08/16/16, Rev 09/09/16 1
Office of Health Care Assurance
State Licensing Section
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
Facility’s Name: Kina ‘Ole Estate Ekolu, LLC
CHAPTER 100.1
Address:
45-219 William Henry Road, Kaneohe, Hawaii 96744
Inspection Date: September 6 and 7, 2018 Annual
THIS PAGE MUST BE SUBMITTED WITH YOUR PLAN OF CORRECTION. IF IT IS NOT, YOUR PLAN OF
CORRECTION WILL BE RETURNED TO YOU, UNREVIEWED.
YOUR PLAN OF CORRECTION MUST BE SUBMITTED WITHIN TEN (10) WORKING DAYS. IF IT IS NOT
RECEIVED WITHIN TEN (10) DAYS, YOUR STATEMENT OF DEFICIENCIES WILL BE POSTED ONLINE,
WITHOUT YOUR RESPONSE.
2
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-13 Nutrition. (i)
Each resident shall have a documented diet order on
admission and readmission to the Type I ARCH and shall
have the documented diet annually signed by the resident’s
physician or APRN. Verbal orders for diets shall be
recorded on the physician order sheet and written
confirmation by the attending physician or APRN shall be
obtained during the next office visit.
FINDINGS
Resident #2 – No documented diet order within the past
year.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
3
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-13 Nutrition. (i)
Each resident shall have a documented diet order on
admission and readmission to the Type I ARCH and shall
have the documented diet annually signed by the resident’s
physician or APRN. Verbal orders for diets shall be
recorded on the physician order sheet and written
confirmation by the attending physician or APRN shall be
obtained during the next office visit.
FINDINGS
Resident #2 – No documented diet order within the past
year.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
4
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-13 Nutrition. (l)
Special diets shall be provided for residents only as ordered
by their physician or APRN. Only those Type I ARCHs
licensed to provide special diets may admit residents
requiring such diets.
FINDINGS
Resident #1 – Diet order on 9/4/2018 states, “finely chopped
texture with nectar thickened liquids.” However; diet order
incomplete as it does not specify the type of diet, i.e.,
regular, diabetic, etc…
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
5
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-13 Nutrition. (l)
Special diets shall be provided for residents only as ordered
by their physician or APRN. Only those Type I ARCHs
licensed to provide special diets may admit residents
requiring such diets.
FINDINGS
Resident #1 – Diet order on 9/4/2018 states, “finely chopped
texture with nectar thickened liquids.” However; diet order
incomplete as it does not specify the type of diet, i.e.,
regular, diabetic, etc…
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
6
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 1/8/2018 medication order for Oseltamivir
states, “75 mg po qd for 10 days.” Another order for the
same medication from 1/22/2018 states, “75 mg po qd,”
without a specific time frame. Medication administration
record (MAR) reflects medication being given from
1/23/2018 to 1/29/2018; seven (7) days. Medication orders
not clarified, and medication not given as prescribed.
PART 1
Correcting the deficiency
after-the-fact is not
practical/appropriate. For
this deficiency, only a future
plan is required.
7
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 1/8/2018 medication order for Oseltamivir
states, “75 mg po qd for 10 days.” Another order for the
same medication from 1/22/2018 states, “75 mg po qd,”
without a specific time frame. Medication administration
record (MAR) reflects medication being given from
1/23/2018 to 1/29/2018; seven (7) days. Medication orders
not clarified, and medication not given as prescribed.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
8
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 1/8/2018 medication order for Acetaminophen
changed to, “500 mg – two (2) tabs po tid.” Medication
order not updated on MAR until 2/4/2018.
PART 1
Correcting the deficiency
after-the-fact is not
practical/appropriate. For
this deficiency, only a future
plan is required.
9
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 1/8/2018 medication order for Acetaminophen
changed to, “500 mg – two (2) tabs po tid.” Medication
order not updated on MAR until 2/4/2018.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
10
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – Hydrocortisone 1% cream on MAR from
7/6/2018; however, no record of medication order until
9/4/2018.
PART 1
Correcting the deficiency
after-the-fact is not
practical/appropriate. For
this deficiency, only a future
plan is required.
