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 Kulana Malama during CMS and state inspections, most recent first.
A resident experienced two unplanned tracheostomy decannulations during care, both of which were managed without distress or complications. Although the incidents were reported in facility incident reports, there was no corresponding documentation in the EHR by nursing or respiratory staff, contrary to facility policy requiring such documentation for changes in condition.
A resident with a history of traumatic brain injury and complex medical needs experienced a fall, after which nursing staff failed to perform and document complete neurological assessments, did not recognize or respond promptly to significant changes in condition, and delayed notifying the physician and transferring the resident for higher-level care. Staff lacked training, competency validation, and access to necessary equipment for neurological checks, and facility policies were insufficiently specific regarding post-fall assessment requirements.
A resident with cognitive impairment, quadriplegia, and nonverbal status following a traumatic brain injury did not have a care plan that included specific interventions for staff to communicate with him using his established nonverbal methods, such as blinking and eye tracking. The care plan lacked documentation of these communication techniques, resulting in the absence of consistent guidance for staff.
A resident who was fully dependent on staff for all ADLs and nonverbal, with quadriplegia and contractures, fell from bed when a CNA left at least one bed rail down, the bed unlocked, and the room poorly lit while moving to the other side of the bed during perineal care. This failure to follow the facility's fall prevention policy directly led to the resident's fall.
A resident with a complex medical history, including TBI, hydrocephalus with shunt, tracheostomy, and quadriplegia, experienced a fall and subsequent decline in condition. Nursing staff were unable to reach the assigned physician for over four hours despite multiple attempts, and did not transport the resident to the ER in a timely manner. The physician was eventually reached and instructed staff to send the resident to the ER, resulting in a delayed transfer.
A resident who was fully dependent on staff for care experienced a preventable fall due to staff not securing safety rails and not following the required two-person assist protocol. The facility did not complete a thorough incident report or root cause analysis, failed to ensure timely physician response and emergency transfer, and did not review these events in its QAPI program. Nursing staff lacked competency in post-fall assessment and documentation, and leadership did not investigate or act on staff concerns, resulting in missed opportunities to identify and address systemic care issues.
A resident in a persistent vegetative state did not receive auditory stimulation, such as music or television, as outlined in their care plan. Despite family requests and care plan interventions for sensory activities, observations showed the resident in a quiet room without stimulation. The Recreation Coordinator noted that dependent residents should have a television on, but this was not consistently done, as confirmed by a nurse who turned on the TV only after being questioned.
A facility failed to ensure a clean environment for a resident when the mesh netting inside her crib became soiled during care and was not promptly cleaned or changed. The resident, who frequently placed her legs against the mesh, had a large liquid bowel movement that soiled the mesh, which was observed over several days. This increased the potential for exposure to an unsanitary environment, as confirmed by a nurse during an interview and record review.
A facility failed to properly document and communicate necessary information during the discharge of a resident with complex medical needs. The physician's discharge summary was insufficient, and there were no documented discharge orders. The RN confirmed verbal communication with the caregiver but did not complete the required discharge instruction form, violating facility policy.
A facility failed to ensure a safe environment for a resident by not conducting a safety assessment after installing a crib canopy. The resident, a 2-year-old with complex medical needs, experienced an unwitnessed fall from her crib. Although a canopy was added as a safety measure, the facility did not evaluate its potential hazards or its impact on the resident's development, as confirmed by staff interviews.
A resident was given insulin despite a blood glucose level below the physician-ordered hold parameter, leading to a critical drop in blood glucose later that day. The error was identified and reported by facility staff, and the resident's physician adjusted the insulin dosage.
The facility failed to provide routine dental care for two residents, with one resident's last dental consult in 2020 and another in 2021, despite care plans requiring regular dental visits. Observations showed poor oral hygiene, and there was no documentation of recent dental exams.
A facility failed to accurately document a medication order for a resident, leading to a discrepancy in the narcotic medication record. The record incorrectly stated a dosage of 8 ml of Lacosamide oral solution via J-Tube twice a day, while the correct dosage was 12 ml as verified by the RN with the electronic medical record and MAR. The RN acknowledged the error and noted that the narcotic form should have been updated.
The facility failed to ensure proper infection control practices, as observed in two incidents. An RN did not perform hand hygiene between glove changes after administering medication via a gastrostomy tube, contrary to facility policy. Additionally, a DCS member was seen with a face mask improperly worn under the chin while providing care, exposing their mouth and nose. These actions were confirmed by interviews with facility staff, highlighting lapses in infection prevention protocols.
