Samuel Mahelona Memorial Hospital

Inspectors wroteBased on record review and interview the facility failed to provide adequate supervision to prevent an accident for one of three residents (R) 13 sampled for accidents related to falls resulting in major injury and pain. The deficient practice puts all residents, who are at a high risk for falls, who are informally monitored on one to one for falls prevention, at great risk for a fall with injury and pain. Findings Include:On 08/06/25 at 4:49 PM the Office of Health Care Assurance received an initial report via fax from the facility reporting R13 had an unattended fall on 07/04/25 at 1:00 PM resulting in an Acute comminuted right femoral neck fracture. R13 was transferred to the hospital on [DATE] and underwent surgical repair on 07/05/25. R13 returned to the facility on [DATE] at 1015. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement individualized dementia care plans for three of four residents (Resident (R) 4, R6, and R7) reviewed for dementia care. This deficient practice placed residents with dementia at risk for unmet needs and failure to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Include:1) R6 is [AGE] year-old female admitted to the facility on [DATE] for long term care. Diagnoses included the following, but not limited, to high blood pressure, vascular dementia, type 2 diabetes, and motor speech disorder. Review of R6's Electronic Health Record (EHR) revealed R6 is prescribed psychotropic medications, has a diagnosis of dementia, and found no care plan related to dementia care. On 05/13/26 at 02:47 PM, an interview was conducted with Director of Nursing (DON). [...]

Inspectors wroteBased on observation and interview, the facility failed to store and label food, and failed to ensure the ice machine in the kitchen was kept in clean and sanitary condition, in accordance with professional standards for food service safety. This deficient practice puts residents at risk for serious complications from foodborne illness as a result of their compromised health status. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents at the facility. Findings Include: On 05/11/26 at 08:29 AM, during initial tour of the facility's kitchen, concurrent observation and interview were done with the Hospital Executive Chef (HEC). Observed large plastic container with expired uncooked rice with a use-by label date of 04/07/26. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident or resident representative was informed of treatment and provided consent for the use of psychotropic medication for one of five residents (Resident (R) 40) reviewed for unnecessary medications. This failure placed R40 at risk for receiving treatment without informed consent and compromised the resident's rights to participate in care planning and treatment decisions. Findings Include: Review of R40's physician orders revealed the resident was prescribed trazodone, an antidepressant medication, 50 milligrams (mg) every morning beginning on 11/10/25. Review of R40's Electronic Health Record (EHR) revealed no documented informed consent for trazodone 50mg prior to administration of the medication. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the discharge/transfer form used by the facility was provided to the resident, resident's representative, and Ombudsman for one of three sampled residents (Resident (R)49).

Inspectors wroteBased on observations and interviews, the facility failed to ensure one of three treatment carts and one of three medication carts were locked when unattended by nursing staff. This deficient practice allowed unauthorized access to medications and treatment supplies, placing medications at risk for diversion and placing residents at risk for not receiving medications and dressing changes as prescribed. Findings Include:1) On 05/13/26 at 08:34 AM, during medication administration observation, observed the treatment cart with prescribed topical medications and other supplies for the residents in the hallway unlocked and unsecured. Registered Nurse (RN) 24 was asked if medication cart should be locked when not in use, or before leaving treatment cart to administer medication to residents, RN24 confirmed that it should be locked and secured. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide education for five of five residents (Resident (R) 1, R3, R4, R7 and R13) or their representative, reviewed for influenza immunizations, regarding the risks and benefits and potential side effects of influenza immunization before offering the influenza immunization and obtaining consent or declination from the resident or their representative. This deficient practice puts all residents at risk of not being fully informed about their risks and benefits and potential side effects of receiving or declining the influenza immunization. Findings Include:On 05/12/26 at 02:53 PM, record review was conducted for R1, R3, R4, R7 and R13 to assure each resident received or declined their annual influenza vaccination for 2025. The facility was able to provide copies of these residents' consent/declination forms. [...]

