Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ka Punawai Ola during CMS and state inspections, most recent first.
A resident with anemia, significant recent weight loss, poor oral intake, and a newly identified unstageable coccyx pressure ulcer experienced an acute change in condition with weakness and fever. Staff last documented stable vital signs in the morning and later obtained a fever of 101°F and elevated HR, but did not document these findings, did not complete progress notes, and did not record physician notification or a clear reason for transfer. The eINTERACT transfer form listed the wrong hospital and only included outdated morning vitals, and the transfer/discharge summary was blank. At the insistence of the family, the resident was sent to the ED, where she was found to have respiratory distress, generalized edema, a large sacral ulcer, and was diagnosed with pneumonia and septic shock. The deficient practice caused harm related to complications of sepsis.
A resident with hemiplegia, muscle weakness, gait disturbance, edema, impaired vision, and impaired memory was admitted for rehab and identified as a fall risk, requiring extensive assistance with transfers and toileting. Over the course of the stay, the resident experienced multiple falls and a near fall, including events where an unlocked wheelchair contributed to a fall, knees buckled while attempting to reach the bathroom, and falls occurred during standing ADLs with staff assistance, culminating in an open tibia/fibula fracture in the bathroom. Despite documented gait imbalance, knee buckling, persistent high fall risk scores, and PT notes describing unsteadiness and recommending 24-hour care, the care plan was not consistently revised to include specific environmental controls (such as wheelchair locks and bed position), interventions for impaired vision and memory, measures for LE edema (TED hose, fluid restriction), or increased supervision and possible two-person assist. Communication of critical PT findings to nursing was not clearly documented, and the DON acknowledged that key interventions and monitoring were missing from the care plan, contrary to the facility’s fall management policy requiring individualized interventions and care plan revision after each fall.
A resident with severe anemia, dependent on blood transfusions and at risk for rehospitalization due to chest pain, SOB, acute pneumonia, and other comorbidities experienced an acute decline that led to transfer to the ED. Although the care plan required timely communication to the physician/NP for any change in condition, there was no EHR documentation that the resident’s decline was recognized, that a physician was notified, or that the transfer to the ER occurred. The DON confirmed the lack of documentation, an APRN reported only that the on-call practitioner may have been contacted, and the RN involved could not recall whether the physician or APRN had been notified.
The facility failed to develop and implement comprehensive, individualized fall-prevention care plans for two residents. One resident with hemiplegia, muscle weakness, difficulty walking, HF, DM, and prior falls had physician orders for fluid restriction and TED hose, and documented visual impairment and multiple in-facility falls, yet these needs and repeated fall causes (including an unlocked wheelchair and legs giving out during transfers) were not fully addressed in the care plan with specific, targeted interventions. Another resident with gout, malnutrition, muscle weakness, dysphagia, and cognitive communication deficits had a care plan calling for bilateral fall mats when in bed, but observations showed the mats were placed against the wall away from the bedside rather than under the bed edges as ordered. The DON acknowledged that the care plan for the first resident could have been more comprehensive and that the floor mats for the second resident were not positioned correctly, confirming failures in both care plan development and implementation.
The facility failed to store food according to professional standards, as observed during a kitchen tour. Juice refills and boxes of fudge brownie mix lacked labels indicating arrival or use-by dates. The Food Service Director could not locate these dates, violating the facility's policy requiring food to be labeled with the date received.
The facility failed to provide appropriate care for five residents, including inadequate management of constipation, edema, and catheter care. One resident experienced prolonged constipation without proper intervention, while another had severe leg edema without a care plan. Additionally, laxatives were administered to residents with loose stools, and a resident with a Foley catheter had sediment-filled tubing and a strong urine odor, indicating a lack of timely catheter changes.
The facility failed to honor the food preferences of two residents, leading to unintended weight loss for one. A resident, admitted for rehab, reported weight loss due to receiving oatmeal and mush despite her documented preference against it. The Food Service Director was aware but the issue persisted. Additionally, another resident's preference for sandwiches on a hot plate was not followed, as observed during a tray line check.
