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 Maunalani Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident dependent on staff for transfers was injured when two staff members, including one not fully trained, operated a mechanical lift and failed to ensure proper sling strap placement, resulting in a fall and serious injuries. In a separate incident, another resident with dysphagia and a physician order for suctioning was found with a suction machine at the bedside that was not fully set up, leaving her at risk in the event of a respiratory emergency.
A resident with complex medical conditions and a high fall risk fell during a physical therapy session due to inadequate supervision, resulting in a head injury. The PTA was positioned too far from the resident and was working alone, contrary to facility policy. The facility's investigation was insufficient, lacking a thorough root cause analysis and specific preventive measures.
The facility failed to complete appropriate discharge summaries for two residents transferred to the hospital and not returning. One resident's summary was completed late and lacked a date, while the other resident's summary was inadequate and inaccurate, failing to reflect his medical condition and therapy needs.
A resident with a history of stroke and other medical conditions experienced a change in consciousness, but the facility failed to recognize the seriousness of her condition, delaying emergency transport. She was later hospitalized for sepsis due to a UTI. Additionally, the facility did not develop a comprehensive care plan for her multiple skin tears, failing to update interventions to prevent further occurrences.
A physician's documentation for a resident in a skilled nursing facility was found to be inaccurate and incomplete. The resident, with a history of diabetes and end-stage renal disease, was admitted for short-term care following an amputation. The physician's note incorrectly documented the presence of dorsalis pedis pulses and stated the resident was there for long-term care. Additionally, the note failed to address the resident's behavioral issues and cognitive status, as well as progress in maintaining or improving well-being.
Two residents experienced deficiencies in care, including inadequate showering and delayed response to call bells. One resident's family noted issues with bathing frequency and lack of follow-up on medications, while another resident had to return to bed unassisted after using the bathroom. The DON acknowledged these concerns.
A facility failed to accurately assess a resident with two pressure ulcers acquired in the facility. The resident's assessment incorrectly coded a stage three pressure injury as present on admission, potentially affecting the care plan and treatment outcomes. The resident, who is cognitively intact but has impairments in bilateral upper and lower extremities and is dependent on staff for self-care and mobility, was incorrectly coded in the MDS. The DON confirmed the pressure ulcers were facility-acquired and acknowledged the need for updating the MDS coding.
A resident developed two stage three pressure ulcers due to the facility's failure to adhere to repositioning protocols. Despite orders to turn and reposition the resident every 1-2 hours and limit sitting time, observations showed the resident frequently lying on her back. The ulcers, acquired after admission, progressed to stage three, with the facility's policy on pressure injury management not being followed.
Failure to Prevent Accidents During Mechanical Lift Transfer and Inadequate Emergency Equipment Setup
Penalty
Summary
A deficiency occurred when a resident who was dependent for transfers was being moved using a mechanical lift by two staff members, one of whom was not fully trained or authorized to operate the lift. During the transfer, the sling straps on the left side slipped off the hanger bar as the resident was being lifted, resulting in the resident falling and sustaining left-sided rib fractures and a pneumothorax, which required hospitalization and chest tube placement. The staff involved included a CNA who was orienting and not permitted to provide care, and another CNA who was responsible for the transfer. The facility's policy required two trained staff for mechanical lift transfers, but documentation confirmed that the orienting aide had not completed the required training checklist. Interviews and vendor inspection determined that the lift was functioning properly and that the incident was due to user error, specifically improper attention to strap placement and monitoring during the lift. Another deficiency was identified when a resident with a history of stroke, gastrostomy, and dysphagia was observed in bed with a suction machine at the bedside that was not fully set up. The machine was missing essential components, including the suction canister, tubing, and yankauer, despite a physician order for suctioning as needed for oral secretions. The nurse on duty confirmed that the suction equipment was not ready for use and acknowledged its importance in preventing accidents, especially given the resident's risk for respiratory emergencies due to her medical condition and NPO (nothing by mouth) status. Both deficiencies were substantiated through interviews, record reviews, and direct observation. The first involved a failure to ensure that only trained staff operated mechanical lifts, leading to a serious resident injury. The second involved a failure to provide care consistent with physician orders, leaving a resident at risk in the event of a respiratory emergency due to incomplete setup of emergency equipment.
