Maluhia

Inspectors wroteBased on interviews and record review, the facility failed to ensure safe handling and modified dressing protocols were used to protect one resident (R) 6, who had severe bilateral upper extremity (BUE) contractures and was totally dependent on staff for care. As result of this deficient practice, R6 suffered harm, a dislocated left shoulder. This was a facility reported event (FRI) #2745775, which the facility identified the noncompliance and conducted a Root Cause Analysis (RCA) and implemented a comprehensive corrective action plan that was fully verified as corrected on 07/17/2026, therefore, past noncompliance was determined. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was revised for two Resident's (R) 27 and 72, of five sampled. 1) R27's care plan did not include interventions to prevent and treat scratches related to non-pressure skin conditions. 2) R72's care plan did not include additional interventions to prevent pulling out the Gastrostomy Tube (GT). As a result of the deficiency, R27 was at increased risk for worsening skin condition and R72 was at increased risk of the GT being pulled out. Findings Include: 1) On 07/07/25 at 08:22 AM, an observation of R27 and interview with Resident Representative (RR) 4 was done. Observed R27 in in her room in bed, her left hand had a blue latex glove on. [...]

Inspectors wroteBased on record review and interviews the facility was aware of Resident (R) 7's nut allergy but failed to document severity of nut allergy, failed to develop and implement a care plan for R7's nut allergy and failed to assure all recipes cooked in the kitchen were on the templates reviewed for food allergies before providing food to residents. The deficient practice resulted in harm to R7 who received food that contained nuts and having an anaphylactic response requiring transport to the emergency room for treatment. Findings Include: According to the United States Department of Agriculture (USDA) A food allergy is a potentially serious response to consuming certain foods or food additives. For those who are sensitive, a reaction can occur within minutes or hours, and symptoms can range from mild to life-threatening. [...]

Inspectors wroteBased on record review and interview the facility failed to report the results of an allegation of staff to resident abuse, involving Resident (R) 5 and a Certified Nurse Aide (CNA), within five working days of the incident to the State Agency (SA). Findings Include: Review of facility's Initial Event Report submitted to the SA on 02/19/25 for R5 included the following information: Head nurse received call from R5's daughter, very upset and yelling that her dad was not treated properly by the CNA who was assigned to him about 7am this morning. I want to know now the CNA who was assigned to my dad, I want to report and call the social worker. My dad is crying and calling me that he wanted me to pick him up and go home. Head nurse went to talk to R5 and he was able to voiced out his concern. R5 was still very emotional and crying while telling head nurse what happened. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident (R) 7) sampled for food allergies, was not served a food allergy. R7 was served mayonnaise on her lunch tray, a documented anaphylactic allergy, after R7's recent anaphylactic incident regarding a nut allergy that happened in the facility. This puts R7 at risk of allergy symptoms or anaphylaxis. Findings Include: On 04/25/25, an abbreviated survey was conducted for a facility reported incident (FRI), ACTs #11581. The facility was found not in compliance with requirements of 42 CFR 483, Subpart B, F684, Quality of Care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience that was not required to treat the resident's medical condition for one of one resident sampled (Resident (R) 68). R68's reclined Geri-chair was not assessed as a restraint, although R68 forgets his physical limitations in standing and walking, R68 was observed to move his Geri-chair or attempt to get up and staff expressed they were unable to provide the constant supervision to prevent falls.

Inspectors wroteBased on record review and interview the facility staff failed to correctly document Resident (R) 6's facility acquired injury, progressing from Moisture-Associated Skin Damage (MASD) on his right gluteus to a stage 3 Pressure Ulcer (PU) on his coccyx, in R6's Discharge Assessment that was submitted to Center of Medicare and Medicaid Services (CMS) on 05/27/24. The deficient practice does not accurately reflect R6's injured skin status. The deficient practice could affect all residents who have an injury that has worsened over time. Findings Include: Cross-reference to F842 Resident Records - Identifiable Information. Based on record review and interview the facility failed to update R6's electronic health record (EHR) to accurately stage his facility acquired injury progressing from Moisture-Associated Skin Damage (MASD) to his right gluteus to a stage 3 PU on his coccyx. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of 19 residents sampled (Resident (R) 68). R68's care plan did not include reclined Geri-chair in visible area for close supervision as an intervention to prevent R68 from falls when restless and expressing he wants to go home.