Failure to Document Unplanned Tracheostomy Decannulations in EHR
Penalty
Summary
The facility failed to ensure proper documentation in the electronic health record (EHR) for two unplanned decannulations of a resident's tracheostomy tube. On two separate occasions, the resident experienced unplanned decannulations while being cared for by certified nurse aides, with both incidents being witnessed and reported in facility incident reports. In both cases, the tracheostomy tube was reinserted without difficulty, and the resident did not show signs of distress or decreased oxygen saturation. However, a review of the resident's EHR revealed that there were no progress notes written by a nurse or respiratory therapist regarding these unplanned decannulations, despite the facility's policy requiring nursing staff to document care provided and changes in the resident's condition in the medical record. Interviews with staff, including the respiratory therapist and the director of nursing (DON), confirmed that the expectation was for the nurse who responded to the incident to document the event in the EHR. The respiratory therapist involved in the incident stated he did not believe it was expected of him to chart the change in the EHR. The DON confirmed that the nurse should have documented the incident. The facility's documentation policy, provided by the DON, specifies that nursing staff are required to document care and changes in the resident's condition in the medical record, including through progress notes.
Failure to Ensure Nursing Staff Competency in Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide safe and appropriate care for residents with complex medical needs, particularly those with neurological impairments. Multiple licensed staff did not demonstrate competency in performing and documenting neurological assessments, identifying medical emergencies requiring timely intervention, or using critical thinking to determine the need for thorough assessments after a fall with potential head or neck injury. Documentation revealed that after a resident with a history of traumatic brain injury, craniectomy, and quadriplegia sustained a fall, staff did not complete full neurological assessments, including level of consciousness and pupillary response, as required by facility policy and standard care protocols. The resident, who had a baseline of neurological impairment and communicated by blinking, experienced a fall from bed while being changed by a CNA. Initial and subsequent nursing documentation focused primarily on vital signs, with incomplete or missing neurological assessment data. Staff failed to consistently document or perform assessments of the resident's level of consciousness and pupil response, and did not recognize or act upon significant changes in the resident's condition in a timely manner. There was a delay in notifying the physician and transferring the resident to a higher level of care, despite clear evidence of altered mental status and neurological decline. Interviews and record reviews indicated that staff were unclear about the components and frequency of neurological assessments, lacked access to necessary equipment such as penlights, and had not received adequate training or competency validation in these areas. The facility's policies lacked specificity regarding post-fall neurological assessments, and there was no evidence of structured training or competency checks for staff involved in the resident's care. The deficiency was determined to be immediate jeopardy due to the involvement of multiple staff and the serious nature of the failures.
Failure to Develop Comprehensive Communication Care Plan for Nonverbal Resident
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident with significant cognitive impairment and nonverbal status following a traumatic brain injury. The resident, who was quadriplegic, had a tracheostomy and a PEG tube, was unable to communicate verbally and relied on nonverbal cues such as blinking, laughing, and tracking with his eyes to interact with staff. Medical records and staff interviews confirmed that the resident used specific blinking patterns to indicate 'yes' or 'no' responses, and also responded with laughter and eye movements. Despite this, the resident's care plan did not include detailed interventions or instructions for staff on how to communicate with him using these established nonverbal methods. The care plan only generally addressed altered communication and cognition, with interventions limited to assessing pain using a specific pain scale. There was no documentation in the care plan about the resident's unique communication methods, such as blinking or tracking with his eyes, nor was there information about his baseline behaviors like laughing or smiling. This omission meant that staff did not have consistent, documented guidance on how to effectively communicate with the resident.
Failure to Secure Bed Rails Results in Resident Fall
Penalty
Summary
A resident with quadriplegia, contractures, and a history of traumatic brain injury, who was completely dependent on staff for all activities of daily living and nonverbal, experienced a fall from bed. The incident occurred when a CNA was changing the resident's diaper and turned the resident onto his right side. The CNA then moved to the opposite side of the bed, leaving at least one bed/safety rail down, the bed unlocked, and the room poorly lit. As a result, the resident fell from the bed while the CNA was on the other side. Facility records and staff interviews confirmed that the side rail on the side closest to the window, where the resident fell, was lowered at the time of the incident. The facility's fall prevention policy required that side rails be kept in the raised position when a resident is in bed. The DON confirmed that the fall was avoidable and that the CNA did not ensure the safety rails were secure and in place before leaving the resident's side, directly leading to the accident.
