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 Hale Ola Kino By Arcadia during CMS and state inspections, most recent first.
A resident's personal property, a bottle of TUMS, was removed from his room without proper communication or consent, leading to distress. The TUMS were later found in the medication cart, and staff confirmed there was no physician's order for them. The facility failed to notify and educate the resident about the removal, and this communication was not documented in the electronic health record.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident with severe malnutrition did not have a dietary care plan, while another with congestive heart failure did not have their potassium levels monitored as required. These oversights were confirmed during interviews and record reviews.
A resident with a left foot contracture did not receive appropriate treatment as the facility failed to apply a prescribed splint consistently. Despite physician orders for the splint to be worn daily from 12:00 PM to 4:00 PM, observations showed it was often not in use. Staff interviews revealed a lack of awareness regarding the splint schedule, leading to non-compliance with the care plan.
A resident with chronic pain syndrome experienced ineffective pain management at the facility. Despite receiving oxycodone, the resident's pain level remained high, and there was no follow-up action documented to address the continued severe pain. Interviews with nursing staff indicated that a pain level of 7 should be considered ineffective, yet the charge nurse was not notified, and no further interventions were documented.
The facility failed to adhere to prescribed resident menus, affecting three residents. A resident on a controlled carbohydrate diet received incorrect portions of mashed potatoes during meals, while another resident on a similar diet initially received an incorrect portion, which was later corrected. Additionally, a resident on fluid restriction due to hyponatremia was served an excessive amount of soup, which was also corrected after review.
The facility failed to discard opened food items by their use-by date, as observed during a survey of the main kitchen. A container of olives in the walk-in refrigerator had an unclear label, and the Dietary Manager confirmed the dates should be written clearly. The cook confirmed the use-by date as 2/15 and stated she would discard the olives. The facility's policy is to discard opened food items seven days after opening.
The facility failed to ensure staff competency in safe transfers and perineal care for two residents. One resident was at risk due to inadequate training for safe transfers, while another resident experienced improper perineal care, including the use of dry cloths, failure to change gloves, and lack of hand hygiene.
The facility failed to provide fresh water to a resident despite multiple requests, leading to dehydration, and did not consistently offer alternate meal options when residents found their meals unappetizing. Observations and interviews revealed that staff did not follow the facility's hydration management policy, and residents expressed dissatisfaction with the food quality and availability of alternate menu items.
The facility failed to store food in accordance with professional standards, as several cardboard boxes of food were found resting on metal trays on the floor of the walk-in refrigerator/freezer. The Dietary Supervisor confirmed the food should be stored off the floor, and the Head Chef was unsure why the items were initially on the floor. The facility's Food Handling Policy requires food to be stored six inches above the floor.
A resident and his family reported an unsafe transfer and poor positioning in bed, but the facility failed to document or resolve the grievance. The resident, with a history of convulsions and hemiplegia, felt scared and unsafe during the transfer performed by an inexperienced CNA. Despite reporting the incident, the complaint was not properly recorded or addressed, leading to a decreased quality of life for the resident.
A resident's care plan for pain management was not followed, leading to ineffective pain control. The care plan was generalized, and interventions such as administering acetaminophen and documenting pain levels were not implemented. The DON and MDS Nurse confirmed that pain assessments were based on observations rather than direct questioning.
A resident with a history of constipation experienced abdominal discomfort and difficulty defecating due to the facility's failure to adequately monitor, care plan, and manage the condition. Despite an admitting diagnosis of constipation, the resident was not started on routine medication until later, and the care plan was not updated. The DON stated there was no bowel protocol, and inconsistencies in medication administration were noted.
The facility failed to ensure resident safety, resulting in a resident sustaining a wound from exposed wooden parallel bars in the Therapy Room and another resident experiencing unsafe transfer practices due to an untrained CNA. The facility did not follow its policy on safe lifting and movement of residents, leading to hazardous conditions.
