Maluhia

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 17, 2026

  Based on interviews and record review, the facility failed to ensure safe handling and modified dressing protocols were used to protect one resident (R) 6, who had severe bilateral upper extremity (BUE) contractures and was totally dependent on staff for care. As result of this deficient practice, R6 suffered harm, a dislocated left shoulder. This was a facility reported event (FRI) #2745775, which the facility identified the noncompliance and conducted a Root Cause Analysis (RCA) and implemented a comprehensive corrective action plan that was fully verified as corrected on 07/17/2026, therefore, past noncompliance was determined. […]

• Actual harm, isolatedF684Apr 25, 2025

  Based on record review and interviews the facility was aware of Resident (R) 7's nut allergy but failed to document severity of nut allergy, failed to develop and implement a care plan for R7's nut allergy and failed to assure all recipes cooked in the kitchen were on the templates reviewed for food allergies before providing food to residents. The deficient practice resulted in harm to R7 who received food that contained nuts and having an anaphylactic response requiring transport to the emergency room for treatment. Findings Include: According to the United States Department of Agriculture (USDA) A food allergy is a potentially serious response to consuming certain foods or food additives. […]

• No harm, potential for more than minimal, widespreadF812Jul 23, 2021

  Based on observation and staff interview, the facility failed to ensure the storage of food in a safe and sanitary manner. Food items in the refrigerator were kept past the use by date and scoopers were left in dry good boxes/container. The deficient practice has the potential to create a risk of food borne illness. Findings Include: During the initial observation of the kitchen with the food service manager (FSM) on 07/20/21 at 09:22 AM, in a walk-in refrigerator observed a bottle of chocolate sauce dated 6/30/21 and a tub of Sunglow butter dated 07/15/21. There were approximately more than half the contents remaining for the chocolate sauce and butter. […]

• No harm, potential for more than minimal, patternF689Jul 22, 2022

  Based on observations and staff interview, the facility failed to secure a storage room located on the 2 [NAME] nursing unit. As a result of this failure, the facility put the residents at risk for accident hazards. Findings include: During an observation on 07/19/22 at 10:30 AM, the storage room located on 2 [NAME] nursing unit was not locked/secured and there was no staff in the immediate vicinity to prevent unauthorized entry to the room. The storage door had a keypad lock installed but the door latch was taped open to prevent the door from being locked. Observer was able to enter the room by just pushing the door open. […]

• No harm, potential for more than minimal, patternF693Jul 22, 2022

  Based on observation, interview, and record review, the facility failed to provide the appropriate treatment and services to prevent potential complications of enteral tube-feeding (TF) for six residents (Residents 33, 35, 63, 34, 12, and 62) in the sample. The TF tubing was not labeled which would indicate that the tubing is changed every day. As a result of this deficient practice, the facility placed all residents who are on enteral nutrition at risk for avoidable infections and complications. Findings include: 1) On [DATE] at 09:02 AM, an observation and concurrent interview were done with Registered Nurse (RN)4 at the bedside of Resident (R)33. Observed that R33's tube-feeding (TF) formula and TF administration set (tubing) were not labeled with the date and time they were hung. […]