Hale Makua - Wailuku

Inspectors wroteBased on interviews and record review, the facility failed to ensure the State Long Term Care Ombudsmen (LTCO) was provided written notification of resident's transfer/discharge from the facility for two of three residents sampled for hospitalizations.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to implement the fall risk plan of care for fall mats to be placed at the sides of the bed for one out of 19 residents sampled for comprehensive care plan review. The deficient practice increased the resident's risk for falls. Findings Include:On 01/27/2026 at 1;00 PM, observed Resident (R) 47 sitting in a wheelchair outside his room. R47 had on a right arm sling. When asked what happened to his right arm, R47 stated he fell yesterday around 3:00 PM when he tried to pick up something he had dropped on the floor. R47 said that he had to be taken to the emergency room (ER) for evaluation and is awaiting the results of his x-ray. R47 stated he is weak on his right side due to a previous stroke and has blurred vision. On 1/28/26 at 08:32 AM, observed R47 asleep in bed and no floor mats in place. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to remove R6's pressure dressing after four hours from the completion of his hemodialysis (HD) treatment for one of two residents sampled for dialysis services. The deficient practice was not consistent with professional standards of practice and put the resident at risk for complications to his access site. Findings Include:On 01/28/2026 08:45 AM, observed Resident (R) 6's left upper arm (LUA) fistula pressure dressing still on from the previous day which was more than 15 hours after he completed the dialysis treatment. R6 said that he came back from dialysis yesterday around 5:00 PM and that staff sometimes do not check his fistula access every shift and will leave the dressing on because of bleeding. At 09:00 AM, conducted an interview with Registered Nurse (RN) 1. [...]

Inspectors wroteBased on observation and interview the facility failed to store food kept in the freezer at 0 degrees Fahrenheit or less. This deficient practice puts all the residents at risk for foodborne illness, Findings Include: On 11/12/24 at 09: 48 AM during initial tour of the kitchen interviewed kitchen staff (KS)1. Inquired about temperature log for the freezer that showed temperatures logged from 0 to 6 degrees Fahrenheit. Review of the Freeze Temp Record form has standard Freeze temperature less than or equal to 0. Review of this form found a row for re check temp and maintenance notified boxes which were left blank. The temperatures above 0 degrees (8) did not have re check temp and maintenance notified filled out. Inquired of KS1 if she is supposed to re-check the temperature of the freezer or notify maintenance and KS1 stated she rechecked the temperatures but did not document it. [...]

Inspectors wroteBased on observations and interviews the facility failed to prevent flies and a bird from entering the dining room while residents were eating their lunch and lunch trays were being made. This deficient practice puts the residents at risk for foodborne illnesses. Findings Include: On 11/14/24 at 11:45 AM while observing kitchen staff put containers of uncovered hot food onto the trayline observed there were flies near the trayline flying above the open food. Food Service Director (FSD) shooed away the flies and covered the food with aluminum foil. FSD spoke with kitchen staff to remind her to cover the food with lids or foil as she is placing the containers on the trayline to prevent flies from going into the food. During this time a small bird was observed flying in the dining room and landed on the counter next to the microwave. [...]

Inspectors wroteBased on observations, interviews and policy review the facility failed to protect Resident (R)47's privacy while receiving peri-care (washing the genitals and anal area) exposing R47's naked body from the waist down to her roommate, R52. This deficient practice puts all residents who require assistance from staff, such as peri-care, at risk for being exposed to others causing psychological harm. Findings Include: On 11/12/24 at 11:40 AM surveyor walked into R47's room. The privacy curtain was pulled to block anyone from the outside walkway seeing R47 who at this time was having peri-care done by Certified Nurse Assistant (CNA)1. Surveyor walked further into the room and observed R47's roommate, R52, sitting in a recliner facing R47's bed. The privacy curtain was too short to go around R47's bed and R47's genitalia was exposed to R52. [...]

Inspectors wroteBased on observations and staff interview, the facility failed to store one oxygen cylinders (O2 tank) in a safe manner. As a result of this deficient practice, the facility put the safety and well-being of the residents, staff, as well as the public at risk for accident hazards.

Inspectors wroteBased on observations and staff interview, the facility failed to establish an infection prevention and control program relating to birds. As a result of this deficiency, there was increase risk of disease outbreak in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure food and drink items were stored in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents who have their meals served by the facility placing them at risk for food-borne illnesses.

Inspectors wroteBased on an interview with one Resident (R)42 of seven residents sampled, the facility failed to provide reasonable accommodations related to R42's showering and meals. As a result of this deficiency, there was risk for decline of R42's maintenance of independent functioning, dignity and well-being.

Inspectors wroteBased on interview and record review, the facility failed to appropriately perform diabetes management for 1 of 18 residents (Resident 22) in the sample by failing to ensure his blood sugars were measured, and his sliding scale insulin was administered at the appropriate times. As a result of this deficient practice, Resident (R)22 was placed at risk for an avoidable decline and/or injury related to his diabetes. This deficient practice has the potential to affect all the residents at the facility with insulin-dependent diabetes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 7 residents (Residents 62 and 29) sampled were free from accident hazards. The facility failed to develop effective interventions to prevent avoidable falls for Resident (R)62, and R29 was transferred from his bed to a shower chair using a mechanical lift device he had not been evaluated as safe to use. Placing residents at risk of avoidable accidents and injuries by not providing the appropriate assessments, planning, monitoring, and recommendations, and/or implementing the appropriate interventions is a deficient practice that has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations, staff interview and review of policy, the facility failed to label the humidified sterile water bottle for one Resident (R)177 of five residents sampled. As a result of this deficiency, the facility put R177 at increase risk for sterile water contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage pain adequately for 1 of 4 residents (Resident 22) sampled for pain. Specifically, the facility failed to ensure that Resident (R)22's pain regimen was implemented on a timely basis. As a result of this deficient practice, R22 was prevented from attaining or maintaining his highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services included an effective process to provide routine drugs to meet the needs of the residents, and failed to dispose of medications past their expiration date. As a result of this deficient practice, 2 residents (Residents 33 and 14) had routine medications that were out of stock, and residents who needed intravenous fluid were placed at risk of receiving expired fluids. This deficient practice has the potential to affect any patient taking medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by 2 medication errors observed out of 28 opportunities for errors, for an error rate of 7%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, two residents were placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff.

Inspectors wroteBased on resident interviews, staff interviews, record reviews and review of policy, the facility failed to ensure that two Residents (R)23, R25 of seven residents sampled understood the Binding Arbitration Agreement. As a result of this deficiency, R23, R25 did not fully understand the details of the Agreement.