Below 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 The Care Center Of Honolulu during CMS and state inspections, most recent first.
A resident with multiple chronic conditions returned from a leave of absence and was assessed by an RN, who documented that the resident was stable, denied pain, had no acute distress, and had no new skin issues. The next day, a head‑to‑toe skin and pain reassessment identified several minor injuries, including scratches, skin tears, abrasions, and blood blisters, and an X‑ray later revealed multiple acute minimally displaced rib fractures. During review, the Administrator acknowledged that the RN’s initial post‑return assessment was not accurate, contrary to facility policy requiring timely and appropriate resident assessments.
Two residents did not receive care according to professional standards when one resident returned from a pass after a fall and an RN’s head‑to‑toe assessment failed to identify multiple abrasions and skin tears associated with the incident, and another resident on short‑term rehab with immune thrombocytopenic purpura, encephalopathy, and atrial fibrillation missed several ordered doses of Eltrombopag Olamine because the family‑supplied medication was discarded once and later unavailable, with no documented notification to the family to obtain more medication.
A resident’s Eltrombopag Olamine, a medication used to boost blood component production, was not administered for multiple consecutive days, and the January MAR documented the missed doses as being on "hold" per a physician order that did not exist. Progress notes instead indicated the facility was awaiting medication from the family, and review of the EHR, including physician orders and scanned notes, confirmed there was no order to hold the drug. An RN and the Administrator both acknowledged the absence of any such order, demonstrating inaccurate and inconsistent medical record documentation.
The facility did not have a comprehensive Water Management Program (WMP) to prevent Legionella and other waterborne pathogens, lacking a risk assessment, detailed water system description, and specific testing protocols. A resident with multiple health conditions tested positive for Legionella antigen after being admitted for rehabilitation, and the facility was unable to provide documentation of a completed risk assessment or a coordinated WMP at the time of the survey. Existing measures, such as water heater temperature logs and ice machine maintenance, were insufficiently documented and did not meet CDC and ASHRAE standards.
A resident reported mistreatment by a staff member but was initially reluctant to file a formal grievance due to fear of retaliation. Despite assurances from the Assistant Administrator that the staff member would not have further contact, the staff member confronted the resident, causing significant psychosocial harm. The facility failed to recognize the incident as potential abuse, did not investigate or report it, and left the resident feeling unsafe and unsupported.
The facility failed to provide a homelike dining environment by serving meals on cafeteria-style trays without considering resident preferences. Observations and interviews revealed that this practice was consistent across different dining areas and times, affecting all residents. Staff were unaware of resident preferences, and care plans lacked documentation of such preferences.
The facility failed to post daily nurse staffing information in a clear and prominent location, making it difficult for residents and their representatives to be informed about staff availability. Observations showed that the information was mixed with other notices and not easily visible, while interviews confirmed that visitors and family members were unaware of its location.
The facility failed to store food according to professional standards, as a container of rice porridge with an expired discard date was found in the refrigerator. Additionally, the facility did not maintain a log for dishwasher sanitizer checks, despite policy requirements. The Dietary Director confirmed these lapses in adherence to the facility's food safety policies.
A resident's privacy was compromised when staff pulled a privacy curtain to assist a roommate, exposing the resident to the hallway. This incident was observed and confirmed by interviews, highlighting a failure to adhere to the facility's policy on resident privacy.
A resident in an LTC facility reported verbal abuse by a staff member, leading to feelings of fear and anxiety. Despite being instructed to avoid contact, the staff member confronted the resident, and the facility failed to recognize this as potential abuse or conduct an investigation. The resident, who was cognitively intact and dependent on staff for care, experienced increased anxiety and nightmares, prompting a request to move rooms for safety.
A resident reported to the Assistant Administrator that a staff member confronted him about a previous complaint, but this was not identified as potential abuse and was not reported or investigated. The resident, who was cognitively intact and required assistance with personal care, experienced fear and anxiety, leading to violent nightmares. The facility did not follow up with the resident or conduct an investigation, and the incident was not documented in the State Agency's tracking system.
