Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Pu'uwai 'o Makaha during CMS and state inspections, most recent first.
The facility failed to provide a comfortable temperature of hot water in two shower rooms and a bathroom sink in Unit Two. The Maintenance Director confirmed ongoing issues with the hot water supply, despite recent repair efforts. Invoices from February to June confirmed previous issues with the hot water on this unit.
The facility was found to have deficiencies in food storage and handling practices, including storing clean dishes on a rust-colored rack, failing to document refrigerator and freezer temperatures, and improper glove use by the Kitchen Manager. These issues could affect all residents and visitors consuming meals from the kitchen.
The facility failed to maintain accurate and complete documentation for several residents, including missing details of a dental appointment, expired hospice certification, and inconsistent code status documentation. Additionally, a resident was observed with a fall alarm without a physician order. These deficiencies indicate lapses in the facility's record management practices.
A facility failed to accurately assess a resident's psychological state in the MDS and did not document the use of a bed alarm. The resident's mood and behavior were not coded with indicators of psychosis, despite prior documentation of agitated behaviors. The bed alarm was noted in nursing records but not coded in the MDS. The Social Services Director indicated that behaviors might not have been present during the assessment, although they were documented earlier.
A resident with a history of cerebral infarction, vascular dementia, and severe anxiety was found agitated and distressed while isolated due to COVID-19. The facility failed to monitor his behaviors, report changes to the physician, or implement non-pharmacological interventions. His Trazodone was put on hold, leading to increased agitation, and no activities were provided during isolation. The lack of monitoring and interventions resulted in poor psychological health and self-inflicted injuries.
A resident missed two dental appointments for a cleaning due to the facility's failure to assist in scheduling. The resident, at risk for mouth pain due to decaying teeth, had a care plan in place. Despite leaving the facility for an appointment, there was no documentation confirming a dental visit. The last dental consult was in August, and the missed appointment was not rescheduled until months later.
A resident with cognitive and physical impairments experienced a fall resulting in a leg fracture. The facility failed to timely update the care plan to reflect the resident's treatment with a splint and later a cast, potentially leaving staff unaware of necessary interventions. This deficiency was confirmed by the Resident Care Manager.
A resident with cognitive and mobility impairments missed a scheduled orthopedic appointment due to the facility's failure to arrange transportation, delaying the removal of her cast. The resident, who uses a wheelchair and has a history of mental health issues, was supposed to have her cast removed following a leg fracture. The Resident Care Manager and Unit Coordinator were responsible for arranging the appointment, but a communication lapse led to the missed appointment, rescheduling it for a later date.
A resident with a history of inappropriate behavior was left unsupervised in a dining area with a female resident, despite a care plan requiring supervision. This lapse in monitoring occurred after a previous incident where the resident inappropriately touched another female resident. The facility's failure to ensure supervision highlights a deficiency in maintaining resident safety.
Hot Water Deficiency in Unit Two
Penalty
Summary
The facility failed to provide a comfortable temperature of hot water to residents in two shower rooms and a bathroom sink in Unit Two. On July 22, 2024, during an initial tour, it was observed that the hot water in the bathroom sink between Rooms 27 and 29 did not get warm. On July 25, 2024, the Maintenance Director confirmed ongoing issues with the hot water supply in Unit Two, despite recent repair efforts. During an interview, the Maintenance Director acknowledged the persistent problem and verified the lack of warm water in the sink and shower rooms. Review of invoices from February to June 2024 confirmed previous issues with the hot water on this unit.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage and handling practices. During an initial tour, it was observed that clean dishes, pots, and pans were stored on a rack that had rust-colored debris. The Kitchen Manager acknowledged the presence of rust-colored debris on the rack. Additionally, there was a failure to document the temperatures of all refrigerators and freezers on their logs for one day. The Kitchen Manager was unable to identify which log belonged to each refrigerator or freezer, and it was noted that two logs had the same heading, making it difficult to differentiate them. Furthermore, during a revisit to the kitchen, the Kitchen Manager was observed wearing dirty gloves while moving between kitchen areas and handling food items without changing gloves or performing hand hygiene. This included handling a lunch tray for a resident and preparing food items without changing gloves. The Kitchen Manager acknowledged the oversight and apologized for the deficient practice. These actions and inactions could potentially affect all residents and visitors who consume meals provided by the kitchen.
