Hale Kupuna Heritage Home, LLC

Inspectors wroteBased on Observation, interviews and record reviews. The facility failed to provide supervision based on the individual resident's assessed needs and the risks identified in the environment to prevent accidents for three of three Residents (R) 7, R5 and R54. The deficient practices resulted in falls with major injuries for two (R5 and R54) of three residents sampled for free of accident hazards/supervision/devices, and an injury for one resident, R7. Findings Include: Cross reference to F725 sufficient nursing staff. Observation and interview with R7 sitting in a chair at the dining room table on [DATE] at 11:14 AM in the dining area on C wing. Observed an adhesive bandage on top of his head. Asked R7 what happened to his head. R7 said he fell in the bathroom last Saturday and went to the emergency room (ER). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that its response to a Resident Council grievance was implemented and sustained in practice for one of four identified concerns. The Resident Council requested that the daily menu boards in the units be updated regularly to reflect current meal offerings. Although the facility developed action plans in response to the grievances, the facility failed to implement and sustain the interventions, resulting in menu boards that were not updated timely, or accessible to residents on a consistent basis. The deficient practice affected the resident's ability to make informed choices about their meals. Findings Include: On 03/09/26 at 10:49 AM, observed the posted daily menu in the building 1, B Wing. The breakfast and dinner menus posted were not updated. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assure that there were sufficient numbers of qualified nursing staff available in areas of the facility where vulnerable residents with high fall risk reside, to provide the supervision needed to promote safety and prevent unwitnessed falls for two of three residents (Resident (R) 7 and R54) sampled for Accident Hazards/Supervision/Devices and sufficient nurse staffing. The deficient practice resulted in pain, hospitalization and decline in function due to injuries that resulted from the falls. Cross reference to F689 Free of Accident Hazards/Supervision/Devices.

Inspectors wroteBased on observation and interview, the facility failed to serve food at a preferable temperature for one lunch tray sampled. The foods that were to be kept cold were not served at the preferred temperature of 40 degrees Fahrenheit. The deficient practice may affect good nutrition and hydration status to help prevent, or aid in the recovery from, illness or injury.

Inspectors wroteBased on observations, interview, and policy review, the facility stored items in the walk-in refrigerator that were past the expired date; an open container was not labeled with an open or expiration date. The deficient practice placed residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff followed infection control and prevention measures while providing care for residents. Staff observed not performing hand hygiene as meals were being served to seven residents. This deficient practice placed the residents at risk for the potential spread of preventable infections and other adverse health complications. Findings Include:On 03/09/26 at 12:03 PM, observed Dietary Staff (DS) 3 bring the meal cart to the unit. Seven residents were in the common area and were waiting for their lunch. DS3 opened the cart and pulled out a tray with the residents' meals. After placing all the food items and drinks on the table in front of the residents, DS3 went back to the cart and immediately pulled another tray for the next resident. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide proper notification of transfer/discharge for one of three residents sampled for closed records review. The facility did not send written notification to the office of the State Long Term Care Ombudsman (LTCO) when Resident (R) 53 was discharged . This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings Include:R53 was a [AGE] year-old resident admitted to the facility for short-term rehabilitation services following the removal of internal fixation device (metal implant used to stabilize broken bones). Diagnoses included but not limited to acute osteomyelitis and infection and inflammatory reaction due to internal right hip prosthesis. [...]

Inspectors wroteBased on record review and interviews, the facility failed to implement the person-centered intervention to provide stand by assist in the care plan to prevent falls for one resident (R) 54 sampled for Free of accident hazards/Supervision/Devices Develop/Implement Comprehensive Care Plan. The deficient practice resulted in an unsupervised fall that resulted in a major injury which caused pain and suffering for the resident.

Inspectors wroteBased on observations and staff interviews, the facility failed to: 1 and 2) ensure food were stored and frozen food thawed in a manner that avoids foodborne illness to the residents and 3) perform hand hygiene when distributing food trays to residents. As a result of these deficiencies, the facility put the residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure staff followed the Infection Prevention and Control policies and procedures for proper use of personal protective equipment (PPE) to follow proper infection control practices. Staff working with residents on isolation precautions did not correctly doff (remove) their PPE after providing care to Covid-19 positive residents in both resident care units in the facility. The same staff were also caring for residents who were not Covid-19 positive. The deficient practice places all residents in the facility at risk for healthcare associated infections that can result in significant adverse consequences.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's right to be informed of the risk and benefits of proposed care for one Resident (R42) sampled. R42 had a decline in cognition due to the resident's health status. R42's cognition was not re-assessed for the resident's capacity to consent to medication(s)/treatment. The resident signed a consent for the use of antidepressant and antipsychotic medications. As a result of this deficient practice, residents with changes in condition which affect the resident's ability to understand the information required to make an informed decision are at risk for the potential of harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one resident (Resident (R)39) was free from resident-to-resident abuse. R20 willful and intentionally punched R39 while smoking with staff present. As a result of this deficient practice, R39 sustained harm due to physical contact. The facility investigated, implemented updated interventions for resident safety, educated staff, and counseled the residents. Past non-compliance was determined as a result of the facility's corrective actions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an injury of unknown source was reported no later than 24 hours to the State Agency (SA) and Adult Protective Service (APS) for one resident (Resident (R)42) sampled. R42 sustained bruising to the left eyebrow and left eyelid. The source of the injury is unknown due to the resident's inability to verbalize what happened and it was not witnessed by staff. The facility confirmed the injury of unknow source was not reported to the SA or APS. Review of the SA's database, Aspen Complaints/Incident Tracking System (ACTS), confirmed the facility did not submit a report of R42's injury of unknown source. As a result of this deficient practice, residents are at risk for more than minimal harm.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate an injury of unknown origin to prevent further potential abuse for one resident (Resident (R)42). Staff reported bruises to R42's left eyebrow and eyelid and the source of the injury was unknown due to the resident's inability to verbalize what happened and the injury was not witnessed by staff. The facility did not identify the injury of unknown source as a potential for abuse of a vulnerable resident and did not investigate the potential source of the injury. As a result of this deficient practice, non-verbal and/or cognitive impaired residents are at risk for more than minimal harm.