A resident reported being confronted and intimidated by a staff member after filing a complaint, leading to fear and anxiety. The facility failed to identify the incident as potential abuse, did not initiate an investigation, and did not report it to state agencies. The resident, who was cognitively intact, expressed feeling unsafe and requested a transfer.
A facility failed to document a stage three pressure ulcer in the RAI for a resident with anoxic brain damage and muscle weakness. Despite a skin and wound evaluation confirming the ulcer's presence, the MDS quarterly assessment did not code it, leading to a discrepancy acknowledged by the MDS Coordinator.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident with a stage four pressure ulcer was not repositioned every two hours as required, while another resident with impaired mobility was not routinely transferred to a wheelchair. These failures placed the residents at risk for a decline in their health status.
A resident with a stage four pressure ulcer did not receive care consistent with professional standards, as the facility failed to reposition him every two hours, leading to the deterioration of the wound. The resident, who required maximum assistance due to his inability to move independently, reported insufficient staff availability for repositioning. The wound, which showed signs of infection, was exacerbated by a recent cardiac procedure. The wound nurse practitioner confirmed the need for regular repositioning to prevent further pressure on the ulcer.
A resident with hemiplegia and hemiparesis was not routinely repositioned or placed in a chair daily as ordered, leading to a deficiency in maintaining or improving her range of motion and mobility. Observations showed the resident lying in bed with signs of discomfort, and records indicated non-compliance with the care plan and physician's orders.
A facility failed to ensure proper medication disposal practices, as observed when an RN disposed of an Aspirin 81 mg tablet in an unsecured trash bin on a medication cart. The RN was unsure of the correct disposal method, and a resident passed by the exposed medication. The Unit Manager later confirmed that such medications should be disposed of in a closed system.
The facility did not maintain and reconcile controlled drug records on one unit. An RN was observed using an unlocked medication cart, and a review showed missing signatures on the Controlled Item Checklist for a narcotic count. The night shift RN admitted to not signing the sheet after the count, prioritizing the handoff of the medication cart to avoid delaying morning medication administration.
The facility failed to act on pharmacist recommendations during monthly medication regimen reviews for two residents. One resident's pain management recommendation was not documented or acted upon by the physician, and another resident's medication administration directions for a feeding tube were not clarified despite the pharmacist's advice. Documentation was missing in both cases.
A resident's request for white bread with every meal was not consistently met, despite clear communication with the dietician and documentation on the meal card. Observations showed the resident did not receive white bread for lunch on multiple occasions, contrary to the facility's policy to accommodate resident preferences.
A facility failed to maintain accurate medical records for a resident with an NPO order, as nurse progress notes incorrectly documented oral intake. The Unit Manager confirmed the documentation was incorrect and appeared copied and pasted. Additionally, a resident's EHR was left visible on a computer screen near the nurse's station, accessible to residents and visitors, violating confidentiality policies and risking HIPAA violations.
A facility failed to ensure that a Binding Arbitration Agreement was explained to a resident's representative in an understandable manner. The representative signed the agreement without understanding its purpose, as it was included in a set of forms sent for e-signature during the resident's readmission. The social services representative responsible for explaining the agreement had left the facility, leading to a communication lapse.
The facility failed to ensure proper infection control practices for two residents. One resident's oxygen humidifier bottle was improperly secured, resting on the unsanitary floor, posing an infection risk. Another resident's wound dressing change was conducted without proper hand hygiene between glove changes, contrary to facility policy, potentially exposing the resident to infection.
A facility failed to maintain accurate medical records for a resident, with errors in documenting the resident's shoulder injury and transfer details. The EMR incorrectly noted the right shoulder as fractured instead of the left and recorded a transfer to the wrong hospital. The nursing supervisor indicated that documentation accuracy is a team responsibility, but the facility's policy for complete and accurate records was not followed.
