Hale Malamalama

Inspectors wroteBased on interview, record and document review, the facility failed to protect one resident (R)1 of two investigated for staff abuse/neglect. Specifically, Certified Nurse Assistant (CNA)2 was witnessed to make inappropriate, unsympathetic comments to R1, and willfully neglected to provide her the necessary services of toileting on more than one occasion. As a result of these willful acts, R1 suffered mental anguish and emotional harm.

Inspectors wroteBased on interviews and record review, the facility failed to report two of a sample size of two allegations of Resident (R)1 and R2 abuse/neglect as mandated to the Office of Healthcare Assurance (OHCA). The Administrator (ADM)was not notified immediately of R1's allegation of mistreatment, and the facility failed to notify OHCA of results and actions taken.

Inspectors wroteBased on interviews and document review, the facility failed to provide evidence they conducted thorough investigations of two Resident (R)1 and R3 abuse/neglect allegations of a sample of two. In addition, the facility failed to remove the alleged perpetrators immediately when identified for R1's case. The facility also failed to internally investigate an Adult Protective Services (APS) case on R3 for neglect to provide needed services because they felt it was a resolved issue with staff assignments. Due to this deficiency, the underlying issue of providing timely services was not investigated to identify any quality issues or neglect.

Inspectors wroteBased on interviews and record review, the facility failed to timely update one Resident's(R)1 care plan. R1 initially required one assist for toileting/transfers. When her condition declined, she required two person assist and then the Hoyer lift to safely transfer her, but the facility did not revise her CP in a timely manner. As a result of this deficiency, there was the potential not all staff were aware of what assistance R1 required to provide safe transfers, increasing the potential for falls with injury or harm.

Inspectors wroteBased on observation, record review (RR) and interviews, the facility failed to provide the needed incontinence care and standards of practice for two residents, (R)2 and R3, of a sample size of three that needed incontinence care. This deficient practice has the potential to affect any resident requiring incontinence care.

Inspectors wroteBased on interviews and record review, the facility failed to create an annual Performance Improvement Project (PIP) that focuses on high risk or problem prone areas identified through the data collection and analysis. This deficient practice has the potential to negatively affect all the residents' overall wellbeing. Findings Include: Interview and facility document review were concurrently conducted on 09/27/24 at 10:33 AM with the facility Administrator. The facility's Quality Assurance and Performance Improvement (QAPI) binders did not contain documents on an annual Performance Improvement Project (PIP). Administrator confirmed that the committee met quarterly to discuss current facility issues and improvements but did not have an official PIP. A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Plan for HALE MALAMALAMA, was conducted. [...]

Inspectors wroteBased on observation, interview, and record review. The facility failed to provide an orderly and comfortable home for the residents residing in the facility, due to the following: Resident care equipment that was not maintained was stored in one resident's room which gave it a disorderly and cluttered appearance. Staff working at night were noisy and disrupted the residents sleep. The temperature in the dining room/ activity room was too cold at night. The efforts of the resident council to address the concerns failed to resolve the problems that were ongoing. The deficient practice affects the rights of the residents to live in a homelike and comfortable environment.

Inspectors wroteBased on observation, interview and review of policy, the facility failed to ensure housekeeping services were being provided to the residents in a manner that was safe. Housekeeping staff were cleaning the dining tables with chemicals that were toxic to the skin and eyes while residents were seated at the table. The deficient practices places the residents at risk for illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat one of 13 sampled residents (Resident (R) 4) with respect and dignity while assisting with R4's meal. This deficient practice has the potential to negatively affect R4's environment in promoting and maintaining her quality of life. This deficient practice has the potential to affect the residents that need assistance with their meals. Findings Include: Observation was conducted on 09/24/24 at 11:42 AM in R4's room. Certified Nurse Aid (CNA) 7 was observed assisting R4 with her lunch. CNA7 was sitting on R4's bed while assisting her with feeding. CNA7 stated that sometimes the CNAs would sit on R4's bed when assisting her with her meals due to a shortage of stools. At the same time and in the same room, CNA15 was observed assisting an unsampled resident with feeding. CNA15 was standing up. [...]

Inspectors wroteBased on record review and interview, the facility failed to revise one of the 13 sampled residents (Resident (R) 18) care plan after R18 had a fall with injury. This deficient practice has the potential to place R18 at risk for future falls and has the potential to affect all 34 residents in the facility. Findings Include: A review of R18's Electronic Health Record (EHR) was conducted. R18's EHR documented that R18 had a fall on 07/19/24. A Registered Nurse (RN) note documented, Resident was conscious and responsive. Skin tears on right arm measuring 3x2cm, left arm 4x1 cm, right leg 2x1cm and abrasion on left elbow 1.5x0.2 cm. Bump and redness on the side of his right face. R18 was then sent out to the emergency room via ambulance. A review of R18's care plan was conducted. R18's care plan did not contain any update or revision for R18's plan of care after the fall on 07/19/24. [...]

