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 Hi'olani Care Center At Kahala Nui during CMS and state inspections, most recent first.
The facility failed to properly store and label food items, with expired and improperly labeled items found in the kitchen and dry storage. Temperature checks for cooked food were not logged, and not all trayline food items were tested before serving. Clean pots and pans were stored on a rack with rusty debris, contrary to facility policies.
A facility failed to provide written notification to a resident's representative and the LTCO during a hospital transfer. Interviews with staff confirmed that only phone calls were made to inform the family, and no written notices were issued, contrary to the facility's policy.
A facility failed to implement a comprehensive care plan for a resident with dementia, kidney disease, and poor food intake. The care plan required weekly weight monitoring for four weeks, but the resident's weight was not recorded weekly as required. The DON confirmed the facility's failure to adhere to the care plan.
A resident with constipation received bowel regimen medications despite having loose stools, contrary to physician orders. Nursing staff misinterpreted EHR documentation, leading to incorrect medication administration. The DON and ADON stressed the importance of following physician orders and obtaining clarification if needed.
The facility failed to maintain accurate controlled drug records for two medication carts, as evidenced by missing nurse signatures for several shifts. The DON confirmed the missing signatures, which are required to verify the accuracy of the controlled medications count and accept legal responsibility for the drugs.
A facility failed to ensure an attending physician reviewed an irregularity identified in a pharmacist's monthly medication review for a resident. The review noted the need to add a frequency of administration to a PRN Tylenol order, but this was not addressed, leaving the order incomplete. A nurse confirmed the oversight, and the facility's policy for reviewing such reports was not followed, risking medication errors.
The facility failed to maintain complete medical records for two residents. One resident's significant weight loss was not properly documented in the EHR, and the weight entry was edited later by a nurse not on duty. Another resident's hospice chart lacked recent progress notes and recertification, which were only added after a surveyor's request. The facility's policy requires up-to-date documentation, which was not followed.
A resident with COPD and bronchiectasis was found with a humidifier bottle improperly secured to their oxygen concentrator, touching the ground. The missing metal clamps led to the bottle being taped to the concentrator, posing a contamination risk. The Nurse Educator/Infection Preventionist confirmed this as a potential infection source, indicating a deficiency in the facility's infection control program.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and temperature monitoring, which could lead to foodborne illnesses among residents and staff. During an initial kitchen tour, expired food items were found, including chicken base and cooked pork, and several items in the dry storage area were opened without proper labeling for open and discard dates. Additionally, a bottle of Dijon mustard in the refrigerator had an unreadable label, making it impossible to determine its discard date. The Head Chef admitted that while temperatures of cooked food were checked, they were not logged, and the facility could not provide any temperature logs. Further observations revealed that not all food items on the trayline were tested for temperature before being served to residents, and the method of temperature checking was inconsistent. A metal rack used to store clean pots and pans was found to have rusty colored debris, which was acknowledged by the Director of Dining Services. The facility's policies on food labeling, cooking, and temperature monitoring were reviewed, highlighting discrepancies between the written procedures and actual practices observed during the survey.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident's representative and the Long-Term Care Ombudsman (LTCO) regarding the resident's transfer to an acute care hospital. This deficiency was identified during a review of the electronic health record of a female resident who was transferred to the hospital. The record lacked documentation of any written notification being provided to the resident's family representative and the LTCO, which is a requirement for such transfers. Interviews with facility staff, including a social worker and the Director of Nursing (DON), confirmed that the standard practice during a hospital transfer involved only a phone call to the resident's family. Both staff members acknowledged that written notifications were not provided to the resident's representative or the LTCO. The facility's own records, titled "Discharge/Transfer of the Resident," indicated that a signed transfer or discharge notice should be given to the resident and/or their representative, even if completed later in the case of an emergency transfer.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as R168, which led to a deficiency. R168, a female resident with a medical history of dementia, kidney disease, and poor food intake, was admitted to the facility and had a care plan that required weekly weight monitoring for four weeks from admission, followed by monthly monitoring if the weight was stable. However, a review of R168's Electronic Health Record (EHR) revealed that her weight was not recorded weekly as required. Specifically, her weight was documented as 89.8 pounds on two occasions, with a subsequent erroneous entry of 0 pounds, and then 80.0 pounds, with no further weights documented after that date. An interview with the Director of Nursing confirmed that the facility did not adhere to the care plan's requirement for weekly weight monitoring for the specified period.
