Inspection Report Summary
The most recent inspection on February 4, 2025, identified multiple deficiencies related to personnel training, resident documentation, medication orders, environmental hazards, and emergency preparedness. Earlier inspections also noted similar issues involving medication management, care planning, personnel clearances, and physical environment concerns. Inspectors cited recurring themes of incomplete training for substitute caregivers, missing or unclear physician orders for medications, inadequate resident documentation, and environmental maintenance problems such as damaged window screens and housekeeping deficiencies. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports, and no complaint investigations were noted. The inspection history shows persistent challenges in several areas without a clear pattern of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
29 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
258% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Annual Inspection
Deficiencies: 37
Date: Feb 4, 2025
Visit Reason
Annual inspection of Lunalilo Home to assess compliance with state licensing regulations including personnel, admission policies, nutrition, food sanitation, medications, personal care services, records and reports, resident accounts, resident health care standards, residents' rights, physical environment, and case management services.
Findings
Multiple deficiencies were identified including incomplete training for substitute caregivers, missing or incomplete resident documentation (admission assessments, financial agreements, care plans), medication orders lacking physician authorization, inadequate signage and signaling devices, environmental hazards such as window screens and housekeeping issues, and missing fire drill documentation. Plans of correction and future plans were submitted for all deficiencies.
Deficiencies (37)
Substitute Caregiver (SCG) #2 – No documented evidence of a PCG training to make medications available.
Resident #1 – Level of care evaluation for admission on 2/16/24 was unavailable for review.
No documented evidence that the menus meet the residents’ nutritional needs as there were no accompanying portion sizes available for review.
Resident #1 – Diet order dated 1/27/25 was not clarified with the physician to specify the exact texture and include the liquid consistency.
Resident refrigerator located in dining room does not have a working thermometer.
Sanitizing spray cans stored unsecured in multiple locations including bathrooms and bedrooms.
Resident #1 – Physician’s order dated 2/1/24-present for Melatonin lacks frequency to administer.
Resident #1 – Medication made available per MAR without physician’s order to administer (Melatonin, Senna, Psyllium Fiber, Bisacodyl, Acetaminophen, Augmentin).
Resident #2 – Calmoseptine PRN order lacked PRN indication and medication was made available without reason to administer.
Resident #1 – Supplement orders lacked dosage to administer; resident administered Ensure Plus despite order for Ensure.
Resident #2 – Supplement order for Boost Plus unavailable for administration.
Resident #1 and #2 – Activity schedules include activities that do not meet residents’ capabilities (e.g., garden walks for wheelchair bound residents).
Resident #1 – Admission assessment for admission on 2/16/24 unavailable for review.
Resident #1 – TAR shows suprapubic catheter care not provided on multiple dates.
Resident #1 – Incident reports for emergency department visits on 7/17/24, 8/24/24, and 12/24/24 unavailable.
Resident Register unavailable for review.
Resident #1 – Resident Financial Agreement unavailable for admission on 2/16/24.
Resident #1 – No documented evidence resident was informed of resident’s rights and responsibilities at admission.
Resident #1 – No documented evidence resident was fully informed orally and in writing at admission of services available and related charges.
Fire drill records incomplete or missing for multiple months in 2024.
Window screens missing or damaged in multiple bedrooms allowing insects/debris to enter.
Bedroom 211A bathroom cabinet contains substantial amount of termite droppings.
Bedroom 217 window ledges covered in brown dirt.
Bedroom 221 single-use hand towels and toilet paper unavailable for resident use.
Large hole in first floor ceiling without safeguards to protect from falling objects.
Bedroom 220 bathroom does not have a receptacle for rubbish or garbage.
Bedroom 201 being used by facility employees but licensed for resident use.
Bedroom 227 contains random facility items stored on bed and floor.
Bedroom 217 pillow and bed sheet contain bodily fluid stains.
Signaling devices not available or not working in multiple bedrooms and bathrooms.
Substitute Caregivers did not complete 12 hours of continuing education within past 12 months (SCG #1: 1 hour, SCG #2: none, SCG #3: 4 hours, SCG #4: 2 hours).
Resident #1 care plan includes medication orders without physician’s order to administer (e.g., bisacodyl suppository, melatonin PRN order).
Resident #1 care plan states 'State of Hawaii Quest Integration Service Plan' but resident is not in Quest program and plan does not accurately reflect resident.
Resident #1 care plan for 'risk of impaired swallowing' lacks specific procedures for coughing or choking during eating or drinking.
Resident #1 care plan not updated to include current diet order dated 1/27/25.
