Inspection Reports for Ka Malama Care Home
45-332 Ka Hanahou Cir, Kaneohe, HI 96744, United States, HI, 96744
Back to Facility Profile
Inspection Report
Annual Inspection
Deficiencies: 7
Feb 25, 2025
Visit Reason
The inspection was conducted as the annual survey for Ka Malama Home II to assess compliance with state licensing regulations.
Findings
Multiple deficiencies were identified related to personnel tuberculosis clearance documentation, medication storage security, medication administration records, and care plan completeness for Resident #1. Plans of correction were submitted addressing each deficiency with specific corrective actions and future prevention plans.
Deficiencies (7)
| Description |
|---|
| Substitute caregiver (SCG) #1 had no documented evidence of an initial (2-step) tuberculosis (TB) clearance. |
| Refrigerated medications stored in a separate container were found unsecured in the fridge - padlock is not engaged. |
| Resident #1 - Senna Plus order was changed from PRN to daily on 10/23/24 but was not carried on the medication administration record (MAR). Current MAR (February 2025) still shows the Senna Plus order as PRN. |
| Resident #1 - No available supply to administer PRN medication, Ondansetron (Zofran), for nausea/vomiting. |
| Resident #1 - The following medication orders did not appear on MAR: Trazodone 50 mg ½ tab po QHS (none on July and August 2024 MAR), Tums 500 mg 2 tabs po BID (none on October MAR), Quetiapine Fumarate 25 mg ½ tab po at lunch time, may repeat every 6 hours PRN for agitation (none on July, August, October, November, December 2024 MAR, and January and February 2025 MAR). |
| Resident #1 - Current care plan does not include all medication orders. |
| Resident #1 - Care plan was not updated to address risk for wandering as noted on physician's note dated 1/8/25, and at risk for bleeding due to long-term use of nonsteroidal anti-inflammatory drug Aspirin. |
Report Facts
Inspection Date: Feb 25, 2025
Inspection Report
Annual Inspection
Deficiencies: 9
Feb 21, 2024
Visit Reason
The inspection was conducted as the annual survey for Ka Malama Home II to assess compliance with state licensing regulations under Chapter 100.1.
Findings
Multiple deficiencies were identified related to nutrition orders, medication administration, records and reports, resident health care standards, and case management qualifications and services. Plans of correction were submitted addressing each deficiency with future plans to prevent recurrence.
Deficiencies (9)
| Description |
|---|
| No physician order for thickening agent use for Resident #1 on nectar consistency. |
| Diet order for Resident #2 was not clarified to indicate grams of sodium; resident on low salt diet. |
| Medication administration record (MAR) for Melatonin showed discrepancy in dosage given versus physician order for Resident #1. |
| Medication flowsheet for Senna S not transcribed in MAR until July 2023 for Resident #1. |
| No documentation of initial tuberculosis clearance for Resident #2; chest x-ray results not acceptable. |
| No documentation in progress notes that diet restriction was acknowledged, clarified, and followed up for Resident #1 on palliative care. |
| Care plan did not address use of hoyer lift for transfers, use of air mattress, nectar thick liquid consistency, and crushing of medications for Resident #1. |
| No physician order to crush medications for Resident #1 who is unable to take medications whole. |
| Proper training and instructions not obtained to prepare and administer Metoprolol Succinate ER 24H for Resident #1; medication must be administered whole. |
Report Facts
Inspection Date: Feb 21, 2024
Inspection Report
Annual Inspection
Deficiencies: 14
Feb 24, 2023
Visit Reason
The inspection was conducted as the annual licensing inspection for Ka Malama Home II to assess compliance with state licensing regulations.
Findings
The report identifies multiple deficiencies related to licensing requirements, personnel and staffing documentation, nutrition and food sanitation, records and reports, physical environment and fire prevention, personal care services, and case management. The facility submitted plans of correction for each deficiency.
Deficiencies (14)
| Description |
|---|
| Primary Caregiver (PCG), Substitute Caregiver (SCG) #1-5, Household Member (HHM) #1,2 – Valid FieldPrint clearance unavailable for review. |
| SCG #3,5 and HHM #1 – Current physical exam unavailable for review. |
| SCG #2-4 and HHM #1 – Initial 2-step TB clearance unavailable for review. |
| SCG #4 and HHM #1 – Annual TB clearance unavailable for review. |
| Resident #1 – Special diet menu (regular chopped) unavailable for review; Resident #2 – Special diet menu (cardiac diet) unavailable for review. |
| Two refrigerators in detached garage containing food served to residents were not equipped with a thermometer. |
| Resident #1 – PCG assessment incomplete; missing resident representative’s signature. |
| Fire drills performed between 4/2022-2/2023 did not include the time of day drills were performed. |
| Hot water unavailable for use; water temperature measured at 80°F. |
| SCG #4 – No documented evidence of 12 hours of annual continuing education courses completed. |
| Resident #1 – Care plan dated 2/18/23 states no documented evidence resident is being repositioned every 2 hours as required. |
| Resident #1 – Care plan dated 2/18/23 states caregiver will check BP/HR daily and notify MD/RN case manager if out of range; however, vital signs log shows resident’s HR was 56 on 2/22/23 with no documented notification. |
| Resident #1 – No documented evidence the resident’s case manager provided caregiver training to SCG #2,4,5. |
| Resident #1 – Physician’s diet order dated 1/23/23 states 'chopped regular, thin liquids, no dietary restrictions'; care plan dated 2/18/23 states caregiver will comply with dietary plan limiting intake of sugar, fat, salt, and alcohol; care plan contradicts physician’s orders. |
Report Facts
Number of caregivers with missing documentation: 7
Number of refrigerators without thermometer: 2
Number of fire drills missing time of day: 1
Water temperature measured: 80
Hours of annual continuing education missing: 12
Inspection Report
Annual Inspection
Deficiencies: 6
Apr 7, 2022
Visit Reason
The inspection was conducted as the annual survey for the facility to assess compliance with state regulations under Chapter 90.
Findings
The report identifies deficiencies related to service plans, including inconsistencies between physician orders and service plans for residents, incomplete documentation of night checks, medication administration issues, and improper labeling of over-the-counter medications. Plans of correction include updating service plans, retraining staff, and implementing audits to ensure compliance.
Deficiencies (6)
| Description |
|---|
| Resident #2's service plan did not reflect physician's order for weekly weights, stating monthly weights instead. |
| Resident #1 and #2's service plans did not reflect consistent performance of night checks as required. |
| Safe swallowing precautions for prescribed special diets for residents #1 and #2 were not reflected in current service plans. |
| Resident #2's medication administration record showed melatonin was unavailable despite orders. |
| Over-the-counter medication bottles were not properly labeled with residents' name, dosage, route, and time. |
| Resident #2 fell and was out of the facility for recovery; nursing tasks were not consistently documented during this period. |
Report Facts
Deficiency completion dates: Plan of correction completion dates range from 04/08/22 to 04/28/22.
Loading inspection reports...
