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 Liliha Healthcare Center during CMS and state inspections, most recent first.
The facility did not maintain required documentation for resident grievances, with all sampled grievances lacking evidence of investigation, follow-up, or written decisions as outlined in facility policy. Multiple concerns reported by residents and a family member, including issues with staffing, personal belongings, and care, were not properly tracked or resolved in writing, and it was unclear if the complainants were satisfied with the outcomes. The Administrator confirmed that documentation was not kept up to date due to a vacant Social Services Director position.
The facility did not have a consistent process or documentation system in place to ensure that residents at risk for pressure ulcers, including those with severe mobility limitations and incontinence, were regularly repositioned as required by their care plans. Nursing documentation was sporadic, CNA documentation was absent, and staff interviews confirmed a lack of clarity and standardized procedures for repositioning, resulting in residents remaining in the same position for extended periods.
The facility did not conduct a comprehensive investigation into an alleged staff-to-resident abuse incident, as required by its policy. Only the accused CNA was interviewed, while other staff present, roommates, and other residents were not interviewed or assessed for signs of abuse. The Administrator confirmed the investigation was limited in scope.
Two residents with complex medical needs did not have their care plans updated to include physician-ordered interventions for skin protection, resulting in staff lacking critical information to address their conditions. One resident's care plan omitted the use of GERI sleeves for fragile skin despite open wounds and an active order, while another's care plan failed to include a Prevalon Boot for ankle protection, which was also not in use at the time of observation.
A resident with multiple comorbidities and a recent COVID diagnosis did not have all required vital signs consistently monitored and recorded by nursing staff, despite physician orders. Documentation showed repeated omissions of pulse, respiratory rate, and pulse oximetry over several days, even after family concerns about the resident's declining condition were raised. The Unit Manager confirmed that the monitoring was incomplete and did not meet the expected standard of care.
The facility did not have a registered nurse serving as DON, as required, after the previous DON left. The Administrator confirmed the vacancy and stated that other staff were covering some DON duties while the facility searched for a replacement. Facility assessment documents listed a DON as part of the required nursing staff, but the position remained unfilled.
The facility did not have a DON present on the Quality Assessment and Assurance Committee, as required, due to the position being vacant for several months. Other staff covered some DON duties, but QAPI meeting minutes confirmed the absence of a DON, resulting in noncompliance with committee membership requirements.
Surveyors found that cooked white rice stored in the kitchen refrigerator was not labeled with the required preparation or discard date, and unopened bottles of sauce in dry storage were missing best-by-date labels due to missing caps. Dietary staff confirmed the labeling omissions and removed the affected sauce bottles from storage.
A resident reported feeling disrespected and undignified when staff frequently spoke in their native language, which the resident did not understand, leading to the perception that staff were talking about them. Facility policy requires residents to be informed of their rights in a language they understand and to be treated with dignity and respect.
A CNA wrapped a resident's hands tightly with the lower portion of the resident's gown to complete incontinence care after the resident resisted by pushing down with her hands. This action was taken for staff convenience and not for medical treatment, contrary to facility policy prohibiting physical restraints for such purposes.
A resident with a history of wandering and exit-seeking behavior, as well as multiple medical and cognitive conditions, was not provided with consistent or one-on-one supervision despite repeated elopement attempts. Staff were unclear about who was responsible for monitoring the resident, and after following a visitor out the main entrance, the resident left the facility and walked unsafely in the community before being returned by staff and the administrator.
The facility did not ensure that cloth napkins provided with meal trays were clean, as evidenced by observations of stained and soiled napkins and acknowledgment by the Dietary Manager. This failure was identified through family interviews, direct observation, and review of facility policy.
Three staff members, including a RN and two CNAs, completed CPR training that did not include hands-on practice or in-person skills assessment, as confirmed by documentation and staff interviews. The facility administrator acknowledged the absence of a written policy for CPR training requirements, and one staff member confirmed the lack of hands-on training.
A medication cart was found left unlocked and unattended in a hallway, with staff passing by before an RN returned to secure it. Both the RN and the unit manager confirmed that medication carts should be locked when unattended, in accordance with facility policy requiring all drugs and biologicals to be stored in locked compartments.
A resident with a sacral wound had her dressing removed and wound assessed by a PA before her incontinence was cleaned and before a clean brief was placed. The CNA cleaned the area only after the wound assessment. Staff interviews confirmed that incontinence should be addressed before wound care to maintain infection control.
