Aloha Nursing & Rehab Centre

Inspectors wroteBased observation, interviews and review of the facility's Food Management System policies, the facility failed to monitor and check the dishwasher sanitizing temperature logs on a consistent basis, properly label open food items in the freezer, and discard food items in the refrigerator by its use-by date. This deficient practice places residents in the facility who are provided with meals, at risk for foodborne illness. [...]

Inspectors wroteBased on observation, interviews, and review of the facility's Feeding Impaired Resident's policy, the facility failed to promote care that maintains the dignity for one out of seven residents (Resident (R) 57) observed during dining observation. This deficient practice has the potential to affect all residents who require assistance with their meals. Findings Include:On 07/29/25 at 12:30 PM, observed R57 in bed waiting for assistance with lunch. At 12:35 PM, Certified Nurse Aide (CNA) 41 came into R57's room to assist R57 with lunch. Observed CNA41 assisting R57 with four to five spoonful of food and sips of juice while standing up. At 12:40 PM, observed CNA41 taking the lunch tray away. CNA41 did not take time to encourage resident to eat more and only spent five minutes assisting R57 with lunch. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to discuss and complete the baseline care plan (BCP) within 48 hours for one out of one residents (Resident (R) 28) sampled for BCPs. This deficient practice places residents at risk for not receiving appropriate and timely care, delays the development of care to address resident's immediate health and safety needs, hinders continuity of care, and impedes communication amongst nursing staff. Findings Include:On 07/30/25 at 09:29 AM, interview with R28 noted that the facility did not include him in care plan decision making when he first was admitted . On 07/31/25 at 3:00 PM, record review of R28's Electronic Health Record (EHR) noted he was admitted to the facility on [DATE]. No BCP found in the EHR and no documentation that BCP was discussed with R28 or Family Member (FM) within 48 hours of admission. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one of two residents (Resident (R) 2), sampled for limited range of motion (ROM), received the appropriate treatment to prevent or delay a further decrease to the contracted lower extremities. This hindered R2's ability to maintain the highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility who have limited ROM.Findings Include:Resident (R) 2 is a [AGE] year-old male admitted to the facility on [DATE] for long term care with a primary diagnosis of anoxic brain damage (brain loses oxygen supply causing permanent brain damage). [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement interventions to prevent avoidable falls for one of one (Resident (R)19) sampled. R19 had fall five fall incidents from 05/11, 06/01, 06/10, 06/17, and 07/17/25. One of the five fall incidents resulted with R19 sustaining an arm injury (abrasion or skin tear). Findings Include: On 07/29/25 at 09:16 AM, during a tour of the facility, observed R19's room was located farthest from the nurses' station and with door completely closed. After knocking and requesting permission to enter R19's room, seen him alone, sitting at the right side of the bed eating breakfast. Reviewed the facility matrix on 07/29/25 at 10:30 AM. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and services to prevent dehydration for one (Resident (R) 21) of one resident in the sample, despite identifying them as at risk for compromised nutrition and hydration. This deficient practice could affect residents who rely on staff to provide fluids to them throughout the day to maintain proper hydration and health. Findings Include:On 07/29/25 at 09:15 AM, concurrent observation and interview was done. Observed no water pitcher found in R115's bedside. Subsequent observation was done at 10:35 AM and found no water pitcher was provided at resident's bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a protocol to identify past trauma experienced for two of two residents (Resident (R) 3 and R40) sampled for mood/behavior. As a result of this deficient practice, both residents did not have their trauma triggers identified, placing them at increased risk of re-traumatization, and was hindered from attaining their highest practicable mental and psychosocial well-being. Findings Include:1) R3 is a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses that include vascular dementia, with other behavioral disturbance and post-traumatic stress disorder (PTSD). A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/25 noted that R3's Brief Interview for Mental Status (BIMS) score of 03, which indicated that R3 has severe cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that medications and equipment in two of three medication carts and wound care supplies for one resident (Resident (R) 9) were stored and labeled in accordance with professional standards. Proper storage and labeling of medications and equipment are necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications and utilize equipment stored in the medication and treatment carts. Findings Include: 1) On [DATE] at 09:44 AM, a medication cup containing a white cream and tongue depressor was observed at the bedside of Resident (R) 9. At 09:47 AM, interviewed Registered Nurse (RN) 75 inside R9's room. [...]

