Kuakini Geriatric Care, Inc

In the surveyor’s words

From the most serious findings on record at Kuakini Geriatric Care, Inc, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Jan 8, 2025

  Based on observation and interview the facility failed to assure kitchen staff using the dishwasher waited for the water temperature to raise to 180 degrees Fahrenheit (F) or more during the final rinse cycle before processing the dishes from the conveyor belt, placing them on the storage racks of clean dishes, failing to assure dishware and silverware were heat sanitized. This deficient practice puts all residents and staff, who eat their meals at the facility, at risk for foodborne illness. The State Agency (SA) identified an Immediate Jeopardy (IJ) at S483.60 (F812) on 01/05/25 at 08:44 AM. Findings Include: On 01/05/25 at 08:43 AM an initial tour was conducted with Food Services Supervisor (FSS)1. […]

• Immediate jeopardy, isolatedF756Jan 13, 2023

  Based on interviews and record reviews, 1) the facility failed to ensure the attending physician reviewed and responded to the identified irregularities on the pharmacist Medication Regimen Review (MRR) for one of five residents R91) sampled for medication review. The pharmacist identified an irregularity for a resident prescribed a psychotropic medication without a diagnosis and recommended a gradual dose reduction (GDR). This placed the resident at risk for harm including negative side effects of the psychotropic medication, experiencing a fall, mental status changes, or sustained negative psychosocial outcomes. The medical record did not show evidence that the attending physician had reviewed and responded to the pharmacist MRR recommendation. […]

• Actual harm, isolatedF684Jun 12, 2026

  Based on interview and record review, the facility failed to ensure that Resident (R) 9 received treatment and care in accordance with professional standards. This was evidenced by the failure to timely assess, treat, and notify the Medical Doctor (MD) 2 regarding R9's complaint of pain during repositioning in bed reported by facility staff on 04/27/26 night shift (11:00 PM - 07:30 AM) and 04/28/26 day shift (07:00 AM - 03:30 PM). This deficient practice had the potential of contributing to worsening injury to R9 as the resident was admitted to the hospital several days later for left hip fracture identified as injury of unknown source.Findings include:The Office of Health Care Assurance (OHCA) received a facility-reported incident (FRI) Intake #3004586 for R9, dated 05/02/26, documenting… […]

• Actual harm, isolatedF726Feb 29, 2024

  Based on interviews, record review (RR) and observation, the nursing staff failed to demonstrate the competence and skill sets to provide safe nursing care in a manner to meet one resident's (R)2 physical needs. Specifically, the Certified Nurse Assistants (CNA) had been administering oxygen (O2), which is outside their scope of practice. In addition, the nursing staff administered oxygen to R2, who had Chronic Obstructive Pulmonary Disease (COPD) when her oxygen saturation level (sat) was outside the parameters ordered by the physician. Due to this deficient nursing practice, there was high likelihood that a Resident with COPD and oxygen administration parameters would be administered oxygen by licensed or unlicensed staff outside the order parameters and suffer harm. […]

• No harm, potential for more than minimal, widespreadF623Jan 12, 2024

  Based on interview and record review, the facility failed to provide proper notification of transfer/discharge for five of 11 residents sampled for hospitalization (Residents (R) 9, R37, R71, R89, and R74). Specifically, the facility failed to issue written notification of transfer/discharge to the residents or their representatives and/or failed to send notification of the transfer/discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO). This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings include: 1) Resident (R) 9 is a [AGE] year-old female originally admitted to the facility on [DATE]. […]