A resident admitted for rehabilitation after a lumbar fracture reported not receiving pain medication regularly, only upon request. Observations and interviews revealed that nursing staff did not consistently assess or document the resident's pain levels, and the care plan for pain management was not followed, leading to increased pain for the resident.
The facility failed to adequately assess and identify past traumas experienced by a resident, leading to a deficiency in trauma-informed care. The resident reported experiencing post-traumatic stress from terrifying hallucinations prior to her hospitalization and subsequent transfer. Despite her distress, no staff member had spoken to her about traumatic events since her admission. The facility's trauma-informed care assessment was insufficient, and the resident's triggers were not identified or addressed, placing her at increased risk of re-traumatization.
Failure to Communicate Removal of Resident's Personal Property
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not properly communicating about the removal of his personal property. The resident, identified as R4, reported that a friend had brought him a bottle of TUMS, which he placed in his drawer. However, the TUMS disappeared from his room without his knowledge or consent. R4 expressed distress and considered calling the police, as he felt his personal property was taken without explanation. A search of his room confirmed that the TUMS were missing. Further investigation revealed that the TUMS were found in the medication cart, labeled with R4's room and bed number. The nursing staff, including an RN and an LPN, confirmed that R4 did not have a physician's order for TUMS, indicating it was his personal property. The RN acknowledged that if a resident brings an over-the-counter medication, the nursing staff should be informed, and the resident should be notified and educated about why the medication cannot be kept in their room. However, this communication was not documented in R4's electronic health record, highlighting a lapse in the facility's protocol for handling residents' personal items and communication regarding their rights.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. One resident, admitted with severe protein-calorie malnutrition, experienced a significant weight loss of 5.35% within a month. Despite the dietician's awareness of the resident's poor intake and food preferences, a dietary care plan was not developed. The resident's care plan lacked a dietary section, which was confirmed by the dietician during an interview and record review. Another resident, with a history of congestive heart failure and edema, had an order for diuretic medication but did not have their potassium levels monitored as required by their care plan. The Director of Nursing confirmed that the monitoring of potassium levels was not implemented, despite being listed in the resident's plan of care. This oversight was identified during a concurrent interview and record review, highlighting a failure to adhere to the facility's policy on comprehensive assessments and care delivery.
Failure to Apply Splint as Ordered for Resident with Foot Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment for a left foot contracture. The resident, who was admitted with diagnoses including dementia, hemarthrosis to the right knee, hemiplegia and hemiparesis following a cerebral infarction, and osteoarthritis, had a care plan that included the use of a splint for the left foot. Physician orders specified that the splint should be applied for four hours daily, from 12:00 PM to 4:00 PM. However, observations revealed that the splint was not consistently applied as ordered. On multiple occasions, the splint was found on a chair or the floor, and the resident was observed without the splint during the prescribed times. Interviews with facility staff, including a CNA and an LPN, indicated a lack of awareness and adherence to the prescribed schedule for the splint application. The CNA was unaware of the specific times the splint should be worn, and the LPN confirmed that the medication nurse was responsible for applying and removing the splint. Despite the resident not refusing the splint, it was not consistently applied, putting the resident at risk of further decrease in range of motion. This deficiency highlights a failure in the facility's processes to ensure compliance with physician orders and proper care for residents with mobility limitations.
Ineffective Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as R84, who was admitted with diagnoses including insomnia, surgical aftercare, and chronic pain syndrome. R84 reported experiencing constant pain in the left shoulder, with pain levels reducing only slightly from 9 to 7 on a 0-10 pain scale after receiving oxycodone. Despite the resident's reports of continued severe pain, the nursing staff did not follow up with additional interventions or medications to further alleviate the pain. The resident had requested an increase in oxycodone dosage, which was implemented, but the pain level remained at 7, indicating the medication was ineffective. The Medication Administration Record (MAR) showed instances where oxycodone was documented as ineffective, yet there was no follow-up action documented. Interviews with the LPN and RN revealed that a pain level of 7 should be considered ineffective, and the charge nurse should have been notified to inform the physician. However, there was no documentation of further actions taken to address the resident's pain on specific dates. The lack of documentation and follow-up on the resident's pain management plan contributed to the deficiency in providing appropriate care.
