Samuel Mahelona Memorial Hospital

In the surveyor’s words

From the most serious findings on record at Samuel Mahelona Memorial Hospital, in the surveyor’s own words.

• Actual harm, isolatedF689May 14, 2026

  Based on record review and interview the facility failed to provide adequate supervision to prevent an accident for one of three residents (R) 13 sampled for accidents related to falls resulting in major injury and pain. The deficient practice puts all residents, who are at a high risk for falls, who are informally monitored on one to one for falls prevention, at great risk for a fall with injury and pain.Findings Include:On 08/06/25 at 4:49 PM the Office of Health Care Assurance received an initial report via fax from the facility reporting R13 had an unattended fall on 07/04/25 at 1:00 PM resulting in an Acute comminuted right femoral neck fracture. R13 was transferred to the hospital on [DATE] and underwent surgical repair on 07/05/25. R13 returned to the facility on [DATE] at 1015. […]

• No harm, potential for more than minimal, widespreadF812Dec 1, 2023

  Based on observation and interview with staff member, the facility failed to ensure food products were stored under sanitary condition and discarded before the expiration or used by date. This failed practice could place all facility residents at risk for food-borne illness. Findings Include: On 11/28/23 at 09:25 AM, concurrent observation and interview was done during the initial kitchen tour with Kitchen Manager (KM). 1) Observed in the kitchen helper three-door fridge, a clear squeeze bottle labeled LV with the date of 11/04. Inquired with KM what was in the clear squeeze bottle, and she stated Lemon vinegar juice. KM further stated the date 11/04 indicated when the lemon vinegar juice was made and should have been discarded a week from when it was made. […]

• No harm, potential for more than minimal, patternF656May 14, 2026

  Based on record review and interview, the facility failed to develop and implement individualized dementia care plans for three of four residents (Resident (R) 4, R6, and R7) reviewed for dementia care. This deficient practice placed residents with dementia at risk for unmet needs and failure to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Include:1) R6 is [AGE] year-old female admitted to the facility on [DATE] for long term care. Diagnoses included the following, but not limited, to high blood pressure, vascular dementia, type 2 diabetes, and motor speech disorder. […]

• No harm, potential for more than minimal, patternF812May 14, 2026

  Based on observation and interview, the facility failed to store and label food, and failed to ensure the ice machine in the kitchen was kept in clean and sanitary condition, in accordance with professional standards for food service safety. This deficient practice puts residents at risk for serious complications from foodborne illness as a result of their compromised health status. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents at the facility. Findings Include: On 05/11/26 at 08:29 AM, during initial tour of the facility's kitchen, concurrent observation and interview were done with the Hospital Executive Chef (HEC). […]

• No harm, potential for more than minimal, patternF812Nov 22, 2024

  Based on observations, interviews and record review, the facility failed to dispose of food items that have passed the use by date and store food in accordance with professional standards. This deficient practice puts all the residents and staff who consume food or drink prepared at the facility at risk for foodborne illnesses. Findings include: 1) On 11/19/24 at 11:16 AM, initial tour of the kitchen was done with Hospital Executive Chef (HEC). Inspection of the dry goods storage was done. Observed three jars of mustard with an expiration date of 05/08/24 on the storage shelf. HEC acknowledged that they were past the manufacturer's stated expiration date and removed them from the shelf. […]