No general operational procedures for meal planning, food purchase, meal preparation and service, and referral and use of consultant registered dietitian available for review.
No documented evidence that consultant dietitian provided special diet training for food preparation staff.
Report Facts
Continuing education hours: 1
Continuing education hours: 0
Continuing education hours: 4
Continuing education hours: 2
Fire drills missing: 5
Fire drills incomplete: 2
Inspection Report
Annual Inspection
Deficiencies: 33
Date: Feb 9, 2024
Visit Reason
The inspection was conducted as the annual licensing inspection for Lunalilo Home to assess compliance with state regulations and licensing requirements.
Findings
The report identifies multiple deficiencies related to licensing, personnel requirements, nutrition, medications, records and reports, physical environment, and case management. Plans of correction were submitted for each deficiency, with corrective actions and future plans detailed.
Deficiencies (33)
Substitute Caregiver (SCG) #1 fieldprint report incomplete, fingerprint process not completed.
SCG #2-4 current fieldprint clearance unavailable for review.
SCG #4 current physical exam unavailable for review.
Primary Caregiver (PCG) and SCG #1-7 initial tuberculosis clearance unavailable for review.
SCG #5 current annual TB clearance unavailable for review.
SCG #1-7 training to make prescribed medications available to residents unavailable for review.
Resident #1 diet order dated 9/22/23 lacks documented evidence of clarification with physician for conflicting diet orders.
Resident #3 diet order dated 4/30/23 lacks documented evidence of clarification with physician for conflicting diet orders.
Resident #2 and #3 over-the-counter medications lack proper labeling on bottles.
Resident #1 physician's order dated 9/22/23 lacks PRN indication on Calmoseptine ointment medication order.
Resident #3 medication administration record (MAR) incomplete for medication administered daily on certain dates.
Resident #3 MAR not filled out on 9/29/23, no determination if medication was administered, withheld, or refused.
Resident #1 medication reevaluation not done every four months as required.
Resident #3 bottle of sterile nasal mist sodium chloride 3.0% unavailable in medication inventory despite physician's order.
Resident #1 medication order dated 1/7/23 not available in medication inventory.
Resident #1 care plan dated 12/22/23 lacks documented evidence of body weight measured at admission.
Resident #1 progress note dated 1/21/24 incident report unavailable for review.
Resident #1 podiatry visits not documented in progress notes for multiple dates.
Two beds in bedroom #201 placed less than three feet apart.
Signaling devices not working in bedrooms #112, 201, 207, 209, 220, 221 and bathrooms in bedrooms #201, 207.
Bedroom #219 hold in window frame due to broken window handle covering; plastic cover cracked and separated allowing insect entry.
Bedroom #110 window screen frame bent and disfigured allowing insect entry.
Resident #1 care plan dated 1/14/24 does not include certain current medication orders.
Resident #3 physician's order discontinued on 7/28/23 but medication administered after that date.
Resident #3 medication error form to be used if wrong medication is provided to facility.
Resident #3 MAR observed using letter 'g' without legend to explain meaning.
Resident #3 MAR observed with technical issues and missing legend on printout.
Resident #3 MAR observed with staff unserviced on reviewing medication orders daily and assessing for completeness.
Resident #1 medication orders not evaluated by physician every four months in timely manner.
Resident #3 MAR not filled out on 9/29/23, no determination if medication was administered, withheld, or refused.
Resident #2 signed financial agreement between resident and facility unavailable for review.
Resident #2 not informed of rights and responsibilities at time of admission.
Resident #2 not informed of services available and related charges at time of admission.
Report Facts
Deficiencies cited: 38
Inspection Report
Annual Inspection
Deficiencies: 28
Date: Feb 7, 2023
Visit Reason
The inspection was conducted as the annual survey of the Lunaililo Home facility from February 7 to 9, 2023, to assess compliance with regulatory requirements.
Findings
Multiple deficiencies were identified related to personnel training, medication administration, resident supervision, record keeping, care planning, and operational policies. Plans of correction were submitted for all deficiencies, with training and procedural updates planned or completed.
Deficiencies (28)
No documented evidence of training for substitute care givers to make prescribed medications available and properly record such action.
During lunch meal, two residents were finishing their meal but no staff were present to provide supervision.
Facility did not follow physician's PRN order status for Acetaminophen and continued giving it routinely three times daily without clarification.
No documented evidence of clarification from physician regarding Nystatin medication orders; two orders existed without clarification.
Medication order for Metoprolol was given multiple times when it should have been held based on parameters.
