Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Annual Inspection
Deficiencies: 5
Jun 19, 2025
Visit Reason
The inspection was conducted as the annual survey to assess compliance with state licensing requirements for The Plaza at Waikiki assisted living facility.
Findings
Multiple deficiencies were found including a pungent urine smell in resident room 531, a non-working pull cord system in the same room, lack of PRN medication supply for Resident #1, a service plan initiated one day after Resident #3's admission, and no documented evidence of clear diet provision and health monitoring for Resident #1 following an ERCP procedure.
Deficiencies (5)
| Description |
|---|
| A pungent urine smell was noted in resident room 531. |
| The pull cord system is not working in resident room 531. |
| Resident #1 – Current medication orders include PRN medications Senna-S 8.6-50 mg and Tylenol 325 mg tablet, but no supply available for PRN administration. |
| Resident #3 moved into the facility on 5/14/25; however, service plan was initiated on 5/15/25. |
| Resident #1 – No documented evidence that a clear diet was provided and health monitoring was performed by licensed staff following an ERCP procedure on 10/29/24. |
Report Facts
Inspection dates: Inspection conducted on June 19 & 20, 2025
Resident admission date: May 14, 2025
Medication dosage: 8.6
Medication dosage: 50
Medication dosage: 325
Procedure date: Oct 29, 2024
Inspection Report
Annual Inspection
Deficiencies: 7
Jun 19, 2024
Visit Reason
The inspection was conducted as the annual survey of The Plaza at Waikiki assisted living facility on June 19 and 20, 2024.
Findings
The report identifies multiple deficiencies related to medication administration, wound care, comprehensive assessments, service plans, nursing assessments, and incident reporting. The facility was required to submit plans of correction addressing these issues.
Deficiencies (7)
| Description |
|---|
| Electronic Treatment administration record (eTAR) shows medication aides administered wound care without documentation of registered nurse delegation and training. |
| Comprehensive assessment did not include nursing services for skin care and prescribed treatments for a resident with sacral pressure injury. |
| Service plan did not include individualized interventions to mitigate frequent falls for a resident with multiple falls. |
| No documented evidence that licensed staff monitored sacral pressure injury healing or wound treatment effectiveness. |
| No documentation in progress notes that physician's recommendations for a resident's sacral decubitus ulcer were carried out or followed. |
| No incident report generated for sacral pressure injury noted on 6/9/23. |
| No documentation of completed falls assessments following multiple falls for a resident. |
Report Facts
Inspection dates: June 19 and 20, 2024
Plan of correction completion date: July 23, 2024
Resident fall dates: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jan Aina | Licensee/Administrator | Signed the plan of correction document |
| Director of Nursing | Communicated wound care and medication aide requirements; named in plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 16, 2023
Visit Reason
The inspection was conducted as the facility's annual regulatory compliance survey.
Findings
Two deficiencies were identified related to the service plan and nursing services. The service plan lacked documented evidence of consistent intervention performance, and nursing assessments did not document monitoring or resolution of a resident's fever.
Deficiencies (2)
| Description |
|---|
| Resident #1's service plan included an intervention for night checks every 4 hours, but no documented evidence showed consistent performance of this intervention between January 2023 and the inspection date. |
| Resident #1's vital signs showed a temperature of 101°F on 6/15/23, but there was no documented evidence that the fever was monitored or resolved. |
Report Facts
Inspection Date: Jun 16, 2023
Inspection Report
Annual Inspection
Deficiencies: 1
Jun 9, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for The Plaza at Waikiki assisted living facility.
Findings
The inspection identified a deficiency related to the service plan for Resident #1, specifically the lack of documented evidence that night check tasks were performed as scheduled on multiple dates.
Deficiencies (1)
| Description |
|---|
| No documented evidence that night check tasks were performed as indicated in the service plan for Resident #1 on multiple dates. |
Report Facts
Dates of missed documented tasks: 13
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