Citations in Hawaii
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Hawaii.
Statistics for Hawaii (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Hawaii
A resident dependent on staff for transfers was injured when two staff members, including one not fully trained, operated a mechanical lift and failed to ensure proper sling strap placement, resulting in a fall and serious injuries. In a separate incident, another resident with dysphagia and a physician order for suctioning was found with a suction machine at the bedside that was not fully set up, leaving her at risk in the event of a respiratory emergency.
Surveyors found an expired container of lemon juice in the kitchen refrigerator and an opened supplement drink in a resident's refrigerator that was not labeled with the date it was opened. Staff confirmed both items were not handled according to facility policy, resulting in a deficiency related to food storage and labeling practices.
A resident admitted for PT and OT with pneumonia and Parkinson's disease was transferred to a hospital for respiratory failure secondary to recurrent aspiration pneumonia. The discharge notice provided to the resident's representative and the LTCO did not include the effective date of transfer, as confirmed by the SSD.
Two vials of expired influenza vaccine were found stored in a medication refrigerator, and both an RN and the Head Nurse confirmed these should have been discarded for safety and efficacy. Facility policy requires immediate removal and disposal of outdated medications, but this was not followed.
A CNA transferred a resident using a mechanical lift without the required second staff member, contrary to the care plan and facility policy. In a separate case, a resident on hospice with an order for PRN oxygen did not have oxygen therapy interventions documented in the care plan, despite facility policy requiring such documentation.
A resident was transferred from bed to wheelchair using a mechanical lift by a CNA working alone, contrary to facility policy and training that require two staff for such transfers. Staff interviews and policy review confirmed that two-person assistance is mandated for safety, but the CNA proceeded alone, stating confidence in her ability and the resident's trust.
A resident's oxygen concentrator tubing was found in use without a label indicating the date of initiation. Both the head nurse and DON confirmed that the tubing should have been labeled with the start date, as required for respiratory care equipment.
The facility did not update care plans for two residents: one with self-inflicted skin abrasions lacked interventions for scratching, and another with a gastrostomy tube did not have care plan interventions to prevent tube removal, despite repeated incidents and physician orders.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with a history of traumatic brain injury and complex medical needs experienced a fall, after which nursing staff failed to perform and document complete neurological assessments, did not recognize or respond promptly to significant changes in condition, and delayed notifying the physician and transferring the resident for higher-level care. Staff lacked training, competency validation, and access to necessary equipment for neurological checks, and facility policies were insufficiently specific regarding post-fall assessment requirements.
Failure to Prevent Accidents During Mechanical Lift Transfer and Inadequate Emergency Equipment Setup
Penalty
Summary
A deficiency occurred when a resident who was dependent for transfers was being moved using a mechanical lift by two staff members, one of whom was not fully trained or authorized to operate the lift. During the transfer, the sling straps on the left side slipped off the hanger bar as the resident was being lifted, resulting in the resident falling and sustaining left-sided rib fractures and a pneumothorax, which required hospitalization and chest tube placement. The staff involved included a CNA who was orienting and not permitted to provide care, and another CNA who was responsible for the transfer. The facility's policy required two trained staff for mechanical lift transfers, but documentation confirmed that the orienting aide had not completed the required training checklist. Interviews and vendor inspection determined that the lift was functioning properly and that the incident was due to user error, specifically improper attention to strap placement and monitoring during the lift. Another deficiency was identified when a resident with a history of stroke, gastrostomy, and dysphagia was observed in bed with a suction machine at the bedside that was not fully set up. The machine was missing essential components, including the suction canister, tubing, and yankauer, despite a physician order for suctioning as needed for oral secretions. The nurse on duty confirmed that the suction equipment was not ready for use and acknowledged its importance in preventing accidents, especially given the resident's risk for respiratory emergencies due to her medical condition and NPO (nothing by mouth) status. Both deficiencies were substantiated through interviews, record reviews, and direct observation. The first involved a failure to ensure that only trained staff operated mechanical lifts, leading to a serious resident injury. The second involved a failure to provide care consistent with physician orders, leaving a resident at risk in the event of a respiratory emergency due to incomplete setup of emergency equipment.
Expired Food and Improper Labeling of Opened Supplement Drink
Penalty
Summary
During a kitchen inspection, surveyors observed a one-gallon container of lemon juice stored in the kitchen refrigerator that was labeled with an expiration date that had already passed. The container was half full and had not been discarded as required by facility policy, which mandates that expired foods are not to be used in food production or served to residents. The kitchen manager acknowledged the oversight when questioned and confirmed that the expired product should have been removed from storage. Additionally, in a resident-accessible refrigerator on the fourth floor, surveyors found an opened supplement drink that was not labeled with the date it was opened. When asked, a registered nurse confirmed that the supplement should have been labeled with the opened-on date in accordance with facility procedures. These findings indicate that staff did not consistently follow established protocols for food labeling and storage.
Discharge Notice Lacked Effective Date for Hospital Transfer
Penalty
Summary
The facility failed to include the effective date of discharge on the discharge notice for one resident who was transferred to an acute care hospital. The resident had been admitted for physical and occupational therapy with primary diagnoses of pneumonia and Parkinson's disease, and was transferred to the hospital three days later due to respiratory failure secondary to recurrent aspiration pneumonia. Upon review of the discharge and transfer notice, as well as email documentation sent to the Long-Term Care Ombudsman, it was found that the notice provided to both the resident's representative and the Ombudsman did not specify the date of transfer. The Social Services Director confirmed during an interview that the effective discharge date was left blank on the notice.
