Maunalani Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and review of medical records, documents and policies, three Resident ((R)1, R2 and R3) of a sample size of three, had incomplete medical records. Physician visits and/or discharge summary and initial admission orders lacked timely signature by the attending physician as required by regulatory standards. In addition. one initial History and Physical (R)1 was not documented in the medical record (EMR). These deficiencies do not meet the requirements for timely and authenticated physician documentation to support continuity of care and compliance with federal regulations.

Inspectors wroteBased on interviews, documents and record review, the facility failed to respond to a family member's (FM) email grievance regarding Resident (R)1's stay at the facility. The facility reported no grievances during period requested (September 2025 to June 8,20-26). There was no follow-up documentation, resolution, or communication to the FM. This failure resulted in several of the FM's concerns remaining unaddressed and caused ongoing dissatisfaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from accidents for one of three residents (Resident (R) 2) sampled for falls and one of one resident (R1) sampled for accident hazards. 1) The facility failed to ensure two trained staff members operated a mechanical lift and upon analysis, indicated human error, which lead to R2's fall from the lift. During transfer with use of a mechanical lift, the left side lift sling straps slipped off the hanger bar as R2 was lifted causing R2 to fall. As a result, R2 was hospitalized with left side rib fractures with pneumothorax (collapsed lung) requiring a pigtail chest tube placement. 2) The facility failed to ensure R1 received care consistent with her physician orders. [...]

Inspectors wroteBased on interviews, observation, record review, the facility failed to provide adequate supervision to one Resident (R)2. On 09/21/2024, R2 fell while in the Physical Therapy gym which resulted in harm. He was hospitalized with a subdural hematoma (bleeding near the brain) which required immediate surgical intervention. In addition, the facility failed to conduct a thorough investigation, document findings, and interventions taken to reduce the likelihood of a similar event. This deficient practice could affect any resident if the appropriate level of supervision is not provided.

Inspectors wroteBased on interview, document and medical record review (RR), the facility failed to ensure appropriate discharge summaries were completed for two out of a sample size of three residents (R). R1 and R2 were transferred to the Hospital for a higher level of care, but when the Resident's families informed the facility the resident would not be returning to the facility, the discharge summaries are required to include a recapitulation of the resident's stay and treatment in the facility. R2's discharge summary was not accurate or complete, and R1's had not been completed prior to survey. As a result of these deficiencies, the provider did not have all the necessary information regarding the resident's clinical status. This deficient practice could affect all discharged resident's.

Inspectors wroteBased on interviews, document and record review, the facility failed to recognize the seriousness of one Resident's (R)1 condition, of a sample size of three. Specifically, R1 exhibited a change in level of consciousness on two consecutive days, and on day two, the nursing staff determined her condition not serious enough to transport to the hospital by Emergency Medical Services (EMS/911). In addition, the facity failed to develop a comprehensive care plan for R1's multiple skin tears. As result of these deficiencies, R1 was 1) hospitalized for sepsis due to urinary tract infection (UTI), and 2) continued to get skin tears. These deficiencies may affect any resident, and has potential to delay transport to a higher level of care.

Inspectors wroteBased on interview and medical record review (RR), one physician's (MD)1 documentation of one Resident's (R)2 visit, did not meet regulatory requirements. MD1's visit note did not accurately reflect R2's total program of care, and included an inaccurate statement.

Inspectors wroteBased on resident interview, family interviews, record review and staff interview, the facility failed to care for two Residents (R) 46 and 188 of eight residents reviewed, with respect and dignity. As a result of this deficiency, R46 and R188 were not given their right to the maintenance and/or enhancement of their quality of life.

Inspectors wroteBased on record review and interview, the facility failed to accurately assess one Resident (R) 2 of three in the sample who had two pressure ulcer's that were acquired in the facility. The resident assessment coded one stage three pressure injury as present on admission. The deficient practice potentially affects the care plan which implements the goals and treatment outcomes. All residents in the facility may be affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent the development of two stage three (full thickness skin loss) pressure ulcers (a localized damage to the skin and/or underlying tissue, as a result of intense pressure in combination with shear) while in the facility for one resident (R) 2 of three in the sample. The facility staff failed to turn and reposition R2 every 1-2 hours. The deficient practice placed the resident at an increased risk of infection and poor health outcomes. All residents who require assistance from staff for mobility are at risk.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to store and handle food items under sanitary conditions. This failed practice could place all facility residents at risk for food-borne illness.

