Inspection Report Summary
The most recent inspection on July 18, 2024, identified deficiencies related to medication accountability, conflicting and incomplete service plan information, and medication administration documentation. Earlier inspections also noted issues with medication refrigerator temperature monitoring, service plan accuracy, and documentation of resident care tasks such as night checks and weight monitoring. Inspectors cited recurring themes involving medication management and service plan updates. There were no complaint investigations or enforcement actions listed in the available reports. The pattern of findings suggests ongoing challenges with documentation and medication procedures, with similar issues appearing across multiple years.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 5
Jul 18, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with assisted living facility regulations under Chapter 90.
Findings
The report identifies deficiencies related to narcotics/controlled medication accountability, conflicting service plan information for a resident, and incomplete medication administration documentation. Plans of correction and future preventive measures were outlined for each deficiency.
Deficiencies (5)
| Description |
|---|
| Narcotic medications were not accounted for on 7/15/24 with missing signatures by two licensed staff. |
| Resident #1's current service plan (4/1/24) shows conflicting information regarding night checks and medication administration. |
| Resident #1's current medication order shows insulin was not administered as ordered on 6/19/24 and 6/12/24. |
| Resident #1's current service plan was not updated to include diabetic interventions such as insulin administration and orange juice administration if blood sugar is below 70. |
| Resident #1's service plan lacked documentation of managed risk agreement for elopement despite an elopement risk assessment indicating risk. |
Report Facts
Inspection Dates: Inspection conducted on July 18 and 19, 2024
Medication incident dates: Insulin not administered on 6/12/24 and 6/19/24
Service plan date: Service plan dated 4/1/24
Elopement risk assessment date: Elopement risk assessment completed on 4/1/24
Inspection Report
Annual Inspection
Deficiencies: 5
Jul 7, 2023
Visit Reason
Annual inspection conducted to assess compliance with state licensing requirements for The Plaza at Moanalua assisted living facility.
Findings
Multiple deficiencies were identified including lack of documented daily temperature readings for medication refrigerators, incomplete service plans reflecting hemodialysis treatments, missing documented monthly weights for residents, inconsistent performance of night checks, and lack of documented medication effectiveness evaluations.
Deficiencies (5)
| Description |
|---|
| No documented evidence of daily temperature readings obtained for medication refrigerators on 3rd and 4th floors for October and November 2022 and specific dates in July 2022. |
| Resident #1's service plan did not reflect hemodialysis treatments three times per week as part of medical needs. |
| Residents #1 and #2 had no documented evidence of monthly weight obtained for specified months. |
| Resident #1's current care plan stated night checks every 2 hours between 2200-0600, but task was not consistently performed as stated. |
| Resident #1 had no documented evidence that medication effectiveness was evaluated following administration of Lasix (PRN) on 10/2/22. |
Report Facts
Dates missing temperature readings: 4
Hemodialysis treatments frequency: 3
Night check interval: 2
Date of medication administration: Oct 2, 2022
Inspection Report
Annual Inspection
Deficiencies: 5
Jul 5, 2022
Visit Reason
The inspection was conducted as the annual survey for The Plaza at Moanalua facility to assess compliance with licensing requirements and regulations.
Findings
The report identifies multiple deficiencies including lack of documented medication refrigerator temperature monitoring, untimely fire drills, unavailable annual tuberculosis clearance for an employee, and incomplete or outdated service plans for residents. Each deficiency is accompanied by a plan of correction focusing on future prevention.
Deficiencies (5)
| Description |
|---|
| No documented evidence medication refrigerator temperature was monitored on 6/29/22 and 7/2/22. |
| No documented evidence a fire drill was conducted in a timely manner between 5/28/21 and 12/3/21. |
| Annual tuberculosis clearance for Employee #1 was unavailable for review. |
| Service plans for residents were not followed or updated timely, including failure to perform night checks as stated, weights not documented, and diet orders not updated. |
| No documented evidence residents' initial comprehensive assessment and service plan were completed prior to admission on 10/22/21. |
Report Facts
Inspection Date: Jul 5, 2022
Dates missing medication refrigerator temperature monitoring: 2
Fire drill missing timeframe: 190
Service plan dates missing or incomplete: 3
Resident weights missing documentation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Certified Staff (CS) | Named in tuberculosis clearance deficiency and correction |
| Meli Cheung | Administrator | Signed plan of correction documents |
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