The facility failed to develop and implement individualized care plans for three residents, leading to a risk of decline in their quality of life. One resident's mobility needs were not addressed, another's care plan lacked frequency for Hemi-Walker use, and a third resident's required assistance for movement was not specified. MDS staff confirmed that care plans were generalized and not individualized.
The facility failed to maintain a comfortable environment by not keeping the wallpaper in the 1st-floor hallway in good repair. Observations showed wallpaper lifting, curling, and missing patches, along with watermarks and unkept areas where pictures had been removed.
The facility failed to treat two residents with respect and dignity. One resident reported that staff would respond to the call bell but not return for several hours, making them feel ignored. Another resident, who required substantial assistance for movement due to extensive edema, reported that staff would take a long time to return, causing increased pain. The lack of timely assistance did not provide care in a dignified manner.
The facility failed to ensure that two residents were informed of their right to develop an advance health care directive (AHCD), were aided in doing so, and were periodically reassessed in their decision-making capacity. No AHCDs were found in the electronic health records, and repeated requests to the Social Services Director and the administrator yielded no documentation showing that the residents had been offered information on formulating an AHCD upon admission or during their stay.
A resident with left-sided hemiplegia and hemiparesis following a stroke was observed multiple times with her head bent uncomfortably to the right, without any supportive devices to assist in proper positioning. The care plan lacked interventions for proper body mechanics, and the Unit Manager was unaware of any ordered orthotic devices. This deficiency hindered the resident from reaching her highest practicable well-being and has the potential to affect all residents with ROM deficits.
A resident with a high risk for falls was observed ambulating with oversized slippers, which were not identified as a safety hazard by the facility. The resident's care plan mentioned the need for proper footwear but did not specify the importance of proper fit, and no assessment had been made regarding the oversized slippers.
A resident with multiple diagnoses, including Alzheimer's and a nearly healed pressure ulcer, continued to receive a routine fentanyl patch without thorough pain assessments. The nurse administered routine acetaminophen for the resident's pain complaint without evaluating the pain's source or using as-needed analgesics. Communication barriers and lack of documentation contributed to the deficiency, confirmed by the unit manager and director of nursing.
The facility failed to provide routine dental services for its residents, as evidenced by a resident who had not received any dental visits since admission. The Unit Manager confirmed that the facility dentist had not been providing services since COVID-19, and residents with dental emergencies were sent out to the dentist's office. This is contrary to the facility's Dental Services policy, which mandates annual inspections and various dental procedures.
Failure to Document and Resolve Resident Grievances per Policy
Penalty
Summary
The facility failed to maintain proper documentation of resident grievances as required by its own policy and federal regulations. Six sampled grievances were reviewed, and none met the documentation requirements for recording the grievance decision. The facility's policy designates the Administrator as the Grievance Official and outlines responsibilities for tracking, investigating, and issuing written decisions regarding grievances, as well as maintaining a grievance log for three years. However, the facility did not follow these procedures, and the required documentation was incomplete or missing for all reviewed grievances. Specific examples include incomplete Concern Forms for multiple grievances reported by two residents and a family member. For instance, one resident reported issues such as mold and water damage, insufficient CNA staffing during night shifts, and missing personal items. The forms lacked documentation of immediate actions taken, investigation, follow-up, or resolution, and did not indicate whether the resident was satisfied with the outcome. Another family member reported concerns about resident care, therapy communication, and food quality, but the forms again lacked documentation of satisfaction, follow-up, or final resolution. During interviews, the Administrator confirmed that the facility did not have a Social Services Director at the time and acknowledged that grievance documentation and the grievance log were not kept up to date. The Administrator stated that some follow-up actions were taken, such as referring maintenance issues and reviewing staffing schedules, but these actions were not documented as required. As a result, it was unclear what actions had been taken in response to grievances and whether residents or their representatives were satisfied with the outcomes.
