Kulana Malama

In the surveyor’s words

From the most serious findings on record at Kulana Malama, in the surveyor’s own words.

• Immediate jeopardy, isolatedF726Jun 18, 2025

  Based on interviews, medical record review and document review, the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing care to meet residents' needs in a safe manner. Specifically, the licensed staff did not demonstrate 1) competency to perform and document neurological (neuro) assessments on a Resident whose baseline was neurologically impaired, 2) competency to identify a medical emergency that required timely response and transfer to a higher level of care, and 3) critical thinking to recognize the need to conduct and document a thorough physical and neurological assessment after a fall with potential head/neck injury, to determine if the Resident could be safely transferred from the floor to the bed. […]

• Actual harm, isolatedF686Mar 18, 2021

  Based on observation, interview and record review, one Resident (R)5 acquired a stage four pressure injury while residing in the facility. In spite of the appropriate and timely wound treatment, and dietary interventions to address the wound, progressed to a stage four pressure ulcer of the coccyx. Surveyor made multiple observations from 03/16/21 to 03/18/21 and noted that R5 was lying in the same position for a minimum of three to three and one half hours. Timely turning and repositioning of the resident is crucial to promote wound healing and avoid continuous pressure on the existing injury. […]

• No harm, potential for more than minimal, widespreadF880Jun 23, 2023

  Based on record review and staff interview, the facility failed to maintain an infection prevention and control program (IPCP) to provide a safe environment to help prevent the transmission of communicable diseases and infections. The facility did not ensure that the IPCP was reviewed annually and updated as national standards change. As a result of this deficient practice, all the residents in the facility were placed at potential risk for developing communicable diseases and infections. Findings Include: On 06/22/23, review of the facility's Infection Control Policy and Procedure manual was conducted. Noted the first page in the inside cover titled, Kulana Malama - IP (infection prevention) Manual Approval Signature Sheet did not have any signatures on it. […]

• No harm, potential for more than minimal, patternF880Sep 26, 2025

  Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff was wearing applicable Personal Protective Equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP), changed gloves after performing a dirty task and before performing a clean task, and ensure connecting tubes for tube feeding were not exposed. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings Include: 1) On 09/23/25 at 09:35 AM, during an initial observation of Resident (R) 24, observed R24's feeding port disconnected from the feeding bag. […]

• No harm, potential for more than minimal, patternF908Jun 23, 2023

  Based on observations, staff interview and review of the Ventec Life Systems User Manual, the facility failed to clean the VOCSN (Ventilator) Air Intake Filter every two weeks as recommended by the Manufacturer. As a result of this deficiency, the facility put the residents at risk for further complications. Findings include: On 06/21/23 at 10:45 AM, an observation of the VOCSN Air Intake Filter showed dust/dirt appearing build up on the surface of the filter. Concurrent staff interview with Respiratory Services Director (Resp Dir) revealed that the facility would only clean the filter once a month. During staff interview on 06/21/23 at 11:00 AM, Resp Dir acknowledged that the facility was not aware of the filter cleaning recommendation for every two weeks. […]