Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hale Makua - Kahului during CMS and state inspections, most recent first.
A resident with dementia, impaired mobility, a history of falls, and documented wandering behavior, who wore a functioning wander management bracelet, was able to leave the facility and go to a nearby family member’s home with the assistance of a visitor who was unaware of facility protocols and did not notify staff. The wander management system was set so doors locked when a bracelet approached and only sounded an alarm if the door was pushed for an extended period or was ajar. On the day of the incident, a staff member heard a door alarm, saw no residents nearby, and silenced the alarm without further checks. Staff did not realize the resident was missing until notified by the resident’s son, and the facility’s elopement policy and protocols did not require immediate accounting for residents wearing wander bracelets when an alarm was activated but no missing resident had yet been identified.
A resident reported that staff took up to 30 minutes to answer the call light, sometimes said they would return and did not, and at times told the resident to urinate in the incontinence underwear. The resident felt ignored and not treated with dignity. The facility policy required all personnel to answer call lights promptly and courteously.
A resident with a pacemaker and sick sinus syndrome had a generator replacement and related cardiology instructions documented in the chart, including incision care and use of a home communicator/monitor. However, the comprehensive care plan did not include the pacemaker or related monitoring and care considerations, and the NS and RN confirmed the omission.
A resident’s comprehensive care plan was not revised after pacemaker generator replacement surgery led to suspension of RNP services. Although cardiology later cleared the resident for normal arm movement, restorative staff were still waiting for physician clearance and a therapy reassessment, and the nursing supervisor could not find documentation that therapy had been notified or that the care plan had been updated to reflect the change in status.
A resident with sick sinus syndrome underwent pacemaker generator replacement and had restorative nursing services suspended afterward. Although cardiology later cleared the resident to resume normal arm movement, nursing did not communicate that clearance to therapy or restorative nursing, and staff continued waiting for a referral and reassessment before restarting services.
A resident with cerebral palsy, cognitive communication deficit, and contractures to both upper extremities was repeatedly observed in bed without the ordered padded elbow extenders or pads. The care plan directed staff to apply the devices for limited ROM, but the NS could not locate documentation of their use, and a CNA said the resident returned from the hospital without the pads and they may have been left there. The DON confirmed staff were to apply the padded elbow extenders as ordered to prevent further decrease in ROM.
Failure to maintain adequate hydration for a resident at risk for dehydration. A resident with hx including CVA with hemiplegia/hemiparesis, dysphagia, HF, and dehydration was observed at bedside on multiple occasions without a water container present, and he stated he felt thirsty and had a dry mouth. The NS confirmed he was not on a fluid restriction, should have had a water pitcher at bedside, and should have been monitored to receive at least 2000 ml of fluids daily; however, the TAR showed the daily fluid goal was not met, and the skin assessment noted dry skin and poor elasticity.
A resident with Parkinson’s disease, osteoarthritis, gout, and pain had orders for scheduled and PRN analgesics plus pain checks every shift. MAR/TAR review showed multiple missing pain assessments on night shift, and an LPN supervisor confirmed the facility did not document pain monitoring as ordered and that acetaminophen was given even when the resident’s pain level was charted as 0.
Expired meds and IV fluids were found stored in multiple med rooms. In one unit, a resident’s Lorazepam vials included expired doses; in another, stock Humulin N insulin pens were expired; and in a third, IV fluid bags were past expiration. The ADON and NS confirmed the items should have been discarded, and the facility policy states outdated meds and related items shall be destroyed.
A resident's nebulizer mask, medication chamber, and tubing were repeatedly observed uncovered and not stored in a labeled bag on the resident's nightstand or near the nebulizer machine. The resident had a current order for Ipratropium-Albuterol solution for cough. The ADON stated nebulizer equipment should be washed, air dried, and stored in a clean, labeled storage bag, and the facility policy required the equipment to be rinsed, disinfected, and stored in a plastic bag with the resident's name and date.
Staff did not treat two residents with dignity, as one resident experienced long delays in call light response, lack of privacy after bathing, inconsistent hand hygiene before feeding, and staff speaking in a language the resident did not understand. Another resident was left in a soiled brief for over forty minutes despite a family member's request for help, with staff failing to respond promptly as required by facility policy.
The facility failed to implement and update care plans for residents at risk of wandering and elopement, leading to incidents where residents wandered unsupervised and one resident eloped. Staff were unaware of interventions, and documentation was inconsistent. The facility did not conduct required assessments or update care plans, resulting in potential safety hazards.
A facility failed to maintain a clean environment when a resident was observed lying in another resident's bed, which was under Enhanced Barrier Precautions due to dialysis treatment. Despite staff presence, the linen was not changed, and a CNA left the unit without addressing the issue. A LN confirmed the need for a linen change, and the IP acknowledged the hygiene concern, although the infection risk was deemed low.
A facility failed to create a comprehensive care plan for a resident with a history of wandering and elopement risk. The resident, with moderate cognitive impairment, was observed wandering without a proper care plan or risk assessments in place. The Administrator admitted the oversight and lack of documentation for an Elopement Risk Evaluation.
A facility failed to revise a care plan after a resident with severe cognitive impairment eloped and continued to wander into other residents' rooms. Despite the resident's history of wandering and the risks involved, the care plan was not updated following these incidents. The Unit Nurse confirmed that a Stop banner was placed on one door but did not confirm any care plan revisions.
A resident with a stage 4 pressure ulcer experienced significant pain during a dressing change due to the facility's failure to assess and manage pain appropriately. Despite the resident's visible distress and verbal complaints, the nursing staff did not premedicate or assess pain levels before the procedure, contrary to the care plan and facility policies. The resident reported severe pain, highlighting a deficiency in pain management practices.
