Maunalani Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Maunalani Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 14, 2025

  Based on interview and record review, the facility failed to ensure residents were free from accidents for one of three residents (Resident (R) 2) sampled for falls and one of one resident (R1) sampled for accident hazards. 1) The facility failed to ensure two trained staff members operated a mechanical lift and upon analysis, indicated human error, which lead to R2's fall from the lift. During transfer with use of a mechanical lift, the left side lift sling straps slipped off the hanger bar as R2 was lifted causing R2 to fall. As a result, R2 was hospitalized with left side rib fractures with pneumothorax (collapsed lung) requiring a pigtail chest tube placement. 2) The facility failed to ensure R1 received care consistent with her physician orders. […]

• Actual harm, isolatedF689Oct 18, 2024

  Based on interviews, observation, record review, the facility failed to provide adequate supervision to one Resident (R)2. On 09/21/2024, R2 fell while in the Physical Therapy gym which resulted in harm. He was hospitalized with a subdural hematoma (bleeding near the brain) which required immediate surgical intervention. In addition, the facility failed to conduct a thorough investigation, document findings, and interventions taken to reduce the likelihood of a similar event. This deficient practice could affect any resident if the appropriate level of supervision is not provided. Findings include: 1) On 09/23/2024, the Office of Healthcare Assurance (OHCA) received an facility reported incident (ACTs # 11218) regarding a witnessed fall with injury. […]

• No harm, potential for more than minimal, patternF712Jun 10, 2026

  Based on interviews and review of medical records, documents and policies, three Resident ((R)1, R2 and R3) of a sample size of three, had incomplete medical records. Physician visits and/or discharge summary and initial admission orders lacked timely signature by the attending physician as required by regulatory standards. In addition. one initial History and Physical (R)1 was not documented in the medical record (EMR). These deficiencies do not meet the requirements for timely and authenticated physician documentation to support continuity of care and compliance with federal regulations. Findings include:1) R1 was admitted to the facility on [DATE] for subacute rehabilitation and skilled nursing management following hospitalization for sepsis secondary to a urinary tract infection. […]

• No harm, potential for more than minimal, patternF661Oct 18, 2024

  Based on interview, document and medical record review (RR), the facility failed to ensure appropriate discharge summaries were completed for two out of a sample size of three residents (R). R1 and R2 were transferred to the Hospital for a higher level of care, but when the Resident's families informed the facility the resident would not be returning to the facility, the discharge summaries are required to include a recapitulation of the resident's stay and treatment in the facility. R2's discharge summary was not accurate or complete, and R1's had not been completed prior to survey. As a result of these deficiencies, the provider did not have all the necessary information regarding the resident's clinical status. […]

• No harm, potential for more than minimal, patternF812Aug 31, 2023

  Based on observations, interviews, and facility policy review, the facility failed to store and handle food items under sanitary conditions. This failed practice could place all facility residents at risk for food-borne illness. Findings include: Observation was conducted on [DATE] at 08:27 AM in the kitchen. A large freezer contained cake, six English muffins, and four bagels. All mentioned food items were wrapped in plastic and did not have a label. On the prep table, a half full bottle of thickener was observed without a label. Observation was conducted in the storage room on [DATE] at 08:40 AM. Six unopened boxes were placed directly on the floor. Large opened bags of penne pasta and macaroni noodles were wrapped in plastic with no labeled open dates. […]