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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pu'uwai 'o Makaha during CMS and state inspections, most recent first.
A resident with quadriplegia, panic disorder, and depression was repeatedly observed in bed with the touch pad call light on the floor and out of reach. A CNA acknowledged the resident could use the call light and that it should be placed close to the resident's arms, and the care plan included keeping the call bell in reach.
Failure to provide complete ADL, oral, and personal hygiene care. A resident who was fully dependent on staff for hygiene, grooming, bathing, and oral care was observed with dry, cracked lips, dry skin, and dried crust in both eyes while CNAs performed a bed bath that did not initially include full facial cleansing, oral care, hair care, or washing of the legs and feet. The resident had Guillain-Barre syndrome, quadriplegia, a colostomy, and a gastrostomy, and the care plan did not specify how often oral care should be provided.
A resident with hemiplegia, hemiparesis, and multiple contractures was observed with severe stiffness and no splints or orthotic devices at the bedside. The resident said ROM therapy and splint use had not been done in a long time, while CNA staff were unsure where the splints were and later found them buried in a box. The PT confirmed daily splints were indicated for the left arm and leg, and the care plan called for regular ROM, stretching, and splinting, but the DON could not explain why documentation showed these interventions as completed when the resident reported otherwise.
A resident with chronic pain conditions experienced severe pain when her PRN Norco was out of stock for multiple periods, and staff did not offer non-pharmacological pain relief measures while the medication was unavailable. She reported that acetaminophen did not help, that her pain limited her activity and mobility, and that she felt much better once the Norco was back in stock.
Expired medications were found in a medication cart, including an eye ointment with a past discard date and an insulin vial that had also passed its discard date, while an RN was also observed leaving a medication cart unlocked and unattended during med pass. Staff acknowledged that expired or discontinued meds should be removed and that medication carts should remain locked when not in use.
A refrigerator used to store resident food and liquids was observed with sediments, red stains, and yellow and brown debris inside the door compartments and freezer. Two unopened yogurt containers with an expired best by date were also found in the freezer, and the RCM confirmed the refrigerator was not clean.
Failure to remove gloves and perform hand hygiene after incontinence care. An RCM and an LPN were observed providing bowel incontinence care to a resident, then continuing with clean tasks such as applying a clean brief, straightening linens, repositioning the resident, applying heel protectors, and placing the top sheet without removing gloves, performing hand hygiene, or donning new gloves. The RCM later stated the gloves should have been removed and hand hygiene performed before touching the resident’s clean items and areas.
A shower room sink was observed leaking water into a bucket and onto the floor, with no wet floor signs posted to warn residents or staff. The RCM confirmed the wet floor, and the DOM and maintenance staff later confirmed they had been notified of the leak one week earlier and that wet floor signage should have been used.
The facility failed to provide a comfortable temperature of hot water in two shower rooms and a bathroom sink in Unit Two. The Maintenance Director confirmed ongoing issues with the hot water supply, despite recent repair efforts. Invoices from February to June confirmed previous issues with the hot water on this unit.
The facility was found to have deficiencies in food storage and handling practices, including storing clean dishes on a rust-colored rack, failing to document refrigerator and freezer temperatures, and improper glove use by the Kitchen Manager. These issues could affect all residents and visitors consuming meals from the kitchen.
The facility failed to maintain accurate and complete documentation for several residents, including missing details of a dental appointment, expired hospice certification, and inconsistent code status documentation. Additionally, a resident was observed with a fall alarm without a physician order. These deficiencies indicate lapses in the facility's record management practices.
A facility failed to accurately assess a resident's psychological state in the MDS and did not document the use of a bed alarm. The resident's mood and behavior were not coded with indicators of psychosis, despite prior documentation of agitated behaviors. The bed alarm was noted in nursing records but not coded in the MDS. The Social Services Director indicated that behaviors might not have been present during the assessment, although they were documented earlier.
A resident with a history of cerebral infarction, vascular dementia, and severe anxiety was found agitated and distressed while isolated due to COVID-19. The facility failed to monitor his behaviors, report changes to the physician, or implement non-pharmacological interventions. His Trazodone was put on hold, leading to increased agitation, and no activities were provided during isolation. The lack of monitoring and interventions resulted in poor psychological health and self-inflicted injuries.
A resident missed two dental appointments for a cleaning due to the facility's failure to assist in scheduling. The resident, at risk for mouth pain due to decaying teeth, had a care plan in place. Despite leaving the facility for an appointment, there was no documentation confirming a dental visit. The last dental consult was in August, and the missed appointment was not rescheduled until months later.