Inspectors wroteOn 08/29/23 at 07:30 AM, six of seven rooms that had Airborne TBP signs outside were observed with the doors left wide open. Upon interview with the Infection Preventionist (IP), it was confirmed that the doors were left wide open to these rooms. Guidelines from the Centers for Disease Control and Prevention (CDC) state that doors will be closed when Airborne TBP are in place, to prevent spread of airborne-transmitted communicable diseases such as COVID. Seven residents were positive for COVID in these rooms and included rooms 214, 216, 217, 218 and 219. Further observations made on 08/29/23 included three wall-mounted fans outside of these open rooms, mounted high on the hallway walls to increase air circulation, were on. This observation was also confirmed with the IP. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff, and visitors, as evidenced by the unlevel and/or multiple floor panels that are lifting in the hallways and dining room(s) of the resident floors, and in the elevator. As a result of this deficient practice, residents, staff, and visitors are placed in an uncomfortable environment and are at risk for avoidable injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Honor one Resident (R)2's wishes to refuse treatment per the advanced healthcare directive for one resident of one in the sample. 2. Did not honor the medical decision to stop medication that potentially prolong's life when the medical decision maker asked the nursing staff not to give the medication that would lower her blood pressure (BP). 3. Follow up with R2 and her medical decision maker about considering comfort care as an option. The deficient practice violates the rights of the resident and her representative to make treatment decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to manage pain adequately for one of one resident (R) sampled for pain (R84). Specifically, the facility failed to ensure that R84's as needed (PRN) pain medication was kept in stock, failed to administer the PRN pain medication when asked for, failed to assess his pain level when needed, and failed to develop pain management goals with the Resident. As a result of this deficient practice, R84 was prevented from attaining or maintaining his highest practicable level of well-being.

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 three medication carts sampled. This deficient practice has the potential to promote medication administration error to the residents in one unit in the facility.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to provide accommodation for food preferences for one of 20 residents sampled, Resident (R)60.

Inspectors wroteBased on observations, review of the facility's policy and procedures, and interview with staff members, the facility failed to ensure a contractor, injecting COVID-19 boosters at the facility, demonstrate proper hand hygiene between glove changes while vaccinating the residents. This deficient practice may increase the spread of infections and has the potential to affect the residents who are receiving vaccinations in the facility. Findings Include: On 10/13/22 at 10:38 PM observation and interview with Contractor (C)1 and Health Information Clerk (HIC)4 was done. Observed C1 and HIC4 in Resident (R)17's room as she expressed that she did not want to get the COVID-19 booster. C1 stated he is at the facility to administer COVID-19 boosters to facility staff members and residents. [...]

Inspectors wroteBased on observations, staff interview and review of Product Safety Data Sheet, the facility failed to perform preventive maintenance on three Biohazard Response Spill Kits, Peroxide Multi Surface Cleaner and Disinfectant bottles located in hallway cabinets on the nursing units. As a result of this deficiency, the facility put the residents, staff, visitors at risk for exposure to hazardous solutions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the comprehensive person-centered care plan was implemented for one (1) of 19 residents sampled. R69's care plan was not implemented and the facility failed to monitor the efficacy of R69's pain management regimen. The deficient practice resulted in R69 experiencing unrelieved pain. R69 is at a potential risk for psycho-social harm. Findings Include: Cross reference to F697 Pain Management. R69 was admitted to the facility on [DATE] with diagnoses that included unspecified polyneuropathy, unspecified gout, and abrasion of lower back and pelvis. Review of the resident's care plan documents R69 to have pain in her right leg and to be managed with pain medication as needed. The care plan further documents she will be comfortable with current pain regimen. Tolerable pain level is 3. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide resident centered needed care and services for one (1) of 19 residents sampled, Resident (R)24. The facility did not follow the physicians order to treat diarrhea for R24. Findings Include: R24 was admitted to the facility on [DATE] with multiple diagnoses which includes, hypertiensive chronic kidney disease and Cauda Equina Syndrome, a rare disease affecting a bundle of nerves in the spine. Review of R24's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/22/22, R24's Brief Interview Mental Status (BIMS) scored her at a 15 (cognitively intact). On 10/11/22 at 12:25 PM interview with R24 was done, R24 reported having frequent loose stools, diarrhea, and her physician was to recommend medication but was never administered any medication to treat diarrhea. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to evaluate the effectiveness of regularly scheduled pain medication for one of two residents sampled for pain management. As a result of this deficient practice, Resident (R)69 had unrelieved pain. Findings Include: Cross reference to F656, Develop/ implement comprehensive care plan. R69 was admitted to the facility on [DATE] with diagnoses that included unspecified polyneuropathy, unspecified gout, and abrasion of lower back and pelvis. Review of R69's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/28/22, R69's Brief Interview Mental Status (BIMS) scored her at a 15 (cognitively intact). [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure one (1) of 19 residents sampled, Resident (R)24 who were served food according to preference. Findings Include: R24 was admitted to the facility on [DATE]. Review of R24's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/22/22, R24's Brief Interview Mental Status (BIMS) scored her at a 15 (cognitively intact). Review of R24's food allergies documented in R24's Electronic Medical Record (EMR) includes Basil and Broccoli. On 10/11/22 at 12:33 PM observation and interview with R24 was done during lunch. R24 stated the facility gives her the menu weekly and she can mark off her preferences, however, on the bottom of the menu she requests for a tuna sandwich and raisins every day just in case she doesn't like the food or is served with food she is allergic to. [...]