Hale Kupuna Heritage Home, LLC

In the surveyor’s words

From the most serious findings on record at Hale Kupuna Heritage Home, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 12, 2026

  Based on Observation, interviews and record reviews. The facility failed to provide supervision based on the individual resident's assessed needs and the risks identified in the environment to prevent accidents for three of three Residents (R) 7, R5 and R54. The deficient practices resulted in falls with major injuries for two (R5 and R54) of three residents sampled for free of accident hazards/supervision/devices, and an injury for one resident, R7. Findings Include: Cross reference to F725 sufficient nursing staff. Observation and interview with R7 sitting in a chair at the dining room table on [DATE] at 11:14 AM in the dining area on C wing. Observed an adhesive bandage on top of his head. Asked R7 what happened to his head. […]

• No harm, potential for more than minimal, widespreadF812Sep 6, 2024

  Based on observations and staff interviews, the facility failed to: 1 and 2) ensure food were stored and frozen food thawed in a manner that avoids foodborne illness to the residents and 3) perform hand hygiene when distributing food trays to residents. As a result of these deficiencies, the facility put the residents at risk for foodborne illness. Findings include: 1) On 09/03/24 at 09:42 AM, initial observation of kitchen, thawing individually wrapped salmon fillets in water in a sink. Inquired with Kitchen Staff (KS)2 about the thawing salmon. KS2 stated they are having miso salmon for dinner and confirmed the salmon has been in the water for about one hour. […]

• No harm, potential for more than minimal, widespreadF880Sep 6, 2024

  Based on observation, interview and policy review, the facility failed to ensure staff followed the Infection Prevention and Control policies and procedures for proper use of personal protective equipment (PPE) to follow proper infection control practices. Staff working with residents on isolation precautions did not correctly doff (remove) their PPE after providing care to Covid-19 positive residents in both resident care units in the facility. The same staff were also caring for residents who were not Covid-19 positive. The deficient practice places all residents in the facility at risk for healthcare associated infections that can result in significant adverse consequences. Findings include: Facility matrix and Electronic Health Record (EHR) reviewed. […]

• No harm, potential for more than minimal, widespreadF867Sep 22, 2023

  Based on record review (RR) and interview, the facility failed to have written, in their policies and procedures, data collections systems, monitoring, adverse event monitoring, feedback from direct care staff and other residents and representatives, opportunities for improvement, established with the minimum qualifications that should be established. This deficient practice has the opportunity for minimum Quality Assurance and Performance (QAPI) measures to be missed. Findings include: Observation of the policy on 09/21/23 at 10:00 AM revealed an incomplete policy and procedure demonstrating information needed to guide quality assurance and performance improvement. […]

• No harm, potential for more than minimal, widespreadF838Sep 2, 2022

  Based on interview and record review, the facility failed to ensure the Facility Assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs. This deficiency has the potential to put residents at risk for harm. Findings include: On 09/02/22 at 11:05 AM, reviewed the facility assessment that was provided to the survey team on 08/30/22. Review of the facility assessment documented in Section A.1. Function- Sufficiency Analysis Summary, considerations for staffing and scheduling systems identified smartlinx for appropriate staffing levels for the census and that the facility ensures one RN (registered nurse) on staff at all times. […]