A resident was hit by another resident's wheelchair, resulting in bruising and a feeling of unsafety. The incident was not immediately reported but was later brought to staff attention due to the physical harm and fear experienced by the affected resident.
The facility failed to properly label and store medications, including blood glucose test strips without 'opened on' dates, insulin stored outside refrigeration, and expired medications not discarded. These deficiencies could impact residents' care by leading to medication errors or adverse effects.
The facility failed to obtain informed consent for the use of psychotropic medications for two residents. One resident's representative was not informed about the administration of Lexapro in addition to Mirtazapine, and the facility lacked documentation of informed consent. Another resident received Mirtazapine without a completed consent form or education on its risks and benefits. This deficiency put residents at risk for more than minimal harm.
The facility failed to accommodate the needs of two residents. A resident with morbid obesity was not provided with a suitable shower chair, hindering her ability to maintain hygiene. Another resident with chronic conditions was unable to consistently access her call light, which was often placed out of reach. These deficiencies were confirmed by staff and violated the facility's policies.
A facility failed to revise the care plan for a resident with Parkinson's disease and dementia, who was observed leaning over in his wheelchair. Despite the care plan indicating the need for assistance to an upright position and cushion support, the plan was not updated to provide adequate support for the resident's tendency to lean over.
A resident with Parkinson's disease and dementia was observed slumped over in his wheelchair without adequate head and neck support. Despite multiple observations of this posture, the care plan lacked specific interventions for support, as confirmed by an LN. A cushion was provided for back support, but no measures were in place for head and neck alignment.
A resident's catheter tubing was found with sediment and blackish growth, indicating inadequate catheter care and a risk of infection. The resident reported the catheter had not been changed for weeks, and staff had not addressed the sediment issue. The EHR lacked specific orders to manage the sediment, and the Unit Manager confirmed the need for staff reeducation on catheter care.
The facility did not ensure accurate reconciliation of controlled medications on a medication cart. During an inspection, it was found that an RN had not signed the Narcotic Signature Sheet to verify the narcotic count, as required by facility policy. This oversight made it appear as if the count was conducted by only one nurse, contrary to the policy that mandates two licensed nurses to perform the count at each shift change.
A facility failed to implement a gradual dose reduction (GDR) for an antipsychotic medication, Seroquel, for a resident with Parkinson's disease and unspecified dementia. Despite the absence of aggressive behaviors, the facility did not attempt a GDR or provide a clinical rationale for maintaining the current dosage. The resident was observed sitting quietly or sleeping, and behavior monitoring sheets showed no aggressive behaviors. The interdisciplinary team recommended a GDR for another medication but not for Seroquel, contrary to the facility's policy requiring GDRs unless contraindicated.
The facility failed to store cutting boards and resident plate lids on racks free of rust-colored debris, as observed during a kitchen tour. The Acting Nutritious Services Director acknowledged the issue and indicated plans to relocate the cutting boards and replace the racks. This deficiency could potentially affect all residents receiving meals from the kitchen, posing a risk of foodborne illness.
An LPN failed to sanitize a blood pressure cuff between using it on two residents, contrary to the facility's policy. The LPN acknowledged the oversight, and the DON confirmed the requirement for sanitizing equipment between residents.
A storage room containing Germicidal Bleach Wipes, Surface Disinfectant Wipes, and Hand Sanitizing Wipes was found unsecured, posing a safety risk. The room, located near the Ilima Nurse Station, could be opened without a code despite having a keypad lock, and no staff was present to prevent unauthorized access. The DON acknowledged the oversight.
A facility failed to implement a person-centered Comprehensive Care Plan for a resident identified as a risk due to smoking behaviors. Despite incidents and a requirement for a nursing escort, the resident was often unsupervised in the smoking area, leading to altercations. Staff interviews revealed inconsistent monitoring, and the resident's care plan interventions were not consistently followed.
A resident with moderate cognitive impairment eloped from the facility, resulting in harm, due to inadequate supervision and failure to follow the elopement risk program. The resident, with a history of alcohol-related conditions, left the premises in his truck and was found by police hours later. The facility did not conduct a timely elopement risk evaluation or update the care plan, and staff interviews revealed communication and documentation lapses.
A resident was denied the right to receive visitors and phone calls of her choosing due to the facility's adherence to the POA's directive, which restricted communication without the resident's consent. This was contrary to the facility's policy that supports residents' rights to choose their visitors. The issue was identified through complaints and confirmed by staff interviews and record reviews.
Two residents in a LTC facility had their care plans inadequately updated, leading to increased risk of negative outcomes. One resident exhibited exit-seeking behavior, and another was found pocketing medications, yet their care plans were not promptly revised to address these high-risk behaviors. This delay in updating care plans highlights a systemic issue in the facility's care planning process.
A resident with a history of stroke and diabetes was not provided with adequate personal hygiene care, receiving only one shower per week despite facility policy requiring twice-weekly showers. Documentation showed a lack of re-approach or involvement of the resident's daughter when showers were refused, leading to extended periods without proper hygiene.
A resident with a history of diabetes and other medical conditions did not receive adequate diabetic foot care, leading to overgrown toenails that posed a risk for injury. Despite being under the care of a DPM, there were significant gaps in follow-up, and her care plan lacked interventions for foot monitoring. Interviews with facility staff revealed a lack of awareness and documentation regarding her foot care needs.
The facility failed to provide incontinence care for two residents, leading to them being left in soiled briefs for an extended period. The issue was discovered by a CNA during rounds and confirmed by a licensed nurse. The facility's investigation revealed that the responsible CNA forgot to change the briefs after being distracted by other tasks.
