Kulana Malama

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff was wearing applicable Personal Protective Equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP), changed gloves after performing a dirty task and before performing a clean task, and ensure connecting tubes for tube feeding were not exposed. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings Include: 1) On 09/23/25 at 09:35 AM, during an initial observation of Resident (R) 24, observed R24's feeding port disconnected from the feeding bag. The feeding bag was full of formula and the tube that connects from the feeding bag to the feeding port was exposed not covered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff members spoke amongst each other in a language understood by the resident they are providing care to, for one of two residents (Resident (R) 18) reviewed for dignity. This puts R18 at risk for feelings of exclusion, loss of dignity, and potential misunderstanding of care being provided. Findings Include: On 09/24/25 at 12:13 PM, during an observation outside of R18's room, observed his curtain drawn, at least two pairs of staff members feet can be seen around R18's bed and another staff member was observed to moving around the room. A Filipino language can be overheard from staff members outside of the room. After surveyor knocked on resident's room door, the staff members began disbursing except for the staff member administering medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that stored food items at the off-site kitchen were discarded by their expiration or use-by dates. This failure created a potential risk of foodborne illness for two of two residents (Resident (R) 21 and R33) who received food for pleasure feeding and/or the introduction of solid foods from the off-site kitchen. Findings Include:On 09/23/2025 at 08:12 PM, during an initial tour of the off-site kitchen, observation and interview were conducted with the Lead [NAME] (LC). LC stated that meals are prepared at this off-site kitchen for a selective few residents, but does not know the specifics. When asked whether food designated for these residents was stored separately, such as on a designated shelf in the refrigerator or a separate area in the dry goods storage room, LC stated there was no separation in place. [...]

Inspectors wroteBased on record review and staff interview the facility failed to assure one of seven residents (R) 25, sampled for Respiratory Care, had documentation of two unplanned decannulations of her tracheostomy tube. The deficient practice does not reflect R25's health status when there was a change in her condition which required prompt staff intervention to maintain her airway. This deficient practice could affect all residents in the facility who have a tracheostomy tube and experience an unplanned decannulation that staff are not documenting a change with the resident in the resident's Electronic Health Record (EHR). Findings Include:On 09/25/25 lead surveyor requested and received a list of adverse events that occurred within the last six months from the Administrator. Review of the incident log provided revealed R25 had two unplanned decannulations on 06/18/25. [...]

Inspectors wroteBased on interviews, medical record review and document review, the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing care to meet residents' needs in a safe manner. Specifically, the licensed staff did not demonstrate 1) competency to perform and document neurological (neuro) assessments on a Resident whose baseline was neurologically impaired, 2) competency to identify a medical emergency that required timely response and transfer to a higher level of care, and 3) critical thinking to recognize the need to conduct and document a thorough physical and neurological assessment after a fall with potential head/neck injury, to determine if the Resident could be safely transferred from the floor to the bed. [...]

Inspectors wroteBased on interviews, medical record review and document review, the facility failed to develop a person-centered comprehensive care plan (CP) to meet the needs of one Resident (R)1 of a sample size of six. R1 had cognitive impairment and was nonverbal. His CP did not include how to communicate with him. As a result of this deficient practice, there was the potential not all staff were aware of how to communicate with him in a consistent manner. If Resident Care Plans are not comprehensive, Residents may not reach their highest medical, mental and psychosocial potential.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 6 residents sampled (Resident 1) was free from accident hazards. Despite being completely dependent on staff for all activities of daily living (ADLs), including toileting, bed mobility, and transfer, staff failed to ensure Resident (R)1's safety rails were secure and in place before walking away from his bed. As a result of this deficient practice, R1 experienced an avoidable fall. This deficient practice has the potential to affect all residents at the facility who are dependent on staff for ADLs and safety.

Inspectors wroteThe facility failed to ensure availability of a physician for emergency care for one Resident (R)1 of a sample size of three. R1 had a fall with a change of condition, and the facility was unable to reach the physician (MD)1 for over four and a half hours. In addition, the staff failed to transport R1 to the emergency room (ER) in a timely manner to obtain physician evaluation when they were unable to reach MD1. As a result of this deficient practice, there was a delay in transferring R1 to a higher level of care. Not having a physician available 24 hours a day could affect any resident who had an emergency, which could put them at risk of negative outcomes.

Inspectors wroteBased on interviews, medical record and document review, the facility failed to systematically analyze one Resident's (R1) adverse event (fall) and two unplanned hospitalizations for altered mental status. In addition, leadership received staff feedback regarding deficient practice related to this case and did not investigate the concerns. Due to this deficiency, system and process issues were not identified and addressed to ensure the nursing care met recognized standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to enhance one Resident (R)6 of 12 residents in the sample's quality of life while in her room in bed. Music, television, or other auditory stimulating activities were not provided to the resident. The deficient practice dishonored the residents right to a dignified existence.

