Leahi Hospital

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to: 1) Discard an expired container of Lemon Juice that was stored the kitchen refrigerator and 2) Label a supplement drink stored in the resident's kitchen refrigerator with the opened-on date once it was opened. As a result of this deficiency, the facility put residents at risk for foodborne illness. Findings Include:1) During the initial tour of the kitchen, on 07/22/25 at 08:50 AM, a one-gallon container of Lemon Juice, in the refrigerator, was labeled with an expiration date of 07/19/25. The container was half full and was located on the middle shelf. Staff interview on 07/22/25 at 08:52 AM, Kitchen Manager (KM) acknowledged that the Lemon Juice container was expired and should have been discarded. KM removed the Lemon Juice container and said they would discard it immediately. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the effective date of discharge in the discharge notice for one Resident (R) 98 of three residents sampled for the transfer discharge process when he was transferred to a hospital. The deficient practice has the potential misinform the representative of the Residents date of transfer.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement the care plan for one resident (Resident (R), R38) sampled for accidents and R92, who was sampled for respiratory care. The deficient practice puts R38 at risk for falls that could result in harm if the mechanical lift is not used appropriately with two staff and puts R92 at risk for respiratory infection who already has compromised health. Cross reference to F689 1) On 07/22/25 at 08:30 AM, observed Certified Nurses Aide (CNA) 41 transferring R38 from bed to wheelchair using a mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that one of one resident (Resident (R), R38) sampled for accidents was free from accident hazard when staff transferred R38 using a mechanical lift with only one person assist. This deficient practice has the potential to affect all residents requiring transfers using a mechanical lift. Findings Include:On 07/22/25 at 08:30 AM, observed Certified Nurse's Aide (CNA) 41 transferring R38 from bed to wheelchair using mechanical lift on her own. When CNA41 was asked if the facility policy allowed her to transfer a resident using the mechanical lift by herself, CNA41 stated that she was able to if she felt capable and that R38 trusted her to do it. On 07/22/25 at 09:00 AM, interview with Registered Nurse (RN) 9. RN9 said that transfers using the mechanical lift should be done with two staff for safety reasons. [...]

Inspectors wroteBased on observations and interviews the facility failed to label the oxygen tubing that was connected to the oxygen (O2) concentrator with the date if initiation for one of one resident (R) 92, sampled for respiratory care. This deficient practice put R92 at risk for infection. Findings Include: On 07/22/25 at 09:04 AM and on 07/23/2025 at 10:31 AM observed R92's oxygen (O2) concentrator in her room near the wall that had tubing connected to it which was not labeled with the date of first use. On 07/24/25 at 10:43 AM interviewed 4th floor Head Nurse (HN) 6 in R92's room. Inquired of HN6 if the O2 tubing, that was attached to the O2 concentrator, should have a date when it was initiated and she confirmed this. On 07/25/25 at 10:15 AM interviewed Director of Nursing (DON) by phone regarding R92's oxygen use. [...]

Inspectors wroteBased on observation, interview, and review of the facility's Storage of Medication Policy, the facility failed to discard two vials of expired Influenza (flu) vaccine in Young 4's medication refrigerator. This deficient practice has the potential to affect all residents in the facility due for flu vaccination. Findings Include:On 07/24/25 at 08:15 AM, medication refrigerator was checked with Registered Nurse (RN) 9. Observed two vials of expired flu vaccine dated 06/2025 still in the refrigerator located on Young 4. RN9 said that it should have been discarded last month for safety purposes. On 07/25/25 at 08:30 AM, interview with Head Nurse (HN) 6 also noted that it should have been discarded and confirmed that discarding expired medications is for the safety of the residents and to ensure the efficacy of drugs given. [...]

Inspectors wroteBased on interview, record review, facility document review and facility policy review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI). Specifically, the facility failed to ensure corrective action was implemented and maintained to ensure sustained compliance with reporting and investigating alleged allegations of abuse. This had the potential to affect all residents that resided in the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disorder, or related condition, to the state-designated mental health or intellectual disability authority for review. The deficiency affected 2 (Resident #9 and Resident #39) of 2 residents reviewed for Pre-admission Screening and Resident Review (PASARR; PASRR) services.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medication carts were locked when not within the line of sight of facility staff for 2 of 6 medication carts.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to report abuse investigation results within five working days to the state survey agency for 2 (Resident #302 and Resident #28) of 6 residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for 1 (Resident #302) of 6 residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure alleged verbal abuse and an injury of unknown source resulting in serious bodily harm, were reported immediately, but not later than 2 hours after the allegation was made to the administrator of the facility and other officials, including to the State Survey Agency (SA) and Adult Protective Services (APS) for two residents (Resident (R)82 and R31) sampled. As a result of this deficient practice, all residents are at a risk of harm, including psychosocial harm.

Inspectors wroteBased on observations and interviews, in response to an allegation of abuse the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further abuse while the investigation was in progress. As a result of this deficient practice, residents are at risk of abuse and experiencing harm.

Inspectors wroteBased on record review, staff interview and review of policy, the facility failed to provide written notice of discharge for two Residents (R)R32 & R90) out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of discharge.

Inspectors wroteBased on observation and interview, the facility failed to assure a safe, clean, and comfortable homelike environment for two of five sampled residents (Resident (R)37, and R43).

Inspectors wroteBased on observations, staff interview and review of policy procedure, the facility failed to post staffing information for one Nursing Unit, 4th floor Young, out of three Nursing Units sampled. As a result of this deficiency the facility failed to follow regulation to make nurse staffing data available to the public for review.

Inspectors wroteBased on observations, staff interview and review of policy, the facility failed to secure a padlock that was attached to the medication refrigerator door on the 3rd floor Young Nursing Unit. As a result of this deficiency, the facility failed to properly store the refrigerated medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to perform proper hand hygiene and follow infection control protocol. This deficient practice places the residents and visitors at risk for the development and transmission of communicable disease and infections.