Inspectors wroteBased on observations, interview, and facility policy 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's medications. This deficient practice has the potential to affect all 34 of the residents in the facility. Findings Include: Concurrent observation and interview were conducted on 09/26/24 at 07:10 AM in the dining room. The medication cart was seen left unattended and unlocked. Two staff members were seen walking pass the medication cart while accompanying a resident. Registered Nurse (RN) 4 was observed administering medications to R27, who was seated at the dining table. RN5 was facing the resident. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care to residents in accordance with professional standards of practice. Resident (R)89 is allergic to iodine (disinfectant) and the facility did not identify and provide a substitute for iodine. The staff member used alcohol pads to cleanse the area before inserting a catheter. This deficient practice had the potential to cause burning of the skin or pain.

Inspectors wroteBased on record review (RR), interview with family and staff, the facility failed to ensure one of two residents sampled were free from accidents. Resident (R) 7 had two avoidable falls. The facility failed to perform a root cause analysis and based on identification of probably contributing factors, develop interventions to prevent falls. The facility also implemented interventions that were not included in the resident's care plan.

Inspectors wroteBased on record review (RR), interviews with family and staff, the facility failed to involve and notify resident's representative(s) of scheduled care plan meetings for Resident (R)6, R7 and R29. The facility also failed to revise care plans.

Inspectors wroteBased on interview with staff, the facility did not assure a system was in place to review the performance/competency of certified nurse aides (CNA) at least once every 12 months. This systemic deficient practice has the potential to affect the care residents receive to maintain and attain their highest practicable physical, mental, and psycho-social level.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide safe storage for foods in the kitchen refrigerators and freezer and failed to develop a process to ensure that their low water temperature and chemical dishwasher was operated and monitored correctly. This deficient practice has the potential to cause harm to their residents, staff, and visitors who receive meals from the kitchen due to the possibility of contracting a food borne illness.

Inspectors wroteBased on observations, record review, and interviews the facility's nursing administration did not assure the facility was administered in a manner that enabled it to develop and maintain systems for residents of the facility to attain or maintain their highest practicable, physical, mental, and psychosocial well-being. The facility failed to: support residents' right to organize and participate in a resident group; support a residents' right to voice grievances; support residents' right to have visitors; create a system for checking the sanitizing of dishes and cookware; and ensure nurse aide competencies/evaluations are being done.

Inspectors wroteBased on interview with the Administrator, the facility did not assure the governing body oversees the Administrator's management and operations of the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The facility does not have a system to collect and use data to identify areas of improvement. Therefore, there is no evidence of performance improvement projects with monitoring of the efficacy of the project. This deficient practice has the potential to affect the quality of life and quality of care of all residents to maintain or attain their highest practicable physical, mental, and psycho-social well-being.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program to include review and update their Infection Prevention & Control-Infection Surveillance Criteria policy annually, did not establish process and outcome surveillance such as monitoring for proper handwashing, use of hand sanitizer, monitoring wound care, monitoring appropriate use of antiseptic prior to use of sterile straight catheter on a resident with iodine allergy and establishing and maintaining a water program to prevent the growth of Legionella and other opportunistic pathogens. The facility also failed to ensure that a wound dressing change for one resident (R), R3, out of a sample of one, was done utilizing clean technique. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the safety of their residents and staff by not providing accessible means to trigger the call light system should they fall in the restroom and shower room. This deficient practice could potentially cause harm to residents and staff.

Inspectors wroteBased on record review (RR) and staff interview the facility failed to inform three of three residents reviewed for the use of psychotropic medications, Resident (R)7, R9 and R25, or the residents' representative, in advance, by the physician or other practitioner or professional, of the risks and benefits of taking medication such as an antidepressant or antipsychotic and alternative treatment options available.

Inspectors wroteBased on interview, the facility failed to ensure the residents of the facility exercised their right to organize and participate in a resident group.

Inspectors wrote2) On 09/12/23 at 10:47 AM went into Resident (R)23's room to introduce self to resident and make observations of his living environment. Observed closet had no door and the closet top shelf had what appeared to be water damage with blackened edges on the shelf facing the resident. On 09/13/23 at 09:02 AM while making observations of R23's room noted the damaged closet shelf was still there. On 09/13/23 at 12:50 PM met with facility maintenance staff (MS) to look at the shelf in R23's room. He noted the shelf was damaged, appeared water damaged and dry which he was able to confirm by touching the shelf and acknowledged the shelf was damaged probably from water from the AC pipes. It was noted there were two pipes coming from the wall behind this shelf. MS reported this is an easy fix as the shelf rests on the rails and he pushed up on the loose shelf showing it is not fixed in place. [...]

Inspectors wroteBased on record review and interview with staff, the facility failed to implement a grievance system to assure residents exercised their right to file a grievance. The facility did not have an identified grievance officer, and did not maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. The facility also did not implement their policy and procedure by accepting an oral grievance. This deficient practice denies the residents' right to file a grievance with an acceptable resolution.

Inspectors wroteBased on observation, record reviews, and interview, the facility failed to ensure that one resident (R), R28, out of two residents sampled, was able to fulfil her right to make choices about her medical treatment by completing an Advance Health Care Directive (AHCD). This deficient practice could potentially cause harm to residents as they may be given medical treatment that they do not want.

