Above average — CMS composite of the measures below.
The next survey window likely opens 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 Oahu Care Facility during CMS and state inspections, most recent first.
A resident with CHF, dysphagia, ESRD, and moderate cognitive impairment was discharged to live with a brother who family said was cognitively and physically unable to provide care. The care conference and text messages showed repeated family concerns that the discharge setting could not meet the resident’s needs, yet the facility did not speak with the brother or assess his capacity to care for the resident. The SW later acknowledged the discharge was not safe and that the resident should have remained in the facility.
Incomplete discharge summary lacked a full recapitulation of a resident’s stay. The resident had CHF, dysphagia, ESRD, and cognitive communication deficit, with a course marked by dialysis dependence, confusion, agitation, wandering, medication refusal, an ED visit for unresponsiveness, and PEG tube removal. The discharge summary only noted a good prognosis and that the resident did well in rehab, which the MD said was not sufficient.
Dignity During Feeding Assistance: A resident with dysphagia and functional quadriplegia, who was fully dependent for eating, was observed being fed pureed food at a moderate to quick pace by an RNA. Food was allowed to get on his mouth, chin, and nose, and the RNA used the same spoon to wipe food from his face and then continued feeding him with it while standing over him. The DON agreed the care was not dignified.
A resident’s MDS incorrectly coded the discharge type as unplanned even though the EHR showed the resident was discharged home as expected and according to the discharge plan. The resident had diagnoses including metabolic encephalopathy, intestinal obstruction, anemia, COPD, bipolar disorder, HTN, and depression, and the MDS Coordinator acknowledged the coding error.
Failure to Document Wound Assessments for Residents With Pressure Ulcers: Two residents with Stage 4 and unstageable pressure ulcers had ordered dressing changes and weekly skin assessments, but the EHR contained no wound status documentation in TARs, nurse notes, or weekly skin assessments. The DON and wound nurse both confirmed that wound assessments should have been documented, and the wound nurse agreed the wound status could not be determined because the wounds had not been assessed/documented for weeks.
A resident with contracture and functional quadriplegia did not receive appropriate ROM, splint, or restorative nursing services to maintain mobility. The resident was fully dependent for ADLs, had a left wrist contracture, and was observed with the wrist drawn up to the chest. OT documented delayed splint arrival and discontinued therapy pending the splint, while RNA staff reported the wrist splint had not been used for a long time and no current order was in place. The RNA hand-off documentation could not be located, and the available form was outdated and unrelated to the resident's upper extremity needs.
A resident who smokes was escorted to the designated smoking area without an ashtray made of non-combustible material because staff could not locate one. The smoking area also lacked a metal container with a self-closing cover device for cigarette butts and ashes, and the resident’s cigarette butt was handled by staff and placed in a pocket instead of being disposed of in the required container.
Discontinued non-controlled medications were found stored in a medication cart for three residents, including insulin pens and nicotine patches, after EHR review confirmed the orders had been discontinued. RN 8 said she received the discontinuation order but could not explain the removal and destruction process, and the facility’s medication policies did not include specific procedures or time frames for disposing of discontinued meds. The DON stated there was no defined time frame for removal from the cart and no specific policy addressing the process.
Failure to monitor and document excessive sleepiness: A resident with dementia and insomnia had orders for melatonin, l-tryptophan, and mirtazapine, along with a directive to monitor sleep every shift. Staff observed her too sleepy to eat breakfast or receive morning meds, and an LPN reported she had been awake all night and then slept through the morning. The charting did not include excessive sleepiness, and the care plan, MAR, TAR, and provider orders did not show specific monitoring for it.
Staff failed to follow TBP in a room on droplet/contact precautions by entering without the required N95, gown, gloves, and face shield, removing and hanging a face shield without cleaning it, and taking dedicated vital sign equipment out of the room to clean it elsewhere. The facility also had uncovered, undated nasal cannulas improperly stored for two residents, including one with the prongs on the floor, despite staff stating cannulas should be kept in a labeled bag when not in use.
A resident with dementia and a history of exit-seeking behavior eloped from the facility after her Wanderguard bracelet failed to trigger the elevator alarm. Staff had last seen her in the dining room, but she left undetected and was later found by a member of the public with injuries from a fall. The device malfunction was confirmed after the incident, and the resident required hospital treatment for abrasions and skin tears.
