Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Maluhia during CMS and state inspections, most recent first.
The facility did not update care plans for two residents: one with self-inflicted skin abrasions lacked interventions for scratching, and another with a gastrostomy tube did not have care plan interventions to prevent tube removal, despite repeated incidents and physician orders.
A resident with a known severe nut allergy was served a dessert containing nuts due to the facility's failure to document the allergy's severity, develop an appropriate care plan, and ensure kitchen staff reviewed recipes for allergens. This led to the resident experiencing an anaphylactic reaction and requiring emergency treatment.
A resident's allegation of abuse by a CNA was not fully investigated or reported to the State Agency within the required five-day period. Although the initial report was submitted and the CNA was placed on leave, the facility did not complete the investigation or submit the final report as mandated by policy and regulation.
A resident with documented anaphylactic allergies to mayonnaise and other foods was served a salad containing mayonnaise, despite clear instructions on the meal ticket and a recent severe allergic reaction to nuts. Staff failed to properly check the allergy-indicated meal ticket before serving, and the required verification process was not followed.
A resident with Alzheimer's and hemiplegia was placed in a reclined Geri-chair without proper restraint assessment, despite attempts to get up and lack of constant supervision. Staff acknowledged the chair's use as a restraint due to insufficient staffing for one-on-one supervision. The facility failed to conduct a required assessment for the Geri-chair, contrary to its policy.
A resident's injury progressed from MASD to a stage 3 PU, but the facility failed to update the electronic health record (EHR) and the Discharge Assessment submitted to CMS. The NP had documented the progression, but the facility's records continued to list the injury as MASD, leading to inaccurate documentation of the resident's condition.
A resident who suffered a stroke and lost control of his right side was not provided with a comprehensive care plan that included the use of a reclined Geri-chair for supervision to prevent falls. The resident was found on the floor multiple times due to restlessness and a desire to go home, and the Geri-chair was not assessed as a restraint in the care plan. Staff were unable to provide constant supervision, leading to repeated falls.
A cognitively intact resident was not invited to her care planning meeting, despite the facility's guidelines requiring resident participation. The resident was unaware of the meeting and expressed willingness to attend if informed. Her EHR showed a meeting occurred without her presence, and the social worker did not recall inviting her.
The facility failed to store and handle food according to professional standards. An opened container of salad dressing lacked proper labeling, and a scooper was improperly stored in a bin with oatmeal. Additionally, a staff member did not wash hands before food preparation after handling other items. The facility's policies require food protection from contamination and hand hygiene before food preparation.
A facility failed to update a resident's EHR to reflect the progression of a skin injury from MASD to a stage 3 PU. Despite evidence from pictures and an NP assessment indicating the progression, the EHR and other documentation continued to list the injury as MASD. Interviews with staff revealed that the EHR system did not allow for a direct update, and a team meeting confirmed the injury's progression, but documentation remained inaccurate.
A facility failed to ensure proper hand hygiene during medication administration. An RN was observed preparing and administering medications to a resident without performing hand hygiene, despite handling various items and acknowledging the requirement to do so. The DON confirmed the RN's actions were against the facility's hand hygiene policy.
Failure to Revise Care Plans for Skin Integrity and GT Management
Penalty
Summary
The facility failed to revise and update care plans for two residents following changes in their conditions and needs. For one resident with a history of self-inflicted scratches and a facility-acquired abrasion to the sacrum, the care plan did not include interventions or treatments to address her self-scratching behavior, despite documentation in the electronic health record and physician's orders for topical treatments and protective measures. Observations and interviews confirmed that staff were aware of the resident's tendency to scratch and the need for regular nail trimming, but these interventions were not reflected in the care plan. For another resident with a gastrostomy tube (GT) and diagnoses including stroke and dementia, the care plan did not include interventions to prevent the resident from pulling out the GT, even though there were multiple documented incidents of the tube being pulled out and specific physician's orders for interventions such as pain assessment, redirection, and one-on-one supervision. Staff acknowledged that these interventions should have been included in the comprehensive care plan but were not at the time of the survey.
