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 Pearl City Post Acute during CMS and state inspections, most recent first.
A resident admitted with an indwelling foley catheter was supposed to have it removed upon admission, but the facility failed to do so, resulting in a urinary tract infection (UTI). The resident's family expressed concerns about the catheter, which were not addressed, leading to the resident's decline and hospitalization. The facility's Director of Nursing confirmed the catheter was not removed as ordered, contributing to the UTI and subsequent health issues.
A resident with rhabdomyolysis and muscle weakness experienced significant weight loss due to the facility's failure to monitor and address her hydration and nutrition needs. Despite orders to track her weight, there was a lack of documentation, and her poor intake was not adequately addressed. The resident declined supplements, and the MD was not informed of the weight loss until later, leading to an unplanned hospitalization.
A facility inaccurately coded the use of restraints for a resident in the most recent MDS assessment, indicating daily use of physical restraints. However, the resident's care plan showed that bed rails were used for bed mobility, not as a restraint. The MDS Coordinator acknowledged the error and stated that a correction would be made.
The facility failed to include a resident's representatives in developing and implementing a comprehensive, person-centered care plan. The resident, with a history of nontraumatic intracranial hemorrhage, chronic respiratory failure, and persistent vegetative state, was admitted without the family being involved in the care planning process. The Social Worker confirmed the absence of IDT documentation in the resident's EHR, and the DON acknowledged the lapse in the notification process.
The facility failed to ensure that a resident received care in accordance with professional standards by using an IV solution bag and lines past the specified discard date. The IV bag and lines, labeled with a start date of 04/18/24, were still in use on 04/22/24, despite having a discard date of 04/21/24. The Director of Nursing confirmed that the IV bag and lines should have been changed on 04/21/24.
A facility failed to identify an electrical hazard when a medical device was plugged into a power strip intended for less critical devices. The Environmental Services Coordinator acknowledged the error, noting that the power strip was meant for items like televisions or cell phones.
A facility failed to provide appropriate catheter care for a resident, as the catheter collection bag was observed touching the floor multiple times. This exposed the resident to potential contaminants, and both a registered nurse and the DON confirmed the improper handling of the catheter bag.
The facility failed to store food items under sanitary conditions, risking food-borne illness for a resident. Five containers of a resident's food in the recreation room refrigerator were found with a 'Use by date' of 04/19/24. RN10 confirmed the food should have been discarded, and the FSM stated that diet aids or nursing staff were responsible for this task, as per facility policy.
The facility failed to maintain accurate medical records for a resident. The resident was observed with a urinary catheter bag touching the floor, and the EHR inaccurately documented the catheter's purpose as preventing soiling of a pressure ulcer. The Nurse Supervisor confirmed the resident had no pressure ulcers, indicating a documentation error.
A resident with a physician's order to hold Senna for loose stools continued to receive the medication despite experiencing loose stools over several days. The MAR confirmed the administration of Senna, and the DON acknowledged that the medication should have been held, indicating a significant medication error.
The facility failed to follow infection control protocols, as a Respiratory Therapist did not perform hand hygiene before a procedure, and a housekeeper used only water to mop a resident's room due to unavailable cleaning solutions. The DON confirmed the need for hand sanitization and daily use of sanitizing solutions.
Failure to Remove Catheter Leads to UTI and Hospitalization
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as R25, who was admitted with an indwelling foley catheter that was supposed to be removed upon admission as per discharge instructions from the acute care hospital. The catheter was not removed until a later date, leading to the development of a urinary tract infection (UTI). The resident's family member repeatedly inquired about the removal of the catheter, expressing concern about the potential for a UTI, which was confirmed when the resident tested positive for a UTI. The resident experienced confusion and a decline in health, resulting in hospitalization for a serious illness. The resident, a female with a primary diagnosis of rhabdomyolysis and generalized muscle weakness, was admitted to the facility with specific instructions for a voiding trial and catheter removal. However, the facility did not attempt a toileting program or remove the catheter as ordered. The resident's condition worsened, with symptoms of confusion and weight loss, and she was eventually transferred to the emergency department. The facility's Director of Nursing confirmed that the catheter had not been removed as per the admission orders, contributing to the resident's UTI and subsequent hospitalization.