The facility did not complete Baseline Care Plans within the required timeframe for three residents, failed to include a Stage 2 pressure ulcer in one care plan, and did not provide written summaries of the plans to two residents or their representatives, as confirmed by staff interviews and record reviews.
Three residents with pressure ulcers did not receive consistent repositioning every two hours as required by their care plans and facility policy. Documentation of repositioning was missing or incomplete for multiple days, despite staff awareness of the requirement. The DON confirmed that repositioning tasks were not always triggered upon admission, and review of the facility's policy showed that documentation standards were not met.
A resident with a history of falls and cognitive impairment was admitted following a subdural hematoma. Despite clear risk factors and multiple documented falls after admission, the care plan did not address fall risk until several days after the first in-facility fall. The omission of timely fall risk interventions in the care plan was confirmed by the DON and was not in accordance with facility policy.
The facility failed to maintain proper food safety and sanitation practices. Expired test strips were used to test sanitizer strength in the kitchen, a rack holding clean meal lids had rust-colored debris, and opened beverages in the nourishment refrigerator were not labeled with opened-on dates.
The facility failed to implement proper infection control measures for residents on isolation, as staff did not consistently wear required PPE when entering rooms of COVID-19 positive residents. Observations showed a Physical Therapist Assistant entering a room without a gown, face shield, or eye protection. Additionally, PPE and waste disposal practices were inadequate, with PPE containers and biohazard trash cans placed outside rooms due to space constraints, contrary to facility policy.
A facility failed to inform a resident of the risks and benefits of psychotropic drugs and did not obtain consent for their use. The resident, with anxiety disorder, dementia, and major depressive disorder, was prescribed mirtazapine and duloxetine. The DON could not locate the necessary consents, even after checking paper files, as the resident was on these medications before the facility's transition to EHR.
A resident capable of independent movement was improperly restrained by positioning wedges placed under the mattress and fitted sheet, restricting movement. Staff confirmed the wedges were not used for medical treatment but functioned as restraints. Despite the resident's high fall risk, no bed alarm was implemented, and care plans did not document the use of wedges.
The facility failed to provide written notification of the bed hold policy to two residents transferred to a hospital. One resident was transferred for acute lower GI bleeding, and the other for fractures after a fall. In both cases, the Social Worker Designee confirmed that the bed hold policy was not communicated in writing, contrary to facility policy.
A facility failed to use interpreter services for a Korean-speaking resident, leading to an inaccurate cognitive assessment and an elopement incident. Despite the care plan's directive to use alternative communication tools, staff attempted to communicate in English, resulting in ineffective interactions and an incomplete BIMS test. The resident, unable to understand English, demonstrated cognitive awareness by eloping from the facility, highlighting the need for proper communication support.
The facility failed to develop discharge plans for two residents admitted for short-term rehabilitation, as required by their policy. One resident, admitted for knee care, and another for a chronic leg wound, both lacked documented discharge plans with measurable objectives and timeframes in their EHRs. This deficiency was confirmed during a review with the DON.
A resident with limited English proficiency was not provided with necessary interpreter services, despite the facility having Korean-speaking staff and an administrator who speaks Korean. The care plan indicated the need for an interpreter, but services were not utilized since admission, leading to potential risk for the resident.
A resident with cognitive impairments eloped from a facility after accessing unattended scissors and cutting off her Wander guard. The facility failed to maintain a hazard-free environment and provide adequate supervision, as scissors were found in a resident-accessible area. The resident's cognitive abilities were underestimated, and her care plan was not updated following the elopement.
The facility failed to maintain accurate records for controlled medications, as a dose of morphine sulfate was administered without the administering nurse's signature on the log. This discrepancy was confirmed by an RN during an inspection, highlighting a breach in the facility's policy requiring immediate documentation of administered controlled substances.
The facility failed to properly store a resident's prescribed ointment and did not label ophthalmic drops with expiration dates for two residents. A CNA was found retrieving ointments from a resident's bedside table, which should have been locked in the treatment cart. Additionally, an inspection revealed that ophthalmic drops were not labeled with the date opened or expiration date, contrary to facility policy.