Inspectors wroteBased on record review and interview with staff member, the facility failed to ensure one (Resident 7) of three residents selected for liability notice review received Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered stay. This deficient practice has the potential to deny residents' right to appeal the facility's decision for discharge.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that a complete medical summary documented by the physician, provided appropriate transfer information for the acute care of one resident (R), R20, out of a sample of one, was sent to the receiving provider. This deficient practice fails to convey R20's development of an acute medical condition and medical care received at the facility to treat the acute medical condition to ensure R20's continuity of care.

Inspectors wroteBased on record review and staff interview the facility failed to develop and implement a baseline care plan within 48 hours for two sampled residents upon admission, Residents (R)6 and R7. The facility was aware residents were prescribed psychotropic medications and failed to develop interventions for the use of these medications.

Inspectors wroteBased on record review and interview with staff members, the facility failed to assure discharge planning was done prior to resident's discharge. There was no evidence to support this was a resident-initiated discharge and the facility did not ensure the resident had durable medical equipment, assess the home, and/or assess whether the resident would benefit from community services to support the resident in the home. This deficient practice has the potential to affect safe discharge.

Inspectors wroteBased on record review and interview with staff member, the facility did not ensure one (Resident 38) of one residents reviewed for discharge had a discharge summary which included a recapitulation of the resident's stay, concise summary of the resident's stay and course of treatment in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to assure one of two residents sampled had an effective pain management program. The resident's pharmacological interventions, including the parameters for use of prn pain medications were not clarified to guide staff in identifying which medication to provide to manage resident's pain. Also, staff was unaware of prn medications that were available to manage the resident's pain. This deficient practice has the potential to affect the resident's well-being (i.e. mood, mobility, sleep).

Inspectors wroteBased on record review and interview with staff, the facility failed to assure 2 (Residents 31 and 23) of 5 residents had the opportunity to receive the pneumococcal vaccines, unless medically contraindicated, refused or was already immunized. Residents consented to the administration of the pneumococcal vaccine and at most, 1-1/2 years later, the facility was not aware of the vaccine status or provided the vaccine. This practice has the potential to place residents at risk for developing pneumonia.

Inspectors wroteBased on complaint report and interview, the facility failed to ensure residents of the facility had the right to receive visitors.

Inspectors wroteBased on observations, record review, interviews, and document review, the facility's nursing administration failed to ensure processes were in place to promptly identify resident-specific care needs including range of motion/contracture management and feeding assistance. Specifically, the facility: - failed to ensure licensed nursing staff regularly assessed residents to determine if their range of motion (ROM) was intact and determine if additional interventions were needed to address declines in range of motion. This failed practice affected 2 (Residents #14 and #28) of 2 sampled residents who had hand contractures. - failed to ensure a process was developed and implemented to ensure a paid feeding assistant provided dining assistance only for residents with no complicated feeding problems. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff implemented appropriate infection control practices during 3 of 3 meals observed. Specifically, staff opened and handled residents' straws and chopsticks with their bare hands while preparing residents' beverages and setting up residents' meal trays.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure a dependent resident was dressed in a manner to maintain the resident's dignity for 1 (Resident #14) of 2 sampled residents reviewed for dignity.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide a homelike environment for 3 (Residents #9, #22, and #24) of 34 residents whose rooms were observed. Specifically, the facility failed to ensure the shared room of Residents #9, #22, and #24 was not used for storage of supplies and equipment.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop a care plan to address hand contractures for 1 (Resident #28) of 2 sampled residents who had hand contractures. This had the potential to affect 11 residents who had contractures, per the Resident Census and Conditions of Residents form dated 10/03/2022.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure nursing care was provided in accordance with accepted standards of practice for Resident #2 and Resident #24. Specifically, the facility: - failed to ensure assistance with repositioning was promptly provided to promote comfort for 1 (Resident #2) of 1 sampled resident reviewed for positioning. - failed to ensure neurological (neuro) checks were consistently conducted and documented after an unwitnessed fall for 1 (Resident #24) of 3 sampled residents reviewed for accidents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure care and services were provided to prevent further potential decline in range of motion (ROM) for 2 (Resident #14 and Resident #28) of 2 sampled residents who had hand contractures. Specifically, the facility failed to: - regularly provide passive range of motion (PROM) exercises for Resident #14 and Resident #28. - promptly identify and address a contracture to Resident #14's right hand. - promptly identify and address bilateral hand contractures for Resident #28. - ensure licensed nursing staff regularly assessed to determine if range of motion was intact for Resident #14 and Resident #28.

Inspectors wroteBased on document review, interviews, and facility policy review, the facility failed to ensure a nursing assistant (NA) who was a full-time employee completed the required competency exam for certification within four months of hire for 1 (NA #1) of 1 NA reviewed for competencies.

Inspectors wroteBased on observations, record review, interviews, and document review, the facility failed to ensure a paid feeding assistant provided dining assistance only for residents who had no complicated feeding problems and that decisions regarding which residents were appropriate to receive assistance from the paid feeding assistant were based on residents' assessments and plans of care for 2 (Resident #24 and Resident #30) of 2 sampled residents reviewed for feeding assistance.