
Deficiencies (9)
F 0550: The facility failed to ensure a dependent resident was dressed in a manner to maintain dignity, specifically Resident #14 was observed wearing socks on hands without documented planned intervention.
F 0584: The facility failed to provide a homelike environment by using a shared resident room for storage of supplies and equipment affecting Residents #9, #22, and #24.
F 0656: The facility failed to develop a care plan addressing hand contractures for Resident #28, potentially affecting 11 residents with contractures.
F 0684: The facility failed to provide appropriate nursing care for Resident #2 and Resident #24, including failure to promptly reposition Resident #2 and failure to conduct consistent neurological checks after Resident #24's unwitnessed fall.
F 0688: The facility failed to provide care to prevent further decline in range of motion for Residents #14 and #28, including failure to regularly provide passive range of motion exercises and to identify contractures timely.
F 0728: The facility failed to ensure a nursing assistant employed full-time completed required competency certification within four months of hire.
F 0811: The facility failed to ensure a paid feeding assistant provided dining assistance only to residents without complicated feeding problems, affecting Residents #24 and #30.
F 0835: The facility's nursing administration failed to ensure processes were in place to promptly identify resident-specific care needs including contracture management and feeding assistance.
F 0880: The facility failed to ensure staff implemented appropriate infection control practices during meal preparation, including handling straws and chopsticks with bare hands.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 11
Residents affected: 2
Residents affected: 2
Nursing assistant reviewed: 1
Residents affected: 2
Meals observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Full-time employee not certified within required timeframe |
| AA #1 | Activity Aide / Temporary Feeding Assistant | Provided feeding assistance without resident selection process |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including contracture care, feeding assistant use, and infection control |
| RN #1 | Registered Nurse | Observed handling straws improperly and interviewed regarding neurological checks |
| CNA #1 | Certified Nursing Assistant | Observed handling chopsticks and straws improperly |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding resident repositioning and contracture care |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding ROM exercises and reporting stiffness |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding resident dignity and repositioning |
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