Inspection Reports for
Hi’olani Assisted Living Center at Kahala Nui
4389 Malia St, Honolulu, HI 96821, HI, 96821
Back to Facility Profile3 Reports
Inspection Report — Jun 27, 2024
Routine
Date: Jun 27, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and medical record maintenance at Hi'Olani Care Center at Kahala Nui.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of resident transfers, incomplete implementation of care plans, failure to follow physician orders for bowel regimens, inadequate pharmaceutical record keeping, incomplete medication regimen reviews, unsafe food handling and storage practices, incomplete resident medical records, and improper infection control related to oxygen humidifier equipment.
Deficiencies (8)
F 0623: The facility failed to provide written notification to the resident's representative and Long-Term Care Ombudsman before transfer or discharge for one sampled resident.
F 0656: The facility failed to implement a comprehensive person-centered care plan for one sampled resident, missing weekly weight monitoring as required.
F 0684: The facility failed to follow physician ordered bowel regimen instructions for one sampled resident, administering medications despite documented loose stools.
F 0755: The facility failed to maintain complete and accurate controlled drug count records for two medication carts, missing licensed nurse signatures.
F 0756: The facility failed to ensure the attending physician reviewed and addressed pharmacist's monthly medication review irregularities for one sampled resident.
F 0812: The facility failed to properly dispose of expired food, store food according to standards, test all food temperatures on the trayline, and maintain clean kitchen equipment.
F 0842: The facility failed to maintain complete medical records for two sampled residents, including missing hospice progress notes and incomplete weight documentation.
F 0880: The facility failed to provide a safe and sanitary environment by not properly securing a resident's oxygen humidifier bottle, risking infection.
Report Facts
Residents sampled: 16
Medication carts sampled: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 10 | Registered Nurse | Edited resident weight documentation as a late entry |
| RN 5 | Registered Nurse | Confirmed medication regimen review irregularity and medication administration issues |
| DON | Director of Nursing | Provided multiple interviews confirming deficiencies and facility practices |
| ADON | Assistant Director of Nursing | Interviewed regarding medication administration and hospice documentation |
| LPN 4 | Licensed Practical Nurse | Interviewed about bowel movement documentation and medication administration |
| NE/IP | Nurse Educator/Infection Preventionist | Interviewed regarding infection control deficiency with oxygen humidifier |
Inspection Report — Aug 10, 2023
Routine
Date: Aug 10, 2023
Visit Reason
Routine inspection of Hi'Olani Care Center at Kahala Nui to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including confidentiality of resident medical information, environmental maintenance, implementation of care protocols, fall prevention, hydration, medication administration, staffing documentation, psychotropic medication use, medication errors, labeling and storage of drugs, food safety, sanitation, and infection control.
Deficiencies (13)
F 0583: The facility failed to ensure resident R263's personal medical information was secured for confidentiality, as insulin cap with resident's name was left unattended in a shared hallway.
F 0584: The facility failed to provide a homelike environment due to scraped paint on walls behind residents' headboards, with delayed or missing maintenance work orders.
F 0684: The facility failed to implement a resident's bowel protocol related to opioid use, resulting in missed administration of prescribed medications and lack of bowel movement documentation.
F 0688: The facility failed to ensure a resident with limited range of motion received appropriate treatment and documentation, including range of motion exercises and splint care.
F 0689: The facility failed to provide adequate supervision and assistance to prevent falls for resident R5, who had multiple falls and was at risk due to impaired balance and other factors.
F 0690: The facility failed to provide adequate hydration and timely toileting assistance for resident R5, increasing risk for dehydration, urinary tract infections, and injury.
F 0692: The facility failed to ensure resident R5 received enough fluids to maintain health, with inadequate fluid intake monitoring and documentation.
F 0732: The facility failed to include the facility census on daily nurse staffing postings as required for Medicare/Medicaid participation.
F 0758: The facility failed to ensure one resident was free from unnecessary psychotropic medication, with inadequate documentation and monitoring of PRN trazodone use for agitation and insomnia.
F 0760: The facility failed to assure a resident was free of significant medication errors, with multiple insulin dosing errors documented for resident R263.
F 0761: The facility failed to ensure resident R263's insulin pen was labeled with a discard by date, risking medication safety.
F 0812: The facility failed to ensure food items were stored under sanitary conditions and failed to maintain appropriate sanitizing solution concentration and documentation at the three-compartment sink.
F 0880: The facility failed to provide infection prevention by leaving resident R263's bile drainage container out in the open instead of discarding it properly, posing an infection control risk.
Report Facts
Medication errors: 6
Falls: 7
Fluid intake: 1
Sanitizing solution concentration: 272
Sanitizing solution concentration: 700
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN5 | Registered Nurse | Involved in medication errors and confidentiality deficiency related to resident R263 |
| DON | Director of Nursing | Interviewed regarding confidentiality, falls, staffing, and medication errors |
| ADON | Assistant Director of Nursing | Interviewed regarding medication monitoring and falls |
| CN5 | Charge Nurse | Interviewed regarding bowel protocol and hydration for resident R1 and R5 |
| RN6 | Registered Nurse | Confirmed nurse staffing posting issues and medication error notification |
| CNA8 | Certified Nurse Aide | Interviewed regarding range of motion care for resident R4 |
| RN7 | Registered Nurse | Confirmed nurse staffing posting did not include census |
| CNA10 | Certified Nurse Aide | Confirmed nurse staffing posting did not include census and hydration issues |
| RN10 | Charge Nurse | Interviewed regarding hydration and UTI status of resident R5 |
| IP | Infection Preventionist | Interviewed regarding infection control for bile drainage |
| KS5 | Kitchen Staff | Tested sanitizing solution concentration in kitchen |
| Sous Chef | Kitchen Staff | Confirmed no log for sanitizing solution testing and concentration too strong |
Inspection Report — Sep 23, 2022
Annual Inspection
Date: Sep 23, 2022
Visit Reason
The inspection was conducted as part of a comprehensive annual survey to assess compliance with regulatory standards in the nursing home.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans for residents, revising care plans after assessments, and properly storing and discarding expired food. These deficiencies posed risks to resident care quality and safety.
Deficiencies (3)
F 0656: The facility failed to ensure comprehensive person-centered care plans were developed and implemented for one resident, resulting in inconsistent use of prescribed palm protectors and towels to prevent contractures.
F 0657: The facility failed to revise a comprehensive care plan after assessment for one resident, resulting in inadequate pain management and lack of non-pharmacological interventions.
F 0812: The facility failed to properly store and discard expired food from the walk-in refrigerator, putting residents at risk for foodborne illness.
Report Facts
Residents sampled: 8
Residents affected: 1
Residents affected: 1
Expired food items: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan deficiencies and missing palm protector | |
| Certified Nurse Aide (CNA)1 | Interviewed regarding missing palm protector | |
| Director of Dining Services | Interviewed regarding expired food storage and discard | |
| Occupational Therapy Staff | Observed transferring resident and interviewed about pain management | |
| MDS Staff (MDSS)1 | Interviewed regarding pain management and care plan revision |
3 CMS Surveys
CMS Survey — Sep 23, 2022
Sep 23, 2022
CMS Survey — Aug 10, 2023
Aug 10, 2023
CMS Survey — Jun 27, 2024
Jun 27, 2024
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