Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arcadia Retirement Residence during CMS and state inspections, most recent first.
A resident who was dependent on staff for toileting hygiene and always incontinent of urine was recorded on a facility cell phone during peri-care while her buttocks and a urine-saturated brief were exposed. The video was then shown to other staff during shift report. The RN admitted she knew recording was not allowed, did not obtain consent, and used the video to remind staff to change the resident more often.
The facility was found to have sanitation issues in the kitchen, with dirty areas between stoves and expired food items in unit kitchens. Expired peanut butter, mustard, and cranberry juice were observed, and LPNs confirmed these should have been discarded according to facility policy.
The facility failed to obtain informed consent for psychotropic medications for three residents, including a male with dementia and Parkinson's, a female with Alzheimer's, and a male with unspecified dementia. The administrator confirmed the absence or incompleteness of consent forms, which are typically signed before treatment.
A resident's code status was inconsistent with their Advance Health Care Directive (AHCD) and POLST, which specified Do Not Attempt Resuscitation (DNAR). Despite this, a Full Code status was recorded in the electronic health record. The facility's policy requires verification and updating of these documents, but this was not adhered to, leading to a potential risk of unnecessary medical intervention.
A resident's care plan was not updated after experiencing two falls, as required by the facility's policies. The DON confirmed that new interventions should have been added to the care plan following each fall, but this was not done.
A facility failed to update a resident's care plan to reflect her shared room arrangement with her husband. Observations showed both residents in a shared room, but the care plan incorrectly stated they would not be sharing a room. The administrator confirmed the care plan was not updated despite having documentation from the POA indicating the shared arrangement.
An unsecured electrical panel on the third-floor nursing unit posed a safety risk, as observed during a survey. The padlock was not latched, and no staff were present to prevent access. A maintenance staff member acknowledged the panel should have been locked, highlighting a lapse in the facility's Lockout/Tagout policy.
A resident and her family requested the discontinuation of melatonin, a sleep aid, as the resident did not have trouble sleeping. Despite this, the medication was administered multiple times due to a lack of timely follow-up with the provider to discontinue the order. The resident appeared groggy and unable to communicate, prompting further concern from the family.
A resident's family member raised concerns about inappropriate comments by a nurse, unwanted melatonin administration, and an uninvestigated fall. The facility's grievance policy lacked essential elements, and staff interviews revealed unclear grievance processes. The family member's concerns were validated but not communicated due to an ongoing investigation.
A resident with Alzheimer's Disease reported an alleged sexual abuse incident to facility staff, but the facility delayed reporting to APS and OHCA. The incident was reported to staff on July 31, but APS was not notified until August 5, and OHCA until August 12. The facility's policy inaccurately directed staff to report only substantiated cases, contributing to the delay.
A resident with multiple health issues had a repeat chest x-ray showing significant changes suggesting pulmonary edema/fluid overload. The facility failed to promptly notify the physician of these findings, as the process for communicating radiology results was inefficient. The resident passed away before the physician was informed of the x-ray results.
Privacy and dignity breached during resident peri-care
Penalty
Summary
The facility failed to maintain a resident’s privacy and dignity when a Registered Nurse recorded a video of the resident during peri-care using the facility’s cell phone. The resident, who had chronic respiratory failure, dysphagia, obstructive sleep apnea, hemiplegia/hemiparesis due to cerebral infarction, type 2 diabetes, mild cognitive impairment, and epilepsy, was documented on the MDS as always incontinent of urine and dependent on staff for toileting hygiene, including perineal care and clothing adjustment. The recorded video showed the resident’s uncovered buttocks and a urine-saturated incontinence brief and pad while care was being provided. The facility’s investigation documented that the video was then shared with other staff during shift-to-shift report and was used to remind staff to change the resident more frequently to prevent skin breakdown. The resident stated she was unaware the video had been taken and would not have agreed to any picture or video being taken of her. The RN acknowledged she knew she was not supposed to take a video, did not request consent, and did not determine whether the resident was aware of the recording. The facility’s policy prohibited audio, photography, and video recording during treatment or care and for documenting resident conditions without authorization.