Elopement of Wandering Resident Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention measures for a resident assessed as at risk for elopement. The resident had dementia, used a wheelchair for mobility, had impairment of one lower extremity, and a history of falls. A recent MDS documented that the resident wandered 1 to 3 days during the assessment period and that this wandering behavior had worsened compared to prior assessments. The resident wore a wander management bracelet that was documented as present and functioning on the day of the incident. The facility’s wander management system was designed so that when a resident with a bracelet approached an exit, the door locked and a visual indicator changed color, with an audible alarm sounding only if the door was pushed for approximately 15 seconds or if the door was ajar and unable to lock. On the date of the incident, the resident left the facility and went to a family member’s home located in front of the facility with the assistance of a visitor of another resident. The visitor, who was unaware of facility protocols, opened the exit door, assisted the resident out of the building, and walked the resident to the nearby home without notifying staff. Staff only became aware the resident was missing when the resident’s son called to report that the resident was in their driveway. A nursing note documented that when the resident was wheeled back into the facility, the door alarm sounded, indicating the wander bracelet was working. During the facility’s investigation, the Administrator reported that a staff member had heard the door alarm earlier, did not see any residents nearby, and turned the alarm off without further action. The DON confirmed that facility protocols did not require staff to immediately check or account for all residents wearing wander management bracelets when an alarm sounded and no resident was observed, and the written elopement policy only addressed procedures after a resident was established as missing, with no guidance on staff response to an activated wander management alarm when no missing resident had yet been identified.
Failure to Respond Promptly and Treat a Resident with Dignity
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not responding promptly to call lights and by making dismissive comments about incontinence care. During interview, the resident reported that staff sometimes took up to 30 minutes to answer the call light, would say they would return and never come back, or would tell the resident to urinate in the incontinence underwear. The resident stated feeling ignored and not treated with dignity because of these interactions. Review of the facility’s call light policy stated that all personnel must answer call lights promptly, in a calm and courteous manner, and must not leave the resident feeling too busy to provide assistance.
Pacemaker Care Not Included in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed the presence of a pacemaker for Resident 10, who was admitted with a cardiac pacemaker in place and had documented diagnoses including Parkinson's disease and atherosclerotic heart disease. Review of the cardiology consultation form dated 11/12/25 showed that the resident had sick sinus syndrome and was scheduled for a dual chamber pacemaker generator replacement on 12/10/25. The consultation included pre- and post-operative instructions such as not eating or drinking for eight hours before the procedure, medication administration instructions, keeping the surgical bandage dry until the one-week follow-up visit, and use of the pacemaker home communicator/monitor. A follow-up cardiology consultation dated 12/17/25 documented an estimated pacemaker battery life of eight years and stated that the resident was cleared to get the incision site wet and resume normal arm movement. Review of the comprehensive care plan showed that the pacemaker and related care considerations were not included. During interview, the Nursing Supervisor and Registered Nurse confirmed that the resident had a pacemaker, recently underwent generator replacement surgery, required monitoring of the incision, and had a machine that should remain on to monitor the pacemaker, but the care plan did not document this information.
Failure to Revise Care Plan After Pacemaker Surgery
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident after pacemaker generator replacement surgery resulted in suspension of restorative nursing program (RNP) services. The resident’s care plan identified decreased strength, balance, and transfer ability, and included goals for participating in RNP services six times per week and remaining free from complications related to immobility. After the surgery, the resident’s restorative services were stopped, but the care plan was not updated to reflect that change or to include steps for resuming those services. The resident’s cardiology follow-up documented that the incision site could get wet and that normal arm movement could resume, and the form was signed by the facility receiving nurse and the attending physician. Restorative nursing aides stated they were waiting for physician clearance and a therapy reassessment before the resident could resume services, and they had not received information that the resident would be returning to RNP. The nursing supervisor confirmed she was not familiar with the resident’s RNP status and could not find documentation that therapy had been notified of the clearance to discuss resuming services.
Failure to Communicate Clearance to Resume Restorative Nursing Services
Penalty
Summary
The facility failed to communicate a resident’s post-operative status within departments so the resident could receive continuous treatment and care as soon as practicable. Resident 10 had a history of sick sinus syndrome and underwent a dual chamber pacemaker generator replacement on 12/10/25. After the procedure, the resident’s restorative nursing program was suspended. A cardiology follow-up consultation on 12/17/25 documented that the resident was cleared to get the incision site wet and resume normal arm movement, and the form was signed by the facility receiving nurse and the attending physician. Despite that clearance, restorative nursing staff reported they were still waiting for physician clearance and a therapy reassessment before resuming services, and they had not received information that the resident would be returning to restorative nursing. The nursing supervisor confirmed there was no documentation that therapy had been notified of the resident’s clearance to discuss resuming restorative nursing services, and confirmed the resident had not had services since surgery. The director of rehab stated the resident had only been referred for a wheelchair assessment, not for restorative nursing status, and the director of nursing confirmed communication between nursing, therapy, and restorative nursing regarding the resident’s care did not occur.
Failure to Provide Ordered ROM Support
Penalty
Summary
The facility failed to provide treatment and services to maintain or prevent decline in range of motion for one resident with limited ROM. The resident was admitted for long-term placement with diagnoses including cerebral palsy and cognitive communication deficit, and was admitted with contractures to both upper extremities. On 01/06/26 and again on 01/07/26, the resident was observed lying in bed without any splints, braces, or pads to the upper extremities, with both hands bent at the wrists and angled downward toward the feet. The care plan dated 11/24/25 directed staff to apply both padded elbow extenders and place pads between the forearm and bicep for 2 to 3 hours as tolerated. During record review and interviews, the Nursing Supervisor could not locate documentation showing the pads were used, and a CNA stated the resident had not had the pads since returning from the hospital because they may have been left there. The Nursing Supervisor stated staff should have notified her when the resident returned without the pads, and the DON confirmed staff were to apply the padded elbow extenders as stated in the care plan to prevent further decrease in ROM.