Failure to Document and Manage Severe Nut Allergy Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to document the severity of a resident's nut allergy, failed to develop and implement a care plan addressing the allergy, and did not ensure that all recipes used in the kitchen were reviewed for food allergens before serving food to residents. The resident, who had a documented history of severe nut allergy, was admitted with multiple diagnoses including asthma and dysphasia, and was cognitively intact. Despite the resident and her family providing information about her nut allergy and its severity, this information was not fully documented in the electronic health record or communicated to the interdisciplinary team. The facility's admission and care planning processes did not include specific details about the resident's allergic reactions, nor were food restrictions related to her allergies included in her orders or care plan. The dietician noted the allergy in personal notes but did not share this information in the resident's chart or with the interdisciplinary team. The kitchen staff were unaware of the resident's nut allergy and continued to use a recipe containing nuts, as the recipe was not included in the template reviewed for allergens. As a result, the resident was served a dessert containing nuts, which led to an anaphylactic reaction. Following the consumption of the dessert, the resident experienced symptoms including periorbital swelling, itching, and oxygen desaturation, requiring administration of Benadryl and oxygen, and subsequent transfer to the emergency room for treatment of anaphylactic shock. Interviews with facility staff revealed that allergies were not routinely included in baseline care plans, and staff relied on discharge summaries rather than direct interviews with residents to determine allergy severity and reactions. The lack of communication and documentation directly contributed to the resident being exposed to a known allergen, resulting in harm.
Failure to Timely Report Results of Abuse Investigation
Penalty
Summary
The facility failed to report the results of an allegation of staff-to-resident abuse within five working days to the State Agency, as required by regulation. The incident involved a resident who expressed emotional distress and dissatisfaction with the care provided by a CNA, as reported by the resident's daughter to the head nurse. The resident was described as emotional and crying, stating concerns about how he was treated and expressing a desire to go home if the situation did not improve. The head nurse documented the resident's account, which included the CNA not providing her name and appearing angry while assisting the resident. Despite the initial event report being submitted to the State Agency, the facility administrator confirmed that the investigation into the CNA's conduct had not been completed, and the final report had not been sent to the Office of Health Care Assurance within the required five-day timeframe. The administrator stated that the investigation was pending due to reliance on a third-party law firm, which had not yet conducted interviews or completed the investigation, even though more than two months had passed since the incident. This delay was in direct violation of both facility policy and federal regulations regarding timely reporting and investigation of abuse allegations.
Failure to Prevent Serving Allergen-Containing Food to Resident with Documented Anaphylactic Allergies
Penalty
Summary
The facility failed to ensure that a resident with documented anaphylactic allergies was not served food containing allergens. Specifically, a resident with known allergies to mayonnaise, salad dressing, mustard, nuts, and teriyaki sauce, and a history of prior anaphylactic reactions, was served a salad with mayonnaise on her lunch tray. This occurred after a recent incident in which the same resident experienced an anaphylactic reaction to nuts, requiring emergency room treatment. The facility was aware of the resident's nut allergy but did not document the severity, develop or implement a care plan for the nut allergy, or ensure that all kitchen recipes were reviewed for food allergies before serving food to residents. On the day of the incident, the resident noticed the presence of mayonnaise on her salad and reported her concern to a CNA. The meal ticket for the resident clearly indicated an allergy to mayonnaise and specified that the salad should be served plain, with no dressing or mayonnaise. Despite this, the meal was not properly checked against the ticket before being served. Staff interviews confirmed that the process for checking meal tickets, especially those marked with yellow to indicate allergies, was not followed as required. The facility's policy required both dietary and nursing staff to verify meal tickets for allergies before serving food, but this protocol was not adhered to in this case.
Inappropriate Use of Geri-chair as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required for medical treatment. The deficiency involved a resident with Alzheimer's disease, dementia, weakness, and hemiplegia affecting the right side, who was placed in a reclined Geri-chair. The resident was observed attempting to move the chair or get up, indicating that the chair was being used as a restraint without proper assessment. Staff members acknowledged the resident's attempts to stand and the lack of constant supervision to prevent falls. Observations revealed that the resident was often left in the reclined Geri-chair in the hallway, sometimes without direct care staff present. The resident was seen trying to signal for assistance and attempting to move the chair, which was not assessed as a restraint. Interviews with CNAs indicated that the resident preferred the chair reclined but would try to get out when it was not reclined, posing a risk of falling. The CNAs admitted they could not provide constant supervision due to other responsibilities. The facility's Director of Nursing confirmed that a restraint assessment for the Geri-chair had not been conducted, despite the resident's attempts to get up and stand. The facility's policy required a three-day assessment period for new devices to determine the necessity of restraints, but this was not followed. The resident's informed consent for the use of physical restraints mentioned the Geri-chair, yet the facility did not have adequate staffing for one-on-one supervision, leading to the inappropriate use of the chair as a restraint.