Inspectors wroteBased on record review and interview the facility failed to assure one of one Resident ((R) 69) sampled for Hospice had a current certification of terminal illness and current Interdisciplinary Group (IDG) Comprehensive Assessment in her hospice binder or electronic health record (EHR). R69's EHR and hospice folder were not updated with current care information putting the resident at risk for not being provided continuity of care at the end of life. Findings Include:On 07/30/25 record review of R69's Electronic Health Record (EHR) and facility provided matrix revealed resident is receiving hospice services. Review of R69's hospice binder revealed it did not have a current hospice certification of terminal illness and the last IDG Comprehensive Assessment Details form from July 2025. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. After exiting a Transmission Based Precaution (TPB) room (a COVID positive resident), Certified Nurse Aide (CNA) 57 was not wearing applicable Personal Protective Equipment (PPE), Registered Nurse (RN) 127 did not perform glove change and any hand hygiene while performing wound care for resident (Resident (R) R104). The facility also failed to assure Resident (R) 67's urinary catheter bag was hanging and not on the ground while he was in bed. These deficient practices placed the resident at risk for developing preventable infections and other adverse health complications. Findings Include: 1) Record review of R67's Electronic Health Record (EHR) on 07/29/25 revealed he is a [AGE] year-old who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews, record and document review, the facility failed to make timely revisions to the comprehensive person-centered care plan of four residents (R)1, R2, R3 and R4, of six residents sampled.

Inspectors wroteBased on interviews and record review, the facility failed to identify and plan in advance for the situation where one Resident (R)4, of one sampled, would have a predictable condition decline, in which health care decision-making would be needed to provide guidance to the direct care staff. Specifically, when R4 had a significant change of condition, clinical interventions where implemented, the Power of Attorney (POA) was notified in a timely manner for direction, but staff failed to immediately consult with the physician about the condition change. As a result of the lack of planning, there may have been a delay in transfer to a higher level of care.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's right to be informed in advance of the risks and benefits of proposed care for two of three residents (R) (R4 and R11) sampled. The facility did not have documentation that the resident or resident representative was informed, in advance, of the risk and benefits of psychotropic medication therapy. As a result of this deficient practice, resident's receiving psychotropic medication are at risk for more than minimal harm.

Inspectors wroteBased on observation, interview and review of the policy, the facility failed to store food in a safe manner and maintain a sanitary cooking area. Two nourishment refrigerators on the first and second floors internal temperatures were not kept at or below 41 degrees. Perishable foods in the refrigerators were found to be at temperatures that were at 49.5 and 51 degrees. One pantry refrigerator in the main kitchen was found with an internal temperature at 43 degrees. Opened foods were not labeled with an indication of when staff should dispose of the food in the pantry, dry storage, and cooking areas. The deficient practice places residents in the facility at risk for foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to include in the facility assessment the staffing resources required to meet the needs of their resident population. This deficient practice has the potential to affect all the facility's resident's ability to maintain or attain their highest practicable physical, functional mental and psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's right to formulate an Advanced Health Care Directive (AHCD) for three of six Residents [(R)151, R87, and R97] sampled.

Inspectors wroteBased on interviews and record review, the facility failed to electronically transmit and complete the Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within 14 days for one Resident [(R)87] sampled.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and/or implemented for three residents (Resident (R)300, R250 and R52) in the sample. Specifically, a care plan was not developed to monitor for adverse effects of taking a blood thinner for R300. No care plan was developed for the care of R250's Peripherally Inserted Central Catheter (PICC) line (tube inserted into a vein in the upper arm and threaded into a large vein above the heart to provide intravenous treatments), The facility did not develop a care plan to address R52's skin condition. As a result of these deficient practices, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's comprehensive person-centered care plan was revised for one Resident (R)87 of 22 residents in the sample.

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (R)150 of 22 in the sample, was free of accidents during her stay in the facility and failed to develop a discharge plan that would ensure the resident was safely discharged . R150 had multiple falls during her stay in the facility. The deficient practice increased the resident's risk for injury and has the potential to affect residents who are discharged home.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate services to prevent urinary tract infections for one resident (Resident (R) 52) sampled. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that staff implemented specific competencies necessary for resident safety. This deficient practice has the potential for harm.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled. This deficient practice increases the risk for diversion of residents' medications.

Inspectors wroteBased on interview and record review, the facility failed to review and act upon a pharmacist's recommendation on a monthly Medication Regimen Review (MRR) for one of five sampled residents (Resident (R) 79). This deficient practice has the potential to negatively affect R79's overall health and well-being. Findings Include: A review of R79's Electronic Health Record (EHR) was conducted. R79's EHR documented a MRR dated 05/31/24. The MRR noted a recommendation by the pharmacist, This resident continues to receive an atypical antipsychotic. Please consider, lipid panel [measurement of cholesterol and triglyceride in the blood], LFT [Liver Function Test], A1C [measurement of the average amount of sugar in the blood in the past few months]. Further review of R79's EHR, did not contain lab results for lipid panel, LFTs, and A1c. [...]