Inadequate Supervision During Physical Therapy Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to a resident during a physical therapy session, resulting in a fall that caused significant harm. The resident, who had a history of diabetes, hypertension, end-stage renal disease, and recent right above-knee amputation, was receiving physical therapy in the gym. During the session, the resident attempted to propel himself to the parallel bars, causing his wheelchair to tip backward, leading to a fall and a head injury. The resident was initially assessed as alert and oriented but later showed signs of confusion and increased pain, prompting an emergency response. The investigation into the incident revealed several deficiencies in the facility's supervision and response protocols. The physical therapy assistant (PTA) was positioned six feet away from the resident during the incident, which was not adequate to prevent the fall. The PTA was also working alone in the gym, which is against the facility's policy of having more than one staff member present. Additionally, the resident's care plan indicated a high risk of falls, requiring substantial assistance during transfers, which was not adequately provided during the therapy session. The facility's response to the incident was also found lacking. There was a delay in calling emergency services, and the investigation into the fall did not include a thorough root cause analysis or identify specific opportunities for improvement. The Director of Nursing and the Director of Rehabilitation did not document any changes or actions taken to prevent similar incidents in the future. Furthermore, the PTA involved had not received a proper orientation specific to the facility, which may have contributed to the inadequate supervision during the therapy session.
Inadequate Discharge Summaries for Hospitalized Residents
Penalty
Summary
The facility failed to ensure appropriate discharge summaries were completed for two residents who were transferred to the hospital for a higher level of care and subsequently did not return to the facility. For the first resident, a female with a history of stroke, hypertension, atrial fibrillation, and mild dementia, the discharge summary was not completed prior to the survey. The resident was transferred to the hospital due to a change in mental status, and her family later informed the facility that she would not be returning. The discharge summary was only completed after the surveyor's inquiry, and it lacked a date. The second resident, a male with diabetes, hypertension, and end-stage renal disease, was transferred to the hospital after a fall and a change in consciousness. His discharge summary was inadequate, as it was a preprinted form that did not accurately reflect his medical condition or the reasons for his physical and occupational therapy needs. Additionally, the summary incorrectly listed dementia as a current problem, which was not part of his diagnosis. The facility did not complete an additional discharge summary after being informed that the resident would not return.
Failure to Recognize Serious Condition and Inadequate Care Planning
Penalty
Summary
The facility failed to recognize the seriousness of a resident's condition, leading to a delay in appropriate medical intervention. The resident, who had a history of stroke, hypertension, atrial fibrillation, and mild dementia, exhibited a change in level of consciousness over two consecutive days. Despite these changes, the nursing staff did not consider the condition serious enough to warrant immediate hospital transport by EMS. Instead, they opted for non-emergency transport, which was not timely, and the family had to call 911 themselves. The resident was eventually hospitalized for sepsis due to a urinary tract infection, which was identified as the cause of her altered mental status. The facility's inaction in promptly addressing the resident's symptoms and the decision to delay emergency transport contributed to the severity of the situation. The nursing staff's failure to repeat blood pressure measurements and their reliance on non-emergency transport options, despite the family's concerns, were significant factors in the deficiency. Additionally, the facility did not develop a comprehensive care plan for the resident's multiple skin tears. The care plans were not updated to reflect new skin tears or to include interventions to prevent further occurrences. This oversight in care planning and documentation further highlights the facility's deficiencies in providing adequate care and monitoring for the resident's condition.
