Inspection Reports for
Legacy Hilo Rehabilitation & Nursing Center
563 Kaumana Dr, Hilo, HI 96720, United States, HI, 96720
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 8
Date: Oct 25, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including call bell accessibility, protection of resident property, notification of transfers/discharges to the Ombudsman, development of comprehensive care plans, catheter care and infection control, medication reconciliation and storage, and hand hygiene practices.
Deficiencies (8)
F 0558: The facility failed to keep the call bell within reach for one resident, limiting their ability to call for help.
F 0584: The facility failed to exercise reasonable care to protect one resident's property from loss or theft, negatively affecting the resident's psychosocial wellbeing.
F 0623: The facility failed to send timely notification of resident transfers or discharges to the Office of the State Long-Term Care Ombudsman for four residents.
F 0656: The facility failed to develop and implement a comprehensive care plan for one resident's frequent pain.
F 0690: The facility failed to provide appropriate catheter care for one resident, including leaving catheter tubing on the ground and flushing without a physician's order or proper hand hygiene.
F 0755: The facility failed to ensure controlled medication was properly reconciled on one medication cart, including pre-signing logs and missing signatures.
F 0761: The facility failed to ensure drugs and biologicals were stored in locked compartments, with medication carts observed unlocked and unattended.
F 0880: The facility failed to implement infection prevention practices, including improper catheter tubing placement and inadequate hand hygiene during catheter flushing and dressing changes.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 1
Residents affected: 4
Medication carts sampled: 4
Controlled medication reconciliation dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN5 | Registered Nurse | Named in catheter care and infection control deficiencies |
| LPN10 | Licensed Practical Nurse | Named in medication cart storage deficiency |
| RN11 | Registered Nurse | Named in medication cart storage deficiency |
| NS3 | Nursing Staff | Named in controlled medication reconciliation deficiency |
| RN23 | Nursing Staff | Named in controlled medication reconciliation deficiency |
| RCM8 | Resident Care Manager | Interviewed regarding controlled medication reconciliation practices |
| CNA1 | Certified Nurse Assistant | Named in catheter tubing placement deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging that a resident received excessive morphine sulfate at end-of-life care.
Complaint Details
The complaint alleged that Resident 1 received too much morphine sulfate on 05/26/24. The complaint was investigated and substantiated by review of medication records and interviews.
Findings
The facility failed to ensure nursing staff had appropriate competencies to safely administer morphine sulfate, resulting in a resident receiving scheduled doses instead of as needed. Additionally, pharmacy services lacked thorough reconciliation of controlled medications, leading to discrepancies in narcotic accounting.
Deficiencies (2)
F 0726: The facility failed to ensure nursing staff had the appropriate competencies to care for residents safely, resulting in a resident receiving morphine sulfate scheduled every hour instead of as needed.
F 0755: The facility failed to ensure pharmacy services included a thorough process to reconcile and account for controlled medications, resulting in discrepancies in morphine sulfate narcotic logs.
Report Facts
Morphine sulfate doses administered: 4
Morphine sulfate doses refused: 2
Date of morphine order change: May 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RCM1 | Resident Care Manager | Interviewed regarding data entry error and narcotic log reconciliation responsibilities |
| LPN1 | Licensed Practical Nurse | Took and incorrectly transcribed morphine sulfate order |
| RN1 | Registered Nurse | Administered morphine sulfate every hour for 3 hours without clarifying the order |
| SD | Staff Development/Educator | Interviewed about incomplete nurse competency checklists and assessment methods |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
The inspection was conducted to investigate an alleged physical abuse incident involving a resident (R23) reported by a roommate and staff members.
Complaint Details
The complaint investigation was substantiated based on interviews with Resident 23's roommate, CNAs involved, social worker, and administrator. The alleged abuse occurred in May 2023 but was not properly escalated or addressed until late October 2023.
Findings
The facility failed to implement its written abuse policy and procedure regarding the alleged physical abuse of Resident 23. Interviews revealed that the incident occurred months prior and was reported to nursing staff, but no action was taken until much later.
Deficiencies (1)
F 0607: The facility failed to develop and implement policies and procedures to prevent abuse, neglect, and theft. The abuse allegation involving Resident 23 was not properly addressed according to facility policy, placing residents at risk of harm.
Report Facts
Date of survey completion: Oct 30, 2023
Date of alleged incident: May 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA35 | Certified Nurse's Aide | Named as involved staff member in alleged abuse incident |
| CNA15 | Certified Nurse's Aide | Witness and assisting staff during alleged abuse incident |
| SW1 | Social Worker | Interviewed regarding awareness and reporting of abuse allegation |
| Administrator | Facility Administrator who became aware of the abuse allegation on 10/26/23 |
Inspection Report
Routine
Deficiencies: 14
Date: Oct 30, 2023
Visit Reason
Routine inspection of Legacy Hilo Rehabilitation & Nursing Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to accommodate resident needs, failure to notify physicians of significant changes, inadequate abuse investigation procedures, incomplete care plans, improper food safety practices, and lapses in infection control.