Failure to Maintain Adequate Hydration
Penalty
Summary
The facility failed to provide care and services to prevent dehydration for one of three sampled residents, R5, despite identifying him as at risk for compromised nutrition and hydration. On 01/06/26, R5 was observed sitting in his wheelchair at bedside with no water container on the bedside table, and when asked if he felt thirsty or if his mouth felt dry, he answered yes. On 01/07/26 and 01/08/26, R5 was again observed at bedside with no water container present. On 01/08/26, the Nurse Supervisor stated that R5 was not on a fluid restriction and confirmed that he should have a water pitcher at bedside; staff then provided a water container filled with ice and water. On 01/09/26, the Nurse Supervisor clarified that R5 should have been adequately hydrated and monitored to receive at least 2000 ml of fluid daily, and stated she educated staff to include monitoring fluid intake and filling his water container as part of daily tasks. Record review showed diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease with heart failure, dysphagia following cerebral infarction, and dehydration. The physician ordered a daily fluid goal of 2000 ml on 01/06/26, but the TAR for January 2026 indicated less than 2000 ml of fluids were met daily as prescribed. The skin assessment documented dry skin and poor elasticity, and the care plan identified R5 as at risk for dehydration related to fluid intake less than desired.
Missed Pain Assessments and Inconsistent Pain Documentation
Penalty
Summary
The facility failed to ensure pain management was provided for one resident, who had diagnoses including Parkinson’s disease with dyskinesia, essential tremor, bilateral osteoarthritis of the hips and knees, gout, abnormal posture, and pain. The resident had physician orders for Hydrocodone-Acetaminophen 5-325 mg three times daily for pain, Acetaminophen 650 mg every four hours as needed for mild to moderate pain, and pain monitoring every shift. The facility’s pain assessment indicators included non-verbal sounds, vocal complaints, and facial expressions. Review of the MAR and TAR showed the resident received Acetaminophen 650 mg on 12/16/25 with a documented pain level of 0, but the TAR was missing pain level assessments for multiple night shifts in December 2025 and January 2026. Missing assessments were documented for December 17, 20, 22, 23, 24, 28, and 29, 2025, and January 2, 3, 6, 7, and 8, 2026. During interview and record review, the Nursing Supervisor confirmed the facility did not document pain assessments every shift and confirmed Acetaminophen was given even with a zero pain level documented on 12/16/25. The supervisor also stated nursing staff should document in progress notes if pain subsided and call the physician if it did not, and did not confirm that the resident’s pain was effectively managed.
Expired medications and IV fluids found in medication rooms
Penalty
Summary
The facility failed to discard expired medications and intravenous solution stored in three of five medication rooms observed. In the Ilima unit medication room, a clear plastic storage bag for Resident 89 contained three vials of Lorazepam 2 mg/ml, and two of the vials had an expiration date of 10/2025; RN 266 confirmed the vials were expired and should have been discarded. In the Gardenia unit medication room, four Humulin N 100u insulin pens were observed as stock supply for emergency use, and all four were expired, with three dated 05/28/25 and one dated 10/10/25; the ADON confirmed they should have been discarded and replaced. In the [NAME] unit medication storage room, two 1000 ml bags and one 500 ml bag of IV fluid solutions were observed, and all three bags had expiration dates of November 2025. The Nursing Supervisor acknowledged the IV bags were past their stated expiration dates and stated they should have been discarded. The facility policy titled Disposal of Medications, Syringes and Needles dated January 2024 stated that outdated, contaminated, or deteriorated medications, and contents of containers with no label, shall be destroyed.
Nebulizer Equipment Not Labeled or Properly Stored
Penalty
Summary
The facility failed to ensure appropriate protective and preventive measures for infection control when R78's nebulizer equipment was not labeled or stored properly. On 01/06/26, R78's undated and uncovered nebulizer mask with medication chamber and tubing connected to the nebulizer machine was observed on the resident's nightstand. On 01/07/26, the same uncovered mask, medication chamber, and tubing were observed wedged between the nebulizer machine and a box of personal belongings on the nightstand. On 01/08/26, the uncovered nebulizer mask with medication chamber and tubing were observed with the tubing and mask placed over the nebulizer machine. A review of the physician orders on 01/09/26 showed a current order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 1 vial inhaled orally three times a day for cough until 01/13/2026. During interview on 01/09/26, the ADON stated that after a nebulizer treatment is given, the mask should be washed with soap and water, air dried, and stored in a clean, labeled storage bag. The facility policy titled, Medication Administration Nebulizers (Updraft), dated 01/23, stated that when treatment is complete, the equipment should be disconnected, rinsed and disinfected, and when completely dry, stored in a plastic bag with the resident's name and the date on it.
Failure to Maintain Resident Dignity and Timely Response to Care Needs
Penalty
Summary
Staff failed to treat two residents with respect and dignity, as evidenced by multiple incidents. One resident reported that staff often took up to forty minutes to respond to call lights, with some staff stating they were not assigned to the room and passing by without assisting. The same resident also reported that privacy was not maintained after bathing, as privacy curtains were left open, leaving the resident exposed. Additionally, staff did not consistently wash their hands before feeding the resident, requiring reminders, and would speak in their native language during care, making the resident feel uncomfortable and excluded. Another resident was left in a soiled incontinent brief for over forty minutes despite a family member's request for assistance. The family member notified a nurse at the nurse's station, who instructed her to activate the call light because she was not assigned to that area. The resident was only assisted after forty-five minutes by a CNA. Interviews with staff and review of facility policy confirmed that all staff are required to respond promptly to call lights and assist residents regardless of assignment, and that the nurse should have helped the resident when requested.
