Below 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 Kuakini Geriatric Care, Inc during CMS and state inspections, most recent first.
The facility failed to ensure proper sanitization of dishware and silverware, as the dishwasher's final rinse temperature was below the required 180 degrees Fahrenheit. Despite logs showing compliance on previous days, the surveyor observed a lapse in practice, with staff unaware of the correct temperature requirements. The facility's policy was not followed, posing a risk of foodborne illness due to improper sanitization.
A facility failed to inform a resident's representative about the risks and benefits of psychotropic medications, resulting in a lack of documented consent. The resident, with severely impaired cognition, was prescribed Trazodone, Seroquel, and Zoloft without the representative's informed consent. Staff interviews confirmed the absence of documentation, as the responsible employee was on leave, leading to potential harm for residents receiving these medications.
The facility failed to implement comprehensive care plans for two residents. One resident with COPD did not have their continuous oxygen use included in their care plan, despite a physician's order. Another resident with a UTI caused by ESBL did not have enhanced barrier precautions in place as required by their care plan. These deficiencies were confirmed by facility staff.
A resident with a history of constipation did not receive prescribed laxatives as ordered, leading to missed doses of Lactulose when the resident did not have a bowel movement for two days. Despite the resident's acknowledgment of constipation and taking stool softeners, the facility failed to administer the medication as per the treatment plan, with no documentation of refusal.
The facility failed to maintain cleanliness of enteral feeding equipment for three residents, leading to unsanitary conditions with dried formula residue on feeding pumps and poles. Staff were unclear about cleaning responsibilities, contributing to the deficiency.
The facility failed to label oxygen tubing for three residents, risking respiratory infections. A resident with COPD used a nasal cannula without a date label, contrary to policy. Another resident with a tracheostomy had unlabeled tubing, and a third resident on droplet precautions had an oxygen meter initially off and unlabeled tubing. The DON confirmed the need for weekly changes and labeling, highlighting a systemic issue in respiratory care management.
The facility failed to implement infection control measures for three residents. A resident on contact isolation lacked proper signage, and another on enhanced barrier precautions did not have a PPE cart or signage. Additionally, a CNA delivered a meal to a resident on droplet precautions without appropriate PPE. These deficiencies were confirmed by the DON and staff, indicating lapses in infection prevention protocols.
The facility failed to notify physicians of abuse allegations involving three residents. One resident reported rough handling by a CNA, another experienced care without communication, and a third was witnessed being abused by a CNA. In each case, the physicians were not informed, contrary to facility policy.
The facility failed to protect residents from physical abuse by staff, involving incidents where a resident was pushed during a shower, another was undressed without consent, and a third was stomped on the foot. These incidents involved contract and night shift CNAs, with one resident expressing fear of retaliation. The facility's policy requires immediate protective actions, but the report does not specify if these were implemented.
The facility failed to report abuse allegations to the state agency within the required timeframe. In two incidents, reports were delayed by two and three days, respectively. One involved a resident who reported a night shift CNA providing care without explanation, and another involved a resident with Alzheimer's who was reportedly abused by a CNA. The facility's policy mandates timely reporting, which was not followed.
The facility experienced staffing deficiencies on two occasions during the second shift, leading to incidents of improper delegation and staff-to-resident abuse. On one occasion, an RN delegated medication administration to a CNA, which is outside the CNA's scope of practice. On another occasion, a CNA reportedly stomped on a resident's foot, who has Alzheimer's and was on 1:1 monitoring. The staffing levels were below the required matrix, contributing to these incidents.
An RN improperly delegated medication administration to a CNA, which is outside the CNA's scope of practice. The CNA was instructed to give a resident her bedtime medication, which the resident refused, questioning the CNA's role. The RN admitted to the delegation due to discomfort with the resident and lack of available staff.
A facility failed to accurately document medication administration for a resident. RN3 asked CNA5 to offer medication to the resident, R40, due to feeling uncomfortable after a prior incident. Despite R40 refusing the medication, RN3 documented in the MAR that R40 had taken Tylenol and Melatonin. RN3 did not seek help from another nurse or the Shift Coordinator.