Inspectors wroteBased on interviews and record review, the facility failed to accommodate a diet preference for one of 25 sampled residents (Resident (R)300). This deficient practice has the potential to affect R300's overall well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. While providing care for Resident (R)250, the facility staff was not wearing applicable Personal Protective Equipment (PPE), did not perform hand hygiene between glove change, and did not follow guidelines to prevent possible cross-contamination of clean supplies. These deficient practices placed the resident at risk for developing preventable infections and other adverse health complications.

Inspectors wroteBased on interviews and record review, the nursing staff failed to demonstrate competency when caring for two residents (R1 and R2) out of a sample size of three. Evidence included: 1. R1 had a change of condition that the Registered Nurse (RN)1 failed to immediately notify the physician (MD1). 2. When MD1 failed to respond, there were no other attempts to contact him or another provider. 3. RN1 failed to monitor R1's condition according to nursing standards. 4. The nursing staff failed to attempt to wean R2 off oxygen as directed by MD order, and 5. MD was not notified R2 refused to wean off oxygen therapy. As a result of these deficiencies, R1 suffered harm when she fell a second time and became unresponsive requiring transfer to the hospital. In addition, R2 was at increased risk of complications due to the oxygen administration. [...]

Inspectors wroteBased on interviews and record/document review, out of a sample of three residents (R), the nursing staff failed to immediately consult one Resident's (R)1 physician when there was a change in condition. In addition, the resident's family was not notified of the change of condition and subsequent transfer to a hospital. As a result of this deficiency, the MD was not aware of the condition change from baseline and was not able to implement interventions which may have prevented further decline. This deficient practice has the potential to affect any resident with a change of condition and may result in harm or death.

Inspectors wroteBased on observation, record reviews, and interview, the facility failed to provide respiratory care that is in accordance with professional standards of practice for two Residents (R)1 and R2, out of a sample size of three. The physician order for R1's oxygen therapy did not include the type of delivery system, when to administer or discontinue the oxygen, and prescribed oxygen flow rates, and R2's oxygen administration was outside the parameters of the physician order. In addition, the facility Oxygen Therapy Protocol does not meet the requirements of a complete order/standing order. These deficient practices could potentially cause harm to any residents who is administered oxygen. Findings Include: 1) R1 was a [AGE] year old female that was transferred to the facility from acute care on 07/19/23 for short term rehabilitation. [...]

Inspectors wroteBased on interviews , medical record and document review, the facility failed to ensure a physician (MD)1 responded when staff attempted to contact him regarding a resident's (R)1 change of condition, on 08/17/2023. As a result of this deficiency, no provider was made aware of R1's status and there were no interventions implemented, that may have prevented further decline of R1's condition. In addition, the facility policy to provide/arrange for provision of physician services 24 hours a day in case of emergency directs staff to contact the medical director if unable to reach the provider, but does not provide arrangements if the medical director does not respond. This deficiency puts all residents at risk of decline which may result in harm or death, if there is not a system in place to reach a physician 24/7 for emergencies.

