Above 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 - Wailuku during CMS and state inspections, most recent first.
Failure to notify the LTCO of resident transfers/discharges occurred for two residents who were sent to the hospital. For one resident, the SW said the notice was not sent because the family did not sign it, and the fax to the LTCO was only completed after the surveyor requested the record. For another resident who had a left AKA, the notice and bed hold policy were sent to the resident’s rep, but LTCO notification was missed and faxed only after it was requested.
Failure to Implement Fall Mat Interventions: A resident with R-sided weakness from a prior CVA and blurred vision fell while reaching for an item from his wheelchair and was sent to the ER for evaluation. Staff confirmed the fall risk care plan required floor mats on both sides of the bed and in place at all times, but repeated observations showed no mats at the bedside or in the room, despite the plan remaining in effect.
A resident receiving HD had a pressure dressing left on the LUA fistula well beyond the required post-treatment timeframe. Staff were unsure of the dressing-removal policy, and a care plan entry allowing the dressing to remain for 24 hours was added without a physician order or documented access-site bleeding, despite the facility policy stating the pressure dressing should remain on for a minimum of 4 hours and bleeding should be monitored.
The facility failed to maintain the freezer temperature at 0 degrees Fahrenheit or less, as required by professional standards, posing a risk for foodborne illness. During a kitchen tour, it was found that the temperature log recorded temperatures from 0 to 6 degrees Fahrenheit, with no documentation of re-checking or maintenance notification for temperatures above 0 degrees. The ADNS confirmed audits of temperature logs but was unaware of recent work orders for the freezer.
The facility failed to prevent flies and a bird from entering the dining room during lunch service. Flies were observed near the trayline above uncovered hot food, and a bird was seen flying in the dining room, landing on a counter. The FSD attempted to address the issue by covering the food and reminding staff to use lids or foil. The DON confirmed the bird's presence and noted that screen doors were left open.
A resident's privacy was compromised during peri-care when the privacy curtain was insufficient to cover her bed area, exposing her to her roommate. The CNA acknowledged the issue, and the DON confirmed the curtain's inadequacy, leading to a dignity concern for the resident.
An O2 tank was improperly stored in a resident's room, leaning upright between a bedside drawer and wall, rather than in an Oxygen Cylinder Cart. This increased the risk of the tank falling over, as acknowledged by a staff nurse during an interview.
The facility failed to implement an infection prevention and control program regarding birds, resulting in an increased risk of disease outbreak. During an observation, three birds were found in a resident's room, with one on the bed and two on the floor. Other rooms had screen door barriers, but this room did not. The DON acknowledged the issue but confirmed the absence of written standards, policies, procedures, or a surveillance system to manage the presence of birds.
The facility failed to store and label food and drink items in accordance with professional standards, as observed during inspections of the off-site kitchen and nourishment refrigerator. Opened items were found without proper labeling, and staff were unable to determine the duration of storage, contrary to the facility's policy.
A resident reported that during times of short staffing, it took thirty minutes to an hour for staff to respond to his call light, and around forty-five minutes to deliver meals to his room. The resident needed assistance reaching for soap while showering. His medical history included multiple serious conditions such as Respiratory Failure and Congestive Heart Failure.
A resident's diabetes was not properly managed as blood sugar checks and sliding scale insulin administration were often delayed, sometimes occurring after meals. This was confirmed by the resident's MAR and interviews with the DON and CN, who acknowledged the importance of timely administration and the lack of a grace period.
The facility failed to prevent falls for a high-risk resident and used a mechanical lift inappropriately for another resident who was completely dependent on staff for all ADLs. The interventions in place were insufficient to prevent multiple falls for one resident, and the other resident was transferred using a lift device without proper evaluation, compromising their safety.
The facility failed to label the humidified sterile water bottle for a resident, increasing the risk of contamination. During an observation, it was noted that the bottle was not labeled with the date and time it was opened. A charge nurse confirmed the oversight and acknowledged that the bottle should have been labeled according to the facility's policy on oxygen administration.