Unsafe discharge planning did not account for caregiver ability
Penalty
Summary
The facility failed to ensure an effective discharge planning process was developed and implemented that considered the caregiver’s availability, capacity, and capability to provide needed care for one resident. The resident was admitted with diagnoses including congestive heart failure, dysphagia, end-stage renal disease, and cognitive communication deficit, and the discharge MDS documented a BIMS score of 9, indicating moderate cognitive impairment. The resident was discharged home with a brother who was described in the record and interviews as cognitively and physically impaired, and the care conference summary documented concerns from the daughter and niece that the brother could not care for the resident. The care conference summary documented that the plan was to return home with the brother, while the niece expressed concern that the brother could not care for the resident because of his own health challenges. The family member interviewed stated the resident was not ready to go home, had a G-tube and dialysis needs, was unsafe and attempting to remove the G-tube, and that the brother had the mentality of a toddler and could not manage the resident at home. The family member also stated the discharge to the brother’s home was not the family’s preference and that the family had informed the Social Worker multiple times that the brother could not safely care for the resident. Text messages reviewed showed the family member had applied for Medicaid long-term coverage as an alternative to discharge and repeatedly stated there was no support at the discharge residence and that the resident could choke or harm himself. The Social Worker acknowledged the facility did not have any form of communication with the brother, and the DON confirmed the facility did not speak with the brother and only spoke with the family member who did not live with him. The DON also stated it was not the facility’s practice to evaluate the caregiver’s ability and capability, and the Social Worker later confirmed that, in hindsight, the discharge was not safe and the resident should have stayed in the facility.
Incomplete Discharge Summary Lacked Required Recapitulation of Stay
Penalty
Summary
The facility failed to ensure that a discharge summary included a recapitulation of the resident’s stay, including diagnoses, course of illness or treatment or therapy, and consultation results for one resident. The resident was admitted with diagnoses including congestive heart failure, dysphagia, end-stage renal disease, and cognitive communication deficit, and was later discharged from the facility. Review of the resident’s progress notes showed a complex course that included dependence on dialysis services with incomplete treatments, confusion and searching for a deceased mother, attempts to enter another resident’s room, difficulty sleeping, agitation and combative behavior, lower back pain rated 9/10, an emergency department visit for unresponsiveness, medication adjustments for hypotension, physician notification for hypertension with medication prescribed, medication for agitation and restlessness, periodic medication refusal, wandering in the hallway without assistance, and placement of a Wanderguard alarm due to elopement and exit-seeking behaviors. The discharge summary reviewed by surveyors contained only the resident’s name, discharge status, admit date, discharge date, medical record number, prognosis of “good,” and the statement “Did well in rehab. GT was removed.” The Medical Director reviewed the discharge summary by telephone and stated it was not sufficient and that more information was needed, especially regarding the PEG tube removal. The DON also reviewed the prognosis and summary, acknowledged that the PEG tube removal was captured, and agreed with the discharge summary.
Dignity During Feeding Assistance
Penalty
Summary
The facility failed to protect and promote the dignity of Resident (R)68 during meal assistance. R68 is a [AGE] year-old male with diagnoses including dysphagia and functional quadriplegia, and his most recent MDS showed that he was fully dependent on facility staff for all ADLs, including eating. During breakfast observation, Restorative Nurse Aide (RNA)3 fed him pureed food with a metal spoon at a moderate to quick pace, spoonful after spoonful, while pureed food got all over his mouth, chin, and nose despite the fact that he was not moving his head excessively. RNA3 used the same metal spoon to wipe up the excess pureed food from his face, including what was on and under his nose, then put the spoon in his mouth and continued feeding him with it. RNA3 was also observed standing over R68 while feeding him. During interview, the DON acknowledged that R68 does not move a whole lot when eating, that care should be taken when feeding him, and that staff should try to ensure pureed food does not get on his nose. The DON agreed that it would not be dignified to use a spoon to wipe food off a resident's face and then continue using it to feed the resident, and stated that a napkin should be used instead.
Incorrect MDS Discharge Type Entry
Penalty
Summary
The facility failed to accurately record the type of discharge in the RAI/MDS for one resident, R92, whose most recent assessment had an ARD of 09/06/25. In Section A310G, the discharge type was marked as Unplanned Discharge, even though the EHR and progress notes showed that R92 was discharged home as expected and in accordance with the discharge plan. R92 had been admitted with diagnoses including metabolic encephalopathy, intestinal obstruction, anemia, COPD, bipolar disorder, hypertension, and depression. During interview, the MDS Coordinator acknowledged the discharge type was entered incorrectly and stated it was inaccurate.