The facility failed to ensure proper infection control measures, as staff did not adhere to transmission-based precautions and hand hygiene protocols. A resident with C. difficile was not provided meals in disposable containers, and staff used alcohol-based hand rub instead of washing hands with soap and water. Additionally, a CNA did not perform hand hygiene between glove changes while providing care to a resident on enhanced barrier precautions.
A resident in a LTC facility expressed dissatisfaction with not knowing the time range for her rehabilitation therapy sessions, which affected her ability to plan her day and manage pain medication. Despite her requests, the facility did not accommodate her preference, as confirmed by the Director of Rehab. This deficiency placed the resident at risk of not attaining her highest practicable well-being and could affect other residents receiving therapy services.
The facility failed to ensure residents were informed of their right to develop an advance health care directive (AHCD) and did not reassess decision-making capacity as required. Four residents were affected, with incomplete or missing AHCDs and lack of follow-up by the social worker. The facility's policy on reviewing advance directives was not followed.
The facility failed to maintain a comfortable environment for two residents due to cold room temperatures, with the thermostat reading 71°F and the air conditioner often left on by staff. Additionally, the kitchen had cleanliness issues with splatters on the ceiling, and the cleaning schedule was not fully adhered to. A resident also reported missing clothing items, with the facility lacking proper tracking and communication procedures for lost laundry.
The facility failed to provide timely written discharge notifications to residents or their representatives and the Ombudsman for three residents. One resident was transferred to a hospital twice without proper notification, another was hospitalized twice due to a stroke without notification, and a third was discharged home without notification following a Medicare Non-Coverage notice.
A facility failed to provide a resident and their representative with written notification of its bed hold policy during two hospitalizations following a stroke diagnosis. The resident's EHR lacked documentation of the notification, and the Administrator confirmed the oversight. The facility's policy requires notification upon admission, hospital transfer, or therapeutic leave.
A facility failed to accurately document a resident's discharge status in the MDS Discharge Assessment. The resident, who was discharged home with home health services, was incorrectly recorded as discharged to a Short-Term General Hospital. This error was confirmed by the MDS Coordinator during an interview.
A resident with severe physical and cognitive impairments was left without sensory stimulation due to the facility's failure to implement a comprehensive care plan. The resident, dependent on staff for all care, was observed without any activities or entertainment, as staff did not turn on the radio or TV. This lack of individualized attention was confirmed by staff and reflected in unchanged, template-like activity progress notes.
A facility failed to maintain accurate POLST documentation for a resident, resulting in conflicting orders regarding resuscitation status. The resident's hard chart indicated CPR should be administered, while a POLST in the unit binder documented DNAR. The discrepancy arose from multiple changes to the resident's code status, with the original POLST being altered instead of issuing a new form. Facility staff were unable to immediately clarify the situation or identify who made the alterations.
Failure to Assess, Document, and Notify Physician for Acute Change in Condition Leading to Septic Shock
Penalty
Summary
The deficiency involves the facility’s failure to identify and intervene for an acute change in condition related to infection, and to provide appropriate treatment and care according to orders, the resident’s preferences, and goals. An older female resident was admitted for rehab services after a hospitalization, with diagnoses including anemia requiring blood transfusions, difficulty walking, muscle weakness, dysphagia, and hypertension. She had experienced a 7.2% weight loss over 13 days, was at nutrition and hydration risk, required substantial/maximal assistance with eating, and was unable to ambulate or perform sit-to-stand. A deep tissue injury/unstageable pressure ulcer to the coccyx was identified one day prior to transfer, and the resident was on continuous oxygen via nasal cannula. On the day of the incident, the last documented vital signs in the EHR were taken in the morning, showing a temperature of 97.5°F, pulse 90, and BP 102/51, with oxygen saturation 93% and above on 2 L O2 and no shortness of breath noted. Later that day, the speech therapist reported to the RN supervisor that the resident was not looking well, and the family member expressed that the resident was not at her baseline, was weak, and had poor oral intake over the past few days. The family member raised concerns about hydration and requested that the resident be sent to the ED. The RN supervisor stated that the plan discussed with the family included calling the physician and possibly offering IV fluids, but the family insisted on transfer to the hospital. The RN assigned to the resident reported that when she assessed the resident, the resident felt warm, and she obtained a temperature of 101°F and noted a high heart rate, but she did not remember the exact pulse rate. Despite these findings, there was no documentation in the EHR of the resident’s acute change in condition, the elevated temperature and other vital signs at the time of decline, or any communication with the physician prior to transfer. The eINTERACT transfer