The Care Center of Honolulu

Inspectors wroteBased on record review and interview, the facility failed to accurately assess one of three residents (Resident (R) 6) selected for review to reflect resident's health status upon returning from out on pass. Findings Include: Resident (R)6 is a [AGE] year-old male admitted to the facility on [DATE] and is currently receiving Intermediate Care Facility level of Care. Diagnoses included but not limited to congestive heart failure, nicotine dependence, osteoarthritis and diabetic neuropathy. On 04/22/26 at 11:00 AM, Office of Health Care Assurance (OHCA) received Facility Reported Incident (FRI) initial report with Intake #2991932. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide care in accordance with professional standards by not performing an accurate assessment of Resident (R)6 returning to the facility, and not taking actions to ensure family-supplied prescription medication was available for R7. As a result of this deficient practice, R6 received delayed medical attention after a fall, and R7 was placed at risk for adverse health effects for not taking prescribed medications.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for Resident (R)7) in accordance with accepted professional standards and practices. The documented reason for R7's missed medication dose was not accurate. This deficient practice has the potential to affect medical care provided to all the residents in the facility.

Inspectors wroteBased on interviews, and document review, the facility failed to provide evidence of a comprehensive Water Management Program (WMP) that is essential to prevent the spread of Legionella bacteria and other opportunistic waterborne pathogens (i.e. Pseudomonas, Acinetobacter) in the building water systems. The facility was not able to provide evidence that a facility risk assessment was conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. In addition, the plan did not include any text or comprehensive description of the building water system, or specify the testing protocols and acceptable ranges for control measures. As a result of this deficiency, the vulnerable residents were at increased risk of exposure to waterborne pathogens, which can cause serious health issues, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals are stored in a locked compartment and properly labeled. Medication was left on a resident beside table; One of nine medication carts was observed unlocked and unattended in the hallway; and insulin syringes were not labeled according to industry standards. The deficient practice compromised the safe storage and administration of medication to the residents and the potential diversion of medications on the unit. Findings Include: On [DATE] at 02:11 PM, concurrent observation and interviews were done inside Resident (R) 57's room. Observed two white tablets inside a medication cup on R57's bedside table, while Registered Nurse (RN)25 was outside resident's room talking on the phone. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that residents received food in accordance with their documented preferences for two [Residents (R) 111 and R104] of three sampled residents reviewed for food preferences, and for two non-sampled residents (R83 and R50) observed during the tray line. Specifically, R111, R104, R83, and R50 were served food items that were documented as dislikes in their dietary records. This failure resulted in residents receiving meals inconsistent with their stated preferences, potentially affecting their nutritional intake and satisfaction with food services. Findings Include: On 09/02/25 at 09:44 AM, an interview was conducted with R111. R111 stated he has concerns with the food at the facility and not following his preferences. R111 reported the facility sometimes doesn't follow his preferences or substitutions. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the personal belongings were inventoried upon admission for one [Resident (R) 29] of three sampled for missing property. R29's hearing aids were not identified as missing until greater than one month, resulting in R29's inability to effectively communicate with others. The deficient practice affected the resident's quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to accommodate the needs of one of one resident [Resident (R)78] sampled by not ensuring that the call light was always placed within reach or positioned so that it could be activated. As a result of this deficient practice, R78 was placed at risk of not having his emergent needs met in a timely manner. This deficient practice has the potential to affect all the residents at the facility who can activate a call light.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of abuse was reported to the State Agency (SA) and Adult Protective Services (APS) for one of two residents (Resident (R) 49) sampled for abuse. R49 alleged that two staff members had held her down in bed, at an undetermined time in the past. Findings Include: On 09/03/25 at 09:30 AM, an interview was conducted with R49. R49 reported that, some time ago, two staff members grabbed her, pushed her down, and held her in bed. R49 could not recall the names of the staff members, when the incident occurred, or the reasons for the interaction. However, she identified the staff members as Certified Nurse Aides (CNAs), noting that one of them was blonde and always wore her hair in a ponytail. R49 described feeling violated and attacked, stating that the staff members treated her as though she were crazy. