Hale Ola Kino by Arcadia

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff followed infection prevention and control measures. Specifically, the facility did not ensure shared medical device was disinfected after use and before used on another resident. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity by protecting and promoting the rights of one of one resident (Resident (R) 4) reviewed for resident rights. R4's personal property was taken from his room without his knowledge or proper communication. This deficient practice has the potential to affect R4's dignified existence.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement the comprehensive person-centered care plan for two of 15 residents (Resident (R) 4 and R21) care plan reviewed. The facility did not develop a dietary care plan for R4 and did not implement R21's care plan for edema. This deficient practice has the potential to negatively affect R4 and R21's health and well-being.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure one of two residents (Resident (R) 3) sampled for limited range of motion received appropriate treatment for left foot contracture. This deficient practice put R3 at risk of further decrease in range of motion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one of three residents (Resident (R) 84) sampled for pain management was consistent with professional standards of practice. R84's pain management was ineffective and not followed up on which has the potential result of discomfort and continued pain.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident menus were followed for one of one resident (Resident (R)10) sampled for food and two of 10 residents (R135 and R28) food trays and menus sampled in the kitchenette during food tray line. This deficient practice has the potential to put R10 and R135 at risk of not maintaining their weight and R28 at risk of low sodium with history of hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure opened food was discarded by the use by date for one of five food items sampled in the walk-in refrigerator. Failure to appropriately label stored food has the potential to affect residents that receive food from the kitchen, and visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff competency in safe transfers and perineal care (peri care) for two residents in the sample (Residents 131 and 13). This deficient practice placed the residents at risk for avoidable injuries and decreased quality of care, and has the potential to affect all the residents at the facility requiring assistance with transfers and/or peri care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a food and hydration program that recognizes and addresses the preferences of each resident. This is evidenced by a failure to provide fresh water throughout the day, despite repeated requests, to one resident (Resident 132), and a failure to offer and provide an alternate menu item when residents found their meal tray unappetizing. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards. The walk-in refrigerator contained boxes of food sitting on the floor. The deficient practice has the potential to affect many residents living in the facility who eat foods prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, although informed of concerns regarding an unsafe transfer and poor positioning in bed, the facility failed to identify and document the verbalized complaint as such, and failed to provide a prompt resolution of the complaint/grievance for one resident (Resident 131) and his family representative(s). As a result of this deficient practice, the resident experienced a decreased quality of life, feeling as if the concerns he and his family representatives voiced were not being taken seriously, or acknowledged. This deficient practice has the potential to affect all the residents at the facility who voice a concern.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one Resident (R)82 of four in the sample. R82's care plan was generalized, written as the resident instead of resident's name; the interventions for pain management were not followed as written on the care plan. The deficient practice placed the resident with ineffective pain control, cross reference (cr) to F697 pain management.

Inspectors wroteBased on interview, and record review, the facility failed to adequately monitor, care plan, and manage, an elevated risk of constipation for 1 of 1 resident (R131) sampled. As a result of this deficient practice, Resident (R)131 experienced abdominal discomfort and difficulty defecating. This deficient practice has the potential to affect all the residents at the facility at risk of constipation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from accidents hazards, both in the Therapy Room, as evidenced by Resident 23 sustaining an injury on an exposed end of the wooden parallel/balance bars, as well as during transfers for Resident 131. This deficient practice has the potential to affect all residents using the Therapy Room or requiring assistance during transfers.

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize and evaluate when the resident experienced pain; and manage pain consistent with the comprehensive assessment, the plan of care, current professional standards of practice, and the resident's goals for one resident (R) 82 in the sample. R82's pain level was not consistently evaluated by the nursing staff, and analgesics were not available to the resident as ordered by the physician. The deficient practice resulted in increased pain for R82.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately assess for and identify past traumas experienced by 1 of 1 residents (Resident 132) sampled for Trauma-Informed Care. As a result of this deficient practice, Resident 132 did not have her triggers identified, placing her at increased risk of re-traumatization, and was hindered from attaining her highest practicable mental and psychosocial well-being.