Inspectors wroteBased on record review, staff interview and review of policy, the facility failed to provide written notice of bed-hold policy for one Resident (R)8 of two residents sampled. As a result of this deficiency, there was potential for miscommunication.

Inspectors wroteBased on record review (RR) and interview, the facility failed to have written, in their policies and procedures, data collections systems, monitoring, adverse event monitoring, feedback from direct care staff and other residents and representatives, opportunities for improvement, established with the minimum qualifications that should be established. This deficient practice has the opportunity for minimum Quality Assurance and Performance (QAPI) measures to be missed.

Inspectors wroteBased on observations and interviews the facility failed to provide sufficient nursing staff to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well being for four out of 15 sampled residents (Resident (R) 37, 22, 34, 36). The deficient practice has the potential to negatively effect all of the facility residents' physical, mental, and psychosocial wellbeing. Findings Include: 1) Concurrent interview and observation were conducted on 09/22/23 at 08:14 AM in the dining room. R37 verbalized that she had requested for her assigned Certified Nurse's Aide (CNA) 1 to take her back to her room a while ago, but CNA1 was nowhere to be found. R37 stated that it is very frustrating. CNA1 was then observed returning to the dining area to take one of the residents, R26, to the bathroom. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide the necessary care and services to ensure that one out of one sampled residents (Resident (R) 37) abilities in activities of daily living do not diminish. This failed practice has the potential to cause a decline in R37's mobility. Findings Include: R37 is a [AGE] year-old female admitted to the facility on [DATE]. R37 has a medical history that includes but not limited to Parkinson's disease. Interview was conducted with R37 on 09/20/23 at 11:51 AM in her room. R37 verbalized wanting to ambulate more often with a walker. R37 also added that she hasn't walked all week. Interview was conducted on 09/22/23 at 08:57 AM in the nursing administration office. State surveyor requested from the Director of Nursing (DON) R37's ambulation records. [...]

Inspectors wroteBased on record review and interview with staff, the facility failed to collaborate with the hospice provider for the development and implementation of the coordinated plan of care for one of one resident selected for hospice review. This is evidenced by the failure to include the hospice provider in the development of a plan of care and no consistent documentation of the hospice providers communication with the facility.

Inspectors wroteBased on observation, record review, and interview, the facility did not assure adequate supervision was provided to mitigate the risk of an accident for 1 (Resident 39) of 4 residents in the sample. The facility failed to ensure staff were present to implement the care plan to prevent Resident (R)39 from unsafe wandering. R39 wandered into R36's room which resulted in finding R39 on the floor. This deficient practice has the potential to result in resident-to-resident altercations.

Inspectors wroteBased on record review and interview, the facility failed to follow through on a gradual dose reduction (GDR) for one of five sampled residents (Resident (R) 16). This deficient practice has the potential to affect all residents on anti-psychotic medications and who need a gradual dose reduction and may be clinically contraindicated at a higher dose.

Inspectors wroteBased on observation, document review, and interview with staff, the facility failed to: ensure potentially hazardous foods (raw chicken and fish) were thawed properly; food items were sanitarily stored; stored food items were uncovered/sealed; stored boxes of food direly on the floor; and food items were not labeled to assure they are discarded in accordance with the facility's policy and procedures.

Inspectors wroteBased on observation and interview with staff, the facility failed to ensure staff followed infection control procedures for a resident on contact precautions. This deficient practice has the potential to result in transmission of communicable infections.

Inspectors wroteBased on observation and interview with staff, the facility did not assure the toilet and shower call light system was accessible for residents lying on the floor. This deficient practice has the potential to affect residents' ability to call for help if they fall to the floor.

Inspectors wroteBased on observation, the facility did not assure it had an effective pest control program. Observation of the kitchen found ants crawling on storage bin. Although the facility has a contract for pest control services, there were observations of ants crawling on the storage bin. This deficient practice has the potential to have food items contaminated resulting in food borne illnesses.