Failure to Accurately Assess Resident After Return From Leave of Absence
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate assessment of a resident’s condition upon return from an out‑of‑facility pass. The resident is an adult male with diagnoses including congestive heart failure, nicotine dependence, osteoarthritis, and diabetic neuropathy, admitted at an Intermediate Care Facility level of care. According to the facility‑reported incident, the resident self‑reported a fall that occurred while he was out on pass. The resident had been out from 11:18 AM and returned at 4:18 PM. Documentation in the electronic health record shows that an RN completed a “Nursing Assessment before/after Resident Transport/Leave of Absence” at 4:18 PM, recording that the resident returned via taxi in stable condition after a personal errand with his wife, was alert and oriented x3, denied pain or discomfort, had no acute distress, and had no new skin issues. Subsequent assessments and diagnostic testing revealed that this initial post‑return assessment did not accurately reflect the resident’s health status. On the following day, a head‑to‑toe skin and pain reassessment identified multiple minor injuries, including a scratch on the right inner forearm, a skin tear with total flap loss on the left elbow with scant serosanguineous drainage, abrasions and intact blood blisters on the left dorsal first digit, and a skin tear on the right dorsal first digit. An X‑ray obtained in the facility later showed acute minimally displaced fractures of the left 6th through 10th ribs. During an interview and record review, the Administrator confirmed that the RN did not accurately assess the resident upon his return. The facility’s policy on Resident Assessments states that the interdisciplinary team conducts timely and appropriate resident assessments, which was not followed in this instance.
Failure to Accurately Assess Post-Fall Injuries and Ensure Availability of Family-Supplied Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide care in accordance with professional standards and physician orders for two residents. One resident returned from an out‑of‑facility pass after a fall that caused multiple skin abrasions and fractured ribs. An RN performed a head‑to‑toe and pain assessment on the day of return but did not identify or document several injuries, including a scratch on the right inner forearm, a skin tear with total flap loss on the left elbow with scant serosanguineous drainage, abrasions and intact blood blisters on the left dorsal first digit, and a skin tear on the right dorsal first digit. The resident was later transferred to a hospital for further evaluation. The second resident, admitted for short‑term rehab with diagnoses including immune thrombocytopenic purpura, encephalopathy, and atrial fibrillation, was prescribed Eltrombopag Olamine 50 mg to be given Monday through Friday. The medication was supplied by the family because it was not available from the contracted pharmacy. After a transfer to an acute care hospital for GI bleeding and an unwitnessed fall, the resident returned to the facility. The MAR showed the medication was not administered on one December date, with progress notes indicating the facility was waiting on delivery from the family, and it was also not administered on multiple January dates for the same reason. An RN stated that the December dose was initially discarded when the resident went to the hospital and later found and given the next day, and confirmed that the January doses were not given because the medication was unavailable. The RN could not find documentation that the family had been notified to provide additional medication.
Inaccurate MAR Documentation for Missed Hematologic Medication Doses
Penalty
Summary
The facility failed to maintain accurate medical records for a resident receiving Eltrombopag Olamine, a medication used to boost production of a blood component to stop bleeding. The January Medication Administration Record (MAR) showed that this medication was not administered from 01/05/26 to 01/14/26, totaling eight missed doses. The documented reason for the missed dose on 01/05/26 was coded as "Hold/See Progress Notes," and the facility’s grievance investigation notes stated that the medication had been put on hold by the attending physician on 01/05/26. However, review of the physician’s orders in the Electronic Health Record (EHR) and the attending physician’s scanned notes revealed no order to hold the medication. Further review of the progress note dated 01/05/26 documented that the facility was awaiting arrival of the medication from a family member, indicating a different reason for non-administration than what was recorded on the MAR. During an interview and concurrent record review, an RN confirmed there was no physician order to hold the medication. In a separate review with the Administrator, it was again acknowledged that no order existed in the EHR to hold Eltrombopag Olamine. These discrepancies between the MAR, progress notes, grievance documentation, and physician orders demonstrate that the facility did not maintain accurate and consistent medical records in accordance with accepted professional standards and practices.
