Inspection Report
Annual Inspection
Deficiencies: 14
May 12, 2025
Visit Reason
Annual inspection conducted to assess compliance with state licensing requirements for an assisted living facility.
Findings
Multiple deficiencies were found including food contamination, lack of staff training, incomplete service plans for residents, inadequate dietitian involvement, improper medication management, and nursing tasks performed beyond staff scope.
Deficiencies (14)
| Description |
|---|
| Observed a strand of hair in Resident #2’s food for lunch. |
| No documented evidence that training was provided for dietary staff for the provision of three meals daily that are appropriate to residents’ needs and choices. |
| Resident #1 service plan did not include aspiration precautions for dysphagia and recreational/social activities. |
| Resident #1 service plan specified total assistance with feeding but staff did not provide feeding assistance during lunch. |
| Resident #2 service plan incorrectly indicated self-management of medications; family manages medications. |
| No documented evidence that menus were reviewed by a dietitian on a semi-annual basis. |
| No documented evidence that menus meet nutritional needs; portion sizes not available for entire menu cycle. |
| No contract available for services provided by a dietitian. |
| No documented evidence that a Consultant Dietitian provided health monitoring/nutritional assessment for Resident #1 with dysphagia and feeding assistance. |
| No documented evidence that a Consultant Dietitian provided health monitoring/nutritional assessment for Resident #2 with weight loss. |
| Resident Assistant documented application of cream to bedsore/sore, a task beyond RA scope. |
| Controlled medications log in memory care unit shows incomplete signatures required by two staff members on multiple occasions. |
| Resident #2 unable to manage own medication regimen; prescription medications stored in unit. |
| Resident #2 shares unit with another resident with Alzheimer's dementia; medications not kept in locked container. |
Inspection Report
Annual Inspection
Deficiencies: 6
May 14, 2024
Visit Reason
The inspection was conducted as the annual survey for the facility Ilima at Leihano on May 14 and 15, 2024.
Findings
The report identifies multiple deficiencies related to medication administration, service plans, nursing assessments, and safety practices, including missing signatures on controlled medication logs, inadequate resident assessments, unsecured medications, and failure to follow up on scheduled tests. The facility submitted plans of correction with future actions to address these issues.
Deficiencies (6)
| Description |
|---|
| Facility policy #5-3.09 Accountability of Controlled Medications shows multiple missing two signatures on shift changes. |
| Resident #1's service plan and assessments did not reflect the resident's ability to self-administer medications safely and appropriately. |
| Unlabeled over-the-counter medication bottles and cream were found unsecured in the resident's unit. |
| Resident #1 had monitored outside foods posing choking risk on a dysphagia pureed diet. |
| Resident #1's nursing staff was unaware of a scheduled barium swallow test and did not follow up until the resident canceled the appointment. |
| Resident #2's medication label did not match the physician's order for Fluticasone nasal spray. |
Report Facts
Inspection dates: 2
Plan of correction completion dates: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Tsuda | Licensee/Administrator | Signed the plan of correction documents |
Inspection Report
Annual Inspection
Deficiencies: 12
May 26, 2023
Visit Reason
The inspection was conducted as the annual survey of the Ilima at Leihano assisted living facility to assess compliance with state regulations.
Findings
Multiple deficiencies were identified related to staff training, service plans, medication administration, health monitoring, and record-keeping. The facility submitted plans of correction addressing each deficiency with timelines and future prevention strategies.
Deficiencies (12)
| Description |
|---|
| First aid certification unavailable for review for Employee #1 and #2. |
| Nursing assessments unavailable for readmission into facility upon discharge from hospital for Resident #1. |
| Medication unavailable for administration despite physician's order for Gabapentin for Resident #1. |
| Vitamin D3 dosage administered does not match physician's order for Resident #1. |
| No documented evidence that four safety checks per shift are being performed in a timely manner for Resident #1. |
| No documented evidence of monthly weight measurement for Resident #1 for several months. |
| No documented evidence of bowel regimen implementation or inclusion in service plan for Resident #1 after hospital treatment for bowel impaction. |
| Diet order not reflected in service plan for Resident #1. |
| No documented evidence health monitoring was provided after multiple emergency department visits for Resident #1. |
| Annual physical examinations unavailable for Residents #3, #4, and #5. |
| Incident reports unavailable for multiple emergency department visits for Resident #1. |
| No documented evidence that consultant registered dietitian was utilized for nutrition consult/assessment for Resident #2 with stage two decubitus ulcer. |
Report Facts
Inspection Date: May 26, 2023
Plan of Correction Submission Deadline: 10
Inspection Report
Annual Inspection
Deficiencies: 7
May 19, 2022
Visit Reason
The inspection was conducted as the annual survey for the facility Ilima at Leihano to assess compliance with state licensing regulations.
Findings
The inspection identified deficiencies related to tuberculosis clearance documentation for employees, lack of documented evidence of monthly weight monitoring for residents, missing semi-annual menu evaluations, and unlabeled over-the-counter medication bottles. Plans of correction were submitted addressing these issues with specific corrective actions and future prevention plans.
Deficiencies (7)
| Description |
|---|
| Employee #1 – Initial 2-step TB clearance unavailable for review; Employee #2 – Annual TB clearance unavailable for review |
| Resident #1 – Service plan stated 'staff will monitor weight monthly' but no documented evidence that weights were taken from July 2021 to September 2021 |
| Resident #1 – No documented evidence that 15 lb weight gain from January 2022 to February 2022, and 10 lb weight loss from February to March 2022 was monitored and addressed |
| Resident #2 – Service plan stated 'take and record weight monthly' but no documented evidence that weights were taken on July 2021 and August 2021 |
| No documented evidence that the menus were evaluated and approved on a semi-annual basis |
| Resident #1 – Over the counter (OTC) medication bottle (Caltrate) does not contain a medication order label |
| Resident #2 – Over the counter (OTC) medication bottles (aspirin, vitamin B-12, arthritis) do not contain a medication order label |
Report Facts
Weight gain: 15
Weight loss: 10
Weight gain/loss threshold: 5
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