Sanitation and Expired Food Issues in Facility Kitchens
Penalty
Summary
The facility failed to maintain proper sanitation practices in the kitchen, as observed on multiple occasions. On October 1, 2024, at 8:00 AM, the area between the stoves was found to be dirty, containing crumpled paper, dirty plastic bags, dirty napkins, and dirty paper bowls. The Kitchen Supervisor acknowledged the unclean condition of the area during an interview conducted shortly after the observation. Further deficiencies were noted on October 3, 2024, in one of the unit kitchens. A metal pan containing condiments and sauces was found to have expired items, including creamy peanut butter and yellow mustard, both past their labeled best-by dates. Additionally, a refrigerator in the same unit kitchen contained a bottle of cranberry juice with an expiration date of August 22, 2024. Interviews with night shift LPNs confirmed that these expired food items should have been discarded, as per the facility's policy on food brought by family or visitors.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide information on the risks and benefits of using psychotropic medications to three out of five sampled residents, which is a deficiency that could negatively impact the residents' well-being. Resident 29, a male with dementia, Parkinson's disease, and generalized anxiety disorder, had been on an antidepressant since May 30, 2024, without a signed consent form from him or his representative. The facility's administrator confirmed that the consent form, which is usually signed before treatment, was not obtained in this case. Similarly, Resident 63, a female with Alzheimer's disease and dementia with behavioral disturbances, had been prescribed an antipsychotic and an antidepressant without documented consent forms. The administrator acknowledged the absence of these consents. Additionally, Resident 46, a male with unspecified dementia and depression, had incomplete consent documentation for his antidepressant and no consent for his antipsychotic medication. The administrator confirmed that the consent form for the antidepressant was not fully filled out, lacking necessary details such as side effects and indications for use.
Inconsistent Code Status with Advance Directive
Penalty
Summary
The facility failed to ensure that the code status of a resident was consistent with their Advance Health Care Directive (AHCD). The resident, identified as R51, was admitted with multiple diagnoses including Supranuclear Ophthalmoplegia, Chronic Kidney Disease, Alzheimer's, Dementia, and High Cholesterol. Despite having a doctor's order indicating a Full Code status, the resident's AHCD and Provider Orders for Life-Sustaining Treatment (POLST) specified a Do Not Attempt Resuscitation (DNAR) status. This inconsistency was identified during a review of the resident's electronic health record. The facility's policy on Advance Directives and POLST requires that residents are encouraged to submit these documents upon admission and that they are verified and updated annually. However, in this case, the Social Worker acknowledged that the resident's current code status did not align with the AHCD. The policy also states that these documents should be scanned into the resident's electronic medical record and sent with the resident in case of an emergency or transfer to a hospital. The failure to ensure the resident's code status matched their documented wishes posed a potential risk of unnecessary medical intervention.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for one of the sampled residents, identified as R63, after she experienced two falls. A review of R63's Electronic Health Record (EHR) revealed that she had falls on 07/26/24 and 09/03/24, but her care plan did not include new interventions following these incidents. An interview with the Director of Nursing (DON) confirmed that the care plan should have been updated with new interventions after each fall. The facility's policy on falls, dated 02/08/24, requires the Interdisciplinary Team (IDT) to meet the next business day after a fall to conduct a root cause analysis and update the care plan with further recommendations. Additionally, the facility's Fall Charting Protocol, dated 12/04/23, mandates that the resident's care plan be updated with appropriate interventions following each fall.
Care Plan Discrepancy in Shared Room Arrangement
Penalty
Summary
The facility failed to correctly update a resident's care plan to reflect that she would be residing in a shared room with her husband. Observations on two separate occasions showed the resident and her husband each resting in their own beds within the shared room. However, a review of the resident's care plan revealed a discrepancy, as it stated that the resident and her husband would not be moved into a shared room together, contrary to the documented request from the resident and family. The administrator confirmed that the care plan was not updated to reflect the current living arrangement, despite having documentation from the Power of Attorney indicating the shared room arrangement.
Failure to Secure Electrical Panel
Penalty
Summary
The facility failed to secure an electrical panel on the third-floor nursing unit, which posed a risk to the safety and well-being of residents and the public. During an observation, it was noted that the padlock on the electrical panel was not latched, and there was no staff present to prevent unauthorized access by residents or visitors. This oversight was acknowledged by a maintenance staff member, who confirmed that the panel should have been locked. The facility's policy on Control of Hazardous Energy (Lockout/Tagout) mandates that all energy isolating devices, such as electrical circuit breakers, must be physically locked to prevent the release or transmission of energy. The policy specifies that only authorized personnel from the Environmental Services Department are permitted to apply or remove these locks. An annual inspection is required to ensure compliance with these procedures. The failure to secure the electrical panel indicates a lapse in adherence to this policy, as the lock was not properly engaged, and the area was left unattended.
Failure to Discontinue Unwanted Medication
Penalty
Summary
The facility failed to honor the rights of a resident by not discontinuing the administration of melatonin despite the resident and her family member's explicit request. The resident, who was admitted for rehabilitation after a small bowel resection and had a history of Alzheimer's disease, was given melatonin as a sleep aid. Both the resident and her family member communicated to the nursing staff that the resident did not need or want the melatonin, as she did not have trouble sleeping. However, the staff did not follow up with the provider to discontinue the medication in a timely manner, resulting in the resident continuing to receive the melatonin. The nursing staff documented the resident's refusal of melatonin and the family's request to discontinue it, but the medication was still administered on multiple occasions. The issue was brought to the attention of the facility leadership after the family member observed the resident appearing groggy and unable to communicate as usual. Despite the documentation to discontinue the medication, it remained an active order until it was finally discontinued after a meeting with the facility's administration. The failure to act on the family's request and the resident's refusal led to the continued administration of the medication against their wishes.
