Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 Oahu Care Facility during CMS and state inspections, most recent first.
A resident with dementia and a history of exit-seeking behavior eloped from the facility after her Wanderguard bracelet failed to trigger the elevator alarm. Staff had last seen her in the dining room, but she left undetected and was later found by a member of the public with injuries from a fall. The device malfunction was confirmed after the incident, and the resident required hospital treatment for abrasions and skin tears.
The facility did not complete Baseline Care Plans within the required timeframe for three residents, failed to include a Stage 2 pressure ulcer in one care plan, and did not provide written summaries of the plans to two residents or their representatives, as confirmed by staff interviews and record reviews.
Three residents with pressure ulcers did not receive consistent repositioning every two hours as required by their care plans and facility policy. Documentation of repositioning was missing or incomplete for multiple days, despite staff awareness of the requirement. The DON confirmed that repositioning tasks were not always triggered upon admission, and review of the facility's policy showed that documentation standards were not met.
A resident with a history of falls and cognitive impairment was admitted following a subdural hematoma. Despite clear risk factors and multiple documented falls after admission, the care plan did not address fall risk until several days after the first in-facility fall. The omission of timely fall risk interventions in the care plan was confirmed by the DON and was not in accordance with facility policy.
The facility failed to maintain proper food safety and sanitation practices. Expired test strips were used to test sanitizer strength in the kitchen, a rack holding clean meal lids had rust-colored debris, and opened beverages in the nourishment refrigerator were not labeled with opened-on dates.
The facility failed to implement proper infection control measures for residents on isolation, as staff did not consistently wear required PPE when entering rooms of COVID-19 positive residents. Observations showed a Physical Therapist Assistant entering a room without a gown, face shield, or eye protection. Additionally, PPE and waste disposal practices were inadequate, with PPE containers and biohazard trash cans placed outside rooms due to space constraints, contrary to facility policy.
A facility failed to inform a resident of the risks and benefits of psychotropic drugs and did not obtain consent for their use. The resident, with anxiety disorder, dementia, and major depressive disorder, was prescribed mirtazapine and duloxetine. The DON could not locate the necessary consents, even after checking paper files, as the resident was on these medications before the facility's transition to EHR.
A resident capable of independent movement was improperly restrained by positioning wedges placed under the mattress and fitted sheet, restricting movement. Staff confirmed the wedges were not used for medical treatment but functioned as restraints. Despite the resident's high fall risk, no bed alarm was implemented, and care plans did not document the use of wedges.
The facility failed to provide written notification of the bed hold policy to two residents transferred to a hospital. One resident was transferred for acute lower GI bleeding, and the other for fractures after a fall. In both cases, the Social Worker Designee confirmed that the bed hold policy was not communicated in writing, contrary to facility policy.
A facility failed to use interpreter services for a Korean-speaking resident, leading to an inaccurate cognitive assessment and an elopement incident. Despite the care plan's directive to use alternative communication tools, staff attempted to communicate in English, resulting in ineffective interactions and an incomplete BIMS test. The resident, unable to understand English, demonstrated cognitive awareness by eloping from the facility, highlighting the need for proper communication support.
The facility failed to develop discharge plans for two residents admitted for short-term rehabilitation, as required by their policy. One resident, admitted for knee care, and another for a chronic leg wound, both lacked documented discharge plans with measurable objectives and timeframes in their EHRs. This deficiency was confirmed during a review with the DON.
A resident with limited English proficiency was not provided with necessary interpreter services, despite the facility having Korean-speaking staff and an administrator who speaks Korean. The care plan indicated the need for an interpreter, but services were not utilized since admission, leading to potential risk for the resident.
A resident with cognitive impairments eloped from a facility after accessing unattended scissors and cutting off her Wander guard. The facility failed to maintain a hazard-free environment and provide adequate supervision, as scissors were found in a resident-accessible area. The resident's cognitive abilities were underestimated, and her care plan was not updated following the elopement.
The facility failed to maintain accurate records for controlled medications, as a dose of morphine sulfate was administered without the administering nurse's signature on the log. This discrepancy was confirmed by an RN during an inspection, highlighting a breach in the facility's policy requiring immediate documentation of administered controlled substances.
The facility failed to properly store a resident's prescribed ointment and did not label ophthalmic drops with expiration dates for two residents. A CNA was found retrieving ointments from a resident's bedside table, which should have been locked in the treatment cart. Additionally, an inspection revealed that ophthalmic drops were not labeled with the date opened or expiration date, contrary to facility policy.