Failure to Implement Comprehensive Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to provide evidence of a comprehensive Water Management Program (WMP) necessary to prevent the spread of Legionella and other waterborne pathogens in the building water systems. During interviews and document reviews, it was found that the facility did not conduct a risk assessment to identify areas where Legionella and other pathogens could grow and spread. The WMP lacked a detailed description of the building water system, did not specify testing protocols, and omitted acceptable ranges for control measures. The documentation provided was a basic outline and did not include required elements such as a specific risk assessment, a detailed water system diagram, or a building description. A resident with multiple comorbidities, including chronic anemia, urinary retention, chronic kidney disease, and asthma, was admitted to the facility for rehabilitation after a hospital stay for septic shock. The resident later tested positive for Legionella antigen during a subsequent hospitalization for septic shock secondary to acute cystitis and pneumonia. The facility received notification of the positive Legionella case but was unable to provide documentation of a completed risk assessment or a comprehensive WMP at the time of the survey. The infection preventionist confirmed that the risk assessment was started only after the notification of the positive case and had not been completed. Further interviews revealed that the facility manager was unaware of when the current water system diagram was developed and confirmed that no risk assessment had been conducted as part of the WMP. Measures in place, such as water heater temperature logs and ice machine maintenance, lacked documentation of acceptable parameters and specific procedures. The facility relied on annual municipal water quality reports, which were not included in the current plan. The documentation and policies provided did not reflect a coordinated WMP consistent with CDC and ASHRAE standards, and there was a lack of documentation of program activities.
Failure to Protect Resident from Retaliation and Intimidation
Penalty
Summary
The facility failed to uphold a resident's right to voice grievances without fear of reprisal, resulting in psychosocial harm to the resident. A resident, identified as R31, reported mistreatment by a staff member, referred to as the Alleged Perpetrator (AP), to the Assistant Administrator (AADM). Despite expressing fear of retaliation and initially not wanting to file a formal grievance, R31 was assured by AADM that AP would not have further contact with him. However, AP later confronted R31 in his room, causing the resident to feel intimidated and unsafe. The facility did not recognize R31's allegations as potential abuse and failed to investigate or report the incident to state and federal agencies. R31 experienced significant psychosocial harm, including anxiety, hypervigilance, and nightmares, as a result of the confrontation and the facility's inaction. The resident's cognitive status was intact, as indicated by a perfect score on the Brief Interview for Mental Status, making him a reliable source of information. Interviews with facility staff revealed a lack of communication and action regarding the incident. The AADM did not initiate an investigation into the confrontation, and the Social Service Director (SSD) was unaware of the allegations due to being on leave. The Director of Nursing (DON) initially claimed an investigation was conducted but failed to provide documentation addressing the confrontation. The facility's failure to act on R31's report of intimidation and potential abuse left the resident feeling unsafe and unsupported.
Failure to Ensure a Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike environment for residents dining in the dining areas. During observations, it was noted that residents' meals were served and remained on cafeteria-style trays throughout the meal service. This practice was confirmed by Dining Staff (DS)3, who stated that all residents dining in the 1st floor dining room have their meals on trays and was unaware of the residents' preferences regarding this practice. Additionally, a family member of a resident reported that they were not given the option to have the food taken off the trays, indicating a lack of consideration for resident preferences. Further observations revealed that this practice was consistent across different dining times and areas within the facility. Interviews with staff, including a Registered Nurse (RN) and the Assistant Administrator (AADM), indicated that eating on meal trays is not typical in a homelike environment. The AADM acknowledged that resident preferences should be documented in their care plans, but a review of a resident's care plan showed no documentation of such preferences. This deficiency affects all residents dining in the facility's dining areas, as their preferences for a homelike dining experience were not considered or documented.