Deficiencies (14)
F 0558: The facility failed to accommodate Resident 69's needs by not ensuring his whiteboard and TV remote were placed on his mobile left side, hindering his independent functioning.
F 0580: The facility failed to notify the physician when Resident 70 became COVID positive and had a significant change in condition requiring hospital transfer.
F 0607: The facility failed to implement their abuse policy for an alleged physical abuse incident involving Resident 23, compromising resident safety.
F 0623: The facility failed to provide written notice of discharge for Resident 35, risking miscommunication.
F 0625: The facility failed to provide written notice of bed-hold policy for Resident 35, risking miscommunication.
F 0641: The facility failed to accurately record that Resident 65 was receiving Hospice Services in the Minimum Data Set.
F 0655: The facility failed to develop and implement a baseline care plan for falls for Residents 89 and 16, placing them at risk for injury.
F 0656: The facility failed to develop and implement comprehensive care plans for Residents 8, 57, 68, and 69, risking decline in quality of life.
F 0676: The facility failed to meet activities of daily living needs for Residents 57 and 69, including hygiene and communication care.
F 0679: The facility failed to provide an ongoing resident-centered activities program for Resident 69, risking psychosocial decline.
F 0689: The facility failed to ensure Resident 89's bed was kept in the lowest position as required by his baseline care plan, increasing fall risk.
F 0758: The facility failed to provide gradual dose reduction for Resident 27 on psychotropic medication, risking adverse effects.
F 0812: The facility failed to maintain food safety standards including dirty kitchen fan, improper food temperature checks, expired sanitizer test strips, unlabeled and dirty nourishment room refrigerators.
F 0880: The facility failed to ensure proper glove use by staff, risking transmission of infections.
Report Facts
Deficiencies cited: 14
Dates of observations: Oct 24, 2023
Dates of observations: Oct 26, 2023
Dates of observations: Oct 27, 2023
Temperature readings: 48
Temperature readings: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in communication and care plan deficiencies related to Resident 69. |
| RCM1 | Resident Care Manager | Interviewed regarding Resident 69's care and communication needs. |
| RN6 | Registered Nurse | Interviewed regarding Resident 70's COVID positive status and physician notification. |
| LPN9 | Licensed Practical Nurse | Interviewed regarding Resident 70's unresponsiveness and physician notification. |
| CNA35 | Certified Nurse Aide | Interviewed regarding alleged abuse incident involving Resident 23. |
| SW1 | Social Worker | Interviewed regarding abuse allegation process. |
| Administrator | Facility Administrator | Interviewed regarding abuse allegation and facility policies. |
| MDSC1 | MDS Coordinator | Interviewed regarding inaccurate hospice status documentation for Resident 65. |
| AD | Activities Director | Interviewed regarding Resident 69's activities program and communication needs. |
| FSM | Food Service Manager | Interviewed regarding kitchen sanitation and food safety practices. |
| RN8 | Registered Nurse | Observed and interviewed regarding improper glove use. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 16, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to issue timely Medicare notices, incomplete pre-employment reference checks, and failure to timely report suspected abuse or misappropriation of resident property.
Complaint Details
The complaint involved failure to timely issue Medicare notices to Resident #42, failure to complete pre-employment reference checks for three employees, and failure to timely report an allegation of misappropriation of resident property for Resident #176. The allegation of misappropriation was unsubstantiated and not reported to police as the resident did not want police involvement.
Findings
The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices and Notices of Medicare Non-Coverage timely for one resident. The facility did not complete pre-employment reference checks for three employees. The facility also failed to report an allegation of misappropriation of resident property to local law enforcement within 24 hours for one resident.
Deficiencies (3)
F 0582: The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice and/or Notice of Medicare Non-Coverage prior to the end of Medicare Part A coverage for Resident #42. The notices were signed almost four months late.
F 0607: The facility failed to complete pre-employment reference checks for three employees, including one Registered Nurse and two Certified Nursing Assistants, contrary to facility policy.
F 0609: The facility failed to report an allegation of misappropriation of resident property to local law enforcement within 24 hours for Resident #176. The allegation was investigated and reported to the state agency and APS but not to the police.
Report Facts
Residents reviewed for advanced beneficiary notices: 3
Employees reviewed for pre-employment reference checks: 4
Residents affected by misappropriation allegation: 1
Amount of missing money alleged: 110
Amount of money remaining: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to issue Medicare notices timely and abuse reporting. |
| Business Office Manager | Business Office Manager (BOM) | Interviewed regarding failure to issue Medicare notices timely. |
| Registered Nurse #2 | Registered Nurse | Personnel file missing pre-employment reference checks. |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Personnel file missing pre-employment reference checks. |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Personnel file missing pre-employment reference checks. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding abuse training and reporting. |
| Social Services Employee #1 | Social Services (SS) Employee | Interviewed regarding investigation of misappropriation allegation. |
| Administrator | Administrator/Abuse Coordinator | Interviewed regarding abuse reporting and investigation. |
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