Failure to Implement and Document Resident Repositioning for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement and document a consistent process for repositioning residents at risk for pressure ulcers. Three residents with significant mobility impairments and incontinence, who required assistance for bed mobility, did not have evidence of being repositioned according to their care plans. The care plans for these residents specified turning and repositioning per a rounding schedule, but there was no established schedule or documentation process for staff to follow. Record reviews showed sporadic and infrequent documentation of turning and repositioning in nursing progress notes, with large gaps between entries and no detailed information about the positions used or the frequency of repositioning. Certified Nurse Assistant (CNA) documentation was absent, and interviews revealed that CNAs were unclear about the rounding schedule and lacked a standardized method to record repositioning tasks. Observations confirmed that residents remained in the same position for extended periods during the survey. Interviews with staff, including a CNA and a Unit Manager, confirmed the absence of a formal process for documenting repositioning. The Unit Manager acknowledged that only nurses were documenting turning and positioning in progress notes, and that CNAs did not have a system in place to record these interventions. This lack of a structured process and documentation increased the risk of pressure ulcer development among residents requiring frequent repositioning.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of staff-to-resident abuse involving one resident. On the date of the alleged incident, the facility's staff schedule showed that four CNAs, including the alleged perpetrator, and two RNs were present on the unit. However, the investigation packet only included information obtained from the accused CNA. There was no documentation that other staff members working at the time, the resident's roommates, or other residents on the unit were interviewed. Additionally, there was no evidence that non-interviewable residents were assessed for signs and symptoms of abuse. During an interview, the Administrator confirmed that the investigation focused solely on the resident who made the allegation and did not include interviews with other potential witnesses or assessments of other residents. This approach was inconsistent with the facility's own policy, which requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegations, as well as providing complete and thorough documentation of the investigation.
Failure to Timely Update Care Plans with Physician-Ordered Interventions
Penalty
Summary
The facility failed to make timely revisions to the comprehensive care plans for two residents, resulting in staff not having all necessary information to address the residents' needs. For one resident, who had a history of chronic obstructive pulmonary disease, stroke, dysphasia, dementia, diabetes, and anemia, and was incontinent with a feeding tube, provider orders indicated the use of GERI sleeves on both arms to protect fragile skin. Despite documentation of open wounds on her arms due to scratching and an order for protective sleeves, the care plan was not updated to include this intervention. For another resident with Parkinson's disease, provider orders required the use of a Prevalon Boot on the right ankle/foot to prevent skin breakdown due to foot rotation causing pressure on the ankle. The care plan did not reflect this intervention, and during observation, the resident was found not wearing the boot, with a small area of redness noted on the ankle. The nurse confirmed the omission in the care plan and subsequently applied the boot. These omissions in care plan updates were identified through observation, interview, and medical record review.
Failure to Consistently Monitor and Record Vital Signs for Resident with COVID
Penalty
Summary
Nursing staff failed to consistently monitor and record all required vital signs for a female long-term resident diagnosed with COVID infection, despite physician orders to do so every shift. The resident, who had advanced dementia, breast cancer, Type 2 diabetes, major depressive disorder, hypertension, and dysphasia, was placed in isolation after her COVID diagnosis. Review of her medical records revealed that from the date of diagnosis through her transfer to the hospital, vital signs such as pulse, respiratory rate, and pulse oximetry were frequently omitted, with multiple days showing no documentation of these parameters. This incomplete monitoring occurred even after the resident's family expressed concern about her condition and changes in her level of consciousness. Progress notes indicated that after the family raised concerns, nursing staff administered a nebulizer treatment and documented some lung assessments, but did not perform a full set of vital signs or a thorough nursing assessment as would be standard practice. The Unit Manager confirmed during an interview that the expectation was for complete vital sign monitoring twice daily, and acknowledged that the records did not meet this standard. The lack of consistent and complete vital sign monitoring represented a failure to provide the standard of nursing care as required by the resident's condition and physician orders.
Failure to Designate a Registered Nurse as Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse as the Director of Nursing (DON) as required. During a staff interview, the Administrator confirmed that there was no DON currently in place and that the facility was in the process of searching for one. The Administrator also stated that the previous DON had left several months prior, and that other staff members were temporarily covering some of the DON's duties and responsibilities. Review of the facility assessment indicated that the facility's stated resources included a DON among the nursing staff, but this position was vacant at the time of the survey.
Lack of DON Participation in QAA Committee Meetings
Penalty
Summary
The facility failed to meet the requirement for the Quality Assessment and Assurance (QAA) Committee to include the Director of Nursing (DON) as a member and to have the DON participate in quarterly meetings. During a staff interview, the Administrator confirmed that there was no DON currently employed at the facility, as the previous DON had left several months prior. Other staff members were temporarily covering some of the DON's responsibilities, but the QAPI meeting minutes for the past two months showed no DON present. A review of the facility's assessment indicated that the DON is considered an essential part of the nursing services team, which is responsible for providing 24-hour nursing care. Despite this, the absence of a DON from the QAA Committee and related QAPI activities was documented, as the facility was still in the process of recruiting for the position. This lack of DON participation resulted in noncompliance with regulatory requirements for the QAA Committee's composition and function.