Inspectors wroteBased on interviews and record review, the facility failed to invite one of the sampled residents (Resident (R) 76) to attend and participate in her care planning meeting. This deficient practice has the potential to affect all the residents in the facility. Findings Include: R76 is a [AGE] year-old female admitted to the facility on [DATE]. A review of R76's Brief Interview for Mental Status (BIMS) with Assessment Reference Date (ARD) 04/17/24 was conducted. R76's BIMS score was a 14, meaning R76 was cognitively intact. Interview with R76 was conducted in her room on 07/01/24 at 09:28 AM. R76 stated that she had not participated in her care planning meeting, and she would have loved to go. R76 stated, I've never heard of them having a meeting about me. If someone told me, I would have remembered and I would go. A review of R76's Electronic Health Record (EHR) was conducted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety.

Inspectors wroteBased on record review and interview the facility failed to update Resident (R) 6's electronic health record (EHR) to accurately stage his facility acquired injury progressing from Moisture-Associated Skin Damage (MASD) on his right gluteus to a stage 3 Pressure Ulcer (PU) on his coccyx. This deficient practice could affect all residents who have skin injuries that are not being documented correctly. Findings Include: On 07/01/24 at 10:09 AM during record review of R6's EHR found he had a newly in-house (facility) acquired MASD injury documented on his skin assessment dated [DATE]. Weekly skin assessments for R6 were filled out from 03/19/24 - 06/19/24 documenting R6 had MASD on his Right Gluteus that at times was deteriorating, stalled or improving. [...]

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure proper hand hygiene procedures were followed by a staff member during medication administration. This deficient practice promotes the development and transmission of communicable diseases and infections. The deficient practice has the potential to affect all the residents in the facility. Findings Include: Concurrent observation and interview were conducted on 07/02/24 at 08:16 AM. Registered Nurse (RN) 10 was observed preparing medications for Resident (R) 8. After placing the pills in the cup, RN10 walked to the refrigerator for apple juice. RN10 could not find apple juice so he/she used the telephone to call the facility kitchen. RN10 then walked back to the medication cart and poured laxative powder into a cup. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodations to one of 18 residents sampled (Resident (R) 57). As evidence by, not ensuring R57's call light was within reach and assessable. This deficient practice has the potential to negatively contribute to resident outcome. Findings Include: R57 is an [AGE] year-old male admitted to the facility on [DATE]. He is Cantonese speaking but understands a small amount of the English language. Observation was conducted on 07/24/23 at 08:46 AM. R57 was in his room, awake, and sitting at the edge of his bed having breakfast. He greeted this surveyor with a wave. R57's call light was wrapped up and hanging on the wall. The placement of the call light was not within reach for R57. Observation was conducted on 07/24/23 at 01:30 PM. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean environment as evidenced by a supply shelf, in the second-floor storage room, found covered with spider webs. As a result of this deficiency, the facility increased the risk for infestation.

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 two of the 18 residents sampled (Resident (R) 22 and R30). This deficient practice has the potential to negatively impact the resident's quality of life. Findings Include: R22 has a medical history that includes but not limited to cerebrovascular disease with hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness), and dementia. R22 has also been receiving hospice care since 06/14/23. Observation and interview were conducted on 07/26/23 at 07:53 AM in R22's room. R22 just finished having her breakfast and was lying in bed. This surveyor asked R22 how she did in bingo yesterday. [...]

Inspectors wroteBased on record review and interviews, the facility failed to communicate necessary discharge information to the resident, resident representative and/or family member (FM), and provider(s) for one resident (R), R74, out of a sample of two residents. Inadequate information was documented by R74's physician detailing R74's course of stay at the facility and incomplete information was noted in the nursing discharge instructions and discharge care plan.

Inspectors wroteBased on record review and interview with staff member the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for two of five residents sampled (Resident (R) 27 and R32). The facility failed to monitor R32's and R27's behaviors and use the appropriate diagnoses related to psychotropic medications.

Inspectors wroteBased on record review and interview with staff member the facility failed to evaluate one of five residents sampled (Resident (R) 32) for gradual dose reduction (GDR) for a psychotropic medication prescribed to treat behaviors that are no longer monitored and exhibited.

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to properly store medications in a manner that facilitates considerations of precautions and safe administration in one out of two medication carts sampled. This deficient practice has the potential to promote medication administration error to one resident in the facility. Findings Include: Observation and interview were conducted on the third-floor hallway near the nurse's station on 07/25/23 at 01:52 PM. A medication cart contained a resident's medication blister pack labeled, Senna 8.6 mg tablets. On the blister pack was a handwritten note indicating, Discard after 5/23. Registered Nurse (RN) 6 was questioned about the medication blister pack. RN6 confirmed that the medication should not have been in the cart and should have been discarded. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure a resident's (Resident (R) 55) menu met her preferences.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow proper infection control during lunch service on a nursing unit and did not do hand hygiene after removing used gloves and putting on clean gloves during one resident's (R)43 care. This deficient practice encourages the development and transmission of communicable diseases and infections and has the potential to affect all residents in the facility.