Life Care Center of Kona

In the surveyor’s words

From the most serious findings on record at Life Care Center of Kona, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 21, 2023

  Based on observations, record reviews and staff interviews, the facility failed to ensure adequate supervision and assistance to prevent accidents for two Residents (R)8 and R36 sampled. As a result of these deficient practices 1) R8 fell and sustained a hematoma to the right side of her forehead and swelling of the right side of her face and 2) R36 was placed at risk for falling when being transported in a wheelchair that had no footrests. Findings include: (Cross Reference to F656: Develop/Implement Comprehensive Care Plan) 1) On 09/17/23 at 11:17 AM, observed R8 in her room sitting up in her wheelchair. R8 had a dressing on the right side of her forehead. When asked what happened to her head, R8 said I fell in the bathroom. Review of electronic health record (EHR) for R8 conducted. […]

• Actual harm, isolatedF726Sep 21, 2023

  Based on interviews and record review, the facility failed ensure competent skills to assure resident safety and maintain the highest practicable well-being for two Residents (R)40 and R34 sampled. Nursing Staff (NS)99 delayed treatment by not immediately informing the physician after R40 fell from the bed sustaining redness and pain to touch (5/10) on the resident's left shoulder to ensure a physician evaluated the resident's overall condition(s), laboratory test, treatment of the resident was under the care of a physician. Approximately four to five hours after the fall, R40 had an acute mental status change and was transferred then discharged to an acute hospital for further treatment. […]

• Actual harm, isolatedF684Feb 23, 2022

  Based on interviews and record review (RR), the facility failed to provide the needed care and services that were resident centered, in accordance with one resident's (R)1 preferences, goals for care and professional standards of practice. There was lack of documentation of R1's choices, preferences and goals to support not treating his critical medical condition related to his blood dyscrasias. Although this may not have been the sole contributing factor, R1 had four falls during [DATE] to [DATE] with progressive functional and cognitive decline that resulted in a transfer to the hospital where he was treated with blood [CONDITION(S)] and diagnosed with a subdural hemorrhage (bleeding in the brain) that required surgical intervention. […]

• Actual harm, isolatedF689Feb 23, 2022

  Based on record review (RR) and interviews the facility failed to provide adequate supervision to one resident (R)1 to prevent several falls in spite of the resident being a high fall risk related to his medical diagnosis. After R1 had a fall on 12/13/2020 he was on alert charting and frequent neurological checks to monitor his condition for signs/symptoms of any potential neurological decline. Although it was documented R1 showed increased signs of confusion, lethargy, and functional decline, the nursing staff did not monitor him appropriately. During that period of time R1 fell again. This deficient practice of the lack of monitoring and supervision resulted in harm from avoidable fall's and the eventual decline and death of R1. […]

• No harm, potential for more than minimal, widespreadF801Jan 15, 2026

  Based on interviews and record review, the facility did not employ a qualified Director of Food and Nutrition Services (DFNS). A qualified DFNS must be a certified dietary manager, or a certified food service manager, or hold national certification for food service management and safety, or who holds an associate's degree or higher in food service management or hospitality. This deficient practice has the potential to compromise the health and nutritional status of all residents at the facility.Findings include:On 01/12/26 at 09:35 AM, an initial tour of the kitchen was done with Dietary Aide (DA) 2 and the Registered Dietician (RD). […]