form listed the wrong receiving hospital and contained only the morning vital signs, not the updated values obtained when the resident was febrile and tachycardic. The transfer/discharge summary in the EHR was blank, with no recorded status, date/time of transfer, reason for transfer, or documentation of physician or family notification. The DON confirmed that progress notes describing the decline, vital signs at the time of change, and physician notification were missing. The RN assigned to the resident acknowledged that she was busy, forgot to document the vital signs, and could not recall whether she had called the physician. The resident was ultimately transported to the ED by EMS at the family’s insistence, where she was found to have fever, tachycardia, respiratory distress, generalized edema, a large sacral pressure ulcer, and was diagnosed with pneumonia and septic shock. The deficient practice caused harm to the resident related to complications of sepsis. In addition, the record review showed that the resident had significant weight loss and was identified as being at nutrition and hydration risk, with poor oral intake mostly 0–50% and occasional refusals. Weekly weights were ordered, but there was a gap in weekly weight monitoring after admission, with only two weights documented over a 13-day period. The dietary manager reported that the weekly weight did not get done as ordered, and that the resident required a Hoyer lift, making weighing more difficult. Nutritional supplements and increased interventions were added only after the weight loss and pressure ulcer were identified. These findings provide further context to the resident’s overall compromised condition at the time of the acute change and subsequent sepsis diagnosis.
Failure to Implement and Revise Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and address fall risks and to implement and revise individualized interventions and supervision to prevent avoidable falls for a resident with significant mobility and balance impairments. The resident was an 87-year-old male admitted for rehabilitation and antibiotic therapy with diagnoses including hemiplegia and hemiparesis following intracerebral hemorrhage, muscle weakness, difficulty walking, heart failure, and diabetes. On admission, he required extensive assistance for transfers, toileting, personal hygiene, and dressing, had gait disturbance and unsteady gait due to right lower extremity weakness, and was identified as a fall risk. He also had moderately impaired vision and multiple skin abrasions. Despite these identified risk factors, the care plan did not include specific interventions for environmental safety such as ensuring wheelchair locks or bed position, nor did it address his visual impairment. The resident experienced multiple falls and a near fall after admission. In the first unwitnessed fall, he attempted to sit in his wheelchair, which had at least one unlocked wheel, and fell onto his buttocks. The incident report identified gait imbalance and ambulating without assistance as predisposing factors, and the DON later acknowledged that the wheelchair was a contributing factor. However, the care plan was not revised to include interventions related to ensuring the wheelchair was locked or other environmental controls, and there was no care plan addressing his moderately impaired vision. In the second unwitnessed fall, the resident attempted to get to his wheelchair to go to the bathroom, stating his knees gave out and he hit the back of his head. The incident report cited gait imbalance, impaired memory, and ambulating without assistance as predisposing factors, but the care plan did not incorporate the bed-in-low-position intervention described in the nursing note or additional interventions to address his impaired memory, such as increased monitoring. A near fall occurred when staff were attempting to obtain the resident’s weight; his leg buckled, causing loss of balance and resulting in a skin tear to his left knee and left great toe. Subsequently, a witnessed fall occurred when a CNA assisted him while standing to pull up his shorts and pivot to the wheelchair; his legs gave out and he was assisted to the floor. This was the resident’s second fall and third incident of his legs giving out, yet the care plan did not include interventions for TED hose application, fluid restriction, or specific measures to address lower extremity edema, memory impairment, continued leg weakness, gait imbalance, or the need for two-person assistance with ADLs. The final witnessed fall occurred in the bathroom during a brief change while the resident was standing and holding the grab bar with the wheelchair locked behind him; as the CNA inserted a new brief and the resident lifted and then put his leg down, he lost balance, the wheelchair shifted, and he sustained an open fracture of the left distal tibia and fibula. Throughout this period, physical therapy documentation showed persistent increased fall risk, unsteadiness, knee buckling, and a recommendation for 24-hour care, but PT1 could not recall communicating these significant findings to nursing, and the DON did not recall them being presented in daily rounds. The facility’s fall management policy required assessment, individualized interventions, and care plan revision after falls, but the interdisciplinary team did not consistently revise the care plan or implement adequate supervision and interventions in accordance with the resident’s evolving fall risk and clinical status. The facility’s own fall management policy stated that residents would be assessed upon admission, with changes in condition, and after any fall event, and that appropriate interventions would be identified and implemented to minimize fall-related injury risk. It also defined adequate supervision as being based on the resident’s assessed needs and required