Inaccurate Physician Documentation for Resident Care
Penalty
Summary
A deficiency was identified in the documentation of a physician's visit for a resident at a skilled nursing facility. The resident, a male with a history of diabetes, hypertension, anemia of chronic renal failure, and end-stage renal disease, was admitted for short-term care following a hospitalization for sepsis and an above-the-knee amputation. The physician's progress note dated 09/20/2024 inaccurately documented the presence of dorsalis pedis pulses, which was not possible due to the resident's amputation. Additionally, the note incorrectly stated that the resident was at the facility for long-term care, whereas the plan was for short-term care with discharge to home. The physician's documentation failed to accurately reflect the resident's condition and total plan of care. It did not address the resident's behavioral issues, cognitive status, or progress in maintaining or improving physical, mental, and psychosocial well-being. The report highlighted that there was no documentation regarding the resident's agitation, refusal of care, or sleep issues, which were noted in the nursing notes. This lack of accurate and comprehensive documentation by the physician did not meet regulatory requirements for resident care review and progress notes.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to provide care with respect and dignity to two residents, resulting in a deficiency in maintaining or enhancing their quality of life. One resident's family expressed concerns about inadequate showering, as the resident was not being bathed three times a week as ordered, and they noticed dirt or fecal matter on the resident's hands or fingernails after supposed showering. Additionally, there was a lack of follow-up from the physician regarding medications for low blood pressure, and during activities, staff spoke loudly, which frightened the resident. The resident had a medical history of cerebral infarction, difficulty walking, muscle weakness, hypertension, and high cholesterol, with a care plan that included bed baths or showers three times a week. Another resident reported that staff took a long time to respond to the call bell and did not return to assist them back to bed after using the bathroom. The resident, who had undergone post-knee joint replacement surgery and required substantial to maximum assistance during toileting transfers and hygiene, had to return to bed without assistance. The Director of Nursing acknowledged these care concerns and stated that the facility was aware of some of the issues and would continue to work with the residents to resolve them.
Inaccurate Assessment of Facility-Acquired Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess a resident who had two pressure ulcers acquired in the facility. The resident's assessment incorrectly coded a stage three pressure injury as present on admission, which could potentially affect the care plan, goals, and treatment outcomes for the resident. The Minimum Data Set (MDS) Annual assessment initially indicated that the resident did not have any unhealed pressure ulcers. However, a subsequent MDS change of status assessment revealed a stage three pressure ulcer coded as present on admission. Further review of the MDS quarterly assessment showed the resident, who is cognitively intact but has impairments in bilateral upper and lower extremities and is dependent on staff for self-care and mobility, was still coded with a stage three pressure ulcer as present on admission. An interview with the Director of Nursing confirmed that the pressure ulcers were facility-acquired and acknowledged the incorrect coding in the MDS, which needs updating.
Failure to Prevent Stage Three Pressure Ulcers
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent the development of two stage three pressure ulcers in a resident. The resident, an elderly female with neurological conditions and coronary artery disease, was readmitted to the facility after a hospital discharge. Upon readmission, she developed a stage three pressure ulcer on her right buttock, which was not present on admission. The facility's staff did not adhere to the care plan orders to turn and reposition the resident every 1-2 hours, and to limit her sitting time to no longer than 30 minutes. Observations showed the resident frequently lying on her back with the head of the bed elevated, indicating a lack of adherence to repositioning protocols. Interviews and record reviews revealed that the resident's pressure ulcers were acquired in the facility after her admission, with the left buttock ulcer progressing from moisture-associated skin damage to a stage three ulcer, and the right buttock ulcer also reaching stage three. The Licensed Practical Nurse confirmed that the resident was only repositioned every two hours and was only mobilized for 30 minutes during weekly Bingo activities. The Director of Nursing verified that the pressure ulcers were facility-acquired and acknowledged the need to update the Minimum Data Set to reflect the presence of two stage three pressure ulcers. The facility's policy on pressure injury management emphasized minimizing pressure and repositioning residents frequently, which was not followed in this case.
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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) |
|---|---|---|---|---|
| Palolo Chinese Home | 0.4 mi | ★★★★★ | 6 | 0 |
| Hi'olani Care Center At Kahala Nui | 1.4 mi | ★★★★★ | 0 | 0 |
| Leahi Hospital | 1.8 mi | ★★★★★ | 0 | 0 |
| Islands Skilled Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 13 | 0 |
| Oahu Care Facility | 2.6 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.