Failure to Follow Prescribed Resident Menus
Penalty
Summary
The facility failed to ensure that resident menus were followed as prescribed, which affected the nutritional management of three residents. Resident 10, who is on a controlled carbohydrate diet for weight control, was observed to receive a full portion of mashed potatoes instead of the prescribed half portion during both lunch and breakfast. This discrepancy was noted by the resident's representative and confirmed by staff during meal observations. Similarly, Resident 135, also on a controlled carbohydrate diet, was initially served a full scoop of mashed potatoes instead of the required half scoop during the lunch tray line, which was later corrected by the dining room server. Additionally, Resident 28, who is on a fluid restriction due to a history of hyponatremia, was served a full bowl of soup instead of the specified 60 mL portion. The dining room server initially served 120 mL of soup, which exceeded the resident's fluid restriction, but corrected the portion after reviewing the menu. The dietician confirmed the importance of adhering to these dietary restrictions to manage the residents' health conditions effectively.
Failure to Discard Food by Use-By Date
Penalty
Summary
The facility failed to ensure that opened food items were discarded by their use-by date, as observed during a survey of the main kitchen. During an initial tour, a surveyor observed a small metal container of olives in the walk-in refrigerator, covered with saran wrap and labeled with a date that was unclear. The label read 'TODAY'S DATE 2/8' and the use-by date was indistinguishable, appearing to be either 2/15 or 2/16. The Dietary Manager confirmed that the dates should be written clearly and acknowledged that the olives should have been discarded if the use-by date was indeed 2/15 or 2/16. The cook, who was responsible for preparing food, confirmed the use-by date as 2/15 and stated she would discard the olives. Further interviews revealed that the facility's policy is to discard opened food items seven days after opening. The Dietary Supervisor confirmed that the cook prepares and cooks food in the main kitchen and then brings it to the facility kitchenette. The failure to clearly label and discard food items by their use-by date has the potential to affect residents, visitors, and staff who consume meals prepared by the facility, placing them at risk for foodborne illness.
Staff Competency Deficiencies in Safe Transfers and Perineal Care
Penalty
Summary
The facility failed to ensure staff competency in safe transfers and perineal care for two residents. In the case of Resident 131, the facility did not provide adequate training for safe transfers, which placed the resident at risk for avoidable injuries. This was identified through interviews and record reviews, highlighting a significant gap in staff training and competency in handling transfers safely. For Resident 13, the deficiency was observed during perineal care performed by a Certified Nurse Aide (CNA). The CNA used dry cloths instead of moistened ones, failed to change gloves when moving from dirty to clean tasks, and did not perform hand hygiene between glove changes. This improper technique led to contamination and compromised the resident's hygiene. The Infection Preventionist confirmed that the CNA did not follow proper procedures, indicating a lack of adequate training and adherence to infection control protocols.
Failure to Provide Adequate Hydration and Alternate Meal Options
Penalty
Summary
The facility failed to implement a food and hydration program that recognizes and addresses the preferences of each resident. This is evidenced by the repeated failure to provide fresh water to Resident 132 despite her multiple requests. Observations on different days showed that Resident 132's water pitcher remained empty for extended periods, and staff members, including CNAs and LPNs, did not take responsibility to ensure she received water. The resident also reported experiencing dark and burning urine, indicating dehydration, and her care plan specifically mentioned the need to encourage fluids to prevent infection and manage pain. Despite this, the facility's hydration management policy was not followed, leading to the resident's continued lack of access to water throughout the day. Additionally, the facility failed to offer and provide alternate menu items when residents found their meal trays unappetizing. Resident 132 reported being denied an alternate meal option because she had not pre-ordered it, contrary to the facility's policy that alternate menu items should always be available. Other residents also expressed dissatisfaction with the food quality and the lack of alternate options during a resident council meeting. Interviews with the Dietary Supervisor, Registered Dietician, and Head Chef confirmed that residents should have access to alternate menu items, but this practice was not consistently implemented, leading to widespread dissatisfaction with the meals provided.
