Inspection Reports for Mililani Care Home
95-117 Waikalani Dr, Mililani, HI 96789, HI, 96789
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 10, 2024, identified deficiencies related to food sanitation, medication availability, and record-keeping. Earlier inspections also noted issues with personnel documentation, medication management, and incomplete progress notes, showing a consistent pattern of record-keeping and medication-related deficiencies. Inspectors cited missing thermometers in the refrigerator, unavailable medications, incomplete progress notes, and a lack of incident reporting for a resident who left the facility unattended. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and no complaint investigations were noted. The facility has shown ongoing challenges with documentation and medication oversight without a clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 10, 2024
Visit Reason
The inspection was conducted as the annual survey for Mililani Care Home LLC to assess compliance with state licensing regulations.
Findings
The inspection identified deficiencies related to food sanitation, medication availability, and record-keeping. The facility submitted plans of correction addressing each deficiency with specific corrective actions and future prevention plans.
Deficiencies (6)
Refrigerator was not equipped with an appropriate thermometer during the time of inspection.
No available metal stem thermometer during the time of inspection.
Medication for Resident #1 (Lumigan 0.01% eye drops) was unavailable for review during the time of inspection; no documentation to confirm if medication was being refilled.
Progress notes for Resident #1 documented in June, July, and August 2024 were incomplete and did not consistently address response to medications, treatments, and diet.
No entry detailing when 'Prolia 60 mg/mL' medication was administered or made available for Resident #1.
No documented evidence of an incident report for Resident #1 when they walked out of care home and was outside for more than two hours on 2/16/24.
Report Facts
Completion Date: Sep 15, 2024
Completion Date: Sep 19, 2024
Completion Date: Sep 19, 2024
Completion Date: Sep 19, 2024
Completion Date: Sep 10, 2024
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Sep 22, 2023
Visit Reason
The inspection was conducted as the annual licensing survey for Mililani Care Home LLC to assess compliance with state licensing requirements.
Findings
Multiple deficiencies were identified related to licensing, personnel requirements, medication labeling and administration, record keeping, and resident rights. The facility submitted plans of correction addressing each deficiency with specific corrective actions and future prevention plans.
Deficiencies (12)
Primary Care Giver (PCG) and Substitute Care Giver (SCG) #1 had no Fieldprint background check available.
PCG had no current annual physical exam.
PCG had no documented evidence of initial 2-step tuberculosis clearance and no annual tuberculosis clearance available.
PCG had no current first aid certification.
Resident #1's medication orders included hold parameters but medication label did not include hold parameters as ordered.
Resident #1's medication administration records (MARs) were not completed from March to June 2023.
Resident #1 had no monthly progress notes available; last note was from September 2022.
Resident #1's records were incomplete, inaccurate, or not current; progress notes and MARs not completed daily/monthly.
Resident #1's emergency information sheet was incomplete; back page was missing.
Resident #1's physician was not notified regarding significant weight loss of 11 lbs from May to June 2023.
Resident #1 had no documentation regarding wound or wound care from March 2023.
Surveillance camera in residents' bedroom had no signed consents available.
Report Facts
Deficiencies cited: 12
Weight loss: 11
Medication MAR incomplete period: 4
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Oct 3, 2022
Visit Reason
The inspection was conducted as the annual survey for Mililani Care Home LLC to evaluate compliance with regulatory requirements.
Findings
The inspection identified deficiencies related to personnel tuberculosis clearance documentation, medication reevaluation and signing by a physician, medication order signatures, medication administration record initials, and progress notes documentation. Plans of correction and future plans were submitted for each deficiency.
Deficiencies (7)
Substitute Care Giver (SCG) #1 – Annual tuberculosis clearance not signed by a physician or APRN.
SCG #2 – No annual tuberculosis clearance available.
Resident #1 – Medications not reevaluated and signed by a physician every four months; medication orders signed on 8/26/2021 state medications are good for six months until 2/26/2022; medication orders not signed by a physician or APRN until 4/11/2022.
Resident #1 – Mirtazapine ordered 11/11/2021; medication order not signed until 4/11/2022, five months later.
Resident #1 – No initials on medication administration record (MAR) for Centrum Silver and Fluticasone on 9/30/2022; no initials on MAR for Mirtazapine and Amlodipine on 9/30/2022 and 9/31/2022.
Resident #1 – No monthly progress notes available from October to December 2021.
Resident #1 – Monthly progress notes did not include observations of the resident’s response to medications.
Report Facts
Medication reevaluation timeframe: 4
Medication order signature delay: 5
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