Failure to Follow Physician's Orders for Bowel Regimen
Penalty
Summary
The facility failed to administer treatment and care in accordance with professional standards for a resident, identified as R15, who was admitted with multiple diagnoses including constipation. Despite physician orders to hold bowel regimen medications such as MiraLAX, Senna Plus, and bisacodyl suppository in the event of loose stools, these medications were administered to R15 on multiple occasions after documented instances of loose stools. Specifically, on two consecutive days, R15 experienced loose stools but continued to receive the prescribed bowel regimen medications, contrary to the physician's instructions. Interviews with nursing staff, including an LPN and RN, revealed a lack of adherence to the physician's orders and a misunderstanding of the documentation system used to track bowel movements. The LPN initially misinterpreted the EHR codes, which led to the incorrect administration of medications. The RN confirmed the administration of medications despite the presence of loose stools and acknowledged the need to follow physician orders. The DON and ADON emphasized the importance of adhering to physician orders and the necessity of obtaining clarification from the physician if a resident insists on taking medication against medical advice.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and reconciled for two medication carts. During a review of the facility's Controlled Drug Count Records for the 4th Floor Carts A and B, it was found that there were missing signatures from licensed nurses for several shifts. Specifically, Cart A lacked signatures for two shifts on June 24 and one shift on June 25, while Cart B lacked signatures for one shift on June 15 and one shift on June 16. An interview with the Director of Nursing (DON) confirmed the missing signatures, which should have been completed as part of the controlled medications count process. The facility's policy requires that both the outgoing and incoming nurses sign the controlled drug count record to verify the accuracy of the count and accept legal responsibility for the drugs at the time of the count.
Failure to Address Medication Review Irregularity
Penalty
Summary
The facility failed to ensure that the attending physician reviewed an identified irregularity from the pharmacist's monthly medication review for one of the residents sampled. Specifically, the pharmacist's review for March noted that a frequency of administration needed to be added to the PRN Tylenol 325 mg tablet order for a resident. However, the follow-through section of the medication review report was left blank, indicating that the issue was not addressed. The resident's physician's order for Tylenol, which was to be given as needed for back pain, did not include a frequency of administration. During an interview, a registered nurse confirmed that the medication review was not addressed and that the Tylenol order should have specified administration every four hours. The facility's policy and procedure for the monthly drug regimen review stated that the medical director or associate medical director would review the report and discuss any recommendations with the attending physicians and relevant staff as needed. However, this process was not followed, leading to the potential for medication error and adverse consequences for the resident.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete medical records for two residents, which was identified during a survey. For one resident, there was a significant weight loss documented in the Electronic Health Record (EHR), but the weight was not updated correctly. The Director of Nursing (DON) acknowledged that the weight loss was significant and should have been reported to the dietician. A handwritten note with a reweigh was found, but it was not documented in the EHR until later, and the entry was edited by a nurse who was not scheduled to work that day. The DON confirmed that weights and notes should be documented in the EHR before the end of the shift and should have been marked as a late entry. For another resident, the facility failed to maintain up-to-date hospice documentation. The resident's hospice chart was missing recent progress notes, recertification, and the last Medical Doctor (MD) visit summary. The missing documents were only added to the chart after the surveyor requested them. The facility's policy requires that documentation in the resident's medical records be complete and up-to-date, but this was not adhered to in this case. The DON stated that hospice nurses communicate with the assigned nurse and are expected to provide progress notes either by fax or in person.
Infection Control Deficiency: Improperly Secured Humidifier Bottle
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for a resident identified as R118. R118, who was admitted with hospice care and diagnosed with bronchiectasis and chronic obstructive pulmonary disease (COPD), was observed using an oxygen concentrator. During an observation, it was noted that the humidifier bottle attached to the oxygen concentrator was hanging and touching the ground, as the metal clamps meant to secure it were missing. R118 mentioned receiving a new humidifier bottle about a week prior and was unaware of how long it had been on the ground. Further observations revealed that the humidifier bottle was later taped to the oxygen concentrator. An interview with the Nurse Educator/Infection Preventionist confirmed that the humidifier bottle should not be on the ground, as it could be a source of contamination, posing an infection control risk. This oversight in securing the humidifier bottle properly could potentially expose the resident to infections, highlighting a deficiency in the facility's infection prevention and control program.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maunalani Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Leahi Hospital | 1.4 mi | ★★★★★ | 0 | 0 |
| Palolo Chinese Home | 1.7 mi | ★★★★★ | 6 | 0 |
| Hale Ola Kino By Arcadia | 3.4 mi | ★★★★★ | 0 | 0 |
| Oahu Care Facility | 3.4 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.