Failure to Properly Label and Date Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly label cooked and stored food in the kitchen, specifically noting a container of cooked white rice in a refrigerator that lacked a label identifying the food item, preparation date, or discard date. The dietary staff member confirmed the rice was prepared that morning and acknowledged that a label with the current date and discard date should have been created. Additionally, in the dry food storage room, multiple unopened bottles of Browning and Seasoning Sauce were found, with two bottles missing the yellow cap that displays the best-by-date. The dietary staff member was unable to determine why these bottles lacked caps and subsequently removed them from storage. Review of the facility's food safety policy confirmed requirements for labeling, dating, and monitoring refrigerated food, including leftovers, to ensure proper use or disposal.
Resident Dignity Compromised by Staff Communication Practices
Penalty
Summary
A deficiency was identified when a resident reported feeling that their right to a dignified existence was violated due to staff members frequently speaking in their native language, which was not English, in the resident's presence. The resident expressed feeling that staff were talking about them, leading to discomfort and a perceived lack of respect and dignity. Review of the facility's policy confirmed that residents are to be informed of their rights in a language they understand and are entitled to a dignified existence, self-determination, and communication. The incident involved one resident and was based on direct resident interview and policy review.
Resident Restrained During Personal Care for Staff Convenience
Penalty
Summary
A Certified Nurse Aide (CNA) wrapped a resident's hands with the lower portion of the resident's gown during personal care after the resident resisted care by pushing down with her hands. This action was taken so the CNA could finish changing the resident's incontinence brief. The CNA confirmed during an interview that the hand wrapping was tight and was done for the purpose of completing care. The facility's policy states that residents have the right to be free from any physical restraint imposed for staff convenience and not required to treat medical symptoms. The incident was identified during a Facility Reported Incident (FRI) investigation and confirmed through interviews and record review.
Failure to Provide Adequate Supervision for Elopement Risk Resident
Penalty
Summary
A deficiency occurred when a resident identified as an elopement risk was not provided with adequate supervision, resulting in the resident leaving the facility without authorization. The resident had a history of medical and cognitive conditions, including pyogenic arthritis, muscle weakness, difficulty walking, anxiety, depression, and a cognitive communication deficit. Upon admission, the resident expressed a desire to go home and was noted to wander the hallways but was generally redirectable. On the day of the incident, the resident attempted to elope multiple times, expressing the intent to leave and return home. Despite these behaviors, supervision was inconsistent. The Social Services Director observed the resident in the lobby but was not specifically assigned to provide one-on-one supervision. The receptionist was asked to monitor the resident but was unable to do so continuously due to other duties. After the first elopement attempt, one-on-one supervision was not implemented, and staff were unclear about who was responsible for monitoring the resident. The Central Supply Coordinator spoke with the resident but was not officially tasked with supervision. Multiple staff interviews confirmed that close supervision was not consistently provided, and there was confusion regarding who was responsible for monitoring the resident after the initial elopement attempt. The resident ultimately exited the facility by following a visitor out the main entrance and proceeded to walk up a busy street, crossing without regard for safety. The Social Services Director and transport driver attempted to intervene, but the resident continued to walk unsafely in the community until the administrator was notified and able to redirect the resident back to the facility. Facility policy required adequate supervision for residents at risk of elopement, but this was not effectively implemented in this case.
Failure to Provide Clean Cloth Napkins with Meal Trays
Penalty
Summary
The facility failed to maintain a clean environment as evidenced by multiple observations and interviews regarding stained and soiled cloth napkins provided with meal trays. During a family interview, concerns were raised about numerous stains and spots on the cloth napkins accompanying meal trays. Subsequent observation of breakfast trays confirmed the presence of several napkins with spot and smudge stains. The Dietary Manager, upon review of the stored cloth napkins, acknowledged that several napkins had spots and stains as described. Review of the facility's policy indicated that maintaining a sanitary environment includes keeping resident care equipment, such as items used in daily living activities, clean and properly stored.