Failure to Document Wound Assessments for Residents With Pressure Ulcers
Penalty
Summary
The facility failed to ensure that two residents with pressure ulcers received the necessary monitoring, treatment, and services consistent with professional standards of practice and their comprehensive care plans. For one resident admitted to hospice/end-of-life care with a Stage 4 coccyx pressure ulcer, the record showed orders for daily and then twice-daily dressing changes and a weekly skin assessment, along with care plan interventions to assess, record, and monitor wound healing, measure the wound, and document the wound perimeter, wound bed, and healing progress. However, review of the electronic health record found no wound status documentation in the treatment record, nurse progress notes, or weekly skin assessments, and one weekly skin assessment was missing altogether. For the second resident, who was re-admitted with a Stage 4 pressure ulcer to the right hip and an unstageable pressure ulcer to the right ankle, the record showed daily dressing change orders and a weekly skin assessment order. The care plan directed staff to provide wound care per treatment order and to monitor, document, and report changes in skin status, including wound appearance, color, healing, signs and symptoms of infection, wound size, and stage. Despite these orders and care plan interventions, review of the electronic health record found no wound status documentation in the treatment record, nurse progress notes, or weekly skin assessments. During interviews, the DON stated that when staff perform dressing changes, she expected a nurse progress note to include a wound assessment, and that the weekly skin assessment should document wound status and appearance. The wound nurse stated that if a resident was not on wound rounds, the assigned nurse completing the weekly skin assessment was responsible for documenting wound assessments. During review of the weekly skin assessments, the wound nurse confirmed that wound status assessments should have been documented for every identified skin issue but were not, and agreed that it could not be determined what the status of the second resident's wounds were because there had been no documentation that they had been assessed for 3 weeks.
Failure to Provide ROM and Splint Services for Resident With Contracture
Penalty
Summary
The facility failed to ensure a resident with contracture and functional quadriplegia received appropriate treatment, equipment, and services to maintain or improve ROM and mobility. The resident was fully dependent on staff for all ADLs, including transfers and mobility, and his MDS documented that he had not received restorative nursing services such as active or passive ROM, splint or brace assistance, or training and skill practice in bed mobility or transfers in the prior 7 days. The resident was observed sitting in a wheelchair with his left wrist drawn up to his chest and a contracture of less than 20 degrees. The restorative nurse aide stated the resident had previously had a wrist splint, but it had not been applied for a long time and there were no current orders for one. The provider record showed OT was discontinued pending arrival of splints, and the OT note documented increased left upper extremity flexor tone, no significant change in ROM due to delayed splints, and that a specialized splint was expected in 2 to 3 weeks. The OT and DOR later confirmed that RNA services should have continued and that no follow-up on the splint order had been done since July. The current RNA hand-off form could not be located, and the most recent form found was from 2023 and applied only to the resident's lower extremities.
Smoking Area Lacked Required Ashtray and Disposal Container
Penalty
Summary
The facility failed to provide one resident who smokes with an ashtray made of non-combustible material while he was smoking, and the designated smoking area did not contain a metal container with a self-closing cover device for cigarette butts and ashes. On 09/23/25, an Activity Aide assisted Resident 12 by wheelchair to the designated smoking area outside near the Administration building. On the way, the aide stopped at the ground floor station and asked an Administration Assistant for an ashtray, but was told the ashtrays were missing. The aide then proceeded with the resident to the smoking area without an ashtray. While in the smoking area, the resident finished smoking and ran the cigarette butt on the concrete ground before handing it to the aide, who placed it in his pants pocket. The designated smoking area did not have a metal container with a self-closing cover device available for disposal of cigarette butts and ashes. Later, the Administration Assistant showed a round black container with holders on the rim and a black cylindrical container, and both lacked a self-closing cover device. The facility policy stated that metal containers with self-closing cover devices are available in smoking areas.
