Hale Makua - Kahului

In the surveyor’s words

From the most serious findings on record at Hale Makua - Kahului, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Oct 19, 2023

  Based on observations, interview, and record review (RR), the facility failed to follow the proper washing and sanitizing practices for the dishes and silverware to prevent the outbreak of foodborne illnesses as evidenced by wash and final rinse temperatures of the water in the High Temperature Dishwasher (using heat sanitization) that were well below the temperatures recommended for safety by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code (https://www.fda.gov/media/110822/download), in addition to not monitoring that the proper temperatures were being maintained as evidenced by no retrievable documentation of temperatures since [DATE]. […]

• Immediate jeopardy, isolatedF607Jan 26, 2022

  Based on observation, interview, and record review, after receiving report of an alleged abuse of Resident (R)1 by a certified nurse aide on 01/07/22 at approximately 05:30 AM, the facility failed to immediately and fully implement their Comprehensive Abuse Policy and Prevention Program in response. Specifically, the facility failed to ensure appropriate protective measures for R1, failed to conduct a thorough investigation, and failed to report the abuse allegation to the state agency (SA) and adult protective services (APS) in a timely manner. As a result of this deficient practice, resident safety was compromised, and an immediate jeopardy (IJ) was identified. […]

• Actual harm, isolatedF600Oct 18, 2024

  Based on interviews and record review, failed to ensure one resident's right to be free from abuse. R106 hit R141 in her legs with his wheelchair, then left laughing. R141 sustained a 10 cm x 10 cm blue/purple discoloration on the left medial knee and 0.5cm x 0.5 cm light red mark on the left leg just below knee and reported to staff that she was going to her room because she was feeling unsafe because R106 hit her. As a result of this deficient practice, residents in the presence of R106 have the potential for abuse and more than minimal harm. Findings include: Review of the Facility Reported Incident (FRI) #11157, documented on 08/21/24 at 01:15 PM, R141 reported R106 hit her with his wheelchair, reversed the wheelchair then propelled away from the resident laughing. […]

• Actual harm, isolatedF697Oct 18, 2024

  Based on observations, interview, Electronic Health Record (EHR) review and policy review the facility failed to assess pain prior to and manage one Resident (R) of the sampled, R252's pain during a dressing change for his stage 4 pressure ulcer (PU) on his right buttock. The deficient practice prevented R252 from attaining and maintaining his highest level of wellbeing. Findings Include: On 10/17/24 at 01:40 PM spoke with Registered Nurse (RN) 26 and inquired if she had done the dressing change for R99. She confirmed she had already done the dressing change to R99's feet/legs. Inquired if she was going to do a dressing change soon and RN26 stated she was going to do a dressing change for R252. On 10/17/24 at 01:50 PM observed dressing change for R252's stage 4 PU to his right buttock. […]

• Actual harm, isolatedF689Aug 12, 2024

  Based on interviews, document and record review, the facility failed to provide the appropriate supervision and put interventions in place to prevent one Resident (R)1 with moderate cognitive impairment from elopement, resulting in harm. Although R1 exhibited exit seeking behavior on [DATE], he was able to leave the premises in his truck on [DATE]. R1 got lost and was returned to the facility approximately five and a half hours later by the local police department. As a result of the elopement, R1 suffered psychological and physical harm. R1 was afraid when police found him. When returned to the facility, he was cold, and both feet were swollen. […]