Staff Lacked Proper Hands-On CPR Training
Penalty
Summary
Three staff members, including a registered nurse and two certified nurse aides, were found to have completed CPR training through an online course that did not include hands-on practice or an in-person skills assessment. Documentation reviewed confirmed that the training lacked these essential components, which are required for proper basic life support (BLS) competency according to accepted professional guidelines. During interviews, the facility administrator acknowledged there was no written policy outlining CPR training requirements. The administrator also stated that, after consulting with the Infection Preventionist, it was clarified that BLS is required for licensed nurses. One of the staff members confirmed that her CPR training did not include any hands-on or in-person skills assessment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the second-floor hallway was observed left unlocked and unattended, with two staff members passing by the cart before a registered nurse returned and secured it. The registered nurse confirmed that the cart should have been locked when unattended. The unit manager also confirmed that unattended medication carts are required to be locked and secured. Review of the facility's policy on medication storage, revised on 06/01/23, documented that all drugs and biologicals must be stored in locked compartments, including medication carts, cabinets, drawers, refrigerators, and medication rooms.
Wound Care Performed Prior to Incontinence Cleaning
Penalty
Summary
During wound care rounds, a resident was observed with a bowel movement on her buttocks, which extended to the bottom edge of her sacral dressing. The physician assistant removed the dressing and assessed the wound before the resident's incontinence was cleaned and before a clean brief was placed under her. The certified nurse aide cleaned the bowel movement only after the wound assessment was completed. Interviews with the infection preventionist, unit manager, and certified nurse aide confirmed that the resident should have been cleaned of incontinence prior to any wound care or assessment to maintain infection control standards.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility did not ensure the development and implementation of comprehensive person-centered care plans for three residents, leading to a risk of decline in their quality of life. For one resident, despite identifying positioning and mobility needs, the facility failed to develop a care plan to address these needs effectively. Another resident expressed a desire to mobilize more with a Hemi-Walker, but the care plan lacked the frequency of occurrence for this intervention. The MDS staff confirmed that the care plans were generalized and not individualized, which contributed to the deficiency. Additionally, a third resident required substantial assistance for movement due to extensive edema in both lower and upper extremities. The care plans in place for this resident did not specify the required amount of assistance needed for various movements, such as moving from lying to sitting and vice versa. The MDS staff member verified that the care plans were generalized and not individualized, failing to address the specific needs of the resident. These deficiencies highlight the facility's failure to develop and implement individualized care plans, placing residents at risk for a decline in their quality of life.
Failure to Maintain Environment in Good Repair
Penalty
Summary
The facility failed to provide a comfortable environment for residents, staff, and the public by not maintaining the environment in good repair. Observations made from January 23, 2024, to January 26, 2024, revealed that the wallpaper on the upper half of the walls in the hallway of the 1st floor was lifting off in several areas and curling over. Outside of room [ROOM NUMBER], a patch of wallpaper approximately 12 x 18 inches was missing, appearing to have been torn off. On the opposite wall, a picture had been removed, leaving an area significantly lighter in color than the rest of the wallpaper, giving an unkept appearance. Additionally, watermarks were apparent on several areas of the wallpapered hallway on the 1st floor unit. These conditions contributed to an environment that was unkept and not conducive to a homelike atmosphere.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to treat two residents, R9 and R139, with respect and dignity. Resident R68 reported that staff would respond to the call bell and promise to return but would not come back for several hours, making the resident feel ignored. Similarly, R9 stated that staff would acknowledge the call bell but take several hours to return, ignore requests to speak to the doctor, and speak to each other in a language other than English, making the resident feel as if they were being talked about. The facility's policy on Resident Rights emphasizes the importance of a dignified existence, self-determination, and communication, which was not upheld in these instances. Resident R139, who required substantial assistance for movement due to extensive edema of both lower and upper extremities, reported that staff would acknowledge the call bell and state they would return soon but would often take a long time, sometimes up to 40 minutes. This delay in assistance caused increased pain for R139, who was tearful during the interview while relaying this information. The lack of timely assistance did not provide care for these residents in a dignified manner, as required by the facility's policy on Resident Rights.
Failure to Inform and Assist Residents with Advance Health Care Directives
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 33 and 55, were informed of their right to develop an advance health care directive (AHCD), were aided in doing so, and were periodically reassessed in their decision-making capacity. For Resident 33, admitted in August 2023, no AHCD was found in the electronic health record (EHR), and the Social Services Director (SSD) confirmed the absence of documentation indicating that the resident had been offered assistance in creating one. Similarly, for Resident 55, no AHCD was found in the EHR, and repeated requests to the SSD and the administrator yielded no documentation showing that the resident had been offered information on formulating an AHCD upon admission or during their stay. This deficiency places residents at risk of not having their healthcare wishes honored should they become incapacitated.