Deficiencies in Grievance Handling and Policy
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal, as evidenced by deficiencies in their grievance policy and handling of specific complaints. The grievance policy lacked essential elements such as the ability to file grievances anonymously, identification and communication of the grievance official, a reasonable timeframe for grievance review, the right to obtain a written review, and ensuring written grievance decisions met documentation requirements. Additionally, the facility did not identify or investigate a concern verbalized by a resident's family member as a grievance, nor did they keep the family member informed of the resolution. A resident, who had a history of coronary artery disease, hypertension, acute hypoxic respiratory failure, and dementia, was involved in the incident. During her second admission for rehabilitation, her family member expressed concerns about inappropriate comments made by a male nurse, the administration of melatonin against their wishes, and a fall that occurred during the resident's initial admission. The facility failed to communicate the request to discontinue melatonin to the provider, resulting in continued administration of the medication. Furthermore, the fall was not acknowledged or investigated in a timely manner, and the family member was not informed of the investigation results. Interviews with facility staff revealed a lack of clarity regarding the grievance process and responsibilities. The Administrator in Training was uncertain about the grievance official's identity, and the grievance log was not consistently maintained. The Director of Nursing confirmed that the family member's concerns were validated but not communicated due to an ongoing investigation by Adult Protective Services. The facility's grievance policy and resident handbook also lacked clear instructions for filing anonymous complaints and contact information for external agencies.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident to the appropriate authorities within the required timeframes. On July 31, 2024, a resident reported to a Certified Nursing Assistant that a male staff member had attempted to force her to touch him inappropriately. Despite this serious allegation, the facility did not report the incident to Adult Protective Services (APS) until August 5, 2024, and to the Office of Healthcare Assurance (OHCA) until August 12, 2024. This delay in reporting was contrary to the facility's policy, which mandates immediate reporting of such incidents. The investigation into the alleged abuse revealed that the resident, who had questionable decisional capacity and was diagnosed with Alzheimer's Disease, reported the incident to the facility staff on July 31, 2024. The facility's Social Worker and Director of CNAs spoke with the resident, who described the alleged perpetrator as a short, white male wearing eyeglasses. The facility reviewed camera footage and identified a potential match. However, the Social Worker did not file a report with APS until prompted by a family member on August 5, 2024, indicating a lack of urgency in addressing the allegation. The facility's policy on residents' rights and freedom from abuse requires immediate investigation and reporting of serious complaints. However, the policy's algorithm for reporting incidents inaccurately directed staff to notify authorities only if the abuse was substantiated by the facility. This misdirection contributed to the delay in reporting the alleged abuse to the appropriate agencies. The Social Worker involved in the investigation acknowledged the oversight and the need for immediate reporting, regardless of the investigation's findings.
Failure to Promptly Notify Physician of Significant Radiology Findings
Penalty
Summary
The facility failed to promptly notify the ordering physician of significant radiology findings for a resident. The resident, a male with a history of hypertension, Parkinson's disease, Alzheimer's, arteriosclerotic heart disease, diabetes, urinary retention, unsteadiness, and muscle weakness, had a repeat chest x-ray that showed significant changes suggesting pulmonary edema/fluid overload. These findings were not communicated to the physician until approximately one hour after the radiologist recorded the interpretation. The resident had been readmitted to the facility after a fall resulting in a fractured femur and was diagnosed with COVID-19 upon return, placed on isolation, and started on antibiotic therapy. The facility lacked a policy or effective process to identify which imaging results should be communicated to the provider. The process involved the Medical Record Manager receiving faxed reports from the radiology vendor and emailing them to the nursing staff, who were responsible for notifying the physician. However, this process was inefficient, as the reports were sent to a new fax machine, and there was no direct phone call from the vendor for urgent findings. The delay in communication contributed to the resident's condition not being addressed in a timely manner, as the resident passed away before the physician was informed of the x-ray results.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Islands Skilled Nursing & Rehabilitation | 0.3 mi | ★★★★★ | 13 | 0 |
| Oahu Care Facility | 0.3 mi | ★★★★★ | 15 | 0 |
| Hale Ola Kino By Arcadia | 0.5 mi | ★★★★★ | 0 | 0 |
| Hale Nani Rehabilitation And Nursing Center | 0.8 mi | — | 26 | 0 |
| Kalakaua Gardens | 0.9 mi | ★★★★★ | 33 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.