A resident with cognitive and physical impairments experienced a fall resulting in a leg fracture. The facility failed to timely update the care plan to reflect the resident's treatment with a splint and later a cast, potentially leaving staff unaware of necessary interventions. This deficiency was confirmed by the Resident Care Manager.
A resident with cognitive and mobility impairments missed a scheduled orthopedic appointment due to the facility's failure to arrange transportation, delaying the removal of her cast. The resident, who uses a wheelchair and has a history of mental health issues, was supposed to have her cast removed following a leg fracture. The Resident Care Manager and Unit Coordinator were responsible for arranging the appointment, but a communication lapse led to the missed appointment, rescheduling it for a later date.
A resident with a history of inappropriate behavior was left unsupervised in a dining area with a female resident, despite a care plan requiring supervision. This lapse in monitoring occurred after a previous incident where the resident inappropriately touched another female resident. The facility's failure to ensure supervision highlights a deficiency in maintaining resident safety.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure call system equipment was within reach for one resident who was cognitively intact and had diagnoses including quadriplegia, panic disorder, and depression. The resident was observed in bed on multiple occasions with the touch pad call light on the floor and out of reach, including after lunch while lying in bed with head elevated, later that afternoon, and again the following day while watching television. A CNA stated the resident was capable of using the call light because he could still move his upper extremities and acknowledged that the call light was out of reach and should always be placed on the bed close to the resident's arms. The resident's care plan included that the call bell be in reach.
Failure to Provide Complete ADL, Oral, and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain activities of daily living, specifically personal hygiene and oral hygiene, for one sampled resident who was completely dependent on staff for all ADLs. The resident was a male admitted for LTC with diagnoses including Guillain-Barre syndrome and quadriplegia, and he also had a colostomy and gastrostomy. His most recent MDS Quarterly Assessment documented complete dependence on staff for oral hygiene, bathing, toileting, dressing, personal hygiene, and mobility. During observation, two CNAs were changing the resident’s incontinence brief and performing what they described as a bed bath, but the resident was observed with extremely dry and cracked lips, dry and flaky skin on his forehead, and thick dried yellowish crust in the inner corners of both eyes. The CNAs wiped only part of his face, did not wipe his forehead, left eye, or left side of his face at first, and did not initially provide oral care or brush his hair. They also did not wipe his legs and feet during the bed bath. Later, oral care was attempted but supplies were not initially available in the room. The resident’s care plan identified dependence on staff for hygiene, grooming, and oral care, but did not specify how often oral care should be performed. The facility’s ADL policy stated that residents unable to carry out ADLs will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to Provide Ordered ROM and Splinting
Penalty
Summary
The facility failed to ensure appropriate care for a resident with left-sided hemiplegia and hemiparesis following a stroke, a prior right femur fracture, and contractures of the left knee and left ankle. The resident’s most recent MDS showed a BIMS score of 13, indicating he was cognitively intact. During observation, his left wrist and fingers were severely contracted, his left knee and ankle were contracted, and his left elbow and shoulder also appeared stiff and contracted, with none of these joints able to be straightened without, or even with, assistance. No splints, braces, or orthotic devices were visible at the bedside. Interviews and record review showed the resident stated he had not received therapy or rehabilitation services for his limited ROM in a long while and that it had been a long time since he wore a splint. CNA staff were unsure where his splints were, and one CNA found them in a large box on the floor above the bed, buried under other items. The PT confirmed the resident should have been wearing daily splints on his left arm and left leg, and the care plan directed application of left knee and ankle splints, left wrist/hand splint, neck stretching, AAROM/PROM to both upper and lower extremities, and stretching of the left elbow, wrist, knee, and ankle every shift. The DON reviewed documentation and could not explain why ROM and stretching were charted as completed when the resident said they were not, or why splints were documented as applied on several occasions when the resident reported they had not been used in a long time.
