Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 9
Oct 10, 2023
Visit Reason
Annual inspection conducted to assess compliance with licensing requirements and regulations for Ohanalani L.L.C.
Findings
Multiple deficiencies were identified including lack of documentation for background checks on substitute caregivers, inadequate special diet menus, missing physician orders for medications, incomplete medication administration records, missing documentation for telephone and verbal medication orders, incomplete progress notes, and lack of fire drill documentation during certain shifts. Plans of correction and future plans were provided for each deficiency.
Deficiencies (9)
| Description |
|---|
| No documentation of background check (fingerprint) clearance for substitute caregiver #1. |
| No special diet menu available to accommodate residents' special diet orders. |
| No physician order for certain medications noted in the medication administration record (MAR) for Resident #1. |
| Medications were not initialed as given, held, or refused by Resident #1 on MAR. |
| Physician order for medication was not recorded on the MAR for Resident #1. |
| Telephone and verbal medication orders were obtained but not recorded on the physician's order sheet or confirmed in writing within required timeframe. |
| Progress notes did not document indication for holding doses of medication for Resident #1. |
| Fire drills were not conducted during the 3rd or night shift from October 2022 to September 2023. |
| Alteration in hydration care plan was not updated to reflect medication changes for Resident #1. |
Report Facts
Completion Date: Oct 18, 2023
Completion Date: Oct 11, 2023
Completion Date: Oct 27, 2023
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 13, 2022
Visit Reason
Annual inspection conducted to assess compliance with state licensing regulations for Ohanalani L.L.C.
Findings
Deficiencies were found related to unsecured medications in residents' rooms, lack of documentation of staff review of care plans, and absence of documentation for annual dental exams for a resident.
Deficiencies (3)
| Description |
|---|
| Unlabeled medications or treatments found unsecured in residents' rooms (Bedroom #3 and Bedroom #4). |
| No documentation that SCG #1 reviewed and acknowledged the RN case manager care plan for resident #1. |
| No documentation of resident #1 having an annual dental exam completed, refused, or dentist stating an annual exam is not warranted. |
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