the interdisciplinary team to review and revise the care plan upon each fall event and as needed thereafter. Despite this, the record shows repeated falls and near falls with similar patterns of leg weakness and knee buckling, impaired memory, gait imbalance, and environmental factors (such as wheelchair positioning and locking) without corresponding, timely care plan revisions or documented communication of critical therapy findings to nursing. The DON acknowledged that interventions such as wheelchair locking, bed in low position, frequent monitoring, TED hose application, fluid restriction, and measures to address lower extremity weakness and memory impairment should have been included in the care plan to direct care and treatment, but they were not. This pattern of inaction and incomplete care planning contributed to the resident’s repeated falls and the serious injury sustained in the final fall.
Failure to Notify Physician of Resident’s Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of an acute change in condition for one resident, which resulted in a transfer to the Emergency Department (ED). The resident was admitted with diagnoses including severe anemia dependent on blood transfusions and had a care plan focus identifying risk for rehospitalization due to chest pain, shortness of breath, acute pneumonia, and other comorbidities. The care plan interventions directed staff to provide timely communication to the physician or NP regarding any change in the resident’s condition. On a documented date, a health status note indicated the resident was to be admitted to the hospital for septic shock. However, when the resident experienced a decline on a later date, there was no documentation in the Electronic Health Record (EHR) that the resident declined, that the physician was notified, or that the resident was sent to the ER. During the survey, the DON reviewed the EHR and confirmed the absence of documentation regarding the resident’s decline, physician notification, or transfer to the ER for that episode. An APRN stated that the nurse may have called the on-call practitioner since the event occurred on a weekend, but this was not documented. In a telephone interview, the RN who was involved in the resident’s care on the date of decline could not remember whether she had called the doctor or APRN to report the change in condition. These findings show that the facility did not follow the resident’s care plan intervention for timely communication to the physician/NP when there was a change in condition that led to hospitalization.
Failure to Develop and Implement Comprehensive, Individualized Fall-Prevention Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans to address fall risk and related needs for two residents. For one male resident in his late 80s with hemiplegia/hemiparesis after intracerebral hemorrhage, muscle weakness, difficulty walking, heart failure, and diabetes, the EHR showed physician orders for a 1500 ml/day fluid restriction and bilateral TED hose for edema that were not incorporated into the care plan. The initial fall risk assessment documented moderately impaired vision, but there was no care plan addressing visual impairment. The resident had a documented history of two falls at home requiring hospitalization and was receiving PT for strength and conditioning, yet these specific risk factors were not fully reflected in individualized care plan interventions. Between early February and late February, this resident experienced three witnessed falls, one unwitnessed fall, and one near-fall incident in the facility, including events where a wheelchair wheel was not locked, the resident’s knees or legs gave out during transfers or attempts to get into the wheelchair, and a loss of balance in the bathroom resulting in a major ankle injury requiring hospitalization and surgery. Despite these repeated incidents and the identified causes, the fall care plan contained only general interventions such as assisting with ADLs, keeping the call light within reach, completing fall risk assessments, orienting the resident to the room, placing a reminder sign to use the call light, encouraging toileting, increasing diuretics, and a speech therapy screen for cognition. There were no nursing interventions addressing the unlocked wheelchair, environmental hazards, or the resident’s memory impairment, such as hourly rounding or close monitoring, and no interventions targeting ongoing lower extremity edema, weakness, unsteady gait, or legs giving out, nor any care-planned consideration of staffing needs to meet the resident’s functional status. For a female resident with left knee idiopathic gout, moderate protein-calorie malnutrition, muscle weakness, dysphagia, and cognitive communication deficits, the care plan identified a focus of fall risk related to deconditioning and functional dependence after hospitalization, with a goal of avoiding serious injury requiring hospitalization. The documented interventions included bilateral fall mats when in bed, keeping the call light and frequently used items within reach, assisting with ADLs as needed, and completing a fall risk assessment. However, observations showed that when this resident was asleep in bed, the bed was in a low position but the fall mats were not placed at the bedside as care-planned; instead, they were positioned flush against the wall in front of the room entrance. The DON acknowledged that the floor mats were not in the correct place and that this placement did not benefit the resident, demonstrating a failure to implement the care-planned intervention for fall prevention. The facility’s own policy stated that comprehensive care plans should be monitored and revised over time based on changes in resident condition, but the documented care and observations showed that this was not effectively carried out for these residents.
