Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 1
Date: Sep 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care and documentation, specifically focusing on safeguarding resident-identifiable information and maintaining accurate medical records.
Findings
The facility failed to document two unplanned decannulations of a resident's tracheostomy tube in the resident's Electronic Health Record (EHR). This deficient practice could affect all residents with tracheostomy tubes who experience unplanned decannulations.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. Specifically, two unplanned decannulations of a resident's tracheostomy tube were not documented in the resident's EHR.
Report Facts
Residents sampled for Respiratory Care: 7
Unplanned decannulations for resident R25: 2
Incident report times: 1430
Incident report times: 2245
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT 16 | Respiratory Therapist | Responded to decannulation incident and reinserted tracheostomy tube |
| DON | Director of Nursing | Confirmed nursing staff responsibility for documentation of decannulation incidents |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 36
Deficiencies: 5
Date: Jun 18, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding the care of Resident 1 (R1), including a fall incident, delayed physician response, and nursing staff competency in neurological assessments and emergency care.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1's fall, delayed physician response, inadequate neurological assessments, and failure to transfer timely to emergency care. Staff concerns about care deficiencies were reported but not adequately addressed by facility leadership.
Findings
The facility failed to develop a comprehensive care plan for R1, ensure safety measures to prevent falls, provide timely physician access for emergencies, and demonstrate nursing staff competency in neurological assessments and emergency response. The facility also failed to conduct thorough quality assurance reviews of adverse events and unplanned hospitalizations.
Deficiencies (5)
F0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including communication methods for a nonverbal resident with cognitive impairment.
F0689: The facility failed to ensure safety rails were secure, resulting in a fall of a dependent resident, and did not provide adequate supervision to prevent accidents.
F0713: The facility failed to ensure 24-hour availability of a physician for emergency care, causing a delay of over four hours in reaching the physician after a resident's fall and condition change.
F0726: The facility failed to ensure nursing staff competency in performing and documenting neurological assessments, identifying medical emergencies, and timely transferring a resident to higher care.
F0867: The facility failed to systematically analyze a resident's adverse event and unplanned hospitalizations, and did not investigate staff concerns, resulting in missed opportunities for quality improvement.
Report Facts
Facility bed capacity: 36
Resident census: 33
Time delay to reach physician: 4.5
Fall incident date: Mar 16, 2025
Resident age: Age redacted in report
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anonymous Staff Member 9 | Staff Member | Provided information on resident baseline and communication |
| Anonymous Staff Member 8 | Staff Member | Observed room conditions at time of fall |
| Anonymous Staff Member 10 | Staff Member | Reported on resident weight and care needs |
| Anonymous Staff Member 6 | Staff Member | Assisted with neurological assessment after fall |
| Director of Nursing | Director of Nursing | Confirmed fall details, investigation, and staff competency issues |
| Administrator | Administrator | Discussed QAPI program and oversight of unplanned transfers |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: 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)
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
Routine
Deficiencies: 8
Date: Jun 6, 2024
Visit Reason
The inspection was a routine survey conducted to assess the facility's compliance with regulatory requirements related to resident care, safety, medication management, environment, and infection control.
Findings
The facility was found to have multiple deficiencies including failure to enhance resident quality of life, maintain a clean environment, ensure proper discharge communication, prevent accident hazards, avoid medication errors, provide routine dental care, accurately document medication orders, and implement proper infection control practices. Most deficiencies were cited with minimal harm and involved few residents.
Deficiencies (8)
F 0550: The facility failed to enhance one resident's quality of life by not providing auditory stimulation such as music or television while the resident was in bed.
F 0584: The facility failed to maintain a clean environment for one resident by not changing soiled mesh netting inside the crib, increasing exposure to unsanitary conditions.
F 0661: The facility failed to ensure necessary information was communicated at discharge for one resident, including lack of physician discharge orders and incomplete documentation of discharge instructions.
F 0689: The facility failed to conduct a safety assessment after installing a crib canopy for one resident, creating a potential accident hazard.
F 0760: The facility failed to hold insulin for one resident when blood glucose was below the ordered threshold, resulting in a significant medication error.
F 0791: The facility failed to ensure routine dental care for two residents, with last dental consults dated 2020 and 2021 respectively.
F 0842: The facility failed to accurately document a medication order for one resident, recording an incorrect dosage on the narcotic medication record.
F 0880: The facility failed to implement proper infection control practices, including failure to perform hand hygiene between glove changes and improper mask use by staff.