Inspectors wroteBased on observations, interview, and record review, the facility failed to completely screen visitors, guest, vendors for signs and symptoms of COVID-19. As a result of this deficiency, residents, staff, and visitors were at increased risk for contracting the COVID-19 virus. Findings Include: Observation on 08/21/23 at 07:50 AM, there was a passive screening station for COVID-19 at the entrance to the facility. The station prompted visitors, guest, vendors to complete a screening questionnaire related to COVID-19. There was no staff in the immediate vicinity to monitor the station. Upon completion of the questionnaire, there was nothing provided to verify that the screening questionnaire was completed. The visitor, guest, vendor could enter the facility and there was no visual validation to show that the screening for COVID-19 was completed. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to treat one resident (R), R46, out of two residents sampled, with dignity and respect. This deficient practice has a negative effect on maintaining and enhancing R46's self-esteem and self-worth. The deficient practice has the potential to cause psychosocial harm to R46. Findings Include: R46 is a [AGE] year-old male admitted to the facility on [DATE]. R46 has a diagnosis that include but is not limited to Parkinson's Disease. A review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/23/23 revealed that R46 was determined to have a Brief Interview for Mental Status (BIMS) score of 14, meaning he was found to be cognitively intact. Observation was conducted on 08/21/23 at 11:18 AM in R46's room. R46 was in the middle of eating a meal. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to document an interdisciplinary (IDT, includes but not limited to, the physician, social worker, dietitian, and nurse) assessment and care plan regarding a resident's self-administration of medication. The lack of this process failed to ensure that resident (R), R56, out of a sample of one, was assessed appropriately for having the capability to self-administer his medication safely and correctly. There also was no process to follow-up with R56 to ensure that he retained the capability to self-administer medication. This deficient practice could potentially harm residents who want to self-administer their medication(s). Findings Include: On 08/23/23 at 08:30 AM, conducted a concurrent observation and interview with Registered Nurse (RN)11 while administering R56's medications in R56's room. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to ensure a safe and effective transition of care for three of five residents (R), (R64, R82 and R12) in the sample. The facility did not provide a copy of the comprehensive care plan goals to the receiving provider. This deficient practice does not provide an accurate picture of the resident and of his/her needs which will result in poor continuity of care. Findings Include: 1) During an interview on 08/22/23 at 09:01 AM, R64 stated he was recently hospitalized for low blood pressure and pneumonia (lung infection). Review of Electronic Health Record (EHR) revealed that R64 is a [AGE] year-old resident admitted on [DATE]. R64 was transferred to an acute care hospital on [DATE] for non-ST-elevation myocardial infarction (less severe form of heart attack), respiratory failure, and pneumonia. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for three of 22 residents (R)26, R34,and R64 in the sample. Care plans and interventions were not personalized to the needs of the residents. As a result of this deficient practice, the residents are at risk of not reaching their highest practicable physical and psychosocial well-being. Findings Include: 1) Cross Reference F692 Nutrition/Hydration Status Maintenance On 08/21/23 at 01:27 PM, observed R26 in her room with the main entree of her lunch not eaten. The whole broccoli pieces were not eaten and were two inches in length. The meal ticket on R26's tray indicated a regular diet with chopped texture. On 08/22/23 at 12:18 PM, observed R26 in her room with her lunch tray on her bedside table pushed to the left side of her bed. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain the nutrition status of one Resident (R)26 out of a sample of four residents. R26's diet texture was not provided to her according to the physician's order, which could potentially impact her dietary intake. This deficient practice rendered R26 under nourished and does not allow R26 to live at her highest practicable physical and psychosocial well-being. Findings Include: Cross Reference to F656 Develop/implement Comprehensive Care Plan On 08/21/23 at 01:27 PM, observed R26 in her room with the main entree of her lunch not eaten. The whole broccoli pieces were not eaten and were two inches in length. The meal ticket on R26's tray indicated a regular diet with chopped texture. Record review of R26's electronic health record (EHR). [...]

Inspectors wroteBased on observation, record reviews, and interview, the facility failed to provide respiratory care that is in accordance with professional standards of practice for one Resident (R)64, out of one resident in the sample. The physician order for the use of oxygen did not include the type of delivery system, when to administer or discontinue the oxygen, and prescribed oxygen flow rates. This deficient practice could potentially cause harm to residents due to the lack of physician direction. Findings Include: On 08/21/23 at 09:59 AM, observed R64 sitting up in bed watching television. R64 had a nasal cannula (plastic tubing placed into the nares) connected to an oxygen concentrator set at 2.5 liter per minute. R64 said he was going out for his hemodialysis treatment and will not be back until later that afternoon. [...]

Inspectors wroteBased on record reviews and staff interview, the facility failed to communicate two medication recommendations, between the pharmacist and the attending physician, for one resident(R), R51, out of five residents sampled. As a result of this deficiency, the facility put R51 at risk for complications related to medications. Findings Include: Review of the electronic health record (EHR) showed R51 was admitted to the facility on [DATE] with diagnosis including Dementia, Diabetes, Post-Traumatic Stress Disorder, Hypothyroidism, and Depression. Review of the Medication Regimen Review (MRR) document completed by the Pharmacist dated 02/23/23 read . Will recommend clarification on diagnosis of Sertraline [antidepressant medication] . There was no documentation that this was communicated to the attending physician. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications. Findings Include: Concurrent observation and interview were conducted on 08/24/23 at 08:11 AM in the first-floor hallway. A medication cart was observed unlocked in the hallway with staff members, residents, and visitors walking by. This surveyor and Director of Nursing (DON) were present when Licensed Practical Nurse (LPN) 1 was interviewed. LPN1 stated, I thought I locked it. He also added that medication carts should always be locked. A review of the facility's policy titled, Medications: Storage, with a revision date of 01/11/23 was conducted. [...]

Inspectors wroteBased on observations and interview, the facility failed to label food items with the dates they were opened to ensure they were not served after the expiration date. As a result of this deficiency, residents, visitors, and staff were put at risk for contracting a foodborne illness. Findings Include: On 08/21/23 at 08:07 AM, conducted the initial brief tour of the kitchen. Observed two thickener containers by the food preparation area that were opened. Both containers did not have a label to indicate when they were initially opened, and both were nearly empty. Observed an open bottle of cranberry juice on another counter that was half full and without a label indicating when it was opened. Interviewed Kitchen Manager (KM) in the kitchen at the end of the intial brief tour conducted on 08/21/23. [...]