Failure to Address Resident's Hydration and Nutrition Needs
Penalty
Summary
The facility failed to recognize, evaluate, and address the hydration and nutrition needs of a resident, leading to significant weight loss and an unplanned hospitalization. The resident, a female with a primary diagnosis of rhabdomyolysis and generalized muscle weakness, was admitted to the facility with specific orders to monitor her weight daily for the first three days, weekly for four weeks, and monthly thereafter. However, there was a lack of documented weights between July 1 and July 16, during which the resident experienced an 11.5% decrease in weight. The average fluid intake was recorded at 274 cc per day, and nutrition intake was documented as 0-25%, indicating inadequate intake. Despite the resident's poor oral intake, skilled nursing notes failed to document any issues, and the resident's weight loss was not identified until July 16. The Registered Dietician noted that the resident's diet was liberalized, and snacks and supplements were offered, but the resident declined them. The Medical Doctor was not updated on the resident's weight loss until July 17. The facility's protocol required monitoring and documentation of weight and dietary intake, as well as reporting significant weight changes to the physician, which was not adhered to in this case.
Inaccurate Coding of Restraint Use in MDS Assessment
Penalty
Summary
The facility inaccurately coded the use of restraints for a resident, identified as R33, during the most recent Minimum Data Set (MDS) assessment. The assessment, dated 03/15/24, incorrectly indicated daily use of physical restraints. However, a review of R33's care plan revealed that bed rails were used for bed mobility and not as a restraint. During an interview, the MDS Coordinator acknowledged the coding error and stated that a correction would be made. This inaccuracy in the MDS assessment put the resident at risk for further inaccuracies in the Resident Assessment Instrument (RAI).
Failure to Include Family in Care Plan Development
Penalty
Summary
The facility failed to include Resident 89's representatives in developing and implementing a comprehensive, person-centered care plan. Resident 89, a [AGE] year-old male with a medical history including nontraumatic intracranial hemorrhage, chronic respiratory failure, and persistent vegetative state, was admitted to the facility on [DATE]. An interview with Resident 89's family representative revealed that she did not recall having a meeting with the facility's Interdisciplinary Team (IDT) since his admission. The Social Worker confirmed that there was no IDT documentation in Resident 89's Electronic Health Records (EHR). The Director of Nursing acknowledged that the normal process of notifying family members about IDT meetings and sending invitations did not occur for Resident 89. The facility's policy requires the IDT, in conjunction with the resident and their family or legal representatives, to develop and implement a comprehensive, person-centered care plan for each resident.
Failure to Change IV Bag and Lines on Time
Penalty
Summary
The facility failed to ensure that Resident 220 received care and treatment in accordance with professional standards of practice. During an initial observation on 04/22/24, it was noted that the resident's IV solution bag and lines were being used past the specified discard date of 04/21/24, 2330. The IV bag and lines, which were labeled with a start date of 04/18/24, were still in use on 04/22/24. An interview with the resident's family member confirmed that the same IV bag and lines had been in use since the resident's admission. A subsequent observation on 04/23/24 showed that a new IV bag and lines had been started. The Director of Nursing confirmed that the IV bag and lines should have been changed on 04/21/24.