Report Facts
Residents in sample: 12
Residents in sample: 4
Medication administration observations: 28
Insulin dose: 55
Blood glucose levels: 79
Blood glucose levels: 69
Medication dose: 12
Medication dose: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 25 | Registered Nurse | Named in insulin medication error and mesh netting cleaning deficiency |
| RN 23 | Registered Nurse | Named in discharge communication deficiency and medication order documentation |
| RN 26 | Registered Nurse | Named in infection control deficiency for improper glove use |
| RN 33 | Registered Nurse | Interviewed regarding safety assessment after crib canopy installation |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding infection control and dental care scheduling |
| Administrator | Administrator | Interviewed regarding dental care scheduling, discharge communication, and infection control |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: 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)
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: 6
Date: Jun 23, 2023
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare standards and regulations at the nursing home Kulana Malama.
Findings
The facility was found deficient in multiple areas including failure to implement care plan interventions for enteral feeding, unsecured medication carts, lack of updated infection prevention and control program, incomplete COVID-19 vaccine refusal documentation, and inadequate maintenance of ventilator air intake filters.
Deficiencies (6)
F0656: The facility failed to implement care plan interventions to elevate the head of bed at least 30 degrees during and after enteral feedings for one resident, risking aspiration.
F0693: The facility failed to provide appropriate care for a resident with a feeding tube, including failure to elevate the head of bed during feeding as per care plan and policy.
F0761: The facility failed to ensure one of six medication carts was kept locked or under direct observation, risking unauthorized access to medications.
F0880: The facility failed to maintain an infection prevention and control program by not reviewing and updating the policy annually as required.
F0887: The facility failed to document COVID-19 vaccine refusal education and consent properly for one resident, not meeting regulatory requirements.
F0908: The facility failed to clean the VOCSN ventilator air intake filter every two weeks as recommended, risking resident safety.
Report Facts
Residents sampled: 3
Medication carts observed: 6
Residents sampled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plan implementation, infection control policy, medication cart security, and COVID-19 vaccine documentation |
| Registered Nurse 1 | Registered Nurse | Interviewed about resident positioning during enteral feeding |
| Respiratory Therapist 5 | Respiratory Therapist | Confirmed medication cart contained medications and should have been locked |
| Respiratory Services Director | Respiratory Services Director | Interviewed about ventilator air intake filter cleaning practices |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: 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)
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
Complaint Investigation
Deficiencies: 5
Date: Jul 15, 2022
Visit Reason
The inspection was conducted following a complaint investigation regarding allegations of staff mistreatment and abuse of Resident 2, as well as concerns about discharge/transfer notifications and medication storage practices.
Complaint Details
The complaint investigation was triggered by an allegation that a Certified Nursing Assistant (CNA5) yelled profanities and used excessive force on Resident 2 during personal care on 09/22/21. The facility submitted an Event Report but failed to report the incident to APS or law enforcement. Interviews with staff confirmed the incident and the facility's failure to report. The complaint also included failure to notify residents and families about discharge/transfer and bed hold policies, and medication storage issues.
Findings
The facility failed to ensure Resident 2 was treated with dignity and respect, with a staff member using profanities and rough handling. The facility also failed to timely report the abuse allegation to Adult Protective Services (APS) or law enforcement. Additionally, the facility did not provide proper written notification of discharge/transfer and bed hold policies to residents and their representatives. Medication carts were observed unlocked and unattended, posing a risk to resident safety.
Deficiencies (5)
F550: The facility failed to honor Resident 2's right to dignity and respect, with a staff member yelling profanities and using excessive force during personal care.
F609: The facility failed to timely report the allegation of abuse of Resident 2 to Adult Protective Services or law enforcement as required by state law.
F623: The facility failed to provide timely written notification of discharge/transfer and appeal rights to residents and their family representatives, affecting Residents 10 and 18.
F625: The facility failed to notify residents or their representatives in writing about the bed hold policy and obtain a signed bed hold agreement upon transfer to an acute care hospital.
F761: The facility failed to ensure all medications were stored in locked compartments, with multiple observations of unlocked and unattended medication carts.
Report Facts
Date of incident: Sep 22, 2021
Date of Event Report submission: Sep 28, 2021
Date of inspection: Jul 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA5 | Certified Nursing Assistant | Named in abuse allegation involving Resident 2. |
| RN38 | Registered Nurse | Witnessed the abuse incident and reported it. |
| RN30 | Registered Nurse | Interviewed regarding the incident and care of Resident 2. |
| RN29 | Registered Nurse | Interviewed regarding care techniques for Resident 2. |
| DON | Director of Nursing | Interviewed about the incident, reporting procedures, and staff conduct. |
| CNA1 | Certified Nursing Assistant | Interviewed about care techniques and behavior of CNA5. |
| HIA | Health Information Associate | Interviewed about discharge/transfer notification procedures. |
| SW | Social Worker | Interviewed about abuse reporting policies. |
| ADON | Assistant Director of Nursing | Observed unlocked medication cart and confirmed it should be locked. |
| RN3 | Registered Nurse | Observed with unlocked medication cart and confirmed it should be locked. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: 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)
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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