Aloha Nursing & Rehab Centre

In the surveyor’s words

From the most serious findings on record at Aloha Nursing & Rehab Centre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 2, 2022

  Based on interviews and document review, the facility failed to provide adequate supervision of one resident (R)2 that had documented behaviors of aggression and wandering into other resident's rooms. As a result of the lack of supervision, on 08/02/2022, R2 self-propelled into R1's room and assaulted her with the remote control causing physical harm. All residents in the facility are at risk of abuse and harm if appropriate supervision is not provided. Findings include: 1) Cross Reference F600: Free from Abuse and Neglect The Office of Healthcare Assurance received an event report of Resident to Resident abuse that occurred on 08/02/2022, which was substantiated by the facility. […]

• Actual harm, isolatedF726Oct 6, 2023

  Based on interviews and record review, the nursing staff failed to demonstrate competency when caring for two residents (R1 and R2) out of a sample size of three. Evidence included: 1. R1 had a change of condition that the Registered Nurse (RN)1 failed to immediately notify the physician (MD1). 2. When MD1 failed to respond, there were no other attempts to contact him or another provider. 3. RN1 failed to monitor R1's condition according to nursing standards. 4. The nursing staff failed to attempt to wean R2 off oxygen as directed by MD order, and 5. MD was not notified R2 refused to wean off oxygen therapy. As a result of these deficiencies, R1 suffered harm when she fell a second time and became unresponsive requiring transfer to the hospital. […]

• Actual harm, isolatedF656Sep 9, 2022

  Based on observations, interviews, and record reviews, the facility failed to appropriately develop and implement the care plans (CP) for three residents (R), R75, R33, and R23, out of a sample of 21 residents. The deficient practices included: 1. Staff failed to implement the identified care needs for R75 that resulted in a facility-acquired stage 2 pressure ulcer (PU), and the facility also failed to develop a person centered CP with interventions to heal and/or prevent the worsening of R75's PU. 2. The facility failed to identify and develop an individual care need for R33, and 3. […]

• Actual harm, isolatedF600Sep 2, 2022

  Based on interviews, observation and document review, the facility failed to provide one resident (R)1 the right to be free from physical abuse, which was substantiated by the facility. On 08/02/2022, R1 suffered harm when she was physically abused by R2 when he entered her room and struck her multiple times with the remote control. R1 was treated at a hospital where she received care for her injuries, which included a laceration of the head requiring sutures. All residents are at risk of abuse with adverse outcomes if the facility does not provide a safe environment. Findings include: 1) The Office of HealthCare Assurance ([NAME]) received an initial event report dated 08/02/2022 at 02:20 PM regarding a resident to resident incident. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2025

  Based observation, interviews and review of the facility's Food Management System policies, the facility failed to monitor and check the dishwasher sanitizing temperature logs on a consistent basis, properly label open food items in the freezer, and discard food items in the refrigerator by its use-by date. This deficient practice places residents in the facility who are provided with meals, at risk for foodborne illness.Findings Include:1) On 07/29/25 at 08:00 AM, initial walkthrough of the kitchen with Kitchen Staff (KS) 1, noted dishwasher heat sanitizing log with missing temperature checks for the following dates and mealtimes for the month of July:07/08-07/29, missing dinner check07/11-07/20, missing breakfast check07/25-07/27, missing breakfast check07/27, miss lunch checkConcurrent… […]