Pain Medication Out of Stock and Non-Pharmacologic Relief Not Offered
Penalty
Summary
The facility failed to provide safe, appropriate pain management for Resident 8, a cognitively intact female with polyarthritis, surgical absence of the left leg below the knee, chronic PTSD, and generalized muscle weakness. During interview, she reported severe pain in her back, left shoulder, neck, right knee, and fingers, rating it 9 out of 10, and stated that her usual Norco controlled her pain well but had been out for a couple of days. She also reported that acetaminophen did not help and that staff had not offered non-pharmacological measures such as a hot pack, cold pack, massage, or exercises while the Norco was unavailable. Record review and staff interviews confirmed that the Norco order remained active but the medication was out of stock for multiple periods, including from 06/11/25 to 06/14/25 and again from the afternoon of 07/21/25 until the afternoon of 07/24/25. The MAR showed the last documented Norco administration on 07/21/25 at 1:15 PM, and the RN confirmed it had been out of stock at least all week. The DON stated the expectation was to refill pain medication when two days remained and agreed that the medication should not have run out and that non-pharmacological interventions should be offered when the primary pain medication is unavailable. The resident later reported feeling much better once Norco was back in stock and stated she had felt unwell, extra tired, and less willing to move or participate in activities while it was unavailable.
Expired medications left in cart and medication cart left unlocked
Penalty
Summary
Medications in two medication carts were not stored and locked in accordance with professional standards. During an inspection of Team 1 medication cart with an LPN present, two expired medications for one resident were found: Genteal Tears Severe 3-94% ointment had an open date of 05/04/25 and a discard date of 07/04/25 on the facility label, and Novolog U-100 Insulin vial had an open date of 06/06/25 and a discard date of 07/04/25 on the facility label. The EHR showed the resident had a readmission date of 06/05/25 with no readmission order for the eye ointment, while the insulin remained an active sliding-scale order given subcutaneously five times daily. The LPN stated expired or discontinued medications should be removed from the medication cart, and the RCM stated medications should be removed when discontinued or expired and that nurses should check expiration dates when administering medications. In a separate observation, an RN prepared medications, returned the blister packs to the medication cart, and walked to a resident's room, leaving the cart unlocked and unattended. After the medications were given, the RN returned to the cart and then locked it. The RCM confirmed that medication carts should always be locked and secured when not in use. The facility policy stated that outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by authorized persons.
Unsanitary Refrigerator and Expired Resident Food Items
Penalty
Summary
The facility failed to keep a refrigerator used to store resident food and liquids in a clean and sanitary condition and failed to discard expired resident food items. On 07/22/25, surveyors observed sediments in the compartments on the inside of the refrigerator door, scattered red stains under the left side of a storage compartment, scattered red stains along the inside top edge of the freezer door, scattered red stains and yellow sediments in a freezer storage compartment, and a buildup of yellow and brown debris at the bottom of the freezer. On 07/23/25, the same conditions were observed again with the Resident Care Manager, who confirmed the sediments, stains, and buildup. During that inspection, two unopened yogurt containers with a best by date of 06/25/25 were found in the freezer, and the Resident Care Manager stated that the refrigerator was not clean and removed the expired yogurt containers.
Failure to Remove Gloves and Perform Hand Hygiene After Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices during incontinence care for R1. On 07/24/25 at 01:58 PM, RCM1 and LPN10 were observed providing bowel movement incontinence care to R1. After completing the incontinence care, they did not remove their gloves, did not perform hand hygiene, and did not put on a new pair of gloves before handling clean items and areas, including applying a clean adult incontinence brief, straightening R1’s linens, repositioning his body, applying bilateral heel protectors, and placing the top sheet over his body. During an interview on 07/24/25 at 02:21 PM, RCM1 stated that the gloves should have been removed and hand hygiene performed before touching R1’s clean items and areas. The facility policy titled Incontinence Care, dated 06/19/23, states to remove gloves and perform hand hygiene before replacing the incontinence pad or applying a disposable brief and replacing the top linen.
Leaking Shower Room Sink Without Warning Signs
Penalty
Summary
The facility failed to provide a safe and clean environment when a sink in a shower room was observed leaking water into a plastic bucket and onto the bathroom floor. On 07/23/25 at 08:32 AM, a bucket almost full of water was observed under the sink, with water dripping from the faucet and from the pipes under the sink onto the floor. No wet floor or other cautionary signs were posted to warn residents or staff of the wet floor. The Resident Care Manager confirmed the floor was wet from the leaking sink and said she would notify maintenance. Later that morning, the Director of Maintenance and a maintenance staff member were observed fixing the leaking sink, and both confirmed they had been notified of the water leak one week earlier. The Director of Maintenance also confirmed that wet floor signage should have been used to warn residents and staff of the unsafe condition in the shower room.