Delay in Emergency Physician Response and Resident Transfer
Penalty
Summary
The facility failed to ensure the availability of a physician for emergency care for one resident who experienced a fall and subsequent change in condition. The resident, a male with a history of traumatic brain injury, subdural hematoma, decompression craniotomy, post-traumatic hydrocephalus with a shunt, tracheostomy, PEG tube, and quadriplegia, fell from bed while being changed by a CNA. Following the fall, the resident exhibited a drop in oxygen saturation and became increasingly lethargic, eventually becoming unresponsive to painful stimuli and verbal questions. Despite these significant changes in condition, nursing staff were unable to reach the assigned physician for over four and a half hours, making multiple attempts to contact him directly and through the physician exchange service. During this period, staff did not transport the resident to the emergency room in a timely manner, despite the inability to reach the physician and the resident's deteriorating condition. The physician was eventually reached after more than four hours and instructed staff to send the resident to the ER, at which point 911 was called and the resident was transferred. Interviews with staff and the DON confirmed the delay in reaching the physician and uncertainty about the appropriate steps to take when the physician could not be contacted, especially as the physician was reportedly out of the country at the time.
Failure to Analyze and Address Quality Deficiencies After Resident Fall and Unplanned Hospitalizations
Penalty
Summary
The facility failed to systematically analyze and address quality deficiencies related to a resident's adverse events, including a fall and two unplanned hospitalizations for altered mental status. The resident was completely dependent on staff for all activities of daily living, including toileting, bed mobility, and transfers, and required a two-person assist and mechanical devices due to weight. Despite these needs, staff did not ensure safety rails were secure before leaving the resident unattended, resulting in a preventable fall. The incident report for the fall was incomplete, lacking documentation on whether the care plan was followed and if appropriate transfer techniques were used. The root cause analysis did not identify that incontinence care was provided by only one staff member instead of the required two, and there was no reminder to staff about the two-person assist requirement. The facility also failed to ensure 24-hour physician availability for emergency care, as the physician could not be reached for over four hours after the resident's fall and condition change. Staff did not transport the resident to the emergency room in a timely manner when unable to reach the physician. The Quality Assurance and Performance Improvement (QAPI) program did not review or identify delays in physician response or unplanned transfers, and did not address staff feedback regarding these issues. QAPI meeting minutes did not include any discussion of the resident's fall or related unplanned hospitalizations, and data elements related to rehospitalization and medical record audits were marked as compliant or not applicable, despite the events. Nursing staff demonstrated deficiencies in competency, including failure to perform and document neurological assessments, identify medical emergencies requiring timely transfer, notify providers of baseline condition changes, and conduct comprehensive assessments after the fall. Leadership received staff feedback about these deficiencies but did not investigate or develop action plans. The Director of Nursing was aware of the fall but did not personally investigate or review the medical record, and the administrator confirmed that unplanned discharges were not routinely reviewed for quality improvement opportunities. As a result, system and process issues were not identified or addressed to ensure nursing care met recognized standards of practice.
Failure to Provide Auditory Stimulation for Resident in Vegetative State
Penalty
Summary
The facility failed to enhance the quality of life for a resident who was in a persistent vegetative state by not providing auditory stimulation such as music or television. Observations over several days showed the resident in bed, either awake with eyes closed or sleeping, in a quiet room without any auditory stimulation. The resident's family member expressed concern about the lack of television or music, stating they had previously requested cartoons or similar programs to be played. Despite these requests, the facility did not consistently provide auditory stimulation. The Recreation Coordinator indicated that the presence of auditory stimulation depended on the resident's activity level, with more active residents having access to devices like iPads or cell phones. However, for dependent residents, a television should be on unless it is time to sleep. The resident's care plan included sensory stimulation activities, yet these were not implemented as observed. A Registered Nurse, when questioned, mentioned that activities would occur later in the day and subsequently turned on the television to a sports channel, highlighting a lack of consistent implementation of the care plan's interventions.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean environment for a resident, identified as R12, who was observed to have soiled mesh netting inside her crib. During care, the mesh netting came into contact with a soiled bedsheet after the resident had a large liquid bowel movement. Despite the resident's tendency to place her legs against the mesh, staff did not clean or change the soiled mesh immediately. Observations over several days confirmed the resident's continued contact with the soiled mesh, increasing the potential for exposure to an unsanitary environment. The deficiency was confirmed during an interview and record review with a registered nurse, who acknowledged the need for the mesh to be changed.
Deficiency in Discharge Documentation and Communication
Penalty
Summary
The facility failed to ensure proper communication and documentation at the time of discharge for a resident identified as R32. The resident, a male with a history of spastic diplegic cerebral palsy, epilepsy, acute respiratory failure, and a tracheostomy, was discharged voluntarily. However, the necessary discharge documentation was incomplete. The physician's discharge summary merely noted a 'stable course' without providing a detailed account of the resident's stay and treatment. Additionally, there were no documented discharge orders from the physician, and the discharge instructions form was not completed or documented in the Electronic Medical Record (EMR). The Registered Nurse (RN) responsible for the discharge confirmed that she verbally communicated the discharge checklist to the resident's caregiver but failed to document this discussion or complete the required discharge instruction form. The facility's policy mandates that all discharges require a physician's order and that the assigned nurse must complete and review the discharge instructions with the resident and responsible party, which was not adhered to in this case. This lack of documentation and communication represents a deficiency in the facility's discharge process.