Dishwasher Sanitization Deficiency
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to proper sanitization procedures for dishware and silverware, as observed during a survey. The deficiency was identified when the surveyor noted that the final rinse temperature of the dishwasher was at 172 degrees Fahrenheit, below the required 180 degrees Fahrenheit necessary for heat sanitization. Despite the facility's logs indicating compliance with temperature standards from previous days, the surveyor's observation revealed a lapse in practice. The Food Services Supervisor and Food Service Workers were unaware of the correct temperature requirements, and the dishwasher did not use a chemical sanitizer, relying solely on heat for sanitization. The facility's policy clearly stated that the final rinse temperature should be 180 degrees Fahrenheit or above, and any deviation should prompt immediate cessation of dishwashing procedures and notification of the Plant Operations department. However, this protocol was not followed, as evidenced by the continued unloading of dishes despite the substandard rinse temperature. This oversight posed a risk of foodborne illness to residents and staff, as the dishware and silverware were not properly sanitized according to professional standards and the U.S. Department of Health and Human Services guidelines.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's representative was informed in advance about the risks and benefits of proposed treatments, specifically the use of psychotropic medications. This deficiency was identified for one of the five residents sampled for unnecessary medications. The resident in question, identified as having severely impaired cognition with a BIMS score of 6, was dependent on staff for all care. The resident was prescribed Trazodone, Seroquel, and Zoloft for dementia behavior, agitation, and anxiety, respectively. However, there was no documentation in the resident's Electronic Health Record (EHR) or the facility's psychotropic medication consent binder indicating that the resident's designated health decision-maker, a family member, had been informed or had consented to the use of these medications. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed the absence of documented consent. The RN acknowledged that the consent process involved emailing the resident's family member, who was off-island, but the responsible employee was on leave, resulting in a lack of documentation. The DON also confirmed that there was no evidence of the family member being informed or consenting to the medication administration, nor was there documentation of the family member being educated on the risks and benefits of the medications. This oversight placed residents receiving psychotropic medications at risk for more than minimal harm.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For one resident with chronic obstructive pulmonary disease (COPD), the care plan did not include the continuous use of oxygen, despite a physician's order for supplemental oxygen to maintain oxygen saturation levels above 90%. This oversight was confirmed by both the Nursing Assessment Specialist and the Director of Nursing, who acknowledged that the resident's care plan should have included the oxygen use. Another resident, who was readmitted to the facility with a urinary tract infection caused by an antibiotic-resistant bacteria (ESBL), had a care plan that required enhanced barrier precautions (EBP) to prevent further infection. However, during an interview, a Certified Nurse Aide revealed that these precautions were not being followed, as there was no signage or personal protective equipment available outside the resident's room. The Director of Nursing confirmed that the care plan required these precautions, but they were not being implemented as intended.
Failure to Administer Laxatives as Ordered for Constipated Resident
Penalty
Summary
The facility failed to implement prescribed interventions for a resident, identified as R79, who was experiencing constipation. R79, an elderly resident admitted for long-term care, had a medical history that included dehydration, muscle weakness, and constipation. Despite having orders for laxatives such as Senna, Lactulose, and Bisacodyl Suppository to manage constipation, the facility did not administer Lactulose as ordered when R79 did not have a bowel movement for two consecutive days on multiple occasions in December 2024 and January 2025. During an interview, R79 mentioned experiencing constipation due to decreased activity and confirmed taking stool softeners, though she was unsure of the frequency. A review of the Medication Administration Record (MAR) revealed that Lactulose was not administered as required, and there was no documentation of refusal by R79. A registered nurse, RN6, acknowledged the oversight and confirmed that some doses were missed, indicating a failure to follow the prescribed treatment plan for R79's constipation.
Inadequate Cleaning of Enteral Feeding Equipment
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications of enteral feeding for three residents. Observations revealed that the equipment used for enteral feeding was not properly cleaned and maintained. For one resident, dried formula residue was observed on the feeding pump, base of the pole, and floor over two consecutive days, indicating a lack of sanitation. A Patient Care Coordinator acknowledged the unsanitary condition and the potential for attracting pests that could carry pathogens. Another resident's feeding pump and pole were also found to be soiled with dried formula. A registered nurse indicated that the night shift was responsible for cleaning the equipment, but the task was not specifically assigned to anyone. Additionally, a third resident's feeding pump was observed with a thickened layer of old formula, and a plastic tray below the pump had dried splatters of formula. The charge nurse confirmed that all staff were responsible for cleaning the equipment, but the lack of clear assignment led to the deficiency.