Failure to Accurately Document Progression of Resident's Skin Injury
Penalty
Summary
The facility staff failed to accurately document a resident's facility-acquired injury, which progressed from Moisture-Associated Skin Damage (MASD) on the right gluteus to a stage 3 Pressure Ulcer (PU) on the coccyx. This deficiency was identified during a review of the resident's Discharge Assessment submitted to CMS, which did not reflect the correct status of the resident's skin injury. The Minimum Data Set (MDS) coordinator indicated that nurses on the unit are responsible for staging skin injuries, but the documentation did not reflect the progression of the injury as identified by the resident's Nurse Practitioner (NP). Interviews with the Head Nurse and the Director of Nursing (DON) revealed that the team had met and agreed that the injury had progressed to a stage 3 PU, but this change was not updated in the resident's electronic health record (EHR). The NP had documented the progression of the injury, and this documentation was provided to the facility, but the facility's records continued to list the injury as MASD. The Discharge Assessment submitted to CMS incorrectly indicated that the resident did not have an unhealed pressure ulcer at stage 1 or higher, which was inconsistent with the NP's assessment.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who had suffered a stroke and lost control of the right side of his body. This resident, identified as R68, was not adequately assessed for the use of a reclined Geri-chair as a restraint, despite his tendency to forget his physical limitations and attempt to stand or move. The care plan did not include the intervention of placing the resident in a reclined Geri-chair in a visible area for close supervision to prevent falls when he was restless and expressing a desire to go home. The deficiency was highlighted by two incidents where the resident was found on the floor next to his bed, with documentation indicating that his restlessness and verbalization of wanting to go home were factors influencing these incidents. Interviews with the resident's representative and the Director of Nursing confirmed that the Geri-chair was not included in the care plan, and staff expressed their inability to provide constant supervision to prevent falls. This oversight in care planning contributed to the resident's repeated falls and the facility's failure to ensure the resident was free from physical restraints imposed for convenience rather than medical necessity.
Resident Not Invited to Care Planning Meeting
Penalty
Summary
The facility failed to invite a cognitively intact resident to participate in her care planning meeting, which is a requirement according to the facility's Comprehensive Care Plan Guideline. The resident, a [AGE] year-old female, was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. During an interview, the resident expressed that she was unaware of any care planning meetings about her and would have attended if informed. A review of her Electronic Health Record (EHR) showed a care plan meeting was held, but the resident was not listed as an attendee, although her son was. The social worker involved did not recall inviting the resident to the meeting.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. During an initial tour of the kitchen, a large container of French salad dressing was found opened and used without an open/preparation date or a use-by-date. This was confirmed by a staff member, who acknowledged that the dressing should have been labeled. Additionally, a scooper was found at the bottom of a plastic container bin with oatmeal, which had oatmeal residue and unidentified debris. The staff member confirmed that the scooper should be hung and not in contact with the bottom of the bin. Further observations revealed a staff member answering the phone, then putting on gloves and a mask without washing hands before returning to food preparation. When questioned, the staff member admitted to not washing hands before donning gloves. An interview with the facility's dietician confirmed that handwashing is required before food preparation to prevent foodborne illnesses. The facility's policies on food preparation and hand hygiene were reviewed, indicating that food should be protected from contamination and that hand hygiene is necessary before preparing or serving food.
Failure to Update Resident's EHR for Skin Injury Progression
Penalty
Summary
The facility failed to update a resident's electronic health record (EHR) to accurately reflect the progression of a skin injury from Moisture-Associated Skin Damage (MASD) to a stage 3 Pressure Ulcer (PU). The resident, identified as R6, had a newly acquired MASD documented in his skin assessment. However, weekly skin assessments and progress notes from March to June continued to document the injury as MASD, despite evidence from pictures and an outside Nurse Practitioner (NP) assessment indicating it had progressed to a stage 3 PU. The NP's documentation, which was faxed to the facility, noted the injury had worsened with pressure. Interviews with facility staff, including the Minimum Data Set (MDS) coordinator and Head Nurse (HN), revealed that the nurses on the unit were responsible for staging the injuries. The HN acknowledged the injury as a stage 3 PU and explained that the EHR system did not allow for a direct update from MASD to PU, requiring the MASD to be resolved first. Despite a team meeting where the injury's progression was discussed and agreed upon, the EHR and other documentation, such as the care plan and doctor's orders, continued to inaccurately reflect the injury as MASD.
Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene procedures were followed by a staff member during medication administration. During an observation, a Registered Nurse (RN) was seen preparing medications for a resident without performing hand hygiene at any point during the process. The RN handled various items, including a telephone and a refrigerator, and mixed a laxative with cranberry juice before administering the medications to the resident. When questioned, the RN acknowledged that hand hygiene should have been performed prior to administering the medications. The Director of Nursing confirmed that the RN should have adhered to the facility's hand hygiene policy, which requires hand hygiene before administering medications.
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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 | 0.4 mi | ★★★★★ | 0 | 0 |
| Kuakini Geriatric Care, Inc | 0.5 mi | ★★★★★ | 0 | 0 |
| The Ching Villas | 0.6 mi | ★★★★★ | 13 | 0 |
| Nuuanu Hale | 0.7 mi | ★★★★★ | 26 | 0 |
| The Care Center Of Honolulu | 0.8 mi | ★★★★★ | 16 | 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.