Maile Aloha

This was an unannounced Plan of Correction follow-up visit. The primary finding is that the facility did not complete the required Plan of Correction by the established due date. Additionally, the facility was cited with civil penalties for this non-compliance.

The inspection revealed multiple deficiencies across several areas, including staff training, resident record keeping, emergency preparedness, and fire safety. Most notably, the facility was cited for an immediate health risk due to lacking a fire clearance for bedridden residents. Several Type B deficiencies were also noted regarding documentation and procedural compliance.

The facility underwent an unannounced Required Annual Inspection. The physical inspection noted that the facility was clean, sanitary, and equipped appropriately for resident care. However, the review of records could not be completed during this visit due to time constraints, necessitating a follow-up inspection.

The unannounced case management visit revealed deficiencies related to mandatory incident reporting. Specifically, the facility failed to submit required reports for multiple resident falls that occurred on dates in June, July, and August. The citations indicate non-compliance with reporting requirements, posing a potential risk to resident safety and health.

FACILITY EVALUATION REPORT

The unannounced case management visit was conducted to issue a deficiency observed during a complaint investigation. The primary finding relates to the facility's admission agreements, specifically regarding the lack of clear documentation for additional services like in-room meals and commode use. The facility must correct this by updating its admission agreements and providing proof of staff training on this matter.

The unannounced case management visit was conducted to issue a deficiency observed during a complaint investigation. The primary finding relates to the facility's admission agreements, specifically regarding the lack of clear documentation for additional services like in-room meals and commode use. The facility must correct this by updating its admission agreements and providing proof of staff training on this matter.

The facility underwent an unannounced Required 1-Year Visit. The inspector observed that the facility has implemented comprehensive infection control practices, including universal entry screening, visitor sign-in policies, and hand hygiene promotion. No deficiencies were observed during this visit.