Electrical Hazard Due to Improper Use of Power Strip
Penalty
Summary
The facility failed to identify a potential electrical accident hazard for one resident. During observations on two consecutive days, a medical device, specifically an air mattress machine, was found plugged into a power strip, which was then plugged into a wall electrical outlet. The Environmental Services Coordinator acknowledged that the medical device should not have been plugged into the power strip, which was intended for less critical devices like televisions or cell phones. The manufacturer’s product description confirmed that the power strip was designed for charging mobile phones, tablets, and other electronic devices, not medical equipment.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter received appropriate treatment and services to prevent urinary tract infections. During multiple observations, the resident's catheter collection bag was found touching the floor, which exposed the resident to potential contaminants. A registered nurse confirmed that the bag should not be in contact with the floor, and the Director of Nursing acknowledged that the cloth privacy cover could get wet and potentially transmit pathogens if left on the floor.
Failure to Discard Expired Resident Food Items
Penalty
Summary
The facility failed to store food items under sanitary conditions, which could place one resident at risk for food-borne illness. During an observation on 04/22/24 at 09:45 AM, five containers of a resident's food items in the fourth-floor recreation room refrigerator were found with a 'Use by date' of 04/19/24. Registered Nurse (RN) 10 confirmed that the food should have been discarded on 04/19/24. The Food Service Manager (FSM) stated that diet aids or nursing staff were responsible for discarding perishable foods on or before the use by date. The facility's policy, revised in March 2022, also documented that nursing staff should discard perishable foods on or before the use by date.
Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to maintain accurate medical records for one of the 24 sampled residents. On 04/22/24, a resident was observed with a urinary catheter bag touching the floor. A review of the resident's Electronic Health Records (EHR) on 04/23/24 revealed that the nurse had documented the presence of a catheter to prevent soiling of a stage 3 or 4 pressure ulcer on multiple dates. However, during an interview and record review on 04/24/24, the Nurse Supervisor confirmed that the resident did not have any pressure ulcers or injuries, indicating that the documented reason for the catheter was inaccurate. The Nurse Supervisor acknowledged the discrepancy and stated she would address it with the nurse involved.
Failure to Hold Medication Despite Loose Stools
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident had a physician's order for Senna, a medication for constipation, to be administered twice daily via G-Tube, with instructions to hold the medication if the resident experienced loose stools. Despite this order, the resident was documented to have loose stools on multiple consecutive days, from December 30, 2023, to January 4, 2024. However, the medication administration record (MAR) showed that Senna was still administered on these days. During an interview, the Director of Nursing (DON) confirmed that the medication should have been held due to the resident's condition, indicating a failure to adhere to the physician's order and prevent significant medication errors.
Infection Control and Cleaning Protocol Failures
Penalty
Summary
The facility failed to adhere to infection prevention and control measures, as evidenced by two separate incidents. In the first incident, a Respiratory Therapist (RT) was observed not performing hand hygiene before donning gloves and suctioning a resident's tracheostomy site. The RT admitted to not sanitizing her hands after consuming a drink and before attending to the resident, despite the facility's policy requiring handwashing prior to such procedures. This lapse in protocol was confirmed by the Director of Nursing (DON), who acknowledged that staff members are expected to sanitize their hands before donning gloves. In the second incident, a housekeeper was observed mopping a resident's room using only water, without any sanitizing solution. The housekeeper reported that they typically use a disinfectant spray or mix it with water, but on this occasion, no chemical solution was used. The Environmental Services Coordinator (EVSC) explained that a peroxide multi-surface cleaner is supposed to be used for mopping, but upon inspection, it was found that the janitor's room lacked the necessary cleaning solutions. The housekeeper confirmed that the cleaning solutions had not been refilled for an unspecified duration. The DON stated that housekeeping staff should be using a sanitizing solution daily in every resident's room, indicating a failure in maintaining proper cleaning protocols.
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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 Pearl City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kulana Malama | 4.9 mi | — | 1 | 0 |
| Avalon Care Center - Honolulu, Llc | 7.2 mi | — | 0 | 0 |
| Nuuanu Hale | 7.9 mi | — | 26 | 0 |
| Maluhia | 8.3 mi | — | 0 | 0 |
| Liliha Healthcare Center | 8.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.