A resident with chronic pain and multiple diagnoses experienced unmanaged pain due to the facility's failure to administer scheduled pain medications on time. Despite the resident's requests to be woken up for his medications, staff frequently administered them late, causing significant discomfort. The DON and CN3 confirmed that medications should be given and documented promptly, but this protocol was not followed.
The facility failed to ensure effective pharmacy services, resulting in two residents missing routine medications and expired intravenous fluids not being discarded. One resident did not receive Losartan for high blood pressure on time, and another missed a dose of Gabapentin for back pain. Additionally, expired Sodium Chloride solution bags were found in the medication storage room.
The facility failed to maintain a medication error rate below 5%, with errors including leaving medication at a resident's bedside and administering Metformin without a meal, contrary to provider orders.
The facility failed to ensure that two residents understood the Binding Arbitration Agreement they signed. Both residents did not remember signing the agreement or understanding its details, and the facility did not meet its policy requirements for explaining the agreement.
Failure to Notify LTCO of Resident Transfers
Penalty
Summary
The facility failed to ensure the State Long Term Care Ombudsman (LTCO) received written notification of resident transfer/discharge for two residents who were hospitalized. For one resident, the facility requested a copy of the transfer/discharge notice to the LTCO, and the record later showed it was faxed only after the surveyor asked for the documentation. The Social Worker confirmed the notice had not been sent and stated it is normally faxed within a day or two of transfer, but in this case it was not sent because the family did not sign the document. For another resident who went to the hospital for a left leg above-the-knee amputation, the EHR showed the notice of transfer/discharge and bed hold policy was sent to the resident’s representative, but no LTCO notification had been completed at the time of record review. When confirmation was requested, the Administrator provided a fax confirmation showing the LTCO notice was sent only after the documentation was requested, and the Social Worker confirmed it was faxed that day and had been missed with November’s batch of notifications.
Failure to Implement Fall Mat Interventions
Penalty
Summary
The facility failed to implement the fall risk plan of care for a resident identified as having fall mats placed at the sides of the bed. On 01/27/2026, the resident was observed sitting in a wheelchair outside his room with a right arm sling and stated he had fallen the previous day around 3:00 PM while trying to pick up something he had dropped on the floor. He reported being taken to the ER for evaluation and awaiting x-ray results. He also stated he was weak on his right side due to a previous stroke and had blurred vision. Subsequent observations on 01/28/26, 01/29/26, and 01/30/26 showed the resident in bed or in a wheelchair with no floor mats in place at the bedside or in the room. During interview on 01/29/26, the Unit Manager confirmed the resident fell outside while sitting in his wheelchair in the hallway when he tried to reach for something he dropped. Review of the Fall Risk care plan dated 09/03/25 confirmed that floor mats should be in place at all times, and the revised Falls care plan dated 01/29/26 still included interventions for fall mats on both sides of the bed and in place at all times. The facility’s Fall Prevention and Management Program Guidelines stated that updated information needs to be communicated to staff, and the Comprehensive Care Plans policy required a comprehensive person-centered care plan with measurable objectives and timeframes.
Hemodialysis Pressure Dressing Left On Beyond Required Time
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis when the facility failed to remove the resident’s pressure dressing within the required timeframe after treatment. On 01/28/2026 at 08:45 AM, Resident 6’s left upper arm fistula pressure dressing was still in place from the previous day, more than 15 hours after the resident returned from dialysis at about 5:00 PM. The resident stated that staff sometimes do not check the fistula access every shift and leave the dressing on because of bleeding. At 09:00 AM, the RN was unable to state the facility’s policy for removing the pressure dressing after hemodialysis and later said it could be removed after 24 hours because it was in the care plan. Record review on 01/29/2026 showed no physician order to leave the dressing on for 24 hours, although a care plan entry to remove the dressing within 24 hours had been created on 01/28/26 by the Unit Manager. The Unit Manager confirmed there was no physician order for a 24-hour dressing and acknowledged he added the intervention because he could not find another intervention for access bleeding, despite no documentation of access site bleeding or related issues in the progress notes.