Failure to Implement and Update Care Plans for Wandering and Elopement
Penalty
Summary
The facility failed to implement and update care plans for residents at risk of wandering and elopement, leading to several incidents. One resident, with severe cognitive impairment and a history of wandering, actually eloped from the facility. The resident's care plan was not revised following the elopement incident, and staff were unaware of the interventions to employ for the resident's wandering behavior. The facility's investigation revealed that the resident was able to exit through an unlocked door, and the WanderGuard system did not alert staff effectively. Additionally, documentation of the resident's wandering behavior was inconsistent, and staff were not adequately monitoring or redirecting the resident. Another resident with a history of wandering did not have a care plan developed to prevent elopement prior to the survey. The facility failed to consistently monitor the resident's targeted behaviors and the functioning of the WanderGuard system. The resident was observed wandering and following staff around the unit, but there was no documentation of a wandering/elopement risk assessment since admission. The facility's policy required quarterly assessments, but this was not done, and the care plan was not updated to reflect the resident's current needs. A third resident, also at high risk for elopement, did not have a quarterly elopement risk assessment completed. The resident was found outside the facility near the social services office, but the incident was not recognized as an elopement, and no follow-up assessment or care plan revision was conducted. The facility's policy required reassessment and care plan updates for residents at risk of elopement, but these were not consistently implemented, leading to potential safety hazards for the residents involved.
Failure to Maintain Clean Environment and Change Linen
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the observation of a resident lying in another resident's bed without the linen being changed. On January 13, 2025, a resident was observed self-propelling in a wheelchair and later transferring herself onto a bed designated for another resident who was under Enhanced Barrier Precautions due to receiving dialysis treatment. Despite staff presence in the room, the linen was not changed after the resident left the bed. A Certified Nurse Aide was seen leaving the unit with personal belongings without addressing the linen change. A Licensed Nurse confirmed the need for a linen change but did not ensure it was done immediately. The Infection Preventionist acknowledged the hygiene concern and potential impact on the resident receiving dialysis, although they assessed the risk of infection transmission as low.
Failure to Develop Comprehensive Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident identified as being at risk for elopement with a history of wandering behavior. The deficiency was identified during observations, record reviews, and staff interviews. The resident, who was assessed with moderate cognitive impairment for decision-making, was noted to exhibit wandering behavior one to three days during the observation period. Despite this, the facility did not conduct annual and quarterly elopement risk assessments, nor did they implement a care plan for the resident's wandering behavior. The Administrator acknowledged that the resident was missed in their audits and confirmed that there was no documentation of an Elopement Risk Evaluation prior to the discovery of the deficiency.
Failure to Revise Care Plan After Elopement Incident
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was reviewed and revised following an actual incident of elopement involving a resident with severe cognitive impairment. The resident, who was assessed with a score of 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment, had a history of wandering behavior. This behavior placed the resident at risk for falls, resident-to-resident altercations, and elopement. Despite these risks, the care plan, which included interventions such as offering drinks, food, or activities, monitoring whereabouts, and providing redirection, was not revised after the resident's elopement incident. The resident's progress notes indicated multiple instances of wandering into other residents' rooms, yet the care plan remained unchanged. During an interview, the Unit Nurse acknowledged that the team decided to place a Stop banner across the door of the room the resident entered but did not confirm any revisions to the care plan. The lack of care plan revision following the elopement and continued wandering incidents demonstrates a deficiency in addressing the resident's specific needs and ensuring their safety.
Failure to Provide Adequate Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R252, during a dressing change for a stage 4 pressure ulcer on his right buttock. On the day of the incident, R252 was observed to be in significant pain during the procedure, crying out and expressing that it hurt. Despite the resident's visible distress and verbal complaints of pain, the nursing staff did not assess or administer pain medication prior to the dressing change. The resident had last received pain medication at 9:14 AM, several hours before the dressing change, and was not premedicated despite having a documented history of severe pain associated with his condition. The resident's care plan, which was reviewed on the same day as the incident, indicated that he was at risk for acute and chronic pain that could affect his well-being. The care plan included instructions to administer pain medications as ordered and to assess and provide pre-medication as indicated prior to activities and treatments to optimize the resident's comfort. However, these instructions were not followed during the dressing change, as the staff did not assess the resident's pain level or offer pain relief before the procedure. The resident later reported his pain level as 8 or 9 out of 10, indicating severe discomfort. Interviews with the nursing staff revealed a lack of adherence to the facility's pain management policies. The unit manager, RN30, acknowledged that the resident should have been assessed for pain and premedicated before the dressing change, especially given the severity of his pressure ulcer. The facility's policies on pain management and wound care emphasize the importance of assessing and managing pain before, during, and after treatments. Despite these guidelines, the staff failed to provide the necessary pain management, resulting in the resident experiencing unnecessary pain and distress during the dressing change.