11
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – Hydrocortisone 1% cream on MAR from
7/6/2018; however, no record of medication order until
9/4/2018.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
12
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 9/4/2018 medication order for Preservision
states, “one (1) soft gel po qd.” MAR and medication label
state, “(one) 1 soft gel po bid.” Medication order does not
match label or MAR.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
13
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 9/4/2018 medication order for Preservision
states, “one (1) soft gel po qd.” MAR and medication label
state, “(one) 1 soft gel po bid.” Medication order does not
match label or MAR.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
14
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – Calcium Citrate available for resident and
documented on MAR, however; no record of medication
order within the past year.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
15
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – Calcium Citrate available for resident and
documented on MAR, however; no record of medication
order within the past year.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
16
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 8/1/2018 medication order for Quetiapine
states, “25 mg po qhs.” MAR and medication label state,
“25 mg – ½ tab po qhs.” Medication order does not match
label or MAR.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
17
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #1 – 8/1/2018 medication order for Quetiapine
states, “25 mg po qhs.” MAR and medication label state,
“25 mg – ½ tab po qhs.” Medication order does not match
label or MAR.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
18
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #2 – Last medication order available from
2/27/2018 states, “Senexon-S 8.6-50 mg - 1 tab po q evening
prn.” MAR and label state, “1 tab po bid prn at 9am &
5pm.” Medication order does not match label or MAR.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
19
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #2 – Last medication order available from
2/27/2018 states, “Senexon-S 8.6-50 mg - 1 tab po q evening
prn.” MAR and label state, “1 tab po bid prn at 9am &
5pm.” Medication order does not match label or MAR.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
20
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #2 – Medication order for stool softener states,
“100 mg po qd prn.” MAR and label state, “100 mg bid
prn.” Medication order does not match label or MAR.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
21
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #2 – Medication order for stool softener states,
“100 mg po qd prn.” MAR and label state, “100 mg bid
prn.” Medication order does not match label or MAR.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
22
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #2 – Two (2) conflicting medication orders for
Acetaminophen from 12/1/2017. One order states,
“Acetaminophen 325 mg, 1-2 tabs po q 8 hours prn pain.”
The other medication order states, “Acetaminophen 325 mg
1-2 tabs po q 6 hours prn pain.” Orders do not match.
PART 1
Correcting the deficiency
after-the-fact is not
practical/appropriate. For
this deficiency, only a future
plan is required.
23
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (e)
All medications and supplements, such as vitamins,
minerals, and formulas, shall be made available as ordered
by a physician or APRN.
FINDINGS
Resident #2 – Two (2) conflicting medication orders for
Acetaminophen from 12/1/2017. One order states,
“Acetaminophen 325 mg, 1-2 tabs po q 8 hours prn pain.”
The other medication order states, “Acetaminophen 325 mg
1-2 tabs po q 6 hours prn pain.” Orders do not match.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
24
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (g)
All medication orders shall be reevaluated and signed by
the physician or APRN every four months or as ordered by
the physician or APRN, not to exceed one year.
FINDINGS
Resident #1 – Medications reevaluated but not signed by a
physician or APRN every four (4) months.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
25
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (g)
All medication orders shall be reevaluated and signed by the
physician or APRN every four months or as ordered by the
physician or APRN, not to exceed one year.
FINDINGS
Resident #1 – Medications reevaluated but not signed by a
physician or APRN every four (4) months.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
26
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (g)
All medication orders shall be reevaluated and signed by
the physician or APRN every four months or as ordered by
the physician or APRN, not to exceed one year.
FINDINGS
Resident #2 – Medications not reevaluated or signed by a
physician or APRN every four (4) months. Last medication
reevaluation was on 2/27/2018, more than six (6) months
ago.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
27
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-15 Medications. (g)
All medication orders shall be reevaluated and signed by the
physician or APRN every four months or as ordered by the
physician or APRN, not to exceed one year.
FINDINGS
Resident #2 – Medications not reevaluated or signed by a
physician or APRN every four (4) months. Last medication
reevaluation was on 2/27/2018, more than six (6) months
ago.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
28
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-17 Records and reports. (b)(1)
During residence, records shall include:
Annual physical examination and other periodic
examinations, pertinent immunizations, evaluations,
progress
notes, relevant laboratory reports, and a report of annual re-
evaluation for tuberculosis;
FINDINGS
Resident #2 – Report of annual reevaluation for
tuberculosis states the date the TB skin test was
administered; however, there is no date for when the skin
test was read.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
29
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-17 Records and reports. (b)(1)
During residence, records shall include:
Annual physical examination and other periodic
examinations, pertinent immunizations, evaluations,
progress
notes, relevant laboratory reports, and a report of annual re-
evaluation for tuberculosis;
FINDINGS
Resident #2 – Report of annual reevaluation for tuberculosis
states the date the TB skin test was administered; however,
there is no date for when the skin test was read.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
30
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-17 Records and reports. (b)(3)
During residence, records shall include:
Progress notes that shall be written on a monthly basis, or
more often as appropriate, shall include observations of the
resident's response to medication, treatments, diet, care
plan, any changes in condition, indications of illness or
injury, behavior patterns including the date, time, and any
and all action taken. Documentation shall be completed
immediately when any incident occurs;
FINDINGS
Resident #1 – Progress notes did not include observations
of the resident’s response to nectar thickened liquids.