Freezer Temperature Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the freezer temperature at 0 degrees Fahrenheit or less, as required by professional standards, which poses a risk for foodborne illness among residents. During an initial tour of the kitchen, it was observed that the temperature log for the freezer recorded temperatures ranging from 0 to 6 degrees Fahrenheit. The Freeze Temp Record form indicated that temperatures should be less than or equal to 0 degrees, and there were sections for re-checking temperatures and notifying maintenance, which were left blank. Despite the presence of temperatures above 0 degrees, there was no documentation of re-checking or maintenance notification. The Acting Director of Nutrition Services (ADNS) confirmed that she or another staff member audits the temperature logs for the facility's refrigerators and freezers. However, she was not aware of any recent work orders for the freezer, and upon further investigation, it was found that there were instances of temperatures recorded above zero. The ADNS stated that she would follow up with the facility maintenance to ensure the freezer is functioning properly, but there was no indication that corrective actions were documented or implemented at the time of the survey.
Pest Control Deficiency in Dining Room
Penalty
Summary
The facility failed to prevent flies and a bird from entering the dining room while residents were eating lunch and lunch trays were being prepared. During an observation, flies were seen near the trayline, flying above uncovered hot food containers. The Food Service Director (FSD) attempted to shoo away the flies and covered the food with aluminum foil, reminding kitchen staff to cover food with lids or foil to prevent contamination. Additionally, a small bird was observed flying in the dining room and landing on the counter next to the microwave. The Director of Nursing (DON) confirmed the presence of the bird and noted that screen doors in the dining room had been left open, allowing the bird to enter.
Privacy Breach During Peri-Care
Penalty
Summary
The facility failed to protect a resident's privacy during peri-care, exposing the resident's naked body from the waist down to her roommate. This incident occurred when a surveyor observed the situation and noted that the privacy curtain was insufficient to cover the resident's bed area fully. The Certified Nurse Assistant (CNA) performing the peri-care acknowledged that the privacy curtain was not large enough to provide adequate coverage, allowing the resident's genitalia to be visible to her roommate. Further investigation revealed that the privacy curtain had been removed for washing and was not reinstalled properly, leading to the privacy breach. The Director of Nursing (DON) confirmed that the curtain was inadequate and acknowledged the dignity issue for the resident. Despite efforts to rehang the curtain, it still did not provide full privacy, leaving the resident exposed to anyone near the foot of her bed, including her roommate sitting in a nearby recliner.
Improper Storage of Oxygen Cylinder Poses Accident Hazard
Penalty
Summary
The facility failed to store an oxygen cylinder (O2 tank) in a safe manner, creating a potential accident hazard. During an observation in a resident's room in the Lanai Nursing Neighborhood, an O2 tank was found leaning upright and propped between the bedside drawer and wall, rather than being secured in an Oxygen Cylinder Cart. This improper storage increased the risk of the O2 tank falling over. A staff nurse acknowledged the improper storage and the associated risk during an interview conducted shortly after the observation.
Inadequate Infection Control Program for Birds
Penalty
Summary
The facility failed to establish an infection prevention and control program concerning birds, leading to an increased risk of disease outbreak. During an observation of the Lanai Nursing Neighborhood, three birds were seen in a resident's room, with one bird on the foot of the resident's bed and two others moving around on the floor. Other resident rooms had screen door barriers, but this particular room did not, allowing birds to enter. In a staff interview, the Director of Nursing (DON) acknowledged awareness of the issue but admitted that there were no written standards, policies, procedures, or a system of surveillance in place to address the presence of birds in resident rooms.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to ensure food and drink items were stored in accordance with professional standards for food service safety. During an initial tour of the off-site kitchen, an opened one-gallon jug of milk was found without an open and discard date in the walk-in refrigerator. Additionally, two opened bottles of juice and two opened jars of mayonnaise were found without proper labeling in another refrigerator. In the freezer near the food preparation area, a partially covered box of cheesecake was also found without an open and discard date. The Nutrition Service Director confirmed that all opened food and drink items should be labeled with the open and discard dates and that all items stored in the refrigerator and freezer should be covered. Further inspection of the nourishment refrigerator in the front wing of the facility revealed an open container of sports drink and a bowl of food covered with foil, both labeled with residents' names but without open and discard dates. When asked, a Certified Nurse Aide stated that food items are good for three days if kept in the refrigerator but admitted that he would have to ask the residents to determine if three days had passed since there were no open dates noted. The facility's policy requires that if food is held for more than 24 hours, it should be clearly marked to indicate the date or day by which the food item should be consumed, sold, or discarded. The policy also specifies different time frames for various food items, such as three days for hot or cold food leftovers, seven days for milk and juices, and thirty days for mayonnaise.