Discontinued Medications Remained in Medication Cart Without Defined Disposal Procedure
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility had no defined policy and procedure for managing discontinued non-controlled medications stored in the medication administration cart. During observation on 09/25/25, medication cart A on the second floor contained discontinued medications for three residents: NovoLog insulin pens for two residents and nicotine patches for one resident. A concurrent review of the EHR showed discontinuation orders for the insulin pens and a discontinuation date for the nicotine patch, and RN 8 stated she had received the discontinuation order but could not describe the specific procedure for removal and destruction. Review of the facility’s Medication Administration, Medication Labeling and Storage, and Discarding and Destroying Medications policies showed they were dated 2001 and did not contain specific procedures for the disposition of discontinued non-controlled medications. The DON stated discontinued non-controlled medications were removed from the cart and placed in the Nursing Supervisor’s office, but there was no defined time frame for removal, and she could not identify a specific policy for the process. She also stated she would like discontinued medications removed from the cart by the end of the shift, but the facility policies did not include that time frame.
Failure to Monitor and Document Excessive Sleepiness
Penalty
Summary
The facility failed to monitor the medication regimen for one resident, a female with diagnoses including dementia and insomnia, who had standing orders for sleep-related products and a medication associated with sleepiness and tiredness. Her orders included monitoring hours of sleep every shift, melatonin at bedtime, l-tryptophan at bedtime, and mirtazapine at bedtime for anorexia. A nutrition/dietary note documented that she was too sleepy during meals and required 1:1 supervision and assistance as needed because of sleepiness. During observation, the resident was found asleep in bed with her breakfast untouched, and she remained sound asleep on a later observation while a nurse aide attempted unsuccessfully to wake her. The LPN stated the resident had been awake all night and had not yet received morning medications because she was too sleepy, and that the resident cycles between staying up for days and then sleeping for a couple of days straight. The health status note for that incident documented only that the resident refused morning medication and was awake all night, with no mention of excessive sleepiness. Review of the TAR, MAR, care plan, and provider orders showed no specific monitoring for excessive sleepiness, and the sleep-monitoring order was implemented only as a numerical entry for hours slept each shift without documentation of sleep quality or timing.
Infection Control Lapses With PPE Use, Dedicated Equipment, and Nasal Cannula Storage
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices for residents on transmission-based precautions in a room with Special Droplet/Contact Precautions signage for residents in beds B, C, and D. The signage directed staff to wear a mask or respirator, face shield or goggles, gown, and gloves, and to use patient-dedicated or disposable equipment and clean and disinfect shared equipment. During observation, a nurse aide entered the room carrying lunch trays without an N95 respirator and remained in the room to assist with feeding a resident. The nurse aide later exited the room, removed her face shield, and hung it on a hook outside the door without cleaning it. A certified nurse aide later entered the same room without gown, gloves, N95, or face shield and removed the basket of dedicated vital sign equipment from the closet so it could be cleaned outside the room. Staff interviews confirmed the expected PPE use and that dedicated equipment should be cleaned in the room. The facility also failed to properly label and store nasal cannulas. One resident’s undated, uncovered nasal cannula was observed wrapped around the oxygen concentrator handle, and later the prongs were observed on the ground while the resident was not in the room. Another resident’s undated, uncovered nasal cannula was observed wrapped around the enabler at the head of the bed while the resident was asleep. An RN stated that proper storage of a nasal cannula when not in use is a brown bag labeled with the resident name and date. The facility policy on oxygen administration stated that oxygen cannulae and tubing should be kept in a plastic bag when not in use.
Failure to Prevent Elopement Due to Faulty Wanderguard Device and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, unsteady gait, and prior exit-seeking behavior eloped from the facility. The resident had been admitted following a hospital stay for an unwitnessed fall and was assessed as high risk for elopement. A Wanderguard bracelet was placed as a safety measure, and the resident was under supervision, with staff aware of her location in the dining room prior to the incident. However, the resident was able to leave the dining room undetected and exited the facility without staff noticing. The Wanderguard bracelet, which was intended to prevent such incidents, was found to be faulty after the event. Although staff had checked the device earlier in the day and found it to be working, it failed to trigger the elevator alarm when the resident exited. The malfunction was confirmed by both facility staff and an external technician after the incident. The resident was found several blocks away by a member of the public and was taken to the emergency department, where she was treated for multiple abrasions and skin tears resulting from a fall that occurred while she was outside the facility. The facility's policy required regular assessment and monitoring of the Wanderguard device, as well as supervision of residents at risk for elopement. Despite these measures, the failure of the Wanderguard system and lack of direct supervision at the time allowed the resident to leave the premises and sustain injuries.