Failure to Prevent Elopement Due to Faulty Wanderguard Device and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, unsteady gait, and prior exit-seeking behavior eloped from the facility. The resident had been admitted following a hospital stay for an unwitnessed fall and was assessed as high risk for elopement. A Wanderguard bracelet was placed as a safety measure, and the resident was under supervision, with staff aware of her location in the dining room prior to the incident. However, the resident was able to leave the dining room undetected and exited the facility without staff noticing. The Wanderguard bracelet, which was intended to prevent such incidents, was found to be faulty after the event. Although staff had checked the device earlier in the day and found it to be working, it failed to trigger the elevator alarm when the resident exited. The malfunction was confirmed by both facility staff and an external technician after the incident. The resident was found several blocks away by a member of the public and was taken to the emergency department, where she was treated for multiple abrasions and skin tears resulting from a fall that occurred while she was outside the facility. The facility's policy required regular assessment and monitoring of the Wanderguard device, as well as supervision of residents at risk for elopement. Despite these measures, the failure of the Wanderguard system and lack of direct supervision at the time allowed the resident to leave the premises and sustain injuries.
Failure to Timely Develop and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to meet regulatory requirements for Baseline Care Plans (BCP) for three residents. For one resident, the BCP was not developed within 48 hours of admission, and for another, the BCP was left blank and not completed until after the required timeframe. Additionally, there was no documentation that two residents were provided with summaries of their BCPs, as required by facility policy. Interviews with the Director of Nursing (DON) and Nursing Supervisor (NS) confirmed that the BCPs were not completed on time and that the summaries were not provided to the residents or their representatives. One resident was admitted for short-term rehabilitation following hospitalization for repeated falls and was noted to have a Stage 2 sacral pressure ulcer on admission. The BCP for this resident did not identify the pressure ulcer, despite hospital discharge instructions including care for the injury. The BCP also lacked signatures from the resident or representative and no evidence was found that a copy was provided. The facility's policy requires BCPs to be developed within 48 hours of admission, to address immediate health and safety needs, and for written summaries to be provided and documented, but these steps were not followed.
Failure to Provide and Document Repositioning for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care by not ensuring that residents with existing pressure ulcers were repositioned as required by their care plans and facility policy. Three residents with pressure ulcers were not consistently turned or repositioned every two hours, and there was a lack of documentation to support that this standard of care was provided. For example, one resident was admitted with a sacral Stage 2 pressure ulcer that was not identified on her baseline care plan, and there was no documentation of repositioning until several days after admission. Another resident with an unstageable coccyx wound requiring substantial assistance had no documentation of repositioning every two hours as directed in the care plan. A third resident with multiple pressure ulcers also lacked documentation of regular repositioning, with records showing that documentation only began several days after admission. Interviews with CNAs confirmed that while they were aware of the need to reposition residents every two hours and document this in the electronic record, there were gaps in documentation, and some days had no entries for repositioning. The Director of Nursing acknowledged the importance of regular repositioning and confirmed that tasks for repositioning were not triggered for some residents upon admission. Review of the facility's repositioning policy further indicated that the required documentation and care practices were not followed, as staff failed to record the position, caregiver, and other required details in the residents' medical records.
Failure to Timely Address Fall Risk in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan (CCP) that addressed a resident's safety needs in a timely manner. The resident, who had a history of falls and was admitted with a subdural hematoma due to a fall at home, was noted on admission to be cognitively impaired, disoriented, and at risk for falls. Despite these risk factors, the baseline care plan did not assess functional ability and goals, and the high risk for falls was not included in the CCP upon admission. The care plan addressing fall risk was only initiated three days after the resident experienced a fall in the facility. During the resident's stay, multiple falls were documented in the nursing notes, including incidents where the resident was found on the floor, confused, and experiencing pain or minor injuries. Interviews confirmed that the high fall risk should have been included in the care plan from admission, in accordance with the facility's policy, which requires staff to identify and implement interventions for residents at risk of falls based on previous evaluations and current data. The failure to timely address the resident's fall risk in the care plan constituted the deficiency.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in their kitchen and nourishment areas. During an observation, it was found that the kitchen staff used expired Hydrion test strips to test the strength of the sanitizer solution in the three-compartment sink. The Food Service Worker confirmed the test strips were expired and replaced them with new ones, which tested the water within the acceptable range. Additionally, a rack holding clean meal lids near the stove was observed to have rust-colored debris, which was confirmed by the Dietary Manager. Furthermore, in the nourishment refrigerator on the second floor, opened beverages such as orange juice, prune juice, and cranberry juice were found without the required opened-on dates, as confirmed by the Nursing Supervisor.
