Kulana Malama
Inspection Findings
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
occurred on 06/18/25 when she had a decannulation of her tracheostomy tube. RT16 confirmed he was working this day and stated he believes he was assigned to Resident R25. RT16 confirmed he helped when the decannulation occurred and he responded when staff yelled for help, and he put the trach back in. RT16 stated She (Resident R25) was not in distress. Inquired if Resident R25's O2 saturations decreased and RT16 stated he could not remember if she desated and stated there was no color change. She tolerates a quick decannulation okay. Inquired if he charted this incident in Resident R25's EHR and he stated he did not believe it is expected of him to chart in the EHR this change that occurred with Resident R25. On 09/26/2025 at 11:44 AM interviewed the Director of Nursing (DON) in the conference room. Inquired who would document an incident such as a decannulation of a resident's tracheostomy tube and he stated the nurse. DON confirmed the nurse who responded to the incident would document in the residents EHR about the incident. Requested a copy of
the facility's documentation policy which the DON provided. Review of the facility policy Nursing Documentation in the Medical Record states Purpose: To provide a legal record of the nursing care that has been administered; to keep an accurate record of the resident's condition and course of stay; and to provide guidelines for documenting in the medical record. Policy: Nursing staff are required to document care provided to the resident in the medical record and to use the documentation as a means of communication and coordination of care with other healthcare providers. This includes Progress Notes, .
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Kulana Malama in EWA BEACH, HI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EWA BEACH, HI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Kulana Malama or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.