Failure to Provide Reasonable Accommodations for Showering and Meals
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's showering and meal needs. During an interview, the resident reported that when the facility was short-staffed, it took around thirty minutes to an hour for staff to respond to his call light. The resident needed assistance reaching for soap while showering, and it took approximately forty-five minutes for staff to deliver meals to his room. The resident's electronic health record indicated multiple diagnoses, including Respiratory Failure, Chronic Obstructive Pulmonary Disease, Pulmonary Edema, Congestive Heart Failure, Atrial Fibrillation, Pulmonary Arterial Hypertension, Atherosclerotic Heart Disease, Cardiomegaly, Abdominal Aortic Aneurysm, and High Cholesterol.
Failure in Timely Diabetes Management
Penalty
Summary
The facility failed to appropriately manage diabetes for a resident by not ensuring timely blood sugar measurements and administration of sliding scale insulin. The resident reported that nurses sometimes checked his blood sugar and administered insulin after he had already started or finished his meal. This was confirmed by a review of the resident's Medication Administration Record (MAR), which showed multiple instances of late insulin administration over two months. Interviews with the Director of Nursing (DON) and the Charge Nurse (CN) revealed that sliding scale insulin should be administered immediately after blood sugar is taken and before the resident begins eating. Both confirmed that there is no grace period for sliding scale insulin and that late administration should not occur. The DON and CN acknowledged that the Unit Managers should be monitoring this daily, but the review showed a significant number of late administrations, indicating a lapse in proper diabetes management for the resident.
Failure to Prevent Falls and Inappropriate Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards. Resident 62, who has a history of traumatic brain injury and multiple fractures, experienced multiple falls despite being identified as a high fall risk. The interventions in place, such as hourly checks, use of a tab alarm, and physical therapy, were not effective in preventing these falls. The resident had a total of 11 falls over a period of less than two months, indicating that the current measures were insufficient to mitigate the risk of falls. Resident 29, who is completely dependent on staff for all activities of daily living following a stroke, was transferred using a mechanical lift device that he had not been evaluated as safe to use. The mechanical lift required the resident to have some degree of weight-bearing ability, which Resident 29 did not possess. During the transfer, the resident was unable to sit up or remain seated without assistance, and the staff had difficulty managing the transfer safely. Additionally, the wheels of the mechanical lift were not locked, further compromising the safety of the transfer. The facility's failure to provide appropriate assessments, planning, and interventions for these residents placed them at risk of avoidable accidents and injuries. The lack of effective fall prevention measures for Resident 62 and the inappropriate use of a mechanical lift for Resident 29 highlight deficiencies in the facility's approach to ensuring resident safety.
Failure to Label Humidified Sterile Water Bottle
Penalty
Summary
The facility failed to label the humidified sterile water bottle for one resident, identified as R177, which increased the risk of sterile water contamination. During an observation of R177's oxygen delivery setup, it was noted that the humidified sterile water bottle was not labeled with the date and time it was opened. A charge nurse acknowledged the oversight and confirmed that the bottle should have been labeled according to the facility's policy on oxygen administration. The policy specifically requires labeling the humidifier with the date, time opened, and the initials of the staff member who opened it.