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to accurately assess three of four resident's status sampled for Resident Assessment, [Resident (R) 5, R140, and R33]. The facility failed to identify R5's use of a mitten restraint on her right hand, instead identified it as not being used. The facility incorrectly coded R140 as receiving insulin one day a week instead of receiving a GLP-1 receptor antagonist, Trulicity. The facility coded R33 as a low risk for developing a pressure ulcer when in fact she is a high risk for developing a pressure ulcer. The deficient practice could affect all residents in the facility if the facility fails to accurately assess resident's medications, risk for pressure ulcer and use of restraints, incorrectly coding resident's status.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for one [Resident (R) 6] of one resident sampled for restraints, The deficient practice could affect all residents at the facility who are using bedrails. Findings Include: On 09/03/25 at 12:13 PM observed R6 in bed with bilateral 1/2 upper bedrails up on her bed. R6 was observed holding onto the rails as she lay in her bed. On 09/04/25 at 02:30 PM requested the Director of Nursing (DON) provide a copy of R6's consent for bedrail use and she stated it is in the resident's restraint physical assessment that was filled out on 07/27/25. The DON also stated the nurse wrote a progress note regarding the conversation with the Resident's daughter giving verbal consent for bedrail use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the care plan for one of two residents investigated for care planning, [Resident (R) 1] was revised by the interdisciplinary team to include interventions to prevent recurring hospitalizations. The resident has had multiple re-hospitalizations within the recent months and was not reflected in his care plan. The deficient practice may impact the resident's quality of life and the right to a dignified existence. Findings Include:Observation on 09/03/2025 at 02:08 PM in R1s room. R1 was lying in his bed and didn't answer make eye contact or speak when asked questions. R1 had a trachea collar that was connected to the mechanical ventilator. Noted a Gastric (G-tube) feeding pump at the bedside and an intravenous (IV) infusion pump on the other side of the bed. R1 was resting with his eyes open. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide the following for one [Resident (R) 15] of one resident sampled for quality of care: A homelike environment with a comfortable room temperature; provision of adequate personal care of hair, skin and nails; and provision of a water pitcher for hydration between meals. The deficient practice impacted the resident's quality of end-of-life care with a comfortable and dignified existence in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and services to prevent dehydration for one of one resident's sampled for nutrition/hydration, [Resident (R) 74]. This deficient practice affects residents who rely on staff to provide fluids to maintain proper hydration and health. Findings Include: On 09/02/25 at 10:29 AM, concurrent observation and interview was done. Observed no water pitcher at R74's bedside. Subsequent observation was done at 11:35 AM, and no water pitcher was observed at resident's bedside. An interview was done at 11:37 AM with R74, when asked if she needed water pitcher at her bedside, R74 stated, Yes, I would like to have my own water pitcher. R74 also explained that she feels thirsty at times and has dry lips but was not provided a water pitcher. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly, within three days, refer a resident with lost dentures for dental services for one [Resident (R) 150] of two residents sampled for dental services. As a result, R150 did not obtain the option or consult of denture replacement, and her dietary order was downgraded. Findings Include: On 09/02/25 at 09:22 AM, an observation and interview were conducted with R150. R150 reported that her dentures were stolen and needs a new pair. She could not recall how long her dentures have been missing, only that it has been a while. She stated she had informed the facility about the loss and was told the dentist comes to the facility. She has been waiting for a dentist to come for a replacement. R150 explained the missing denture has been affecting her ability to chew while eating. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff was wearing applicable personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP) and improper hand hygiene and glove changes between a dirty and clean task. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to support the resident's right to voice a complaint without the fear of reprisal or retaliation for one resident (Resident (R) 31) sampled. R31 reported an allegation of mistreatment by the Alleged Perpetrator (AP) to the Assistant Administrator (AADM). Initially, R31 reported he did not want to file a formal grievance due to being fearful what AP's reaction would be, and that R31 would not receive assistance from staff, or care would be withheld. During the facility's investigation, the facility informed R31 and AP that there should not be any form of contact between the two individuals. R31 informed AADM that despite this instruction, AP went into the resident's room and confronted him in a manner which made him feel fearful, intimidated, and unsafe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment. The facility did not remove any of the resident meal trays (an institutional characteristic) after serving residents in the dining room. This deficient practice affects all residents dining in the dining areas.