Deficient Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted in a clear, identifiable, and prominent place, leading to a deficiency in informing residents and their representatives about the number of staff available for resident care. Observations on multiple occasions revealed that the daily staffing information was posted on a bulletin board near the entrance of the building, mixed with other employee-related notices, making it difficult to identify. The form was printed on a small piece of paper, and the print was not legible from a distance, requiring individuals to stand very close to read it. Additionally, there was no larger sign indicating that the form was the 24-Hour-Daily Staff Posting. Interviews with visitors and family members confirmed that they were unaware of the location of the daily staffing information. Further observations on the facility's units showed that the staffing information was written on dry erase boards located at the back of the nurses' stations, over 10 feet from the entrance, making it difficult for residents and visitors to see. The Director of Nursing confirmed that the daily staffing information was posted on these boards and at the entrance, but acknowledged the issue when informed that the postings were not easily identifiable or visible. The deficiency was further highlighted when a family member with good eyesight confirmed that he had never seen the daily staffing information and was not informed by the staff about its location.
Deficiencies in Food Storage and Dishwasher Sanitizer Logging
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by two specific deficiencies. Firstly, during an observation and interview in the facility kitchen, a refrigerator was found to contain a container of rice porridge with a discard date of the previous day, indicating it should have been discarded. The Dietary Director acknowledged that the kitchen staff conducts audits twice daily, yet the expired food was not removed. The facility's policy on Food Receiving and Storage, revised in 2017, mandates that food be stored in compliance with safe food handling practices. Secondly, an observation and interview with a Dietary Aide revealed that while the dishwasher sanitizer was checked using a quality assurance strip, the results were not logged. The Dietary Aide confirmed that only the dishwasher's temperature was recorded, and there was no log for the sanitizer checks. The Dietary Director confirmed the absence of such a log. The facility's policy on Dishwashing Machine Use, revised in 2010, requires that a supervisor checks the sanitizer concentration and records it in a log, which was not being done.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy of a resident, identified as R415, which negatively impacted her psychosocial well-being. On multiple occasions, staff members pulled the privacy curtain from around R415's bed to provide privacy to her roommate, inadvertently exposing R415 to individuals passing in the hallway. This was confirmed during an interview with R415, who expressed her discomfort with being exposed to others while in a vulnerable state. An observation on a subsequent day confirmed the issue when a Certified Nurse Aide (CNA62) pulled the privacy curtain in a manner that exposed R415 to the hallway. R415 was left exposed for 20 minutes until the situation was addressed by a State Agency representative. The Director of Nursing acknowledged that the staff should have closed the door to ensure privacy, as per the facility's policy on resident rights, which emphasizes the protection of bodily privacy during personal care.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, resulting in a deficiency. The incident involved a resident who had filed a complaint against a staff member, referred to as the Alleged Perpetrator (AP), for inappropriate behavior. Despite being instructed not to have any contact with the resident, AP confronted the resident in an intimidating manner, causing the resident to feel unsafe and fearful. The Assistant Administrator (AADM) was informed of this confrontation but did not recognize it as potential abuse and failed to initiate an investigation. The resident, who was admitted for physical and occupational therapy, had intact cognitive abilities and was dependent on staff for personal care. After the confrontation, the resident experienced increased anxiety, hypervigilance, and nightmares, which were unusual for him. The resident expressed a lack of trust in the facility's ability to keep him safe, as the initial report of AP's behavior did not result in protective actions. The resident requested to be moved to another room to avoid further contact with AP. The facility's Social Service Director (SSD) was not initially informed of the incident due to being on leave, and no investigation was conducted until later. The Administrator was unaware of the confrontation and stated that AP would have been placed on leave if the incident had been reported. The lack of immediate action and failure to recognize the incident as potential abuse left the resident exposed to further risk of verbal abuse.