Inadequate Infection Control Measures for Residents on Isolation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for residents on isolation, specifically those on transmission-based precautions (TBP). Observations revealed that staff did not consistently wear the required personal protective equipment (PPE) when entering rooms of residents who tested positive for COVID-19. For instance, a Physical Therapist Assistant was seen entering a resident's room without a gown, face shield, or eye protection, despite the room being marked for Special Droplet/Contact Precautions. The Director of Nursing confirmed that all staff were expected to wear a gown, gloves, mask, and eye protection when entering such rooms, as per the facility's policy. Additionally, the facility's handling of PPE and waste disposal was inadequate. PPE containers and biohazard trash cans were placed outside the rooms of residents who tested positive for COVID-19 due to space constraints inside the rooms. This practice was justified by the facility's administrator, citing advice from an Infection Control Consultant. However, the facility did not implement alternative solutions such as over-the-door PPE caddies and trash bag holders, which were discussed but not observed during the survey. The facility's policy required that PPE be donned upon entry and discarded in a dedicated container before leaving the resident room, which was not consistently followed.
Failure to Obtain Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform a resident of the risks and benefits associated with the use of psychotropic drugs and did not obtain the necessary consent for one of the five residents sampled for unnecessary medications. The resident in question was an elderly individual with diagnoses including anxiety disorder, dementia, and major depressive disorder, and was prescribed mirtazapine and duloxetine, both antidepressants. Upon review of the resident's Electronic Health Records (EHR), it was found that documentation of consent for these medications, including education on their risks and benefits, was missing. The Director of Nursing (DON) was asked to provide the consents for the use of these antidepressants, but he was unable to locate them, even after checking the paper files, as the resident had been on these medications before the facility transitioned to the EHR system. This deficiency placed the resident at risk for more than minimal harm due to the lack of informed consent.
Improper Use of Positioning Wedges as Restraints
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints used for staff convenience rather than medical necessity. Observations revealed that positioning wedges were placed under the mattress and fitted sheet of a resident's bed, creating a concave shape that restricted the resident's ability to move freely. The resident, who was capable of moving independently, confirmed that the wedges hindered his movement and that he could not remove them. Interviews with staff corroborated that the wedges were not used for repositioning or treating a medical condition, but rather functioned as a restraint. The resident was identified as a high fall risk, having recently fallen out of bed, yet no bed alarm was implemented as a precautionary measure. The resident's care plans for skin integrity and high fall risk did not include the use of wedges, indicating a lack of appropriate documentation and planning. The facility's policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident, which was applicable in this case. This deficiency placed residents with the ability to move independently at risk of harm.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for two residents who were transferred to an acute care hospital. The first resident, a [AGE] year-old, was admitted to the facility and later transferred to a hospital for acute lower gastrointestinal bleeding. The electronic health record (EHR) did not contain documentation that the resident's representative was provided with a written notification of the bed hold policy. The Social Worker Designee (SWD) confirmed that the policy was communicated via phone call but not in writing, which is against the facility's policy requiring a written agreement within 24 hours of discharge. The second resident was transferred to a hospital for pain related to fractures of the right hip and shoulder after an unwitnessed fall. Upon review, it was found that neither the resident nor the resident's representative was notified of the bed hold policy at the time of transfer. The SWD confirmed this oversight. This deficiency in communication has the potential to affect all residents transferred to an acute care hospital, as it could lead to miscommunication regarding the bed hold policy.
Failure to Implement Interpreter Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a Korean-speaking resident, identified as R56, by not utilizing interpreter services as documented in the resident's care plan. During an observation, staff attempted to communicate with R56 in English, despite the resident's inability to understand the language, as noted in the resident's Electronic Health Record (EHR). The care plan specified the need for alternative communication tools, such as interpreter services, which were not used during the Brief Interview for Mental Status (BIMS) assessment, resulting in an inaccurate score of 99, indicating the test could not be completed. Interviews with the MDS Coordinator and a Registered Nurse revealed that interpreter services had never been used for BIMS testing, and the resident's cognitive abilities were not accurately assessed due to the language barrier. The resident, who was minimally able to communicate with English-speaking staff, demonstrated cognitive awareness by eloping from the facility after observing staff behavior and disabling the Wander guard system. The RN confirmed that the resident's behaviors and elopement attempt could have been mitigated if interpreter services had been implemented to address the resident's needs and explain her circumstances.