Inspectors wroteBased on record review and interview the facility failed to provide education for one of five residents (Resident (R) 1) or their representative, reviewed for COVID-19 vaccine, regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine before offering the vaccine and obtaining consent or declination from the resident or their representative. This deficient practice puts all residents at risk of not being fully informed about the benefits and risks and potential side effects associated with the COVID-19 vaccine administered at the facility. Findings Include:On 05/12/26 at 02:53 PM, record review was conducted for R1 to assure the resident received or declined their COVID-19 vaccine. The facility was able to provide a copy of R1's consent/declination form. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to dispose of food items that have passed the use by date and store food in accordance with professional standards. This deficient practice puts all the residents and staff who consume food or drink prepared at the facility at risk for foodborne illnesses.

Inspectors wroteBased on observation and interviews, the facility failed to ensure a comfortable temperature level for one Resident (R12) sampled. Observed R12 was lying in bed with a blanket covering his entire body, including his face and R12's Family Member (FM)3 seated under the air conditioner (AC). The room was noticeably colder in R12's portion of the room and the AC was blowing directly onto R12. R12 and FM3 reported the room is too cold, the air conditioner constantly blows cold air directly onto him, and must cover his entire body, head included, to avoid the cold air even when he has visitors. Director of Nursing (DON) confirmed the temperature in R12's room was colder than the temperature displayed on the AC controller and the cold air from the AC is not a comfortable temperature for R12. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to discard expired medication stored in the medication cart for one Resident. The deficient practice potentially places residents at risk for more than minimal harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's preferences documented on the Advance Health Care Directive (AHCD) was accurately documented on the resident's Physician Order for Life-Sustaining Treatment (POLST) for one of three residents sampled. Review of Resident (R)40's AHCD via Electronic Health Records (EHR) documented the resident's preferences to receive medical treatment to prolong the resident's life. However, review of R40's POLST documented contradicted the resident's AHCD and documented the resident should not have Cardiopulmonary Resuscitation (CPR) and do not attempt to resuscitate. Also, the resident's active diagnosis documented R40 as Do Not Resuscitate (DNR). As a result of this deficient practice, residents are at risk for more than minimal physical harm.

Inspectors wroteBased on observation and interview with staff member, the facility failed to ensure food products were stored under sanitary condition and discarded before the expiration or used by date. This failed practice could place all facility residents at risk for food-borne illness. Findings Include: On 11/28/23 at 09:25 AM, concurrent observation and interview was done during the initial kitchen tour with Kitchen Manager (KM). 1) Observed in the kitchen helper three-door fridge, a clear squeeze bottle labeled LV with the date of 11/04. Inquired with KM what was in the clear squeeze bottle, and she stated Lemon vinegar juice. KM further stated the date 11/04 indicated when the lemon vinegar juice was made and should have been discarded a week from when it was made. KM confirmed the lemon vinegar juice was made longer than one week ago. [...]

Inspectors wroteBased on record review and interview with staff member, the facility failed to assure one of two residents (R)17 sampled exercised their right to formulate an advanced health care directive (AHCD). This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain a safe environment as evidenced by having four cracked, broken electrical outlet covers in the resident's room.

Inspectors wroteBased on review of the facility's policy and procedures and staff interview, the facility failed to immediately report allegation of abuse to the adult protective services (APS) in accordance with State Law for a facility reported incident related to allegations of abuse.

Inspectors wroteBased on record review and interviews, the facility failed to accurately document the code status of one of the residents sampled (Resident (R) 5). This deficient practice has the potential to adversely affect the level of care for all residents in the facility. Findings Include: A review of R5's Electronic Health Record (EHR) was conducted on [DATE]. R5's EHR contained a completed document titled, Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE]. The POLST document on section A titled, Cardiopulmonary Resuscitation (CPR), indicated that R5 had chosen, Do not attempt resuscitation/DNAR (Allow natural death). Further review of R5's EHR contained a completed document titled, Hawaii Advance Heath Care Directive, dated [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all residents who were eligible for the Pneumococcal vaccine received it and/or their medical record indicated that the resident or resident's representative were provided education regarding the benefits and potential side effects of the Pneumococcal vaccine. This deficient practice places one of five residents (Resident (R) 11) sampled at risk for developing pneumonia related complications. This deficient practice has the potential to affect all the residents in the facility. Findings Include: Record review of R11's Electronic Health Record (EHR) was conducted on 11/30/23. R11's EHR indicated that her Pneumococcal vaccination status was unknown. Interview was conducted with the facility's Infection Preventionist (IP) on 11/30/23 at 02:29 PM in the conference room. [...]