Hot Water Deficiency in Unit Two
Penalty
Summary
The facility failed to provide a comfortable temperature of hot water to residents in two shower rooms and a bathroom sink in Unit Two. On July 22, 2024, during an initial tour, it was observed that the hot water in the bathroom sink between Rooms 27 and 29 did not get warm. On July 25, 2024, the Maintenance Director confirmed ongoing issues with the hot water supply in Unit Two, despite recent repair efforts. During an interview, the Maintenance Director acknowledged the persistent problem and verified the lack of warm water in the sink and shower rooms. Review of invoices from February to June 2024 confirmed previous issues with the hot water on this unit.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage and handling practices. During an initial tour, it was observed that clean dishes, pots, and pans were stored on a rack that had rust-colored debris. The Kitchen Manager acknowledged the presence of rust-colored debris on the rack. Additionally, there was a failure to document the temperatures of all refrigerators and freezers on their logs for one day. The Kitchen Manager was unable to identify which log belonged to each refrigerator or freezer, and it was noted that two logs had the same heading, making it difficult to differentiate them. Furthermore, during a revisit to the kitchen, the Kitchen Manager was observed wearing dirty gloves while moving between kitchen areas and handling food items without changing gloves or performing hand hygiene. This included handling a lunch tray for a resident and preparing food items without changing gloves. The Kitchen Manager acknowledged the oversight and apologized for the deficient practice. These actions and inactions could potentially affect all residents and visitors who consume meals provided by the kitchen.
Deficiencies in Resident Documentation and Record Management
Penalty
Summary
The facility failed to maintain complete and accurate documentation for four residents, which could potentially affect all residents if their medical records are not properly managed. For one resident, there was a lack of documentation regarding a dental appointment, as the progress notes did not specify where the resident went or returned from on the specified date. The Resident Care Manager was unable to verify the appointment details due to the absence of a dental consult in the resident's record. Another resident's hospice certification had expired, and there were missing hospice progress notes and care plans in the resident's record. The Director of Nursing had to obtain these documents from the hospice company after the surveyor's request, indicating a lapse in documentation management. Additionally, there was an inconsistency in the documentation of a resident's code status, where a social service progress note inaccurately recorded the resident's wishes. Another resident was observed with a fall alarm attached to their gown, but there was no physician order for this alarm in the resident's record. The Director of Nursing and Social Services Director confirmed the absence of such an order during an interview. These deficiencies highlight the facility's failure to adhere to accepted professional standards in maintaining accurate and complete medical records for its residents.
Inaccurate Resident Assessment and Bed Alarm Documentation
Penalty
Summary
The facility failed to provide an accurate assessment of a resident's psychological state in the quarterly Minimum Data Set (MDS) and did not identify the use of a bed alarm. Specifically, the resident's mood and behavior were not coded with any indicators of psychosis on the Annual MDS, despite documentation of agitated behaviors in the nursing care plan prior to the assessment date. Additionally, the bed alarm, which was documented in the nursing notes as being in place, was not coded in the MDS. During an interview, the Social Services Director suggested that the behaviors may not have been present at the time of the assessment, although the surveyor noted that the behaviors were documented before the annual review date.
Failure to Provide Behavioral Health Care and Monitoring
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as R32, who was observed to be agitated and distressed while isolated in his room. R32, a male resident with a history of cerebral infarction, vascular dementia with behavioral disturbances, aphasia, and severe anxiety, was placed in isolation due to a COVID-19 diagnosis. During the survey, R32 was found yelling and acting out, with his bed placed in the middle of the room to prevent him from kicking the window. The resident was nonverbal, appeared distressed, and had tangled sheets and a wet gown. The nursing staff did not monitor his behaviors adequately or report changes to the physician for four days. The report highlights that R32's Trazodone, a medication used to treat depression, was put on hold due to an interaction with COVID medication, leading to increased agitation. Despite the resident's agitation, there was no documentation of behavioral observations by the staff, and non-pharmacological interventions were not implemented as per his care plan. The care plan included measures such as purposeful rounding, keeping the call light in reach, and providing meaningful distractions, none of which were documented as being followed. The resident's agitation was noted in progress notes, but there was no evidence that the physician was informed of these behaviors until the surveyor's inquiry. Additionally, the Activity Director confirmed that no activities were provided to R32 while in isolation, and the nursing staff was expected to turn on the TV for him, which was not done. The Director of Nursing and Social Services Director were unable to provide documentation verifying that the physician was contacted regarding R32's behaviors. The lack of monitoring and failure to implement non-pharmacological interventions resulted in the resident experiencing poor psychological and emotional health, as well as self-inflicted injuries from his behavioral outbursts.