Failure to Label Oxygen Tubing in Respiratory Care
Penalty
Summary
The facility failed to properly label oxygen tubing when it was initiated for three residents, which placed them at risk of facility-acquired respiratory infections. Resident 89, who has a diagnosis of chronic obstructive pulmonary disease (COPD) and other respiratory conditions, was observed using a nasal cannula connected to wall oxygen without a date label on the tubing. The resident confirmed that the oxygen was on at 2 liters per minute continuously and stated that staff changed the nasal cannula when requested. The facility's policy requires nasal cannula changes weekly and as needed, with labeling to indicate the date of change. Resident 19, who requires oxygen therapy and tracheostomy care, was observed with a trachea collar connected to an aerosol bottle, but the tubing lacked a date label. The Director of Nursing (DON) confirmed that respiratory tubing should be changed weekly and labeled accordingly. The facility's policy specifies that the nebulizer, tracheostomy collar, and tubing setup should be changed daily and as needed. Resident 216, on droplet precautions for respiratory syncytial virus (RSV), was observed with a nasal cannula for oxygen delivery, but the oxygen meter was initially off, and the tubing was not labeled with a change date. A registered nurse confirmed that the oxygen was supposed to be set at 2 liters and acknowledged the absence of a label on the tubing. The facility's failure to label the oxygen tubing as per policy was consistent across multiple residents, indicating a systemic issue in respiratory care management.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control measures for three residents. Resident 23, who was on contact isolation due to Methicillin Resistant Staphylococcus Aureus, did not have the required signage outside their room to alert staff and visitors of the transmission-based precautions. This was confirmed by both the Patient Care Coordinator and the Director of Nursing, who acknowledged that signage should have been placed to prevent the spread of infections. Similarly, Resident 38, who had a history of ESBL and was on enhanced barrier precautions, did not have the necessary PPE cart or signage outside their room, as confirmed by a Certified Nurse Aide and the Director of Nursing. Additionally, a Certified Nurse Aide was observed delivering a meal to Resident 72, who was on droplet precautions due to testing positive for Respiratory Syncytial Virus, while only wearing a surgical mask. The Director of Nursing confirmed that the staff should have been wearing a face shield, gown, an approved mask, and gloves when entering the room. These lapses in infection control measures placed residents and staff at risk of preventable infections.
Failure to Notify Physicians of Abuse Allegations
Penalty
Summary
The facility failed to consult with physicians regarding allegations of abuse involving three residents. Resident 12 reported being roughly handled by a CNA during a shower, which made her afraid of potential retaliation. Despite the incident being reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), there was no documentation in the resident's electronic health record (EHR) indicating that the physician was notified. Similarly, Resident 26 reported an incident involving a night shift CNA who provided care without communication, but again, the physician was not informed. The physician stated that if notified, they would have requested an investigation and checked for harm. In another incident, Resident 33 was witnessed being abused by a CNA, who stomped on the resident's foot. The nursing supervisor was informed of the incident but did not ensure the physician was notified. The EHR review confirmed the lack of notification to the physician, and the physician later confirmed they were unaware of the incident. The facility's policy requires immediate notification of the physician and family in such cases, but this procedure was not followed, leading to a deficiency in the facility's handling of abuse allegations.
Failure to Protect Residents from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect residents from physical abuse by staff, as evidenced by multiple incidents involving three residents. One resident reported to her family that a staff member had pushed her head against the wall during a shower. The family informed the facility, and the resident confirmed the incident to the Registered Nurse (RN) and the Assistant Director of Nursing (ADON). The resident expressed fear of retaliation, although she was not physically hurt. The staff member involved was a contract worker, and her contract was subsequently canceled. Another resident reported feeling violated when she woke up to find herself undressed by a night shift Certified Nurse Assistant (CNA) without prior notification. The resident expressed discomfort with the staff member's actions, which were reported to the RN and subsequently to the ADON and Director of Nursing (DON). The incident was investigated, and it was determined that the night shift CNA had not communicated with the resident before providing care. A third incident involved a resident with Alzheimer's who was reportedly stomped on the foot by a CNA. The incident was witnessed by another CNA, who reported that the action appeared intentional. The resident was on a one-to-one monitoring plan due to restlessness and agitation. The CNA involved claimed the action was a response to the resident attempting to hit her with a walker. The facility's policy requires immediate action to protect residents from suspected abuse, but the report does not detail if this was followed in this case.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required two-hour timeframe after being reported to the Charge Nurse (CN), Nursing Supervisor (NS), or Assistant Director of Nursing (ADON) and Director of Nursing (DON). In two separate incidents involving residents, the facility delayed reporting to the state agency. For one resident, the incident was reported to the CN and subsequently to the state agency two days later. The resident had reported that a night shift CNA began providing care without informing her of the actions being taken. The Facility Reported Incident (FRI) was sent to the Office of Healthcare Assurance (OHCA) two days after the initial report. In another case, a resident with Alzheimer's and a history of agitation was reportedly abused by a CNA who stomped on the resident's foot. This incident was reported to the NS and DON, but the FRI was sent to the state agency almost three days later. The ADON confirmed that the CNA admitted to stepping on the resident's foot, describing it as a light touch, but it was believed to be intentional. The facility's policy requires notifying state officials within 24 hours or by shorter timeframes as per regulatory guidelines, which was not adhered to in these cases.