Failure to Manage Pain Adequately for a Resident
Penalty
Summary
The facility failed to manage pain adequately for a resident, resulting in the resident not attaining or maintaining his highest practicable level of well-being. The resident, a [AGE] year-old male with diagnoses including spondylosis, spinal fusion, osteoarthritis, and chronic pain, reported consistent issues with the timely administration of his pain medications. During an interview, the resident expressed that his pain medications were often administered late, particularly between 03:00 PM and 11:00 PM, causing significant discomfort. The resident rated his pain as a 7 out of 10 and emphasized the importance of receiving his medications on time to manage his pain effectively. Despite his requests to be woken up for his scheduled medications, the staff failed to comply, leading to further delays in pain management. A review of the resident's Medication Administration Record (MAR) for March and April 2024 revealed multiple instances of late administration for various pain medications, including Acetaminophen, Baclofen, Gabapentin, Marinol, and Oxycodone. The Director of Nursing (DON) and the Administrative Nurse/Charge Nurse (CN)3 acknowledged that scheduled pain medications should be administered on time and documented immediately after administration. However, the facility's failure to adhere to these protocols resulted in the resident experiencing unmanaged pain and discomfort.
Medication Management and Inventory Deficiencies
Penalty
Summary
The facility failed to ensure pharmacy services included an effective process to provide routine drugs to meet the needs of the residents and to dispose of medications past their expiration date. Specifically, two residents experienced issues with medication availability. One resident, who required Losartan for high blood pressure, did not receive the medication on time because it was out of stock. The nurse confirmed that the medication should have been reordered before the last dose was administered, but the process was not followed correctly. Another resident, who required Gabapentin for back pain, did not receive the medication as it was not delivered on time despite being reordered seven days prior. The nurse confirmed that the medication delivery process did not include checking against a list of what was ordered, leading to the missed dose. Additionally, an inspection of the medication storage room revealed that five one-liter bags of 0.9% Sodium Chloride solution were past their expiration date and had not been discarded. One of the bags was also missing its protective plastic cover. The charge nurse confirmed that these expired items should have been removed from the storage. These deficiencies indicate lapses in the facility's medication management and inventory processes, potentially affecting the quality of care provided to the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in an observed error rate of 7%. During a medication pass, a Registered Nurse (RN) prepared and administered Polyethylene Glycol to a resident, splitting the dose into two cups. The RN administered one cup and left the second cup at the resident's bedside while attending to another resident. The Unit Manager confirmed that medications should not be left at the bedside, and there were no orders for the resident to self-administer medications. This action was against the facility's policy, which requires staff to remain with the resident while medication is swallowed. In another instance, the same RN administered Metformin to a resident without ensuring it was given with a meal, as required by the provider's orders. The resident had already completed breakfast by the time the medication was administered. These actions placed residents at risk of negative outcomes due to medication errors and demonstrated a failure to adhere to safe medication administration practices.
Failure to Ensure Residents Understood Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that two residents, R23 and R25, understood the Binding Arbitration Agreement they signed. During interviews, both residents stated they did not remember signing the agreement or understanding its details. R23 was admitted to the facility on 05/22/23 and signed the agreement on 05/28/23, while R25 was admitted on [DATE] and signed the agreement on 05/28/23. Both residents expressed a lack of awareness about the agreement during interviews conducted on 05/01/24. A staff interview with the Administrative Assistant on 05/03/24 revealed that the facility follows its policy on Binding Arbitration Agreements during the admission process. However, the facility's policy requires that residents or their representatives be explicitly informed of their right not to sign the agreement as a condition of admission or continued care. The policy also mandates that the agreement be explained in a manner and language that the resident or representative understands, and that they acknowledge their understanding. The findings indicate that these requirements were not met for R23 and R25.
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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 Wailuku
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hale Makua - Kahului | 1.2 mi | ★★★★★ | 13 | 0 |
| Kula Hospital | 15.7 mi | ★★★★★ | 0 | 0 |
| Lanai Community Hospital | 28.1 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.