Inspection Report
Annual Inspection
Deficiencies: 8
Apr 8, 2025
Visit Reason
The inspection was conducted as the annual survey of The Plaza at Kaneohe assisted living facility on April 8 and 9, 2025, to assess compliance with state regulations.
Findings
The report identifies multiple deficiencies related to service plan reviews, staff training, medication management, and documentation of resident care. The facility submitted plans of correction with future actions to address these deficiencies.
Deficiencies (8)
| Description |
|---|
| Service plan was not reviewed/updated timely (at least semi-annually) between 2/3/24-2/5/25 for Resident #3. |
| Training in providing services to residents in the extended care unit did not occur prior to working there for Employees #1, #2, #3, #4, and #6. |
| Required Resident Care Aide (RCA) and Medication Aide (MA) onboarding training was not appropriately completed for Employee #2 and Employee #7. |
| Active medication orders for Residents #1 and #2 included PRN medications not available for administration. |
| Service plans for Residents #1 and #2 were not followed, with incomplete documentation on the Plan of Care for multiple care activities and BM checks. |
| Fall risk evaluation was not completed for Resident #3 following fall incidents on 9/25/24 and 9/19/24. |
| No documented evidence that the charge nurse assessed and monitored Resident #1 for complaints of lower back pain (LBM) and right hip pain on specified dates. |
| Expired medications (Zolpidem tablets and Clotrimazole topical cream) were found on medication carts. |
Report Facts
Inspection dates: April 8 and 9, 2025
Plan of correction completion dates: Most corrective actions planned for completion by 04/18/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dorothy Abreu | Administrator | Signed report and responsible for oversight of corrective actions |
| Employee #2 | Resident Care Aide (RCA) | Named in deficiency related to incomplete onboarding training |
| Employee #7 | Medication Aide (MA) | Named in deficiency related to incomplete onboarding training |
Inspection Report
Annual Inspection
Deficiencies: 10
Apr 23, 2024
Visit Reason
The inspection was conducted as the annual survey of The Plaza at Kaneohe assisted living facility on April 23 and 24, 2024.
Findings
The inspection identified multiple deficiencies related to staff training, resident care plans, medication administration, nursing assessments, and record-keeping. Several deficiencies required future plans of correction rather than immediate correction.
Deficiencies (10)
| Description |
|---|
| Records of four resident care aides assigned to the Lamaku unit did not show completion of CNA certification or nurse aide training course. |
| Resident #1 had multiple shower refusals with no documentation that the RN reassessed care needs or updated the service plan accordingly. |
| Resident #1's electronic medication administration record showed Lactulose oral solution was ordered but no supply was available for PRN administration. |
| Resident #1's current service plan indicated medications to be administered by Charge Nurse, but medications were being administered by Medication Aides. |
| Resident #5 had unlabeled Neosporin tube and medicated shampoo unsecured on bathroom countertop. |
| Resident #1's eMAR showed Pantoprazole Sodium delayed release medication to be given before breakfast, but pharmacy label instructions conflicted. |
| Resident #1's Atenolol medication was not held on specified dates despite orders to hold if blood pressure or heart rate were below thresholds. |
| Resident #2's medication order and eMAR did not indicate if medication was given, held, refused, or unavailable. |
| Resident #3's tuberculosis clearance was not documented as urgent or unexpected despite admission records. |
| Resident #4's annual TB testing was completed but clearance was not signed by the physician. |
Report Facts
Resident care aides without CNA certification: 4
Inspection dates: 2
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 6, 2023
Visit Reason
Annual inspection conducted to assess compliance with state licensing regulations for The Plaza at Kaneohe assisted living facility.
Findings
Deficiencies were found related to missing temperature log readings for the medication refrigerator, lack of documented initial service plan for a resident, and untimely performance of night checks as per the service plan. For all deficiencies, only future plans of correction were required as correcting after the fact was deemed not practical or appropriate.
Deficiencies (3)
| Description |
|---|
| Medication refrigerator located on Memory Care Unit - Temperature log missing temperature readings for multiple dates between 9/17/22 and 2/28/23. |
| Resident #3 - No documented evidence the initial service plan was developed prior to admission on 1/1/22. |
| Resident #1 - Service plan intervention states night checks every 4 hours between 2200-0600 and every 2 hours between 2200-0600 from 4/4/23-present; however, checks are not being performed timely as stated. |
Report Facts
Temperature log missing dates: 11
Inspection Report
Annual Inspection
Deficiencies: 11
Feb 22, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state licensing regulations for the facility Ka Malama Home II.
Findings
Multiple deficiencies were identified related to personnel health documentation, nutrition, physical environment, personal care services, and case management. The facility submitted plans of correction addressing each deficiency with future plans to prevent recurrence.
Deficiencies (11)
| Description |
|---|
| Substitute Caregiver (SCG) #1 annual physical exam unavailable for review. |
| Substitute Caregiver (SCG) #1 initial and annual tuberculosis clearances unavailable for review. |
| Substitute Caregiver (SCG) #1 valid CPR certification unavailable for review. |
| Substitute Caregiver (SCG) #1 valid first-aid certification unavailable for review. |
| Resident #1 observed eating food not prepared as ordered per physician's diet order. |
| Special diet menus for residents unavailable for review. |
| Indoor hot water temperature measured at 125°F, exceeding the regulated range. |
| Resident #1 care plan lacked documented evidence of required resident checks and ROM exercises. |
| Resident #1 case manager did not perform a documented pre-admission comprehensive assessment. |
| Resident #1 case manager directive did not reflect physician's orders for diet. |
| Resident #1 case manager did not document face-to-face contact every 30 days as required. |
Report Facts
Indoor hot water temperature: 125
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