Deficiencies in Resident Documentation and Record Management
Penalty
Summary
The facility failed to maintain complete and accurate documentation for four residents, which could potentially affect all residents if their medical records are not properly managed. For one resident, there was a lack of documentation regarding a dental appointment, as the progress notes did not specify where the resident went or returned from on the specified date. The Resident Care Manager was unable to verify the appointment details due to the absence of a dental consult in the resident's record. Another resident's hospice certification had expired, and there were missing hospice progress notes and care plans in the resident's record. The Director of Nursing had to obtain these documents from the hospice company after the surveyor's request, indicating a lapse in documentation management. Additionally, there was an inconsistency in the documentation of a resident's code status, where a social service progress note inaccurately recorded the resident's wishes. Another resident was observed with a fall alarm attached to their gown, but there was no physician order for this alarm in the resident's record. The Director of Nursing and Social Services Director confirmed the absence of such an order during an interview. These deficiencies highlight the facility's failure to adhere to accepted professional standards in maintaining accurate and complete medical records for its residents.
Inaccurate Resident Assessment and Bed Alarm Documentation
Penalty
Summary
The facility failed to provide an accurate assessment of a resident's psychological state in the quarterly Minimum Data Set (MDS) and did not identify the use of a bed alarm. Specifically, the resident's mood and behavior were not coded with any indicators of psychosis on the Annual MDS, despite documentation of agitated behaviors in the nursing care plan prior to the assessment date. Additionally, the bed alarm, which was documented in the nursing notes as being in place, was not coded in the MDS. During an interview, the Social Services Director suggested that the behaviors may not have been present at the time of the assessment, although the surveyor noted that the behaviors were documented before the annual review date.
Failure to Provide Behavioral Health Care and Monitoring
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as R32, who was observed to be agitated and distressed while isolated in his room. R32, a male resident with a history of cerebral infarction, vascular dementia with behavioral disturbances, aphasia, and severe anxiety, was placed in isolation due to a COVID-19 diagnosis. During the survey, R32 was found yelling and acting out, with his bed placed in the middle of the room to prevent him from kicking the window. The resident was nonverbal, appeared distressed, and had tangled sheets and a wet gown. The nursing staff did not monitor his behaviors adequately or report changes to the physician for four days. The report highlights that R32's Trazodone, a medication used to treat depression, was put on hold due to an interaction with COVID medication, leading to increased agitation. Despite the resident's agitation, there was no documentation of behavioral observations by the staff, and non-pharmacological interventions were not implemented as per his care plan. The care plan included measures such as purposeful rounding, keeping the call light in reach, and providing meaningful distractions, none of which were documented as being followed. The resident's agitation was noted in progress notes, but there was no evidence that the physician was informed of these behaviors until the surveyor's inquiry. Additionally, the Activity Director confirmed that no activities were provided to R32 while in isolation, and the nursing staff was expected to turn on the TV for him, which was not done. The Director of Nursing and Social Services Director were unable to provide documentation verifying that the physician was contacted regarding R32's behaviors. The lack of monitoring and failure to implement non-pharmacological interventions resulted in the resident experiencing poor psychological and emotional health, as well as self-inflicted injuries from his behavioral outbursts.