Improper Food Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a return visit to the kitchen. Several cardboard boxes of food were found resting on metal trays on the floor of the walk-in refrigerator/freezer on the B1 floor. The Dietary Supervisor (DS) confirmed that the food should be stored off the floor and instructed another kitchen staff to move the food. The Head Chef (HC) later confirmed that the items had been placed on shelves but was unsure why they were initially on the floor. The facility's Food Handling Policy requires food to be stored six inches above the floor.
Failure to Address and Document Resident Grievance
Penalty
Summary
The facility failed to properly address and document a grievance raised by a resident and his family representative regarding an unsafe transfer and poor positioning in bed. The resident, a male with a history of unspecified convulsions, left hemiplegia, and left hemiparesis following a stroke, reported that a certified nurse aide (CNA) performed a mechanical lift transfer without adequate preparation or explanation, causing the resident to feel scared and unsafe. The CNA was described as rough and inexperienced, and the transfer was deemed unsafe by both the resident and his family representative. Despite reporting the incident to the Director of Rehabilitation (DOR) and the Minimum Data Set Coordinator (MDSC), the complaint was not documented or resolved satisfactorily, leaving the resident and his family feeling ignored and blamed for the incident. The facility's grievance log showed no documentation of the complaint, and interviews with the DOR and MDSC confirmed that the incident was not properly recorded or addressed. The facility's policy on grievance management requires that all complaints be documented and investigated to ensure satisfaction and improve services, but this was not followed in this case. The failure to document and resolve the grievance resulted in a decreased quality of life for the resident and had the potential to affect all residents who voice concerns at the facility.
Failure to Implement Person-Centered Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident admitted for rehabilitation services after suffering a lumbar fracture. The care plan for the resident was generalized and did not include the resident's name. Additionally, the interventions for pain management outlined in the care plan were not followed. Specifically, the care plan included interventions such as assisting with repositioning for comfort and offering analgesics according to physician orders, but these were not implemented. The Medication Administration Record (MAR) and pain log revealed that acetaminophen was not documented as given over several days, and the pain level and non-pharmacological interventions were not recorded. During an interview, the Director of Nursing (DON) and MDS Nurse indicated that nurses typically rate the resident's pain based on their observations rather than asking the resident to rate their pain on a scale. This practice led to the failure to document and manage the resident's pain effectively. The resident's pain management was not adequately addressed, as evidenced by the lack of documentation and adherence to the care plan interventions.
Failure to Monitor and Manage Constipation
Penalty
Summary
The facility failed to adequately monitor, care plan, and manage an elevated risk of constipation for a resident, resulting in abdominal discomfort and difficulty defecating. The resident, a [AGE] year-old male with a history of unspecified convulsions, left hemiplegia, left hemiparesis following a stroke, and constipation, was admitted on [DATE]. Despite an admitting diagnosis of constipation, the resident was not started on a routine medication for constipation until 02/20/24, and the care plan was not updated to reflect this change. The resident's family representative reported that the resident experienced hard stools and difficulty defecating, and had requested a suppository but was told it was only for no bowel movements after three days. The nursing progress notes documented constipation on 02/06/24, with the last bowel movement on 02/01/24, but the resident did not receive appropriate medication until 02/20/24. Additionally, there were inconsistencies in the administration of as-needed medications for constipation, with Lactulose and Bisacodyl suppository being administered despite documented bowel movements on previous days. The Director of Nursing (DON) stated that the facility has no bowel protocol and that staff should follow the doctor's orders. However, the resident's comprehensive care plan did not specifically address the constipation problem identified on admission and was not revised when the routine medication was added or increased. The care plan only referenced as-needed medications and was included under an Alteration in Comfort care plan related to other conditions. This lack of a specific care plan and inconsistent medication administration contributed to the resident's ongoing constipation issues and discomfort.