Expired Flu Vaccine Not Discarded from Medication Refrigerator
Penalty
Summary
Surveyors observed that two vials of expired influenza vaccine, dated 06/2025, were still stored in the medication refrigerator on Young 4 during a check with an RN. The RN acknowledged that the expired vaccines should have been discarded the previous month for safety reasons. An interview with the Head Nurse confirmed that expired medications must be discarded to ensure resident safety and drug efficacy. Review of the facility's Storage of Medication policy indicated that outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to established procedures. The failure to remove and discard the expired flu vaccines was directly observed and confirmed by staff.
Failure to Implement and Document Care Plan Interventions for Transfers and Oxygen Therapy
Penalty
Summary
A deficiency was identified when a Certified Nurses Aide (CNA) transferred a resident from bed to wheelchair using a mechanical lift without the required assistance of a second staff member. The CNA stated she performed the transfer alone because she felt capable and the resident trusted her, despite facility policy and the resident's care plan specifying that two staff are required for mechanical lift transfers. The Head Nurse confirmed that this protocol is in place for resident safety and is clearly documented in the care plan accessible to all staff. Additionally, another resident receiving hospice services and with a physician's order for oxygen use as needed did not have any interventions related to oxygen therapy documented in her care plan. The Director of Nursing reviewed the care plan and confirmed the absence of any mention of oxygen use, despite the resident having an active order for titrated oxygen per nasal cannula as needed. The facility's policy on oxygen administration requires review of the care plan for special needs, which was not reflected in the resident's documentation.
Mechanical Lift Transfer Performed Without Required Two-Person Assistance
Penalty
Summary
A deficiency occurred when a certified nurse's aide (CNA) transferred a resident from bed to wheelchair using a mechanical lift without the required assistance of a second staff member. The CNA performed the transfer alone, stating she felt capable and that the resident trusted her to do so. However, both a registered nurse and the head nurse confirmed that facility policy mandates two staff members for all mechanical lift transfers to ensure resident safety. Review of the facility's policy and training materials further confirmed that at least two nursing assistants are required for such transfers, and the CNA had completed relevant training. The incident was observed directly by surveyors and confirmed through staff interviews and record review.
Failure to Label Oxygen Tubing with Initiation Date
Penalty
Summary
A deficiency was identified when a resident's oxygen concentrator tubing was observed on two separate occasions without a label indicating the date of initiation. The tubing, connected to the oxygen concentrator in the resident's room, lacked documentation of when it was first used. During an interview, the head nurse confirmed that the oxygen tubing should be labeled with the date it was started. The DON also verified that the resident had an order for titrated oxygen via nasal cannula as needed and acknowledged that the tubing must be labeled with the initiation date. These findings were based on direct observation and staff interviews.
Failure to Revise Care Plans for Skin Integrity and GT Management
Penalty
Summary
The facility failed to revise and update care plans for two residents following changes in their conditions and needs. For one resident with a history of self-inflicted scratches and a facility-acquired abrasion to the sacrum, the care plan did not include interventions or treatments to address her self-scratching behavior, despite documentation in the electronic health record and physician's orders for topical treatments and protective measures. Observations and interviews confirmed that staff were aware of the resident's tendency to scratch and the need for regular nail trimming, but these interventions were not reflected in the care plan. For another resident with a gastrostomy tube (GT) and diagnoses including stroke and dementia, the care plan did not include interventions to prevent the resident from pulling out the GT, even though there were multiple documented incidents of the tube being pulled out and specific physician's orders for interventions such as pain assessment, redirection, and one-on-one supervision. Staff acknowledged that these interventions should have been included in the comprehensive care plan but were not at the time of the survey.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Ensure Nursing Staff Competency in Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide safe and appropriate care for residents with complex medical needs, particularly those with neurological impairments. Multiple licensed staff did not demonstrate competency in performing and documenting neurological assessments, identifying medical emergencies requiring timely intervention, or using critical thinking to determine the need for thorough assessments after a fall with potential head or neck injury. Documentation revealed that after a resident with a history of traumatic brain injury, craniectomy, and quadriplegia sustained a fall, staff did not complete full neurological assessments, including level of consciousness and pupillary response, as required by facility policy and standard care protocols. The resident, who had a baseline of neurological impairment and communicated by blinking, experienced a fall from bed while being changed by a CNA. Initial and subsequent nursing documentation focused primarily on vital signs, with incomplete or missing neurological assessment data. Staff failed to consistently document or perform assessments of the resident's level of consciousness and pupil response, and did not recognize or act upon significant changes in the resident's condition in a timely manner. There was a delay in notifying the physician and transferring the resident to a higher level of care, despite clear evidence of altered mental status and neurological decline. Interviews and record reviews indicated that staff were unclear about the components and frequency of neurological assessments, lacked access to necessary equipment such as penlights, and had not received adequate training or competency validation in these areas. The facility's policies lacked specificity regarding post-fall neurological assessments, and there was no evidence of structured training or competency checks for staff involved in the resident's care. The deficiency was determined to be immediate jeopardy due to the involvement of multiple staff and the serious nature of the failures.
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