Failure to Develop Discharge Plans for Short-Term Rehab Residents
Penalty
Summary
The facility failed to develop a discharge plan for two residents, leading to a deficiency in ensuring safe and appropriate discharge processes. Resident 61, a [AGE] year-old individual admitted for short-term rehabilitation for knee care, did not have a discharge plan documented in their comprehensive care plan. Despite the resident's indication of being at the facility for short-term rehabilitation, the electronic health record (EHR) lacked measurable objectives and timeframes necessary for a safe discharge, putting the resident at risk of premature discharge and potential readmission. Similarly, Resident 219, a [AGE] year-old admitted for short-term rehabilitation following hospitalization for a chronic right leg wound, also lacked a documented discharge plan in their EHR. The resident expressed a desire to return home once able to walk a short distance, yet their care plan did not include the necessary discharge goals or timeframes. During a review with the Director of Nursing (DON), it was confirmed that both residents' comprehensive care plans were missing the required discharge plans, contrary to the facility's policy expectations.
Failure to Provide Interpreter Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R122, was provided with appropriate communication services, specifically interpreter services, despite the resident's limited English proficiency. During the survey, it was discovered that the resident's primary language is Korean, and her ability to speak English is very limited. The care plan for R122, which was initiated and revised while surveyors were onsite, indicated that the resident requires an interpreter for communication. However, interviews and record reviews revealed that interpreter services were not offered or used for R122 since her admission, except when family and friends were available. Interviews with staff, including a registered nurse and admissions staff, indicated a lack of consistent use of interpreter services. The registered nurse was unsure if interpreter services were being used, while the admissions staff confirmed that no staff interpreters were used during the admission process. Although the facility has Korean-speaking staff and the administrator speaks Korean, these resources were not utilized to facilitate communication with R122. This oversight placed non-English speaking residents at potential risk for more than minimal harm due to impaired communication.
Resident Elopement Due to Inadequate Supervision and Hazardous Environment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision, resulting in a resident's elopement. During an observation, a pair of metal scissors was found unattended in a resident-accessible area, contrary to the facility's policy that scissors should be stored in the treatment cart. This oversight allowed a resident to access scissors and elope from the facility without staff knowledge, posing a risk of more than minimal harm to residents. The resident involved, a woman with a history of hypotonic hyponatremia, encephalopathy, depression, suicidal ideations, hypertension, and dementia, used scissors from her manicure kit to cut off her Wander guard, enabling her to exit the building undetected. The resident's cognitive abilities were underestimated, as she had previously tested the Wander guard system and observed staff disarming it. Despite her inability to complete the BIMS test due to language barriers, staff confirmed her awareness and cognitive functioning. The incident highlighted a lapse in supervision and environmental safety, as well as a failure to update the resident's care plan post-elopement.
Controlled Medication Recordkeeping Deficiency
Penalty
Summary
The facility failed to ensure that records for controlled medications were maintained and accurate, which could potentially lead to the diversion of controlled substances. During an inspection of the medication cart on the second floor, a discrepancy was found in the controlled medication logs. Specifically, a dose of morphine sulfate, an opioid pain-relieving medication, was administered to a resident, but the log lacked the signature of the staff member who administered it. This incident occurred on 08/16/24 at 11:01 PM. Registered Nurse (RN)9 confirmed that the staff member should have signed the log immediately after administering the medication, as per the facility's policy on controlled substances. The policy clearly states that the licensed nurse administering the medication must immediately enter their signature on the accountability record.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store physician-prescribed topical ointment for a resident and did not ensure that medicated ophthalmic drops were properly labeled with an expiration date for two residents. In the first instance, a resident with bowel and bladder incontinence had prescribed ointments stored improperly in her bedside table. A CNA was observed retrieving medicine cups containing creams and ointments from the resident's bedside table, which were not supposed to be left there. A registered nurse admitted to placing the ointment in a medicine cup for another nurse who did not have access to the locked treatment cart, assuming the ointment would be applied to the resident. In the second instance, an inspection of the medication cart revealed that three bottles of ophthalmic drops for two residents were not labeled with the date they were opened or an expiration/discard by date. This made it impossible to confirm when the medicated ophthalmic drops were opened. The facility's policy requires that multi-dose vials be labeled to ensure product integrity, and nursing staff should document the date opened on multi-dose vials. The registered nurse confirmed that the bottles should have been labeled according to the facility's policy.
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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) |
|---|---|---|---|---|
| Islands Skilled Nursing & Rehabilitation | 0 mi | — | 0 | 0 |
| Hale Ola Kino By Arcadia | 0.2 mi | — | 0 | 0 |
| Arcadia Retirement Residence | 0.3 mi | — | 1 | 0 |
| Kalakaua Gardens | 0.8 mi | — | 33 | 0 |
| Hale Nani Rehabilitation And Nursing Center | 1 mi | — | 26 | 0 |
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