Failure to Report Allegation of Potential Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a resident to the Administrator, the State Agency, and Adult Protective Services as required by state law. A resident, who was cognitively intact and a reliable source of information, reported to the Assistant Administrator that a staff member confronted him about a previous complaint he had made. This confrontation was not identified as potential abuse by the Assistant Administrator, and therefore, it was not reported or investigated further. The resident, who was admitted for physical and occupational therapy and required assistance with personal care, experienced fear and anxiety following the confrontation, leading to violent nightmares. The facility did not follow up with the resident or conduct an investigation, leaving them unaware of the resident's new feelings of anxiousness and feeling unsafe. The incident was not documented in the State Agency's Aspen Complaints/Incidents Tracking System, indicating a failure in the facility's reporting procedures.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse involving a resident who reported being confronted and intimidated by a staff member after filing a complaint. The resident, who was cognitively intact and a reliable source of information, experienced fear, anxiety, and nightmares following the incident. Despite the resident's report to the Assistant Administrator, the incident was not identified as potential abuse, and no investigation was initiated. The Social Service Director, who was on leave at the time, was not informed of the allegations, and the Assistant Administrator, acting as the Grievance Officer, did not take appropriate action. The staff member involved was not placed on leave, and the incident was not reported to state agencies. The resident expressed feeling unsafe and requested a transfer to another facility. The lack of investigation and follow-up resulted in the facility being unaware of the resident's increased anxiety and feelings of unsafety.
Failure to Document Stage Three Pressure Ulcer
Penalty
Summary
The facility failed to accurately document the presence of a stage three pressure ulcer in the Resident Assessment Instrument (RAI) for a resident identified as R56. This resident, a male with anoxic brain damage, muscle weakness, and contractures, was admitted with a stage three pressure injury to the sacrum. A skin and wound evaluation dated 08/12/2024 confirmed the presence of this ulcer, noting it was present on admission and described its dimensions and condition. However, the Minimum Data Set (MDS) quarterly assessment dated 07/18/24 did not code the resident with an unhealed pressure ulcer, despite the prior discharge assessment on 04/24/24 indicating a stage three pressure ulcer. An interview with the MDS Coordinator confirmed the omission, acknowledging that the resident was diagnosed with a stage three pressure ulcer during the look-back period.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement the care plan for two residents, leading to deficiencies in their care. Resident 126, a male with a primary diagnosis of heart failure, septicemia, wound infection, and an unhealed stage four pressure ulcer, was not repositioned at least every two hours as required by his care plan. Observations over several days showed the resident consistently lying on his back with the head of the bed elevated, which did not align with the care plan's goal to promote healing and prevent further complications related to immobility. Resident 218, a female with depression, hemiplegia, and hemiparesis, was also not repositioned or transferred to a wheelchair as outlined in her care plan. The care plan specified that the resident should be up in a wheelchair daily, but documentation showed she was only in a chair on two occasions, with the rest of the time spent in bed. This failure to follow the care plan placed both residents at risk for a decline in their functional and physical health status.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care for a resident with a stage four pressure ulcer, which was not treated in accordance with professional standards to promote healing and prevent infection. The resident, who is cognitively intact, required maximum assistance for repositioning due to his inability to move independently. Despite the care plan indicating the need for repositioning every two hours, the resident reported that staff were not always available to assist, leading to prolonged periods of pressure on the wound. This lack of repositioning contributed to the deterioration of the pressure ulcer, which was observed to have green drainage and a foul odor, indicating infection. The resident, a male with a history of heart failure, septicemia, and COPD, was admitted with an unhealed stage four pressure ulcer on the sacral region. The wound nurse practitioner confirmed the resident's inability to reposition himself and emphasized the importance of regular repositioning to alleviate pressure on the wound. The resident's condition was further complicated by a recent cardiac procedure, during which he was immobile on a hard surface, exacerbating the wound. The wound was observed to be deep with yellow slough, and a culture sample was taken to assess the infection. The facility's failure to consistently reposition the resident as required placed him at risk of worsening his condition.