PART 1
Correcting the deficiency
after-the-fact is not
practical/appropriate. For
this deficiency, only a future
plan is required.
31
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-17 Records and reports. (b)(3)
During residence, records shall include:
Progress notes that shall be written on a monthly basis, or
more often as appropriate, shall include observations of the
resident's response to medication, treatments, diet, care plan,
any changes in condition, indications of illness or injury,
behavior patterns including the date, time, and any and all
action taken. Documentation shall be completed
immediately when any incident occurs;
FINDINGS
Resident #1 – Progress notes did not include observations of
the resident’s response to nectar thickened liquids.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
32
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-19 Resident accounts. (d)
An accurate written accounting of resident's money and
disbursements shall be kept on an ongoing basis, including
receipts for expenditures, and a current inventory of
resident's possessions.
FINDINGS
Resident #2 – Inventory of resident’s possessions not
updated since admission, over one (1) year ago.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
33
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-19 Resident accounts. (d)
An accurate written accounting of resident's money and
disbursements shall be kept on an ongoing basis, including
receipts for expenditures, and a current inventory of resident's
possessions.
FINDINGS
Resident #2 – Inventory of resident’s possessions not updated
since admission, over one (1) year ago.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
34
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-88 Case management qualifications and services.
(c)(2)
Case management services for each expanded ARCH resident
shall be chosen by the resident, resident's family or surrogate
in collaboration with the primary care giver and physician or
APRN. The case manager shall:
Develop an interim care plan for the expanded ARCH
resident within forty eight hours of admission to the
expanded ARCH and a care plan within seven days of
admission. The care plan shall be based on a comprehensive
assessment of the expanded ARCH resident’s needs and shall
address the medical, nursing, social, mental, behavioral,
recreational, dental, emergency care, nutritional, spiritual,
rehabilitative needs of the resident and any other specific
need of the resident. This plan shall identify all services to be
provided to the expanded ARCH resident and shall include,
but not be limited to, treatment and medication orders of the
expanded ARCH resident’s physician or APRN, measurable
goals and outcomes for the expanded ARCH resident;
specific procedures for intervention or services required to
meet the expanded ARCH resident’s needs; and the names of
persons required to perform interventions or services required
by the expanded ARCH resident;
FINDINGS
Resident #1 – No nutrition care plan developed for this
resident with nutrition risks, i.e., significant weight changes,
special diet, and nutrition supplement.
PART 1
DID YOU CORRECT THE DEFICIENCY?
USE THIS SPACE TO TELL US HOW YOU
CORRECTED THE DEFICIENCY
35
RULES (CRITERIA) PLAN OF CORRECTION
Completion
Date
§11-100.1-88 Case management qualifications and services.
(c)(2)
Case management services for each expanded ARCH
resident shall be chosen by the resident, resident's family or
surrogate in collaboration with the primary care giver and
physician or APRN. The case manager shall:
Develop an interim care plan for the expanded ARCH
resident within forty eight hours of admission to the
expanded ARCH and a care plan within seven days of
admission. The care plan shall be based on a
comprehensive assessment of the expanded ARCH
resident’s needs and shall address the medical, nursing,
social, mental, behavioral, recreational, dental, emergency
care, nutritional, spiritual, rehabilitative needs of the
resident and any other specific need of the resident. This
plan shall identify all services to be provided to the
expanded ARCH resident and shall include, but not be
limited to, treatment and medication orders of the expanded
ARCH resident’s physician or APRN, measurable goals and
outcomes for the expanded ARCH resident; specific
procedures for intervention or services required to meet the
expanded ARCH resident’s needs; and the names of persons
required to perform interventions or services required by the
expanded ARCH resident;
FINDINGS
Resident #1 – No nutrition care plan developed for this
resident with nutrition risks, i.e., significant weight changes,
special diet, and nutrition supplement.
PART 2
FUTURE PLAN
USE THIS SPACE TO EXPLAIN YOUR FUTURE
PLAN: WHAT WILL YOU DO TO ENSURE THAT
IT DOESN’T HAPPEN AGAIN?
36
Licensee’s/Administrator’s Signature: _________________________________________
Print Name: __________________________________________
Date: __________________________________________