Failure to Assist Resident in Scheduling Dental Appointment
Penalty
Summary
The facility failed to assist a resident, identified as R13, in scheduling a dental appointment that was missed on two occasions, 11/28/23 and 12/05/23, for a cleaning. The resident had a care plan in place due to being at risk for mouth or facial pain related to decaying or broken natural teeth and oral thrush. During a record review, it was found that there was no documentation confirming that R13 attended a dental appointment on 12/05/23, despite leaving the facility for an appointment that day. The facility's Resident Care Manager was unable to determine if the appointment was for the dentist, and no dental consult form was found for that date. Further investigation revealed that the last dental consult report for R13 was dated 08/15/23, and the resident had not been seen by the dentist in November or December 2023. The facility staff had informed the dental clinic that R13 was not feeling well on 11/28/23, leading to the missed appointment, but did not reschedule until 07/29/24. This oversight in scheduling and documentation could potentially affect all residents requiring assistance with dental appointments.
Failure to Timely Revise Care Plan for Resident's Fractured Leg
Penalty
Summary
The facility failed to revise a resident's care plan in a timely manner to reflect the current status and treatment of a fractured leg after a fall. The resident, who has cognitive communication deficits, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance, fell and injured her left lower leg, resulting in a fracture of the tibia/fibula. She was treated at the emergency room and returned to the facility with an orthopedic boot splint. However, the care plan was not updated until several days later to include the necessary interventions and monitoring for the splint. Furthermore, when the resident's splint was replaced with a cast at an orthopedic appointment, the care plan was again not revised to reflect this change. This oversight was confirmed during an interview with the Resident Care Manager, who acknowledged that the care plan had not been updated to reflect the current status of the resident's fracture. This deficiency in updating the care plan could lead to staff being unaware of the required treatment plan and necessary interventions.
Failure to Arrange Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to arrange transportation for a resident to attend a scheduled appointment with an orthopedic consultant, resulting in a delay in the removal of the resident's cast. The resident, who has been living at the facility since March 2021, has a history of cognitive communication deficit, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance. She is moderately impaired with a BIMS score of 8 and uses a wheelchair for mobility due to muscle weakness and difficulty walking. After sustaining a fracture of the tibia/fibula from a fall, the resident was treated with a cast and instructed to follow up for cast removal on July 15, 2024. However, the facility did not ensure the resident attended the follow-up appointment. The Resident Care Manager (RCM) and Unit Coordinator (UC) were responsible for arranging transportation for outside appointments. The RCM reviewed the consult notes and was supposed to notify the UC to make the necessary arrangements. Despite another appointment being made, the UC was not informed of the original appointment for July 15th, leading to a missed appointment and a delay in the cast removal, which was rescheduled for August 5th.
Inadequate Supervision of Resident with Behavioral Issues
Penalty
Summary
The facility failed to provide adequate supervision for a male resident, R3, who had a history of inappropriate behavior towards female residents. An incident was reported where R3 was observed by a CNA touching a female resident, R6, inappropriately over her clothing in the dining area. Despite R6's limited short-term memory, she confirmed the non-consensual nature of the contact and expressed a desire for police involvement. The facility's investigation confirmed the incident, and R3's care plan was updated to require supervision when he was in the presence of vulnerable female residents. Despite the care plan's stipulations, R3 was observed unsupervised in the dining area with another female resident, R39, which posed a risk to her safety. The surveyor noted that R3 was left alone in the dining area for approximately 10 minutes without staff supervision, contrary to the care plan's requirements. The Charge Nurse and Administrator were unaware of R3's unsupervised presence, indicating a lapse in the facility's monitoring procedures. R3's medical history includes impulsivity and a history of aggressive behavior, which necessitates close supervision to prevent further incidents. The facility's failure to adhere to the care plan and ensure R3's supervision in common areas highlights a significant deficiency in maintaining a safe environment for all residents, particularly vulnerable females.
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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.
Illustrative
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Nursing homes near Waianae
How nearby facilities compare on the same public inspection record.
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| Ka Punawai Ola | 11.2 mi | ★★★★★ | 4 | 0 |
| Daniel K Akaka State Veterans Home | 12.5 mi | — | 7 | 0 |
| Kulana Malama | 14.1 mi | ★★★★★ | 1 | 0 |
| Pearl City Post Acute | 16.3 mi | ★★★★★ | 9 | 0 |
| Avalon Care Center - Honolulu, Llc | 23.4 mi | ★★★★★ | 5 | 0 |
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