Failure to Timely Develop and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to meet regulatory requirements for Baseline Care Plans (BCP) for three residents. For one resident, the BCP was not developed within 48 hours of admission, and for another, the BCP was left blank and not completed until after the required timeframe. Additionally, there was no documentation that two residents were provided with summaries of their BCPs, as required by facility policy. Interviews with the Director of Nursing (DON) and Nursing Supervisor (NS) confirmed that the BCPs were not completed on time and that the summaries were not provided to the residents or their representatives. One resident was admitted for short-term rehabilitation following hospitalization for repeated falls and was noted to have a Stage 2 sacral pressure ulcer on admission. The BCP for this resident did not identify the pressure ulcer, despite hospital discharge instructions including care for the injury. The BCP also lacked signatures from the resident or representative and no evidence was found that a copy was provided. The facility's policy requires BCPs to be developed within 48 hours of admission, to address immediate health and safety needs, and for written summaries to be provided and documented, but these steps were not followed.
Failure to Provide and Document Repositioning for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care by not ensuring that residents with existing pressure ulcers were repositioned as required by their care plans and facility policy. Three residents with pressure ulcers were not consistently turned or repositioned every two hours, and there was a lack of documentation to support that this standard of care was provided. For example, one resident was admitted with a sacral Stage 2 pressure ulcer that was not identified on her baseline care plan, and there was no documentation of repositioning until several days after admission. Another resident with an unstageable coccyx wound requiring substantial assistance had no documentation of repositioning every two hours as directed in the care plan. A third resident with multiple pressure ulcers also lacked documentation of regular repositioning, with records showing that documentation only began several days after admission. Interviews with CNAs confirmed that while they were aware of the need to reposition residents every two hours and document this in the electronic record, there were gaps in documentation, and some days had no entries for repositioning. The Director of Nursing acknowledged the importance of regular repositioning and confirmed that tasks for repositioning were not triggered for some residents upon admission. Review of the facility's repositioning policy further indicated that the required documentation and care practices were not followed, as staff failed to record the position, caregiver, and other required details in the residents' medical records.
Failure to Timely Address Fall Risk in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan (CCP) that addressed a resident's safety needs in a timely manner. The resident, who had a history of falls and was admitted with a subdural hematoma due to a fall at home, was noted on admission to be cognitively impaired, disoriented, and at risk for falls. Despite these risk factors, the baseline care plan did not assess functional ability and goals, and the high risk for falls was not included in the CCP upon admission. The care plan addressing fall risk was only initiated three days after the resident experienced a fall in the facility. During the resident's stay, multiple falls were documented in the nursing notes, including incidents where the resident was found on the floor, confused, and experiencing pain or minor injuries. Interviews confirmed that the high fall risk should have been included in the care plan from admission, in accordance with the facility's policy, which requires staff to identify and implement interventions for residents at risk of falls based on previous evaluations and current data. The failure to timely address the resident's fall risk in the care plan constituted the deficiency.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in their kitchen and nourishment areas. During an observation, it was found that the kitchen staff used expired Hydrion test strips to test the strength of the sanitizer solution in the three-compartment sink. The Food Service Worker confirmed the test strips were expired and replaced them with new ones, which tested the water within the acceptable range. Additionally, a rack holding clean meal lids near the stove was observed to have rust-colored debris, which was confirmed by the Dietary Manager. Furthermore, in the nourishment refrigerator on the second floor, opened beverages such as orange juice, prune juice, and cranberry juice were found without the required opened-on dates, as confirmed by the Nursing Supervisor.
Inadequate Infection Control Measures for Residents on Isolation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for residents on isolation, specifically those on transmission-based precautions (TBP). Observations revealed that staff did not consistently wear the required personal protective equipment (PPE) when entering rooms of residents who tested positive for COVID-19. For instance, a Physical Therapist Assistant was seen entering a resident's room without a gown, face shield, or eye protection, despite the room being marked for Special Droplet/Contact Precautions. The Director of Nursing confirmed that all staff were expected to wear a gown, gloves, mask, and eye protection when entering such rooms, as per the facility's policy. Additionally, the facility's handling of PPE and waste disposal was inadequate. PPE containers and biohazard trash cans were placed outside the rooms of residents who tested positive for COVID-19 due to space constraints inside the rooms. This practice was justified by the facility's administrator, citing advice from an Infection Control Consultant. However, the facility did not implement alternative solutions such as over-the-door PPE caddies and trash bag holders, which were discussed but not observed during the survey. The facility's policy required that PPE be donned upon entry and discarded in a dedicated container before leaving the resident room, which was not consistently followed.