Inspectors wroteBased on observations and interview, the facility failed to ensure a clean environment for one resident ((R)12) sampled. The mesh netting on the inside of R12's crib became soiled during care and staff did not change or clean the mesh. R12 regularly puts her legs vertically on the mesh which increases the resident's likelihood of encountering the soiled mesh. As a result of this deficient practice, residents with mesh on the inside of the crib have an increased potential for exposure to an unsanitary environment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the following at the time of the resident's discharge for one resident (R) 32 of four in the sample: Communication of necessary information to one resident and the residents care giver; document a concise summary from the physician of the residents stay and course of treatment in the facility; and reconciliation of medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's environment remains free of accident hazards for one resident (R27) sampled. Past non-compliance was determined for an incident on 03/01/24, R27 had an unwitnessed fall from the crib. The facility was not in compliance for accident hazard at the time the fall occurred, the noncompliance happened after the last survey date and prior to this survey, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey related to falls. However, in response to the fall, the facility installed a crib canopy, but did not conduct a safety assessment or assess for potential accident hazards for R27 after the canopy was implemented. [...]

Inspectors wroteBased on record review and interview the facility failed to assure Resident (R) 15's insulin was held when his blood glucose level was less than 80 as ordered by the physician. The facility was not in compliance for significant medication error at the time the significant medication error occurred, the noncompliance happened after the last survey and prior to this survey. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey related to significant medication errors. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had routine dental care for two residents (R10 and R5) sampled. R10's most recent dental consult was conducted on 11/27/20. R5's most recent dental consult was conducted on 11/11/21.

Inspectors wroteBased on observations, interview and record review, the facility failed to accurately document a medication order in the narcotic medication record for one resident (R)20, of 28 medication administration observations in the sample. The dosage was documented to give Lacosamide oral solution 10 milligram (mg) per milliliters (ml); give eight ml via Jejunostomy tube (J-Tube) two times a day. The Registered Nurse (RN) 23 verified the order should read give 12 ml via J-Tube two times a day.

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff implemented infection control practices for infection prevention and and prevention of communicable diseases. Observed Registered Nurse (RN) 26 take off dirty gloves and put on clean gloves without performing hand hygiene. Observed Direct Care Staff (DCS)1 provide suctioning to a resident then enter another resident's room all while the staff's face mask was pulled under his/her chin, exposing the staff's mouth and nose.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an infection prevention and control program (IPCP) to provide a safe environment to help prevent the transmission of communicable diseases and infections. The facility did not ensure that the IPCP was reviewed annually and updated as national standards change. As a result of this deficient practice, all the residents in the facility were placed at potential risk for developing communicable diseases and infections. Findings Include: On 06/22/23, review of the facility's Infection Control Policy and Procedure manual was conducted. Noted the first page in the inside cover titled, Kulana Malama - IP (infection prevention) Manual Approval Signature Sheet did not have any signatures on it. At 01:46 PM, a concurrent interview and record review was conducted with the Director of Nursing (DON) in his office. [...]

Inspectors wroteBased on observations, staff interview and review of the Ventec Life Systems User Manual, the facility failed to clean the VOCSN (Ventilator) Air Intake Filter every two weeks as recommended by the Manufacturer. As a result of this deficiency, the facility put the residents at risk for further complications.

Inspectors wroteBased on observations, interviews, and record review. The facility failed to implement interventions in a care plan to provide effective and person-centered care that meet professional standards of quality care for one of the three residents sampled (Resident (R) 2). Findings Include: Cross tag with F693. The facility failed to provide appropriate treatment and services to prevent complications for a resident who receives enteral feeding. R2 was admitted to the facility on [DATE]. R2's diagnosis included dysphagia, respiratory disorder, and gastroesophageal reflux disease without esophagitis. Observation was conducted on 06/20/23 at 01:50 PM in R2's room. R2 was lying flat in bed on his left side. Enteral feeding bag was attached and infusing. Observation was conducted on 06/21/23 at 01:21 PM in R2's room. R2 was observed lying flat in bed on his left side. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feeding for one of the three residents sampled (Resident (R) 2) Findings Include: Cross tag with F656. The facility failed to implement interventions in a care plan to provide effective and person-centered care that meet professional standards of quality care. R2 was admitted to the facility on [DATE]. R2's diagnosis included dysphagia, respiratory disorder, and gastroesophageal reflux disease without esophagitis. Observation was conducted on 06/20/23 at 01:50 PM in R2's room. R2 was lying flat in bed on his left side. Enteral feeding bag was attached and infusing. Observation was conducted on 06/21/23 at 01:21 PM in R2's room. R2 was observed lying flat in bed on his left side. R2's enteral feeding bag was attached and infusing. [...]

Inspectors wroteBased on observation, record review, and interview with staff members the facility failed to ensure one of six medication/respiratory (containing medication) carts were kept locked or under direct observation of authorized staff.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure documentation of COVID-19 vaccine refusal education providedd was included in the medical records for one of the five residents (R) 11 sampled. As a result of this deficiency, the facility did not meet the regulation for documenting the reason R11 did not receive the COVID-19 vaccine and education provided regarding the benefits and potential risks associated with the vaccine. Findings Include: On 06/22/23 at 07:48 AM, review of Electronic Health Records (EHR) was conducted. R11 is a [AGE] year-old resident admitted on [DATE]. Diagnoses include chronic respiratory failure, tracheostomy (surgical opening through neck into the windpipe to allow air into lungs) and ventilator (breathing machine) dependence. Vaccination records revealed that there was no documentation if R11 received the COVID-19 vaccine. [...]