Failure to Label and Date Food Items in Accordance with Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an initial tour of the facility's kitchen, it was observed that juice refills for a juice dispenser, including apple juice, orange juice, cranberry juice, and passion orange guava juice, were stored in a small prep-refrigerator without labels indicating when they arrived at the facility. Additionally, the Food Service Director (FSD) was unable to locate a use-by date on the juice refills. Furthermore, three boxes of fudge brownie mix were found without a use-by date or a date indicating when the facility received them. The facility's policy and procedure on Food Safety, revised on 04/26/23, requires that food be labeled with the date received if not already indicated on the item, using the First In, First Out (FIFO) method.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and resident preferences for five residents, leading to increased risks of avoidable declines and injuries. One resident, admitted for short-term rehabilitation following fractures, experienced prolonged constipation without adequate intervention despite having multiple laxative orders. The facility's Unit Care Coordinator acknowledged the oversight in not administering a suppository or documenting the reason for its omission, contrary to the facility's bowel protocol policy. Another resident, admitted with severe lower leg edema, did not have a care plan or provider orders to address the condition, such as leg elevation or compression stockings. Despite documentation of edema in nurse progress notes and an emergency room visit for increased swelling, the Director of Nursing confirmed the lack of a care plan and consistent monitoring. The resident was observed with inadequate leg elevation and no footrests on her wheelchair, exacerbating her condition. Additional deficiencies included the administration of constipation medications to residents with documented loose stools, contrary to physician orders to hold the medication in such cases. One resident had 33 loose stools over 25 days, yet received most doses of prescribed laxatives. Another resident with a Foley catheter experienced a strong urine odor and sediment-filled tubing, indicating a lack of timely catheter changes. The Unit Care Coordinator confirmed the catheter was not changed as documented, and the facility's policy did not address changing the catheter for visible sediment, leading to potential negative outcomes for the resident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to unintended weight loss. A cognitively intact female resident, admitted for short-term rehabilitation following a hip fracture, reported a weight loss of 5.8 pounds since admission. Despite her clear preference against oatmeal and mush, which was documented on her meal ticket under both Allergies/Dislikes and Preferences, she continued to receive these items. The Food Service Director acknowledged awareness of her preference and confirmed that the meal tickets were checked, yet the issue persisted. Additionally, during a tray line observation, an unsampled resident's preference for having sandwiches served on a hot plate was not honored. The Registered Dietician checked the order form twice before the cart was sent to the unit, but the oversight was only noticed after the cart was ready to go. The Food Service Director confirmed the error, indicating a lapse in following documented food preferences for residents.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures, as evidenced by multiple instances of staff not adhering to transmission-based precautions (TBP) and proper hand hygiene protocols. A resident, who was on contact enteric precautions due to a confirmed Clostridium difficile infection, was not provided meals in disposable containers, and staff did not consistently follow the required hand hygiene procedures. Observations included a registered nurse and certified nurse aides failing to wash hands with soap and water after doffing personal protective equipment (PPE) and using alcohol-based hand rub instead, which is not effective against C. difficile spores. Additionally, a certified nurse aide was observed carrying a resident's water pitcher out of the room, contrary to the infection control policy, and not wearing the appropriate PPE when re-entering the room. The aide also failed to perform hand hygiene after handling potentially contaminated items and before touching other surfaces, which could lead to cross-contamination. The infection preventionist confirmed these lapses in protocol and acknowledged the need for staff to adhere to the established guidelines for handling residents on contact precautions. In another instance, a certified nursing assistant did not perform hand hygiene between glove changes while providing perineal care to a resident on enhanced barrier precautions due to open wounds. This oversight was confirmed by the unit care coordinator, who stated that staff are expected to sanitize their hands between glove changes. These deficiencies in infection control practices have the potential to affect all residents, healthcare personnel, and visitors in the facility.