Failure to Obtain Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform a resident of the risks and benefits associated with the use of psychotropic drugs and did not obtain the necessary consent for one of the five residents sampled for unnecessary medications. The resident in question was an elderly individual with diagnoses including anxiety disorder, dementia, and major depressive disorder, and was prescribed mirtazapine and duloxetine, both antidepressants. Upon review of the resident's Electronic Health Records (EHR), it was found that documentation of consent for these medications, including education on their risks and benefits, was missing. The Director of Nursing (DON) was asked to provide the consents for the use of these antidepressants, but he was unable to locate them, even after checking the paper files, as the resident had been on these medications before the facility transitioned to the EHR system. This deficiency placed the resident at risk for more than minimal harm due to the lack of informed consent.
Improper Use of Positioning Wedges as Restraints
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints used for staff convenience rather than medical necessity. Observations revealed that positioning wedges were placed under the mattress and fitted sheet of a resident's bed, creating a concave shape that restricted the resident's ability to move freely. The resident, who was capable of moving independently, confirmed that the wedges hindered his movement and that he could not remove them. Interviews with staff corroborated that the wedges were not used for repositioning or treating a medical condition, but rather functioned as a restraint. The resident was identified as a high fall risk, having recently fallen out of bed, yet no bed alarm was implemented as a precautionary measure. The resident's care plans for skin integrity and high fall risk did not include the use of wedges, indicating a lack of appropriate documentation and planning. The facility's policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident, which was applicable in this case. This deficiency placed residents with the ability to move independently at risk of harm.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for two residents who were transferred to an acute care hospital. The first resident, a [AGE] year-old, was admitted to the facility and later transferred to a hospital for acute lower gastrointestinal bleeding. The electronic health record (EHR) did not contain documentation that the resident's representative was provided with a written notification of the bed hold policy. The Social Worker Designee (SWD) confirmed that the policy was communicated via phone call but not in writing, which is against the facility's policy requiring a written agreement within 24 hours of discharge. The second resident was transferred to a hospital for pain related to fractures of the right hip and shoulder after an unwitnessed fall. Upon review, it was found that neither the resident nor the resident's representative was notified of the bed hold policy at the time of transfer. The SWD confirmed this oversight. This deficiency in communication has the potential to affect all residents transferred to an acute care hospital, as it could lead to miscommunication regarding the bed hold policy.
Failure to Implement Interpreter Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a Korean-speaking resident, identified as R56, by not utilizing interpreter services as documented in the resident's care plan. During an observation, staff attempted to communicate with R56 in English, despite the resident's inability to understand the language, as noted in the resident's Electronic Health Record (EHR). The care plan specified the need for alternative communication tools, such as interpreter services, which were not used during the Brief Interview for Mental Status (BIMS) assessment, resulting in an inaccurate score of 99, indicating the test could not be completed. Interviews with the MDS Coordinator and a Registered Nurse revealed that interpreter services had never been used for BIMS testing, and the resident's cognitive abilities were not accurately assessed due to the language barrier. The resident, who was minimally able to communicate with English-speaking staff, demonstrated cognitive awareness by eloping from the facility after observing staff behavior and disabling the Wander guard system. The RN confirmed that the resident's behaviors and elopement attempt could have been mitigated if interpreter services had been implemented to address the resident's needs and explain her circumstances.
Failure to Develop Discharge Plans for Short-Term Rehab Residents
Penalty
Summary
The facility failed to develop a discharge plan for two residents, leading to a deficiency in ensuring safe and appropriate discharge processes. Resident 61, a [AGE] year-old individual admitted for short-term rehabilitation for knee care, did not have a discharge plan documented in their comprehensive care plan. Despite the resident's indication of being at the facility for short-term rehabilitation, the electronic health record (EHR) lacked measurable objectives and timeframes necessary for a safe discharge, putting the resident at risk of premature discharge and potential readmission. Similarly, Resident 219, a [AGE] year-old admitted for short-term rehabilitation following hospitalization for a chronic right leg wound, also lacked a documented discharge plan in their EHR. The resident expressed a desire to return home once able to walk a short distance, yet their care plan did not include the necessary discharge goals or timeframes. During a review with the Director of Nursing (DON), it was confirmed that both residents' comprehensive care plans were missing the required discharge plans, contrary to the facility's policy expectations.
