Hale Malamalama
HALE MALAMALAMA in HONOLULU, HI — inspection on January 31, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Investigation Report Form revealed it contained no details related to the verbal comments CNA2, made to R1, or that she neglected to provide the needed services of toileting.
On 01/30/2025 at 10:20 AM, interviewed RN3 by telephone.
Inquired about the behavior note she wrote on R1 01/07/2025.
She confirmed she wrote the note, and that R1 was afraid to be alone that night, and wanted someone there with her all the time. RN3 said they left the lights, and she thought maybe it was a new environment for R1.
She said she did not pursue the issue further or ask why she was afraid. 5) Observed R1 in bed.
She was awake, appeared comfortable, but unable to answer questions.
125050 01/31/2025
Hale Malamalama 6163 Summer Street Honolulu, HI 96821
was aware a CNA was accused of verbal abuse and was going to determine actions based on the APS
this case was actively being investigated by APS, and confirmed the allegation and findings (within 5 days) had not been reported to OHCA.
She said when she was made aware of the event, she notified the DON, but did not notify the Administrator (ADM). 2) On 01/14/2025, OHCA received an anonymous report of caregiver neglect of R3.
The report alleged on 12/18/2024, caregivers did not provide the necessary services and care to R3 when she was soiled with feces and needed a diaper change.
Despite the fact that APS notified the facility they opened a case related to R3 for investigation, and the facility knew of concerns related to R3 being soiled and CNA assignments, the facility failed to investigate for neglect and notify OHCA. 3) Reviewed the facility policy titled Reporting Abuse to Facility Management, with date at bottom of policy 04/00.
The policy included: 4.
When an alleged or suspected case of mistreatment, neglect, injury of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a.
The State Licensing/Certification agency (OHCA) responsible for surveying/licensing the facility; .
Reviewed the facility policy titled Protection of Residents During Abuse Investigations with date at bottom of policy 09/07.
The policy included: 2.
Upon completion of the investigation, the resident, the resident's representative, the ombudsman, state survey and certification agencies (OHCA) .will be provided a written report of the findings of the investigation and summary of corrective action taken to prevent such incident from recurring.
Reviewed the facility policy titled Reporting Abuse to State Agencies and Other Entities/Individuals with date at bottom of policy 04/00.
The policy statement was All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law.
The policy included 1.
Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse . be reported, the facility administrator, or his/her designee, will promptly notify the following persons to agencies (verbally and written) of such incident: a.
Department of Health Office of Healthcare Assurance; .
125050 01/31/2025
Hale Malamalama 6163 Summer Street Honolulu, HI 96821
promptly and thoroughly investigated by .management.
to whom the accused employee provides care or services; .
125050 01/31/2025
Hale Malamalama 6163 Summer Street Honolulu, HI 96821
reviewed, and revised by a team of health professionals.
interviews and record review, the facility failed to timely update one Resident's(R)1 care plan. R1
person assist and then the Hoyer lift to safely transfer her, but the facility did not revise her CP in a timely manner. As a result of this deficiency, there was the potential not all staff were aware of what assistance R1 required to provide safe transfers, increasing the potential for falls with injury or harm.
Findings include: R1 is a [AGE] year old female admitted to the facility from the hospital on [DATE] for skilled nursing services.
She had a history that included, but not limited to hypertension, cardiomyopathy, heart failure, atrial fibrillation, malignant neoplasm of stomach, malignant ascites, Type 2 Diabetes, difficulty in walking and muscle weakness.
Reviewed the electronic medical record which included the following entries: 01/03/2025 at 02:44 PM, Nursing note: .Toileted by staff with extensive assist as per request. 01/05/2025 at 03:37 AM, Nursing note: While trying to put her in recliner, knee buckled and staff slide [sic] and guided down the Res (resident) to the floor. No c/o of pain.
Able to get up with 2 assist with good weight bearing.: 01/06/2025 09:35 PM, Nursing note: .CNA reports resident requiring more assistance with toileting. 01/07/2025 12:52 PM, Nursing note: Resident had her last PT (physical therapy) session this shift and able to participate with some activities given by the therapist, but weakness noted per PT. 01/22/2025 02:10 PM, Social Services note: Late entry significant change for 01/16/2025: Resident was readmitted to .Hospice on 01/08/2025 as she was previously on hospice before she had a fall and sent to the hospital.
She has hospice diagnosis of Gastric Cancer .she requires extensive to total assistance with her ADL's (activities of daily living) and care due to increased weakness.
She is unable to ambulate but can bear weight partially and requires 2-3 staff assistance during transfers.
Reviewed R1's active care plan (CP), which included the focus The resident has an ADL self-care performance deficit r/t (related to) impaired mobility, muscle weakness.
The interventions included the following: - Toilet Use: The resident requires substantial/maximal assistance by (1) staff for toileted.
Date initiated 12/26/2024.
Revision on 01/15/2025. - Transfer: The resident requires substantial/maximal assistance by (1) staff to move between surfaces as necessary.
Revision on 01/15/2025.
R1 was documented to require more assistance with toileting on 01/06/2025 and on 01/22/2025, indicated she required 2-3 staff assistance for transfers. On 01/28/2025, it was documented she required the Hoyer lift for transfers.
The CP was not revised to include these changes in a timely manner.
125050 01/31/2025
Hale Malamalama 6163 Summer Street Honolulu, HI 96821
and she needed to have her briefs checked every one to two hours due to incontinence. At that time,
the facility policy for incontinence care was to check the resident every two hours to see if they needed to be changed, and to document in the computer if the resident was incontinent or did not void. At that time, reviewed the documentation of CNA tasks for incontinence checks on R3 and the DON confirmed the gaps in documentation.
She said staff may have been busy and unable to document, but agreed it was the expectation to do so.
F-F600 Free from Abuse/neglect
125050
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 125050 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hale Malamalama 6163 Summer Street Honolulu, HI 96821
F-F684 Quality of care
The facility failed to provide the needed incontinence care and standards of practice for R3, which was to check her every two hour checks to ensure she was clean and dry. RR revealed staff did not provide these checks on multiple occasions, which put her at increased risk of skin breakdown. On review of CNA task documentation revealed on [DATE], R3 was checked at 12:00 PM, and not again until 07:25 PM.
3) Reviewed the facility policy titled Protection of Residents During Abuse Investigations with date at bottom of page ,d+[DATE].
The policy included:
125050
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 125050 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hale Malamalama 6163 Summer Street Honolulu, HI 96821
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.