Failure to Honor Resident's Therapy Schedule Preferences
Penalty
Summary
The facility failed to honor and support a resident's preference to be informed of a time range for rehabilitation therapy services. The resident, a cognitively intact [AGE] year-old female admitted for short-term rehabilitation following fractures, expressed dissatisfaction with not knowing when her therapy sessions would occur. She wanted to plan her day, including visits from her grandson, and prepare for therapy by requesting pain medication in advance. Despite her repeated requests to the therapy staff for a time range, her preference was not accommodated. The Director of Rehabilitation confirmed that therapy schedules are printed the day before and provided to the nursing staff, who then prepare therapy slips for residents. However, the facility does not schedule residents for specific times or time blocks, which led to the resident's needs not being met. This deficiency in supporting resident choice placed the resident at risk of not attaining her highest practicable well-being and has the potential to affect all residents receiving therapy services at the facility.
Failure to Ensure Advance Health Care Directives for Residents
Penalty
Summary
The facility failed to ensure that residents were informed of their right to develop an advance health care directive (AHCD) and did not periodically reassess their decision-making capacity as required by state law. This deficiency was identified for four residents. For Resident 2, the facility did not have a completed AHCD on file, and the social worker confirmed that the existing Power of Attorney (POA) was for financial matters only. Despite the resident being cognitively intact, there was no documentation of follow-up discussions regarding AHCD options. Resident 16's AHCD was incomplete and lacked necessary signatures or notarization. The social worker acknowledged the deficiency and attempted to rectify it by contacting the resident's aunt, who was listed as the decision-maker. However, the aunt did not have a fully completed AHCD, and the facility had not ensured the document was properly executed. For Resident 40, who had severe cognitive impairment, the facility did not have an AHCD or a fully completed Declaration of Authority to Act As A Surrogate form. Similarly, Resident 7's records lacked an AHCD or POA, and there was no follow-up with the resident's daughter to obtain these documents. The facility's policy required review of advance directives upon resident admission, quarterly, and with any change in condition, but this was not adhered to in these cases.
Deficiencies in Resident Comfort, Kitchen Cleanliness, and Laundry Management
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for residents, as evidenced by uncomfortable room temperatures and cleanliness issues in the kitchen. Observations revealed that two residents, R283 and R284, experienced discomfort due to cold temperatures in their room, with the thermostat consistently reading 71 degrees Fahrenheit. Interviews with the residents and staff indicated that the air conditioner was often left on by staff, causing the room to become uncomfortably cold, especially at night and early morning. Despite complaints from the residents, the issue persisted, highlighting a lack of attention to maintaining a comfortable environment. Additionally, the facility's kitchen was found to have cleanliness issues, with multiple light brown splatters observed on the ceiling. The Food Service Director was unaware of the cause of the splatters, and it was only after the surveyor's observation that the splatters were cleaned. The cleaning schedule did not include ceiling cleaning, and there were gaps in the cleaning schedule sign-offs, indicating a lack of adherence to the facility's policy for maintaining a clean and sanitary environment. The facility also failed to protect a resident's clothing from loss, as evidenced by R32's complaint about missing clothing items. The resident reported that several articles of clothing were not returned from the laundry, leading her family to take over her laundry needs. The Housekeeping Director explained the process for handling missing laundry but did not keep track of missing items or residents. The Social Worker was unaware of R32's missing laundry issue, and no documentation was found regarding the incident, indicating a breakdown in communication and procedure adherence for addressing lost clothing.