Failure to Ensure Resident Safety in Therapy Room and During Transfers
Penalty
Summary
The facility failed to ensure residents were free from accident hazards in the Therapy Room and during transfers. Resident 23, a cognitively intact female with a history of convulsions, syncope, and muscle weakness, sustained a wound on her left forearm from an exposed end of the wooden parallel bars in the Therapy Room. The injury occurred when the resident slipped while using the bars, and the exposed end caused a skin tear. The injury report was completed by a nurse who was not present during the incident, and the exposed ends of the parallel bars remained unprotected even after the injury was reported and observed by staff. Resident 131, a male with left hemiplegia and hemiparesis following a stroke, experienced unsafe transfer practices. The resident and his family reported that a CNA attempted a mechanical lift transfer alone without explaining the process, causing the resident to feel scared and unsafe. The CNA was described as rough and inexperienced, and the transfer was not conducted according to the resident's assessed needs, which required 100% assistance or two or more helpers. The CNA had not completed the required training for safe transfers and had not been tested on the specific mechanical lifts used in the facility. The facility's policy on safe lifting and movement of residents was not followed, as nursing staff did not consult with rehabilitation staff before attempting the transfer. The DON confirmed that the CNA had not completed all required training, including the Transferring Safely component. The failure to ensure proper training and adherence to safety protocols led to unsafe conditions for residents in the Therapy Room and during transfers.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to recognize and evaluate when a resident experienced pain and did not manage the pain consistent with the comprehensive assessment, plan of care, and current professional standards of practice. The resident, a [AGE] year-old male admitted for rehabilitation services after a lumbar fracture, reported that he was not receiving pain medication regularly and only when he requested it. Observations revealed that nursing staff did not consistently ask the resident about his pain level, and the pain log did not document pain levels or non-pharmacological interventions. The resident's care plan included interventions for pain management, but these were not followed as prescribed, leading to increased pain for the resident. Interviews with the Director of Nursing (DON), MDS Nurse, and other staff indicated a lack of consistent practice in assessing and documenting pain levels. The DON stated that nurses document pain levels based on their observations rather than asking residents directly. The facility's pain management guidelines emphasize the importance of recognizing pain and using specific strategies for different levels and sources of pain, but these guidelines were not adhered to in the case of this resident. The failure to follow the care plan and professional standards resulted in inadequate pain management for the resident.
Failure to Adequately Assess and Identify Past Traumas
Penalty
Summary
The facility failed to adequately assess and identify past traumas experienced by a resident, leading to a deficiency in trauma-informed care. The resident, a cognitively intact female, reported experiencing post-traumatic stress from terrifying hallucinations prior to her hospitalization and subsequent transfer to the skilled nursing home. Despite her distress, the resident stated that no staff member had spoken to her about traumatic events in her life since her admission. The facility's trauma-informed care assessment, conducted by the Minimum Data Set Coordinator (MDSC), consisted of only two questions, and the resident's assessment had 'no' marked as the answer to the first question, which led to the second question not being asked. The MDSC admitted to not always reading all the examples given in the assessment questions, which may have contributed to the oversight. During interviews, the resident expressed that she was visibly upset and experienced physical symptoms of distress when recounting her traumatic experiences. She also reported that certain staff members and background noises triggered her anxiety, yet these triggers were not identified or addressed by the facility. The lack of a thorough trauma-informed care assessment and the failure to recognize and address the resident's triggers placed her at increased risk of re-traumatization and hindered her mental and psychosocial well-being.
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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.
Illustrative
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Illustrative
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Nursing homes near Hon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oahu Care Facility | 0.2 mi | ★★★★★ | 15 | 0 |
| Islands Skilled Nursing & Rehabilitation | 0.2 mi | ★★★★★ | 13 | 0 |
| Arcadia Retirement Residence | 0.5 mi | ★★★★★ | 1 | 0 |
| Kalakaua Gardens | 0.7 mi | ★★★★★ | 33 | 0 |
| Hale Nani Rehabilitation And Nursing Center | 1.2 mi | — | 26 | 0 |
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