Daniel K Akaka State Veterans Home

In the surveyor’s words

From the most serious findings on record at Daniel K Akaka State Veterans Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Apr 23, 2026

  Based on observation and interview, the facility failed to ensure opened food was stored in accordance with professional standards for food safety for one of one observed walk-in refrigerator, placing residents at risk for foodborne illness. Specifically, a carton of heavy whipping cream and a large container of raw chicken were not properly stored.Findings Include: On 04/20/26 at 08:27 AM, during an initial kitchen tour with the Dietary Manager (DM), an open carton of heavy whipping cream was observed in the walk-in refrigerator that was not properly sealed or closed. The DM stated the heavy whipping cream is usually stored in another container.Further observation revealed a large container of raw chicken for chicken pot pie. […]

• No harm, potential for more than minimal, isolatedF600Apr 23, 2026

  Based on record review and interviews, the facility failed to ensure that a resident was free from abuse for one of one resident (Resident (R) 7) reviewed for abuse. Specifically, R7 accused R82 of taking his belonging which resulted in R82 willfully striking R7.Findings Include: On 02/20/26, the facility submitted a completed event report to the State Agency (SA), Intake #2746056. The report documented that on 02/17/26 at 7:23 AM, R7 and R82 were in the dining area during breakfast. While R82 was ambulating to his table, R7 called R82 over. The residents began speaking, which escalated to both residents raising their voices and yelling. Staff responded and attempted to separate the residents. However, before staff could successfully intervene, R82 struck R7 on the forehead. […]

• No harm, potential for more than minimal, isolatedF657Apr 23, 2026

  Based on resident interview, staff interview and record review, the facility did not update/revise the care plan for three Residents (R) 3, 7, 8 of nineteen residents reviewed. As a result of the deficient practice there was an increased risk of uncoordinated delivery of care. Findings Include: 1) During Resident interview on 04/20/26 at 09:30 AM, R3 said that he accidentally spilled hot liquid on himself on 04/03/26. Staff interview on 04/22/2026 at 10:20 AM, Staff Nurse 3 was aware of the incident, previously mentioned, and said since the incident they had implemented an intervention where only the kitchen would be allowed to heat up any liquids for the residents. […]

• No harm, potential for more than minimal, isolatedF689Apr 23, 2026

  Based on observation, interview and record review, the facility failed to ensure the four resident unit lanai gate alarms were on. The deficient practice could affect all residents who are living on the first floor and are able to walk/wander on their own outside of the unit, putting them at risk for harm. Findings Include:On 04/20/2026 at 10:55 AM Resident (R) 47 was observed sitting in the unit dining room near the nurse's station. R47 was observed not wearing a wanderguard. A concurrent interview was conducted with Registered Nurse (RN)12 who was sitting at the nurse's station. Surveyor asked RN12 if R47 was wearing a wanderguard and RN12 confirmed resident was not wearing a wanderguard. […]

• No harm, potential for more than minimal, isolatedF695Apr 23, 2026

  Based on observations, interview, and record review, the facility failed to ensure that one of two residents (Resident (R) 41) reviewed for oxygen (O2) services had a physician's order to receive oxygen therapy. The deficient practice placed the resident at risk of receiving unsafe or inappropriate oxygen therapy without proper medical authorization.Findings Include: On 04/20/2026 at 10:02 AM, R41 was observed in his room with O2 concentrator set at 3 litters via nasal cannula. The nasal cannula was not properly placed in the resident's nostrils and was positioned on his cheek. On 04/20/2026 at 10:04 AM, an interview was conducted with Registered Nurse (RN) 4. RN4 was informed that R41's nasal cannula was not properly placed. […]