Life Care Center of Kona

Inspectors wroteBased on interviews and record review, the facility did not employ a qualified Director of Food and Nutrition Services (DFNS). A qualified DFNS must be a certified dietary manager, or a certified food service manager, or hold national certification for food service management and safety, or who holds an associate's degree or higher in food service management or hospitality. This deficient practice has the potential to compromise the health and nutritional status of all residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, monitor and maintain food items and kitchen equipment in accordance with professional standards for food service safety. Specifically, prepared food items and food items stored in containers in the refrigerator were not labeled, dated and/or expired, food items in the freezer were stored on the ground, chemical sanitization for the dishwasher was not completed for January 2026, refrigerator/freezer temperature logs missing entries for December 2025 and no recordings logged for January 2026, and expired food items found in the pantry. These deficient practices have the potential to compromise the health of all the residents and was a potential source of pathogen exposure at the facility.

Inspectors wroteBased on review of facility assessment and staff interview, the facility did not update the assessment annually, as required. As a result of this deficiency, the facility could not evaluate its resident population and identify resources needed to provide the necessary care and services.

Inspectors wroteBased on observations and interviews, the facility failed to maintain infection control practices to help prevent the transmission of communicable diseases/infections for two of four residents sampled for transmission-based precautions. As a result of this deficient practice, residents are at an increased risk of communicable diseases/infections.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's right to formulate an Advance Health Care Directive (AHCD) for one (Resident (R) 6) of three residents sampled for AHCD.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one (Resident (R) 6) of five residents selected for medication regime review.

Inspectors wroteBased on observations, record review and staff interview, the facility did not develop a comprehensive care plan for one (Resident (R) 57) of 15 residents reviewed. As a result of this deficiency, there was increased risk for complications related to R57's Peripherally Inserted Central Catheter (PICC) and colostomy.

Inspectors wroteBased on interview and record review the facility failed to perform annual performance reviews with their Certified Nurse Aides (CNAs) in identifying any weaknesses they may have and address them with in-service education. This deficient practice puts all the residents in the facility at risk for not receiving quality care from CNAs who have had their weaknesses identified and education provided that enhances the resident's life. Findings Include: On 09/25/24 at 11:04 AM an interview was conducted with the Director of Nursing (DON) and Administrator. Inquired if DON does annual performance reviews with CNAs and she stated, they are currently sitting on my desk. Inquired again, yes or no, if this was done and DON stated no. Requested from the Administrator a list of facility CNA names, date last performance review was done and next performance review is due. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to monitor the temperature for the refrigerator and freezer to ensure the foods are stored in accordance with professional standards. The facility also failed monitor the disinfectant level for the dishwasher to ensure the dishes used to serve food were appropriately sanitized. This deficient practice placed all the residents in the facility at risk for possible foodborne illnesses.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents dignity for four residents (Resident (R)14, R156, R35, and R5) sampled. Residents were observed and/or reported having to wait 25 minutes or more for staff to address the resident's call lights and/or provide care as needed by the resident. As a result of this deficient practice, resident is at risk for more than minimal harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's right to be free from abuse for two (Residents (R)8 and R5) sampled. R8 informed two different staff that R23 had run over her feet twice with his wheelchair, then cursed at R8 when she responded verbally to R23. On 07/16/24, an incident occurred where R5 informed staff that the Alleged Perpetrator (AP) caused her pain by handling the resident's gait belt roughly when transferring the resident to the toilet, AP yelled in R5's ear causing the resident numbness in her ear canal, and AP told R5 that the resident is fussy and that's why no one (staff) wants to work with her in response to the resident informing the staff of her preferences for transferring on and off the toilet. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to report allegations of abuse of two residents (Residents (R)8 and R5) of 51 residents at the facility, to the facility administrator and/or state agency within two hours of being reported to staff by the resident. During the review of R8's allegation of abuse two facility staff were notified by R8, and the facility administrator was not notified abuse had occurred. Initial report of R8's allegation of abuse was submitted by the facility to the state agency on 09/24/24. The facility did not identify R5 allegations as having the potential for abuse and classified the incident as a customer service issue and did not report the incident within the two-hour timeframe. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations are thoroughly investigated, in response to an allegation of abuse for one (Resident (R)5) sampled. On 07/16/24, R5 reported an incident that the Alleged Perpetrator (AP) was rough with the resident's gait belt when assisting the resident during a transfer, yelling in the resident's ear, and told the resident she was fussy and that's why no one wanted to work with her. RN23 reported spent approximately 30 minutes deescalating R5 after she reported the incident to the Director of Nursing (DON). The DON conducted an interview only with AP, did not interview the resident, did not conduct a thorough investigation, did not identify the incident as having a potential for abuse (physical, verbal, and psychosocial harm), and classified the incident as a customer service issue. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide proper notification of transfer/discharge for two of four residents sampled for Hospitalization (Residents (R)1 and R8). Specifically, the facility failed to provide written notification of transfer/discharge to the residents or their representatives. This deficient practice has the potential to affect all residents at the facility who are discharged or transferred.

Inspectors wroteBased on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to three of four residents sampled for Hospitalization (Residents (R)1, R30 and R8). This deficient practice has the potential to affect all residents at the facility who are discharged to an acute care hospital.

Inspectors wroteBased on observation, record review (RR), and interview the facility failed to develop and implement a comprehensive care plan for two residents (Resident (R)8 and R32) sampled. R8 has a physician's order for 2 (two) liters/(per) minute of continuous oxygen via nasal cannula and a care plan was not developed for this medical intervention. R32 has a physician's order for an opioid pain medication and R32's care plan did not include non-pharmacological pain-relieving interventions. The deficient practice could affect all residents at the facility if the facility fails to develop and implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical well-being.