Resident Abuse Incident Involving Wheelchair
Penalty
Summary
A resident, identified as R106, hit another resident, R141, with his wheelchair, causing physical harm. The incident resulted in a 10 cm x 10 cm blue/purple discoloration on R141's left medial knee and a 0.5 cm x 0.5 cm light red mark on the left leg just below the knee. R141 reported feeling unsafe and believed the act was intentional, as R106 laughed and left the scene after the incident. The incident was not reported immediately by R141 but was later brought to the staff's attention due to the resulting bruising and fear for her safety. The facility's failure to protect R141 from this abuse led to the deficiency being cited.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, leading to several deficiencies. Observations revealed that five out of six blood glucose test strip bottles in two medication carts lacked an 'opened on' date, which is necessary to ensure they are used within the manufacturer's recommended 90-day period. Registered Nurses (RNs) confirmed the absence of these dates and were unable to determine which bottles had been opened due to the lack of seals. Additionally, a narcotic count sheet was not signed by a nurse, and unopened insulin was improperly stored in a medication cart instead of a refrigerator, contrary to manufacturer instructions. This insulin was intended for a resident but was not stored correctly, which could affect its efficacy. Further inspection of medication storage practices revealed that medications were not consistently stored according to manufacturer recommendations. In one instance, an unopened box of Humulin R insulin was found in a medication cart instead of being refrigerated, as required. The RN responsible was unaware of how or when the insulin was placed in the cart. Additionally, an expired medication, Hydrocortisone 25mg, was found on a storage cart, which should have been discarded by the labeled discard date. These practices could potentially impact residents' care by leading to medication errors or adverse effects.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and consented to the use of psychotropic medications, specifically antidepressants, which led to a deficiency. For Resident 134, the resident's representative, RR4, was not informed about the administration of Lexapro, an antidepressant, in addition to Mirtazapine, which was already being administered for appetite stimulation. RR4 was not provided with information regarding the risks and benefits of Lexapro, nor did they sign a consent form for its use. The facility's records did not contain any documentation of informed consent or education provided to RR4 about Lexapro prior to its administration. In the case of Resident 141, the facility also failed to obtain informed consent for the administration of Mirtazapine. The resident's electronic health record lacked documentation of a consent form or any education provided to the resident or their representative, RR3, regarding the risks and benefits of Mirtazapine. The medication was administered without the necessary informed consent, and the facility did not complete the consent form even after the medication was given. The deficiency was identified during a survey, where it was confirmed that the facility did not have the required documentation of informed consent for the use of these psychotropic medications. The lack of informed consent and education on the risks and benefits of the medications put the residents at risk for more than minimal harm, as they were not fully informed about their treatment options.
Failure to Accommodate Resident Needs and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs of two residents, leading to deficiencies in their care. Resident 28, a female with morbid obesity, was not provided with a suitable shower chair that fit her comfortably and allowed her to shower thoroughly. Despite the availability of a larger shower chair, it was not used because the shower room where it was stored had been repurposed for storage, and the larger chair did not fit in the resident's bathroom shower stall. This resulted in Resident 28 being unable to maintain good hygiene as outlined in her care plan. Resident 67, a female with chronic obstructive pulmonary disease and other medical conditions, was unable to consistently access her call light, which was often placed out of reach. During observations, the call light was found on a chair against the wall and on the floor, making it inaccessible for the resident to call for help. The Director of Nursing confirmed that call lights should always be accessible, as per the facility's policy. These deficiencies hindered the residents from attaining their highest practicable well-being.
Failure to Revise Care Plan for Resident in Wheelchair
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R32, who was observed leaning over in his wheelchair. R32 is an elderly male with a primary diagnosis of Parkinson's disease and unspecified dementia. He was admitted to the facility on a specified date. During random observations in the East dining/activity area over several days, R32 was seen sitting in a high back wheelchair with his neck bent to the right side, leaning over and sleeping. The care plan, which was reviewed, had an approach start date of 09/19/2024, indicating that R32 had a tendency to lean over in his wheelchair or have his head to the side while sleeping. The care plan instructed staff to assist him to an upright position and use a cushion for support as allowed. However, the facility did not revise the care plan to adequately address the support needed for R32 when he leaned over in his wheelchair.
Inadequate Head and Neck Support for Resident in Wheelchair
Penalty
Summary
The facility failed to provide adequate support for a resident's head and neck while he was seated in his wheelchair. The resident, an elderly male with Parkinson's disease and unspecified dementia, was observed on multiple occasions slumped over to the right side and sleeping in his high back wheelchair. Despite these observations, the care plan did not include interventions for head and neck support, although a cushion was provided for back support. This deficiency was identified through observations and an interview with a licensed nurse, who confirmed the lack of specific care plan interventions for the resident's posture while seated.
Inadequate Catheter Care Leads to Risk of Infection
Penalty
Summary
The facility failed to provide appropriate treatment for a resident who is incontinent of bladder, leading to a risk of urinary tract infections. During an observation and interview, it was noted that the resident's catheter tubing contained a significant amount of sediment and blackish growth, which had not been addressed by the staff. The resident reported that the catheter had not been changed for three weeks, and prior to that, it had remained unchanged for three months. The resident also confirmed that staff had not discussed the sediment issue or flushed the catheter tubing as part of their care. A review of the resident's Electronic Health Record (EHR) showed an order for Foley catheter care, including monitoring for signs of infection, but there was no specific order to address the sediment or blackish growth. The Unit Manager confirmed the absence of a care plan to address the sediment and acknowledged that the blackish growth was indicative of bacterial or fungal presence, which was inappropriate. The Unit Manager also recognized the need for staff reeducation on catheter care, as the visible sediment and growth should have been addressed but were not.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to implement a thorough process to ensure accurate reconciliation and accounting for controlled medications on one of the sixteen medication carts. During an inspection of the North Team 2 medication cart, it was observed that the oncoming day shift nurse, RN3, had not signed or initialed the Narcotic Signature Sheet to verify that the narcotic count was correct. Although the off-going nurse had signed the sheet, RN3 had not, which made it appear as if the off-going nurse conducted the count alone. RN3 initially stated that she usually signed it before the end of her shift but later confirmed that she should have signed it immediately after the count was completed. The facility's policy requires that a physical inventory of all controlled substances be conducted by two licensed nurses at each shift change, and this was not adhered to in this instance.