Failure to Provide Appropriate ROM Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment, equipment, and services to maintain or improve the range of motion (ROM) of her neck and head. The resident, a [AGE] year-old female with diagnoses including left-sided hemiplegia and hemiparesis following a stroke, was observed multiple times with her head bent heavily and uncomfortably to the right. Despite being completely dependent on staff for positioning, there were no interventions addressing proper body mechanics or positioning in her care plan. Observations over several days showed the resident in bed with her head misaligned, without any supportive devices like pillows, neck rolls, or braces to assist in positioning her head correctly. On one occasion, a wedge pillow under her right shoulder further exacerbated her discomfort, causing her to moan in her sleep. An interview with the Unit Manager (UM) revealed that the UM was unaware of any neck braces or orthotic devices ordered to assist in positioning the resident's head. The UM also confirmed that the resident appeared uncomfortable with her head misaligned with her shoulders and body. The lack of appropriate interventions and equipment to maintain or improve the resident's ROM led to the resident being hindered from reaching her highest practicable well-being. This deficiency has the potential to affect all residents at the facility with ROM deficits.
Failure to Address Oversized Footwear as a Fall Risk
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards, specifically regarding the use of oversized slippers. Resident 52, a [AGE] year-old female with a history of dementia, difficulty in walking, syncope, and restlessness, was observed ambulating with slippers that were too large for her feet. Despite being identified as a high risk for falls, the facility did not recognize the oversized slippers as a potential hazard until it was pointed out by the State Agency. The resident's electronic health record did not document any discussion about the risks versus benefits of using the oversized slippers for ambulation. During an interview, the Unit Manager confirmed that the oversized slippers were a safety hazard and that they were provided by the resident's family. The resident loved her slippers and refused to wear non-slip socks, always opting for the oversized slippers when walking. The Unit Manager also confirmed that the oversized slippers had not been previously identified as a safety hazard and were not included in the resident's care plan. The care plan did mention the need for proper well-maintained footwear but did not specify what proper footwear would entail, such as proper fit, which had not been assessed before.
Failure to Ensure Nurse Competency in Pain Assessment
Penalty
Summary
The facility failed to ensure nurse competency in pain assessment for a resident, leading to the continued use of a narcotic with a high risk of addiction and dependence. The resident, a [AGE] year-old female with diagnoses including Alzheimer's disease, muscle weakness, an almost healed sacral pressure ulcer, and severe protein-calorie malnutrition, was found to be on a routine fentanyl patch. During morning rounds, the resident complained of pain in her feet, but the nurse only administered routine acetaminophen without conducting a thorough pain assessment or using as-needed analgesics. The nurse was uncertain about the location, source, or character of the resident's pain and did not document any pain assessments in the electronic health record (EHR). The unit manager and director of nursing confirmed that there was no clear documentation of the resident's pain, and a more thorough pain assessment was needed to determine if the routine fentanyl order was still necessary. The resident's primary language is Cantonese, and communication barriers may have contributed to the inadequate pain assessment. The nurse did not assess the resident's feet or legs when she complained of pain and relied on routine medication without evaluating the effectiveness or necessity of the narcotic. The unit manager believed the fentanyl order was a carryover from when the resident was on hospice care for a pressure ulcer, which was almost healed. The director of nursing confirmed that nurses are expected to conduct thorough pain assessments when administering any pain medication, whether routine or as needed. This deficiency placed the resident at risk for avoidable addiction and dependence on fentanyl, as well as other adverse effects of the medication.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for its residents, as evidenced by the case of a female resident who had not received any routine dental visits since her admission. During an interview, the resident's family representative reported the lack of dental care. A review of the resident's electronic health record confirmed the absence of any dental visits or exams. The Unit Manager admitted that the facility dentist had not provided routine or emergency dental services since the onset of COVID-19, and residents with dental emergencies were sent out to the dentist's office. The facility's Dental Services policy mandates annual inspections and various dental procedures, which were not being followed.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 177 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kuakini Geriatric Care, Inc | 0.1 mi | ★★★★★ | 0 | 0 |
| Maluhia | 0.4 mi | ★★★★★ | 0 | 0 |
| The Care Center Of Honolulu | 0.6 mi | ★★★★★ | 16 | 0 |
| 15 Craigside | 0.6 mi | ★★★★★ | 0 | 0 |
| The Ching Villas | 0.7 mi | ★★★★★ | 13 | 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.