Staffing Deficiencies and Incidents in Skilled Nursing Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff on two occasions during the second shift on the skilled nursing unit, specifically on 02/07/24 and 07/05/24. On 02/07/24, the staffing matrix indicated that the unit should have had 2 RNs, 2 LPNs, and 4 or 5 CNAs for 37 residents. However, the actual staffing was 2.5 RNs, no LPNs, and 3.5 CNAs, resulting in a shortage of 1.5 LPNs and 0.5 to 1 CNA. This staffing deficiency led to an incident where an RN improperly delegated medication administration to a CNA, which is outside the CNA's scope of practice. The Associate Director of Nursing (ADON) confirmed that the facility does not teach nurses to delegate medication pass to CNAs, and a meeting was held with the involved staff to discuss their scope of practice. On 07/05/24, the unit had 31 residents and should have been staffed with 1 RN, 2 LPNs, and 4 or 5 CNAs according to the staffing matrix. However, the actual staffing was 2.5 RNs, no LPNs, and 4 CNAs, resulting in a shortage of 0.5 LPN and up to 1 CNA. During this shift, an incident of staff-to-resident abuse occurred when a CNA reportedly stomped on a resident's foot. The resident involved, who has Alzheimer's and a history of agitation, was on a 1:1 monitoring at the time. The CNA admitted to stepping on the resident's foot, describing it as a light touch, but it was suspected to be intentional due to the resident's behavior.
Improper Delegation of Medication Administration
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) and a Certified Nurse Aide (CNA) practiced within their professional scope of practice, which could potentially affect all residents. On February 7, 2024, an RN delegated the task of medication administration to a CNA, which is outside the CNA's scope of practice. The Associate Director of Nursing (ADON) confirmed that the Director of Nursing (DON) had informed him of this incident. The ADON and DON subsequently met with the involved staff, RN3 and CNA5, to discuss their professional boundaries and the facility's policies. The incident involved a resident, R40, who was demanding her bedtime medication. CNA5, who was not licensed to administer medication, was instructed by RN3 to give the medication to R40. CNA5 was aware that this was outside her scope of practice but proceeded to offer the medication, which R40 refused to take, questioning why a CNA was administering it instead of a nurse. RN3 admitted to delegating the task due to feeling uncomfortable with R40 after a previous incident and because the other nurse and Nursing Supervisor were busy. The facility's policy clearly states that only licensed individuals are permitted to administer medications.
Inaccurate Medication Documentation for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident, identified as R40. On the evening of 07/18/24, RN3, a registered nurse, admitted to asking CNA5, a certified nursing assistant, to offer medication to R40 because RN3 felt uncomfortable entering the resident's room after an incident the previous day where R40 yelled at her. RN3 did not seek assistance from another nurse or the Shift Coordinator, citing that the other nurse was busy. RN3 remained at the resident's door while CNA5 offered the medication, which R40 refused. However, a review of R40's Medication Administration Record (MAR) on 07/19/24 revealed that RN3 inaccurately documented that R40 had taken Tylenol 625 mg and Melatonin 3 mg by mouth at 2113, despite the resident's refusal.
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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) |
|---|---|---|---|---|
| Liliha Healthcare Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Maluhia | 0.5 mi | ★★★★★ | 0 | 0 |
| 15 Craigside | 0.6 mi | ★★★★★ | 0 | 0 |
| The Care Center Of Honolulu | 0.6 mi | ★★★★★ | 16 | 0 |
| The Ching Villas | 0.8 mi | ★★★★★ | 13 | 0 |
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