Failure to Implement Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to manage and monitor the medication regimen for a resident by not implementing a gradual dose reduction (GDR) for the use of an antipsychotic medication, Seroquel, or providing a clinical rationale from the physician that it was not recommended. The resident, a male with Parkinson's disease and unspecified dementia, was observed multiple times sitting quietly or sleeping in his wheelchair without any aggressive behavior. Despite the absence of aggressive behaviors, the facility did not attempt a GDR for the Seroquel, which had been prescribed since June 2022. The Medication Regimen Review (MRR) and behavior monitoring sheets from July to October 2024 were requested, revealing that no behaviors were recorded that would necessitate the continued use of the antipsychotic at the current dosage. Interviews with staff indicated that the resident sometimes refused care but did not exhibit aggressive or resistive behaviors. The interdisciplinary team reviewed the medications and recommended a GDR for Citalopram but not for Seroquel. The facility's policy requires GDRs unless clinically contraindicated, but no documentation was provided to justify the continued dosage of Seroquel without reduction.
Improper Storage of Kitchen Equipment
Penalty
Summary
The facility failed to properly store cutting boards and resident plate lids, as observed during a kitchen tour. On October 15, 2024, at 10:04 AM, a rack storing cutting boards was found to have rust-colored debris. The Acting Nutritious Services Director acknowledged the issue and indicated plans to relocate the cutting boards. Additionally, on October 17, 2024, at 10:50 AM, another rack with rust-colored debris was observed storing lids for residents' plates. The Acting Nutritious Services Director confirmed the presence of rust-colored debris and mentioned that both racks were in the process of being replaced. This deficiency could potentially affect all residents receiving meals from the kitchen, posing a risk of foodborne illness.
Failure to Sanitize Equipment Between Residents
Penalty
Summary
The facility failed to ensure proper cleaning procedures for shared equipment were followed by a staff member, specifically a Licensed Practical Nurse (LPN). During an observation, the LPN was seen using a vital signs machine on two residents without cleaning the blood pressure cuff between uses. After taking the vital signs of the first resident, the LPN proceeded to use the same equipment on a second resident without sanitizing the cuff. Additionally, the LPN did not clean the machine or its attachments before placing it in the hallway. An interview with the LPN confirmed that she was aware of the facility's policy requiring the cuff to be sanitized between residents. The Director of Nursing also confirmed that staff should adhere to this cleaning protocol. A review of the facility's policy on blood pressure measurement indicated that the cuff should be sanitized with a solution or wipe and allowed to dry between uses.
Unsecured Storage Room Poses Safety Risk
Penalty
Summary
The facility failed to secure a storage room containing Germicidal Bleach Wipes, Surface Disinfectant Wipes, and Hand Sanitizing Wipes, which posed a risk for accident hazards. On 10/16/24 at 02:00 PM, it was observed that the Storage Room near the Ilima Nurse Station was not secured, and no staff was present to prevent unauthorized entry. Although a keypad lock was installed on the door, it could be opened by simply pulling it. During a staff interview at 02:25 PM on the same day, the Director of Nursing acknowledged that the Storage Room should have been secured to prevent unauthorized access and potential accident hazards.
Failure to Implement Smoking Care Plan
Penalty
Summary
The facility failed to implement a person-centered Comprehensive Care Plan (CP) for a resident identified as a risk for accident/safety hazards due to his smoking behaviors. Despite multiple documented incidents related to his smoking, the CP was not consistently implemented. The resident was involved in a physical altercation with another resident due to smoking behaviors, and observations revealed that the resident was often in the designated smoking area without staff supervision, contrary to the CP's requirement for a nursing escort. Interviews with staff confirmed that the resident was not consistently monitored, and the ashtray in the smoking area was frequently found open with cigarette butts on the ground, indicating a lack of adherence to the facility's smoking policy. The resident's CP included interventions such as reminders not to ask others for cigarettes, wearing a smoking apron, and ensuring a nursing escort while smoking. However, these interventions were not consistently followed, as evidenced by the resident's unsupervised presence in the smoking area and interactions with other residents. Staff interviews revealed a lack of clarity and consistency in monitoring the resident, with no specific time allotted for smoking and only occasional checks. The administrator confirmed that a staff escort was added to the CP, but the expectation for staff to stay with the resident during smoking was not met, leading to the deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent a resident with moderate cognitive impairment from eloping, which resulted in harm. The resident, who had a history of alcohol-induced acute pancreatitis, alcoholic cirrhosis of the liver, alcohol dependence with withdrawal delirium, and anemia, exhibited exit-seeking behavior but was able to leave the premises in his truck. He was found by the police approximately five and a half hours later, having gotten lost and suffered psychological and physical harm, including being cold and having swollen feet. The facility did not follow its own elopement risk program. After the resident's initial exit-seeking behavior, a WanderGuard was placed on him, but the RN did not obtain a physician's order, revise the care plan, or implement frequent monitoring. The facility's policy required an elopement risk evaluation to be conducted after any exit-seeking behavior, but this was not done until after the resident had already eloped. The facility also failed to update the resident's care plan to include his high-risk behaviors until after the elopement occurred. Interviews with staff revealed a lack of communication and documentation regarding the resident's exit-seeking behavior and the facility's elopement risk program. The Director of Nursing was unaware of the resident's previous exit-seeking behavior, and the Unit Manager did not conduct a thorough investigation or root cause analysis following the elopement. The facility's policy discrepancies regarding the WanderGuard order and monitoring expectations were also noted, contributing to the failure to prevent the resident's elopement.