Failure to Assist Resident in Scheduling Dental Appointment
Penalty
Summary
The facility failed to assist a resident, identified as R13, in scheduling a dental appointment that was missed on two occasions, 11/28/23 and 12/05/23, for a cleaning. The resident had a care plan in place due to being at risk for mouth or facial pain related to decaying or broken natural teeth and oral thrush. During a record review, it was found that there was no documentation confirming that R13 attended a dental appointment on 12/05/23, despite leaving the facility for an appointment that day. The facility's Resident Care Manager was unable to determine if the appointment was for the dentist, and no dental consult form was found for that date. Further investigation revealed that the last dental consult report for R13 was dated 08/15/23, and the resident had not been seen by the dentist in November or December 2023. The facility staff had informed the dental clinic that R13 was not feeling well on 11/28/23, leading to the missed appointment, but did not reschedule until 07/29/24. This oversight in scheduling and documentation could potentially affect all residents requiring assistance with dental appointments.
Failure to Timely Revise Care Plan for Resident's Fractured Leg
Penalty
Summary
The facility failed to revise a resident's care plan in a timely manner to reflect the current status and treatment of a fractured leg after a fall. The resident, who has cognitive communication deficits, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance, fell and injured her left lower leg, resulting in a fracture of the tibia/fibula. She was treated at the emergency room and returned to the facility with an orthopedic boot splint. However, the care plan was not updated until several days later to include the necessary interventions and monitoring for the splint. Furthermore, when the resident's splint was replaced with a cast at an orthopedic appointment, the care plan was again not revised to reflect this change. This oversight was confirmed during an interview with the Resident Care Manager, who acknowledged that the care plan had not been updated to reflect the current status of the resident's fracture. This deficiency in updating the care plan could lead to staff being unaware of the required treatment plan and necessary interventions.
Failure to Arrange Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to arrange transportation for a resident to attend a scheduled appointment with an orthopedic consultant, resulting in a delay in the removal of the resident's cast. The resident, who has been living at the facility since March 2021, has a history of cognitive communication deficit, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance. She is moderately impaired with a BIMS score of 8 and uses a wheelchair for mobility due to muscle weakness and difficulty walking. After sustaining a fracture of the tibia/fibula from a fall, the resident was treated with a cast and instructed to follow up for cast removal on July 15, 2024. However, the facility did not ensure the resident attended the follow-up appointment. The Resident Care Manager (RCM) and Unit Coordinator (UC) were responsible for arranging transportation for outside appointments. The RCM reviewed the consult notes and was supposed to notify the UC to make the necessary arrangements. Despite another appointment being made, the UC was not informed of the original appointment for July 15th, leading to a missed appointment and a delay in the cast removal, which was rescheduled for August 5th.
Inadequate Supervision of Resident with Behavioral Issues
Penalty
Summary
The facility failed to provide adequate supervision for a male resident, R3, who had a history of inappropriate behavior towards female residents. An incident was reported where R3 was observed by a CNA touching a female resident, R6, inappropriately over her clothing in the dining area. Despite R6's limited short-term memory, she confirmed the non-consensual nature of the contact and expressed a desire for police involvement. The facility's investigation confirmed the incident, and R3's care plan was updated to require supervision when he was in the presence of vulnerable female residents. Despite the care plan's stipulations, R3 was observed unsupervised in the dining area with another female resident, R39, which posed a risk to her safety. The surveyor noted that R3 was left alone in the dining area for approximately 10 minutes without staff supervision, contrary to the care plan's requirements. The Charge Nurse and Administrator were unaware of R3's unsupervised presence, indicating a lapse in the facility's monitoring procedures. R3's medical history includes impulsivity and a history of aggressive behavior, which necessitates close supervision to prevent further incidents. The facility's failure to adhere to the care plan and ensure R3's supervision in common areas highlights a significant deficiency in maintaining a safe environment for all residents, particularly vulnerable females.
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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 Waianae
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ka Punawai Ola | 11.2 mi | — | 4 | 0 |
| Kulana Malama | 14.1 mi | — | 1 | 0 |
| Pearl City Post Acute | 16.3 mi | — | 0 | 0 |
| Avalon Care Center - Honolulu, Llc | 23.4 mi | — | 0 | 0 |
| Nuuanu Hale | 24.1 mi | — | 26 | 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.