Failure to Maintain Resident's Range of Motion and Mobility
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion and mobility for a resident, identified as R218, who was not routinely repositioned or placed in a chair daily as ordered by the physician. The resident, a [AGE] year-old female with diagnoses including depression, hemiplegia, and hemiparesis, was observed on multiple occasions lying on her back in bed, exhibiting signs of discomfort such as shaking, facial grimacing, and moaning. Despite having a physician's order to be up in a wheelchair daily at 10:30 AM, records indicated that the resident was only documented as being up in the chair on two occasions, with the rest of the days showing she remained in bed. The resident's care plan included instructions for turning and repositioning, as well as using a mechanical lift for transfers, but these were not consistently followed. An interview with a Restorative Nurse Aide revealed that the resident was working with an outside rehabilitation agency, yet there was no indication that the facility's staff were providing the necessary restorative care. The lack of adherence to the care plan and physician's orders placed the resident at increased risk of a decline in functional status, as noted in the report.
Improper Medication Disposal by RN
Penalty
Summary
The facility failed to ensure that staff implemented specific competencies necessary for resident safety, as observed during a survey. On August 14, 2024, a Registered Nurse (RN) was seen disposing of a medication tablet, specifically Aspirin 81 mg, in an unsecured trash bin attached to a medication cart on Unit 4. This action left the medication visible and accessible to anyone passing by, including residents. The RN admitted uncertainty about the proper disposal method for the medication. During this incident, a resident independently wheeled past the medication cart, with the exposed Aspirin tablet still visible. The following day, the Unit Manager confirmed that non-controlled medications should be disposed of in a sharps container or another closed system, not in an unsecured trash bin.
Failure to Maintain and Reconcile Controlled Drug Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and reconciled on one of the four units. During an observation at the nurses' station, a registered nurse (RN24) was seen preparing medications from an unlocked medication cart. A review of the facility's Controlled Item Checklist revealed missing signatures from both the outgoing night shift nurse and the incoming day shift nurse for the narcotic count on the morning of the observation. RN24 acknowledged the oversight and later signed the checklist along with RN20. RN20, who was the only nurse on the night shift, admitted to not signing the controlled item sheet after performing the narcotic count with RN24. She explained that she handed off the medication cart to RN24 before signing the sheet to avoid delaying the morning medication administration.
Failure to Act on Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the physician, medical director, or director of nursing acted upon irregularities reported by the pharmacist during the monthly medication regimen review (MRR) for two residents. For one resident, the pharmacist recommended optimizing pain management by adding a medication for severe pain. However, the attending physician did not document any review or rationale for not changing the medication order, and the documentation was not found in the resident's electronic health record (EHR) or hard chart. The Director of Medical Records (DMR) was unable to provide documentation that the physician was notified or the rationale for the decision. For another resident, the pharmacist recommended clarifying medication administration directions for a resident with a feeding tube. Despite the recommendation, the medication orders were not updated to reflect administration via the feeding tube. The Licensed Practical Nurse (LPN) confirmed that the medications should have been administered through the feeding tube, but the orders still indicated administration by mouth. The facility did not document any response from the physician or nursing staff regarding the pharmacist's recommendation.
Failure to Meet Resident's Dietary Preferences
Penalty
Summary
The facility failed to adhere to a resident's food preferences, specifically for Resident 106, who requested white bread with every meal. Despite the resident's clear communication with the facility's dietician about her preference for white bread at every meal and milk every morning, these requests were not consistently fulfilled. Observations revealed that the resident did not receive white bread for lunch on multiple occasions, even though her meal card specified the provision of two slices of bread daily. The resident expressed confusion and frustration over having to repeatedly request these items, indicating a lack of consistent adherence to her documented dietary preferences. Interviews with the Dietary Director confirmed that the meal card should have ensured the resident received her requested items at each mealtime. The facility's policy, revised in October 2017, states that meals and nutritional supplements should be provided per scheduled mealtime or by request, accommodating resident choices and preferences. However, the facility did not meet this standard for Resident 106, as evidenced by the repeated failure to provide the requested white bread, highlighting a deficiency in the facility's food and nutrition services.