Failure to Provide Interpreter Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R122, was provided with appropriate communication services, specifically interpreter services, despite the resident's limited English proficiency. During the survey, it was discovered that the resident's primary language is Korean, and her ability to speak English is very limited. The care plan for R122, which was initiated and revised while surveyors were onsite, indicated that the resident requires an interpreter for communication. However, interviews and record reviews revealed that interpreter services were not offered or used for R122 since her admission, except when family and friends were available. Interviews with staff, including a registered nurse and admissions staff, indicated a lack of consistent use of interpreter services. The registered nurse was unsure if interpreter services were being used, while the admissions staff confirmed that no staff interpreters were used during the admission process. Although the facility has Korean-speaking staff and the administrator speaks Korean, these resources were not utilized to facilitate communication with R122. This oversight placed non-English speaking residents at potential risk for more than minimal harm due to impaired communication.
Resident Elopement Due to Inadequate Supervision and Hazardous Environment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision, resulting in a resident's elopement. During an observation, a pair of metal scissors was found unattended in a resident-accessible area, contrary to the facility's policy that scissors should be stored in the treatment cart. This oversight allowed a resident to access scissors and elope from the facility without staff knowledge, posing a risk of more than minimal harm to residents. The resident involved, a woman with a history of hypotonic hyponatremia, encephalopathy, depression, suicidal ideations, hypertension, and dementia, used scissors from her manicure kit to cut off her Wander guard, enabling her to exit the building undetected. The resident's cognitive abilities were underestimated, as she had previously tested the Wander guard system and observed staff disarming it. Despite her inability to complete the BIMS test due to language barriers, staff confirmed her awareness and cognitive functioning. The incident highlighted a lapse in supervision and environmental safety, as well as a failure to update the resident's care plan post-elopement.
Controlled Medication Recordkeeping Deficiency
Penalty
Summary
The facility failed to ensure that records for controlled medications were maintained and accurate, which could potentially lead to the diversion of controlled substances. During an inspection of the medication cart on the second floor, a discrepancy was found in the controlled medication logs. Specifically, a dose of morphine sulfate, an opioid pain-relieving medication, was administered to a resident, but the log lacked the signature of the staff member who administered it. This incident occurred on 08/16/24 at 11:01 PM. Registered Nurse (RN)9 confirmed that the staff member should have signed the log immediately after administering the medication, as per the facility's policy on controlled substances. The policy clearly states that the licensed nurse administering the medication must immediately enter their signature on the accountability record.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store physician-prescribed topical ointment for a resident and did not ensure that medicated ophthalmic drops were properly labeled with an expiration date for two residents. In the first instance, a resident with bowel and bladder incontinence had prescribed ointments stored improperly in her bedside table. A CNA was observed retrieving medicine cups containing creams and ointments from the resident's bedside table, which were not supposed to be left there. A registered nurse admitted to placing the ointment in a medicine cup for another nurse who did not have access to the locked treatment cart, assuming the ointment would be applied to the resident. In the second instance, an inspection of the medication cart revealed that three bottles of ophthalmic drops for two residents were not labeled with the date they were opened or an expiration/discard by date. This made it impossible to confirm when the medicated ophthalmic drops were opened. The facility's policy requires that multi-dose vials be labeled to ensure product integrity, and nursing staff should document the date opened on multi-dose vials. The registered nurse confirmed that the bottles should have been labeled according to the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 162 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Islands Skilled Nursing & Rehabilitation | 0 mi | ★★★★★ | 13 | 0 |
| Hale Ola Kino By Arcadia | 0.2 mi | ★★★★★ | 0 | 0 |
| Arcadia Retirement Residence | 0.3 mi | ★★★★★ | 1 | 0 |
| Kalakaua Gardens | 0.8 mi | ★★★★★ | 33 | 0 |
| Hale Nani Rehabilitation And Nursing Center | 1 mi | — | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.