Hale Makua - Wailuku

In the surveyor’s words

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

• Immediate jeopardy, patternF600May 20, 2022

  Based on record reviews and interviews, the facility failed to prevent Resident, (R)34's alleged sexual abuse by R52, and did not monitor R52's sexual behavior, and failure to report R52's behavior to R52's physician. The facility failed to protect R34, who was a vulnerable resident from sexual abuse. This deficient practice has the potential to affect all vulnerable residents residing in the facility. Findings include: On 05/18/22 at 11:59 AM, reviewed the completed Event Report dated 05/13/22 retrieved from the Aspen Complaints/Incidents Tracking System (ACTS), intake number 9520. The Event Report was completed by the facility's Administrator and described an alleged sexual abuse incident between R34 and R52 that occurred on 05/12/22 at 12:06 AM. The physician was notified on 05/12/22. […]

• Actual harm, isolatedF684May 20, 2022

  Based on observations, interviews, and record reviews, the facility failed to provide quality care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for three (3) residents (Resident (R)11, R38, and R68) sampled. R11 treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R11 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11 annual minimum data set (MDS) with an assessment review date (ARD) of 02/22/22 documented in Section G. R11 requires extensive assistance (resident involved in activity, staff provides weightbearing support) for bed mobility. R11's pain was not managed according to professional standards of care. […]

• Actual harm, isolatedF689May 20, 2022

  Based on observations, record review, and interviews, the facility failed to protect Resident (R)27 from any more potential falls by not ensuring that: 1) the Care Sense fall prevention alarm placed on R27's bed was engaged to alert staff if R27 got out of bed unassisted, 2) other staff were aware that R27 was able to disengage from her clothing a personal tab alarm used for fall prevention, 3) R27's care plan was updated and individualized to recognize R27's capability of unclipping her personal tab alarm from her clothing and her refusals to wear the alarm, and 4) staff were following facility policy and procedures. These deficient practices places R27 in at a high of injury due to her medical diagnosis and history of falls. […]

• No harm, potential for more than minimal, widespreadF812Nov 15, 2024

  Based on observation and interview the facility failed to store food kept in the freezer at 0 degrees Fahrenheit or less. This deficient practice puts all the residents at risk for foodborne illness, Findings Include: On 11/12/24 at 09: 48 AM during initial tour of the kitchen interviewed kitchen staff (KS)1. Inquired about temperature log for the freezer that showed temperatures logged from 0 to 6 degrees Fahrenheit. Review of the Freeze Temp Record form has standard Freeze temperature less than or equal to 0. Review of this form found a row for re check temp and maintenance notified boxes which were left blank. The temperatures above 0 degrees (8) did not have re check temp and maintenance notified filled out. […]

• No harm, potential for more than minimal, widespreadF925Nov 15, 2024

  Based on observations and interviews the facility failed to prevent flies and a bird from entering the dining room while residents were eating their lunch and lunch trays were being made. This deficient practice puts the residents at risk for foodborne illnesses. Findings Include: On 11/14/24 at 11:45 AM while observing kitchen staff put containers of uncovered hot food onto the trayline observed there were flies near the trayline flying above the open food. Food Service Director (FSD) shooed away the flies and covered the food with aluminum foil. FSD spoke with kitchen staff to remind her to cover the food with lids or foil as she is placing the containers on the trayline to prevent flies from going into the food. […]