Deficiencies in Medical Record Accuracy and EHR Confidentiality
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as R313, who was admitted for short-term rehabilitation with diagnoses including acute respiratory failure with hypoxia, epilepsy, and esophageal obstruction. Despite having an active provider order for an NPO diet, indicating nothing by mouth, the nurse progress notes inaccurately documented that R313 was taking nutrition and hydration orally over several days. The Unit Manager acknowledged that the documentation was incorrect and appeared to be repeatedly copied and pasted, which should not have occurred. This inaccurate documentation posed a risk to the quality and competency of care provided to the resident. Additionally, the facility failed to keep a resident's Electronic Health Record (EHR) confidential. An observation near the nurse's station revealed a medication cart with a computer screen displaying a resident's EHR, visible to residents and visitors in the vicinity. A visitor was observed looking at the screen while waiting for staff assistance. The Registered Nurse nearby confirmed that the computer should not have been left open and unattended, as per the facility's policy, which requires users to log off when leaving a workstation. This lapse in confidentiality placed residents' EHRs at risk for HIPAA violations.
Failure to Explain Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the Binding Arbitration Agreements (BAA) were explained to residents or their representatives in a manner they could understand. This deficiency was identified during an interview with the family member (FM3) of a resident, who stated that she did not understand the BAA she had signed. FM3 reported that the BAA was included in a set of forms sent to her for signature when the resident was being readmitted from an acute care hospital. She did not recall the BAA being explained to her and stated that she was unaware of its purpose. After the state agency explained the BAA to her, FM3 confirmed that she would not have signed it had she understood its implications. Further investigation revealed that the BAA was part of an Admission Packet containing approximately 27 forms requiring signatures. The Director of Medical Records confirmed that these forms, including the BAA, were sent for e-signatures. Additionally, the social services representative who was supposed to review the BAA information with FM3 had already left the facility, indicating a lapse in communication and proper explanation of the agreement to the resident's representative.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for two residents, leading to potential infection risks. In the case of one resident, the humidifier bottle attached to their oxygen concentrator was improperly secured, with broken rubber bands and tape that had fallen off, causing the bottle to rest on the unsanitary floor. This situation was acknowledged by the Infection Preventionist as unacceptable due to the risk of germs and infectious diseases present on the floor, which could compromise the resident's health. In another instance, during a dressing change for a resident with a stage four sacral wound, a Licensed Practical Nurse (LPN) did not sanitize her hands after removing dirty gloves and before donning clean ones. This oversight was observed by a surveyor, who questioned the LPN about the proper procedure, prompting her to correct the mistake by applying hand sanitizer before putting on new gloves. The facility's wound care policy clearly outlines the need for hand hygiene between glove changes, which was not initially followed, potentially exposing the resident to infection.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to discrepancies in the documentation of the resident's condition and transfer details. Specifically, the electronic medical record (EMR) contained two entries that incorrectly documented the resident's fractured shoulder as the right shoulder, whereas the injury was actually in the left shoulder. Additionally, there was an error in the documentation regarding the resident's transfer to an acute care hospital. The EMR indicated that the resident was admitted to hospital A, but the resident was actually transferred and admitted to hospital B. The inaccuracies in the medical records were identified during a review of the EMR for the resident. The admission note initially documented the correct injury on the left arm, but subsequent skilled nursing notes incorrectly referenced the right arm. Furthermore, a general note inaccurately recorded the resident's transfer details. Interviews with the nursing supervisor revealed that the responsibility for ensuring accurate documentation is shared among the team, including the Director of Nursing and the Minimum Data Set Coordinator. The facility's policy on charting and documentation emphasizes the need for objective, complete, and accurate records, which was not adhered to 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) |
|---|---|---|---|---|
| 15 Craigside | 0 mi | ★★★★★ | 0 | 0 |
| The Ching Villas | 0.4 mi | ★★★★★ | 13 | 0 |
| Liliha Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Kuakini Geriatric Care, Inc | 0.6 mi | ★★★★★ | 0 | 0 |
| Maluhia | 0.8 mi | ★★★★★ | 0 | 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.