Failure to Provide Timely Discharge Notifications
Penalty
Summary
The facility failed to provide timely written notification of discharge to residents or their representatives, as well as to the Office of the State Long-Term Care Ombudsman, for three residents. Resident 25 was transferred to an acute hospital twice, but the facility did not document or provide written notification to the resident's representative or the Ombudsman for either transfer. An email was sent to the resident's representative two days after the second discharge, but no notification was provided for the first discharge. Similarly, Resident 7 was transferred to the hospital twice due to a stroke, but no written notification was given to the resident or their representative, nor was the Ombudsman notified. Additionally, Resident 29 was discharged home following a Notice of Medicare Non-Coverage, but again, no written notification was provided to the resident or their representative, and the Ombudsman was not informed. The facility's administrator confirmed these lapses in communication during interviews.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident and their representative during two hospitalizations. The resident, who had been diagnosed with a stroke, was transferred and admitted to the hospital twice. A review of the resident's Electronic Health Record revealed no documentation that the facility provided the required written notification regarding the bed hold policy for the hospitalization period. During an interview, the Administrator confirmed that the facility did not give the written notification to the resident or their representative as required by the facility's policy. The facility's policy mandates that the bed hold policy should be given upon admission, upon transfer to the hospital, or when a resident goes on therapeutic leave, ensuring residents are aware of the policy before and upon transfer.
Inaccurate Discharge Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Discharge Assessment for a resident accurately reflected the resident's discharge status. During a record review, it was noted that a resident was admitted to the facility and later discharged to home. However, the Minimum Data Set (MDS) Discharge Assessment incorrectly documented the resident as discharged to a Short-Term General Hospital. An interview with the MDS Coordinator confirmed that the Discharge Assessment had been incorrectly documented and transmitted, and the resident had actually been discharged home with home health services.
Failure to Implement Comprehensive Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who is totally dependent on staff for all care. The resident, who has a diagnosis of intracranial hemorrhage, convulsions, quadriplegia, aphasia, and bilateral stiffness and contractures, was observed lying in bed without any activities or sensory stimulation. The resident's care plan included interventions such as encouraging leisure interests like listening to the radio or watching TV, but these were not implemented as the resident is unable to turn on these devices independently and relies on staff assistance. Observations over several days revealed that the resident was left without any form of entertainment or stimulation for extended periods. An interview with a staff member confirmed that the resident is dependent on staff to turn on the radio or television, and if staff are busy or forget, the resident remains unstimulated. The activity progress notes for the resident were mostly unchanged and appeared template-like, indicating a lack of individualized attention to the resident's needs.
Inaccurate POLST Documentation for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the Physician Orders for Life Sustaining Treatment (POLST) for one resident. The resident's hard medical record chart at the nursing station contained a POLST indicating that the resident should receive cardiopulmonary resuscitation (CPR) in the event of a medical emergency. However, a separate POLST located in the unit's POLST binder documented the resident as Do Not Attempt Resuscitation (DNAR). This discrepancy was identified during a review of the resident's electronic health record and discussions with the facility's social worker and social worker assistant. The investigation revealed that the resident's code status had been changed multiple times, with conflicting documentation in the medical records. The social worker confirmed that the hard chart contained the incorrect POLST and acknowledged that any changes to a resident's POLST should be documented with a new form rather than altering the original document. The facility staff could not immediately explain why there were two different POLST forms for the resident or identify who had altered the original POLST form.
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What surveyors actually found near you
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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 Kapolei
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kulana Malama | 4.5 mi | — | 1 | 0 |
| Pearl City Post Acute | 9.1 mi | — | 0 | 0 |
| Pu'uwai 'o Makaha | 11.2 mi | — | 0 | 0 |
| Avalon Care Center - Honolulu, Llc | 14.8 mi | — | 0 | 0 |
| Nuuanu Hale | 15.4 mi | — | 26 | 0 |
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