Failure to Conduct Safety Assessment for Crib Canopy
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, resulting in a deficiency related to the safety of a resident's crib. A resident, a 2-year-old female with complex medical conditions including George's syndrome, paralysis of vocal cords and larynx, and chronic respiratory failure, experienced an unwitnessed fall from her crib. The incident occurred after staff had suctioned her tracheotomy and left the room, only to find her on the ground later with her GJ tube dislodged. Following this incident, the facility implemented a crib canopy as a safety intervention but did not conduct a safety assessment or evaluate the potential accident hazards associated with the new equipment. The lack of a safety assessment after the installation of the crib canopy was confirmed during interviews with facility staff, including a registered nurse and the administrator. The canopy, made of heavy-duty plastic, distorted the images on the television that the resident watched, which was not considered in terms of its impact on the resident's development. The facility's failure to assess the safety of the canopy and its effects on the resident's environment and development contributed to the deficiency identified in the report.
Insulin Administration Error Due to Ignored Hold Parameter
Penalty
Summary
The facility failed to ensure that a resident's insulin was withheld when their blood glucose level was below the physician-ordered threshold. Specifically, the resident was administered 55 units of Lantus Solostar insulin despite having a blood glucose level of 79 mg/dl, which was below the hold parameter of 80 mg/dl. This incident occurred during the morning medication round, and the error was identified later that day by the facility staff. The resident's blood glucose level was monitored throughout the day, and it was found to drop to a critical level of 69 mg/dl in the evening, necessitating intervention with glucose tablets. The error was reported to the charge nurse, the Director of Nursing, the resident's physician, and the resident's son. The physician subsequently adjusted the insulin dosage and maintained the same hold parameters.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure routine dental care for two residents, R10 and R5, as evidenced by outdated dental consults. R10's most recent dental consult was conducted in November 2020, despite having a care plan initiated in January 2020 that required yearly and as-needed dental consults. During a record review, it was found that there was no documentation of R10 being seen by a dentist in 2023, and the Assistant Director of Nursing was unable to confirm any recent dental visits. Similarly, R5's last documented dental consult was in November 2021, although the resident's care plan required dental examinations twice a year. Observations revealed that R5 had poor oral hygiene, with yellow and dirty teeth and white residue in the mouth. Despite the facility's claim that the dentist visits once a year, there was no documentation of a dental exam for R5 after 2021. The Unit Clerk was unable to provide evidence of a 2023 dental visit, as the dentist's office was closed at the time of inquiry.
Incorrect Documentation of Medication Dosage
Penalty
Summary
The facility failed to accurately document a medication order in the narcotic medication record for a resident, identified as R20, during a medication administration observation. The narcotic medication record incorrectly stated that Lacosamide oral solution 10 mg/ml should be administered at a dosage of 8 ml via J-Tube twice a day. However, upon verification with the electronic medical record and the medication administration record (MAR), it was confirmed that the correct dosage was 12 ml. The Registered Nurse (RN) 23 acknowledged the discrepancy and noted that the narcotic form should have been updated to reflect the correct dosage. The medication bottle had small labels indicating that the dosage had been changed in the medical record, but this update was not reflected in the narcotic medication record, leading to the deficiency.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented by staff, leading to deficiencies in infection prevention and control. On June 5, 2024, a Registered Nurse (RN) was observed administering medication to a resident via a gastrostomy tube. After completing the task, the RN removed her dirty gloves and donned a new pair without performing hand hygiene in between. When interviewed, the RN stated that she did not believe her hands were dirty, indicating a lack of adherence to the facility's hand hygiene policy, which requires hand hygiene immediately after glove removal. This was confirmed by the Assistant Director of Nursing, who acknowledged the requirement for hand hygiene between glove use. Additionally, on June 3, 2024, a Direct Care Staff (DCS) member was observed providing suctioning to a resident and then entering another resident's room with their face mask pulled down under the chin, exposing their mouth and nose. This was confirmed during an interview with the Infection Control Physician, who stated that staff should wear a face mask properly covering the mouth and nose while in a resident's room and during procedures like suctioning. These observations highlight lapses in the facility's infection control practices, specifically regarding hand hygiene and proper use of personal protective equipment (PPE).
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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 Ewa Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ka Punawai Ola | 4.5 mi | — | 4 | 0 |
| Pearl City Post Acute | 4.9 mi | — | 0 | 0 |
| Avalon Care Center - Honolulu, Llc | 10.3 mi | — | 0 | 0 |
| Nuuanu Hale | 11 mi | — | 26 | 0 |
| Maluhia | 11 mi | — | 0 | 0 |
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