Resident's Right to Visitors Denied Due to POA Restrictions
Penalty
Summary
The facility failed to honor the right of a resident, referred to as R3, to receive visitors and phone calls from individuals of her choosing. This deficiency was identified through interviews and record reviews, revealing that R3 was denied the opportunity to speak with her son and receive visits from her husband. The facility's visitation policy, which allows 24-hour access to visitors with the resident's consent, was not followed. Instead, the facility adhered to the power-of-attorney's (POA) directive to restrict R3's communication and visitation without her consent. This practice was documented in the resident's electronic health record, where notes indicated that calls and visits were denied based on the POA's instructions. The issue came to light following complaints from the Long-Term Care Ombudsman and R3's family member, who reported being denied access to R3. Interviews with facility staff confirmed that a strict protocol was in place, requiring all visitors and phone calls to be screened and approved by the POA. This protocol was enforced despite the facility's policy supporting the resident's right to choose her visitors. The deficiency was identified when it was noted that the POA's documentation did not permit such restrictions, leading to a change in protocol that allowed R3 to receive visits from her family members.
Failure to Update Care Plans for High-Risk Behaviors
Penalty
Summary
The facility failed to ensure timely review and revision of comprehensive care plans for two residents, leading to increased risk of negative outcomes. The first resident, a male with a history of severe alcohol use disorder and other medical conditions, exhibited exit-seeking behavior shortly after admission. Despite being observed attempting to leave the facility, his care plan was not updated to address this behavior until two days later. Staff members were aware of the incident, but the necessary revisions to the care plan were delayed, increasing the risk of elopement. The second resident, also a male with a history of chronic severe alcohol use disorder and other medical issues, was found to be pocketing and not swallowing his medications at the time of administration. This behavior was observed multiple times by staff, who noted that the resident would hide pills in his mouth or pocket them for later use. Despite these observations, the resident's care plan was not updated to include this high-risk behavior, leaving the potential for medication misuse unaddressed. Both cases highlight the facility's failure to promptly update care plans to reflect significant changes in resident behavior, which is crucial for ensuring resident safety and appropriate care. The delay in revising care plans for these residents could potentially affect all residents, as it indicates a systemic issue in the facility's care planning process.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate care and services to maintain the activities of daily living, specifically personal hygiene, for a resident. The resident, an elderly female with a history of cerebral infarction, chronic kidney disease, and diabetes, was not given showers as per her care plan. Her care plan indicated a preference for showers and outlined steps to take if she refused, including re-approaching and involving her daughter. However, documentation showed that she received only one shower per week in July, with no evidence of re-approach or involvement of her daughter when she refused. Observations and interviews revealed that the resident had a noticeable body odor, indicating a lack of proper hygiene care. The facility's policy required showers twice a week, but the resident's records showed inconsistencies and gaps in care, with extended periods without showers. Staff interviews confirmed that showers should be offered again if initially refused, and all attempts should be documented, which was not done in this case.
Inadequate Diabetic Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate diabetic foot care for a resident, identified as R3, who was at risk for avoidable injuries due to this deficiency. R3, an elderly female with a history of cerebral infarction, chronic kidney disease, and diabetes with diabetic peripheral angiopathy, was admitted for long-term care. Despite being under the care of a Doctor of Podiatric Medicine (DPM) since December 2021, there were significant gaps in her podiatric follow-up, with no documented visits between December 2021 and November 2022. Her comprehensive care plan lacked interventions for foot or toenail monitoring, and her toenails were found to be overgrown and potentially hazardous during an assessment. The Unit Manager (UM) and Director of Nursing (DON) interviews revealed a lack of awareness and documentation regarding the resident's foot care needs. The UM admitted that toenail assessments were only documented if a problem was noted, and there was no record of any issues in the weekly skin assessments. The DON confirmed that nurses should not cut the resident's toenails without consulting a physician due to her medical history. The failure to monitor and address the resident's toenail condition in a timely manner led to the deficiency, as her toenails were found to be elongated and curved, posing a risk for injury.
Failure to Provide Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care in accordance with professional standards of practice and individual care plans for two residents, R1 and R2. On the evening of 02/24/2024, CNA1 reported that R1 and R2 were allegedly not provided incontinence care by CNA2 during the day shift. R1, a female with a primary diagnosis of nontraumatic intracerebral hemorrhage with hemiplegia and hemiparesis, was found with a wet bed pad and a soaked brief. R2, diagnosed with vascular dementia with mood disturbance, depression, and anxiety, was also found with a soaked brief. Both residents have moderate cognitive impairment with a BIMS score of 8/15 and are always incontinent as documented in their care plans and MDS assessments. The facility's investigation revealed that CNA2 failed to provide the necessary incontinence care during her shift. CNA1 discovered the issue during her rounds at 3:30 PM and immediately notified LN1, who confirmed the soaked briefs with urine and bowel movement. CNA2 admitted in an email that she forgot to change one of the residents' briefs after being distracted by other tasks. The facility's policy on incontinence care emphasizes the importance of keeping the skin clean, dry, and free of irritation to prevent skin breakdown and infection. However, the documentation showed that there were no brief changes recorded by CNA2 during her shift, leading to the residents being left in soiled briefs for an extended period. Interviews with the staff, including CNA2, CNA1, LN1, and the DON, confirmed the expectations for incontinence care and the failure to meet these standards on the day in question. The DON stated that all staff receive training on incontinence care during orientation and ongoing. The investigation included resident and staff interviews, skin assessments, and a review of the facility's policy on incontinence care. The findings indicated that the deficient practice had been identified and addressed, with no issues of skin integrity found during the survey.
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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 Kahului
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hale Makua - Wailuku | 1.2 mi | ★★★★★ | 3 | 0 |
| Kula Hospital | 14.5 mi | ★★★★★ | 0 | 0 |
| Lanai Community Hospital | 28.6 mi | ★★★★★ | 7 | 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 October 2026) and official state health department websites.