Inspectors wroteBased on observation and interview the facility failed to provide adequate supervision for one Resident (R)52 who was found outside of the facility sitting in her wheelchair, by herself, at a table with her back facing the facility door. The deficient practice puts residents at risk for accidents if they are not provided proper and adequate supervision. Findings Include: On 09/23/24 at 04:30 Surveyors were leaving the facility and noticed a female resident was sitting outside of the facility in her wheelchair with her back facing the facility door. R52 called out I need help! Can you help me? Surveyor inquired what she needed and R52 stated she wanted to go back inside. Surveyor buzzed the front door and asked for staff to come and assist R52 back into the building. Facility staff came out to help R52 back into the unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an account of all controlled drugs is maintained. Reconciliation of the controlled medication reconciliation sheet and the medication documented a discrepancy between the count of the medication and the number of actual pills. As a result of this deficient practice, there is the potential for more than minimal harm.

Inspectors wroteBased on record review and interview the facility failed to assure two residents reviewed, of the 18 sampled, had accurate information placed in their Electronic Health Record (EHR). Review of R20's Advanced Health Care Directive (AHCD) found it was signed by the agent the resident had selected to be his decision maker and not by the resident. R2's physician documented resident as [AGE] years old over a three-year span, identified the resident as full code when he is a Do Not Resuscitate (DNR) and documented resident did not have any allergies when he is allergic to Clindamycin. The deficient practice puts all residents at risk if the resident's AHCD is not filled out correctly prior to it being utilized by the facility and resident's health status is not accurately documented by the physician. Findings Include: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents on isolation. The facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to Resident (R)1, who was on Enhanced Barrier Precautions (EBP), and performing hand hygiene between glove changes. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure pneumococcal vaccine was offered to one of the five residents (Resident (R)1) in the sample. This deficient practice placed the resident at risk for acquiring, transmitting, and developing possible complications from pneumococcal disease.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to ensure adequate supervision and assistance to prevent accidents for two Residents (R)8 and R36 sampled. As a result of these deficient practices 1) R8 fell and sustained a hematoma to the right side of her forehead and swelling of the right side of her face and 2) R36 was placed at risk for falling when being transported in a wheelchair that had no footrests.

Inspectors wroteBased on interviews and record review, the facility failed ensure competent skills to assure resident safety and maintain the highest practicable well-being for two Residents (R)40 and R34 sampled. Nursing Staff (NS)99 delayed treatment by not immediately informing the physician after R40 fell from the bed sustaining redness and pain to touch (5/10) on the resident's left shoulder to ensure a physician evaluated the resident's overall condition(s), laboratory test, treatment of the resident was under the care of a physician. Approximately four to five hours after the fall, R40 had an acute mental status change and was transferred then discharged to an acute hospital for further treatment. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to follow safe food storage requirements. This deficient practice has the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for food-borne illnesses.

Inspectors wroteBased on interviews and record review, the facility failed to set priorities for its performance improvement activity that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in that area, and affect health outcomes, and resident safety.

Inspectors wroteBased on interviews and review of the Staffing Report from the Centers for Medicare and Medicaid Services (CMS), the facility failed to have sufficient nursing staff to provide 24-hour nursing care. As a result of this deficiency, the call bell response was delayed for one Resident (R)13 out of four residents sampled and the CMS Staffing Report identified this facility for having low staffing.

Inspectors wroteBased on staff interview, the facility failed to designate an individual as the Infection Preventionist (IP) that works at least part-time at the facility. The individual designated as the IP is also working full-time as the Director of Nursing (DON).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify the resident's physician or inform the resident's representative of a serious medical incident for two Residents (R)23 and R40 sampled. The deficient practice placed the residents at risk of harm.

Inspectors wroteBased on interviews and record review, the facility failed to provide notification of transfer and/or discharge to the resident, resident's representative, and/or to the Office of the State Long-Term Care Ombudsman (LTCO) for two residents (Resident (R)55 and R4) sampled.

Inspectors wroteBased on interviews and record review, the facility failed to provide a written bed-hold notice at the time of transfer of a resident to hospitalization to the resident and the resident representative which specifies the duration of the bed-hold policy for two Residents (R)4 and R55 sampled. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on record review, staff interview and review of Minimum Data Set (MDS) instruction, the facility failed to properly transmit the discharge MDS to the Centers for Medicare and Medicaid Services (CMS) System, for three Residents (R)33, R42, R43 out of three residents sampled. As a result of this deficiency, there was inaccurate data in the CMS System.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the comprehensive person-centered care plans were implemented for one Resident (R)8 in the sample. R8 was left alone in the bathroom and had an unwitnessed fall. As a result of the fall, R8 was injured and sustained a hematoma on the forehead. There were signs in R8's bathroom to not leave the resident alone and the resident's care plan documented an intervention to not leave the resident alone in the bathroom. As a result of this deficient practice, R8 was physically harmed and is at risk for a decline in their quality of life. There is the potential for all residents to not attaining their highest practicable physical, mental, and psychosocial well-being if the resident's comprehensive person-centered care plan is not implemented.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to revise a resident's comprehensive person-centered care plan for one Resident (R)4 sampled. The deficient practice places all residents at risk of harm, with the potential to not reach their highest quality of life, and/or the highest physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident receives the necessary services to maintain grooming for one Resident (R)29 sampled.

Inspectors wroteBased on record review and staff interview, the facility failed to provide annual in-service education for one Certified Nursing Assistant (CNA)18 out of eleven staff sampled. As a result of this deficiency, the facility failed to conduct in-service education at least once every twelve months as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's own medication stored in the medication cart was properly labeled in accordance with professional standards, including the expiration date and cautionary instruction. As a result of this deficient practice, residents are at a potential risk of harm.