Inspection Reports for The Plaza at Mililani
95-1050 Ukuwai St, Mililani, HI 96789, United States, HI, 96789
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to service plan updates, medication management, and staff training on specialized treatments like BiPAP and oxygen therapy. The most recent report from January 28, 2025, identified multiple issues including lack of staff training documentation, medication storage concerns, and incomplete adherence to resident care plans. Earlier reports also noted problems with inconsistent service plans, missing health monitoring documentation, and incomplete medication administration records. No fines, enforcement actions, or immediate jeopardy findings were listed in the available reports. While deficiencies have been consistent over time, the facility has submitted plans of correction after each inspection to address these areas.
Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 7
Jan 28, 2025
Visit Reason
The inspection was conducted as the annual survey of The Plaza at Mililani assisted living facility on January 28 and 29, 2025.
Findings
Multiple deficiencies were identified related to staff training on BiPAP and oxygen therapy, service plan assessments and updates, medication assessments, and medication storage and administration policies. Plans of correction and future plans were submitted to address these issues.
Deficiencies (7)
| Description |
|---|
| Lack of documentation that staff were trained in the provision and management of the BiPAP machine and oxygen therapy for Resident #1. |
| Resident #1's service plan not followed for diaper rash treatment; resident self-administers medications but facility was out of supply of prescribed ointment. |
| Service plan not followed for oxygen therapy and use of BiPAP machine as evidenced by blank initials on electronic Treatment Administration Record. |
| No documented nursing assessment and health monitoring for Resident #1 with physician-ordered treatments for blister and swelling. |
| No documented evidence that RN completed medication assessment to determine Resident #1's capacity to self-administer medications following readmission. |
| Prescription medications stored in resident's possession in dining/activity room, contrary to facility policy requiring medications to be kept in the unit. |
| Resident #1's oxygen order did not clarify turning off oxygen during ADLs such as toileting, showering, and oral care. |
Report Facts
Completion Date: Feb 7, 2025
Completion Date: Feb 5, 2025
Completion Date: Feb 21, 2025
Completion Date: Jan 21, 2025
Completion Date: Jan 31, 2025
Completion Date: Feb 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Choy | Licensee/Administrator | Signed the plan of correction document on 02/13/2025 |
Inspection Report
Annual Inspection
Deficiencies: 6
Jan 18, 2024
Visit Reason
Annual inspection conducted to assess compliance with state regulations and identify any deficiencies in the facility's service plans and medication administration.
Findings
Deficiencies were found related to service plans not reflecting physician orders accurately for residents, medication availability issues, and documentation of physician orders and medication administration. Plans of correction were submitted addressing these issues with retraining of staff and updates to service plans and medication procedures.
Deficiencies (6)
| Description |
|---|
| Resident #1 service plan showed blood pressure check weekly; however, electronic medication administration record indicated monthly checking. |
| Resident #2 service plan was not updated to reflect safe swallowing precautions as recommended by the speech therapist, including weekly weights and diet texture modifications. |
| Resident #2 physician order for Anusol cream was not available for resident use as medication was not brought in timely. |
| Resident #2 physician ordered sitz bath due to external hemorrhoids, but no documentation showed the order was carried out, endorsed, or discontinued. |
| Resident #2 physician order for Glucosamine-Chondroitin did not indicate medication/supplement administration or refusal in e-MAR. |
| Resident #2 physician order for Anusol cream was administered BID routinely but documentation was incomplete. |
Report Facts
Completion Date: Feb 1, 2024
Completion Date: Feb 7, 2024
Inspection Report
Annual Inspection
Deficiencies: 4
Jan 25, 2023
Visit Reason
The inspection was conducted as the facility's annual inspection to assess compliance with state regulations.
Findings
The report identified deficiencies related to the lack of a managed risk plan for bed rail use, outdated service plans not reflecting current orders, and failure to notify physicians of significant weight changes in residents. The facility submitted plans of correction including retraining staff, updating service plans, and implementing monitoring procedures.
Deficiencies (4)
| Description |
|---|
| No managed risk plan was developed for the use of bed rail for Resident #1. |
| Service plans for Resident #1 and Resident #2 were not updated to reflect current orders. |
| No documented evidence that the physician was notified of significant weight changes for Resident #1. |
| Service plan was not updated to indicate Resident #1's use of bed rails. |
Report Facts
Completion Date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Fajota | Licensee/Administrator | Signed the plan of correction document |
Inspection Report
Annual Inspection
Deficiencies: 6
Jan 20, 2022
Visit Reason
Annual inspection conducted to evaluate compliance with state regulations for The Plaza at Mililani assisted living facility.
Findings
The inspection identified deficiencies related to inconsistencies and untimely updates in residents' service plans, lack of documented health monitoring assessments by a consultant registered dietitian, and missing daily weight and vital sign recordings as ordered by physicians.
Deficiencies (6)
| Description |
|---|
| Resident #1 service plan weights to be done weekly not consistent with physician's order for daily weights. |
| Resident #1 daily weight readings unavailable for multiple dates; night checks not provided timely on multiple dates. |
| Resident #2 blood pressure readings unavailable for multiple dates despite physician's order. |
| Resident #4 service plan not updated timely between 3/24/21 and 11/6/21. |
| Resident #5 service plan not updated timely between 1/22/20 and 9/11/20. |
| No documented evidence that the facility provided health monitoring for residents with specific dietary needs by the Consultant Registered Dietitian. |
Report Facts
Order dates: 2
Missing daily weight readings: 6
Missing night checks: 17
Missing blood pressure readings: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Fajota | Licensee/Administrator | Signed the plan of correction documents dated 02/03/2022 and 02/14/2022. |
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