No initials for Carvedilol administration on medication administration record (MAR) for certain dates.
No documented evidence medications were reevaluated and signed every four months by physician or APRN.
Medications made available to residents were not recorded on flowsheets with required details and initials missing for some medications.
Annual tuberculosis clearance not signed by a physician or APRN for resident.
Monthly progress notes did not include observations of resident's response to medications.
No incident reports available for residents from March to June 2022.
Inventory of resident possessions last updated in 2020; missing current inventory.
No documented evidence physician was notified of significant weight changes for resident during several months.
No documented evidence that facility notified case manager for weight loss >3 lbs. and >5 lbs. as indicated in care plan.
Care plans did not include specific procedures for choking/obstruction risk for residents.
No documented evidence staff was trained by case manager on how to use Hoyer Lift.
Residents at risk for nutritional deficit did not have updated care plans including weekly weights ordered by physician.
Care plans for blood pressure parameters were reviewed; no residents had blood pressure outside parameters.
No documented evidence of ongoing evaluation and monitoring of expanded ARCH resident status and care quality.
No documented evidence care plans were updated for residents at risk for nutritional deficit.
No documented evidence care plans were updated for residents at risk for impaired skin integrity due to immobility.
No documented evidence care plans were updated for residents at risk for aspiration.
No documented evidence care plans were updated for residents with blood pressure outside parameters.
No documented evidence staff training on Hoyer Lift; training planned and instructions placed in care manager binder.
No documented evidence care plans were updated for residents at risk for nutritional deficit as of October 2022.
No documented evidence care plans were updated for residents at risk for impaired skin integrity due to immobility.
No documented evidence care plans were updated for residents at risk for aspiration.
No documented evidence care plans were updated for residents at risk for impaired skin integrity due to immobility.
Report Facts
Inspection duration days: 3
Training date: Feb 16, 2023
Medication administration errors: 2
Weight loss thresholds: 3
Medication reevaluation frequency months: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Keolamaikai | Licensee/Administrator | Signed plan of correction on 3/29/2023 |
| Sheri Richards | Signed plan of correction on 3/29/2023 | |
| Director of Nursing | Director of Nursing (DON) | Provided training on medication administration and oversight |
| Dr. Christopher Lee | Physician | Mentioned in resident nursing assessments |
| Dr. Christina Lee | Physician | Mentioned in resident nursing assessments |
Inspection Report
Annual Inspection
Deficiencies: 18
Date: Feb 3, 2022
Visit Reason
The inspection was conducted as an annual survey of the Lunailio Home facility to assess compliance with state regulations under Chapter 100.1.
Findings
Multiple deficiencies were identified related to personnel requirements, nutrition, medication administration, records and reports, and general operational policies. The facility submitted plans of correction for each deficiency, with some deficiencies requiring only future plans due to impracticality of immediate correction.
Deficiencies (18)
Substitute Care Giver (SCG) #3, #4, and #5 had no annual physical exam.
SCG #3 and #5 had no annual tuberculosis clearance.
SCG #1 and #2 had no current first aid certification.
No documented evidence that residents received nutritionally adequate meals; menu substitutions were not recorded when menus were not followed or items unavailable.
There was a 15-hour gap between the substantial evening meal at 4:00 pm and breakfast at 7:00 am; no evidence all residents received a substantial evening snack during this gap.
Refrigerator in dining hall had a lock, potentially limiting residents' access to snacks between meals.
Resident #1 was administered Rhopressa medication 3 days in a row despite order for every other day; medication was not available for administration at times.
Resident #1 had no documented evidence supporting discontinuation of Dutasteride-Tamsulosin and Finasteride medications.
Resident #1 medication Rhopressa was not available for administration.
Multiple dates for multiple medications were not initialed as administered on resident's medication administration record (MAR).
Resident #1 had no acceptable procedure to separately secure or dispose of discontinued medications; medication was still available in medication cart after discontinuation.
Resident #1 and #2 admission/re-admission assessments were not signed or dated by primary care giver.
Resident #1 monthly summaries did not accurately reflect appetite in relation to weight fluctuations.
Resident #2 monthly progress notes mentioned response to medications but were not actually written; wounds and healing were mentioned instead.
Resident #1 care plan was not accurate; nursing assessments stated resident was continent when he was not.
Policies and procedures related to dietary services did not reflect the facility's day-to-day operations.
Resident #1 had no care plan developed for dysphagia.
Resident #1 case manager had not signed nursing assessment and unable to determine if face-to-face contact occurred in October 2021.
Report Facts
Deficiency count: 18
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