Inspectors wroteBased on observations and interviews, the facility failed to ensure posted nurse staffing information was in clear and in an identifiable and prominent place. As a result of this deficient practice, residents and resident representatives are not informed of the number of staff available for resident care.

Inspectors wroteBased on observations, interview, and record review, the facility failed to store and serve food in accordance with professional standard for food service safety. This deficient practice has the potential to place facility residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for one of the sampled residents (Resident (R) 415). This failed practice had a negative affect on R415's psychosocial well being and has the potential to affect all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to be free from verbal abuse for one resident (Resident (R)31) sampled. After filing a complaint with the facility regarding the Alleged Perpetrator's (AP) treatment of R31, AP was informed not to have any form of contact with the resident. Following this instruction, R31 reported to the Assistant Administrator (AADM) that AP had verbally confronted and intimidated him while he was alone in his room. AADM confirmed that he did not identify AP's confrontation and intimidation of R31 as potential abuse, and did not initiate an investigation into the incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of potential abuse to the Administrator of the facility, the State Agency (SA), and Adult Protective Services in accordance with State law through established procedures. R31 reported to the Assistant Administrator (AADM) that a staff member [alleged perpetrator (AP)] confronted him about an initial complaint he had made about AP. AADM confirmed the incident was not identified as potential abuse, and because of not identifying it as possible abuse, it was not reported accordingly.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of potential abuse for one resident (Resident (R)31) sampled. R31 reported to the Assistant Administrator (AADM) that a staff member confronted and intimidated him about a complaint he made about the staff member. AADM confirmed the incident was not identified as potential abuse and an investigation into the incident was not initiated.

Inspectors wroteBased on record review and interview, the facility failed to correctly document the presence of a stage three pressure ulcer in the Resident Assessment Instrument (RAI) for one Resident (R) 56 of 32 in the sample. As a result of this deficient practice, R56 was not properly coded which could affect the resident's care plan and potential outcomes. All residents have the potential to be affected.

Inspectors wroteBased on observation and record review, the facility failed to implement the care plan for two Residents, (R)126 and R218, of 32 residents in the sample. R126 was not repositioned at least every two hours to promote healing of his pressure ulcer and R218 was not routinely repositioned or transferred to a wheelchair. The deficient practice placed the residents at risk for a decline in their functional and physical health status. All residents who are dependent on staff have the potential to be affected.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment consistent with professional standards of practice to promote the healing and prevent infection of an existing stage four pressure ulcer for one Resident (R) 126. R126 required maximum assistance and was not repositioned off of the wound at least every two hours. The deficient practice places placed the resident at risk of worsening a stage four pressure injury. All residents who require maximum assistance from staff have the potential to be affected.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide the care to maintain or improve the highest level of range of motion and mobility for one Resident (R) 218 of 32 in the sample. The resident was not routinely repositioned and placed up in the chair daily as ordered by the physician. The deficient practice placed the resident at an increase risk of a decline in functional status.

Inspectors wroteBased on observation and interview, the facility failed to ensure that staff implemented specific competencies necessary for resident safety. This deficient practice has the potential for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled on 1 of 4 units in the facility. This deficient practice increases the risk for diversion of resident medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician, the facility's medical director, and/or director of nursing acted upon irregularities the pharmacist reported during the monthly medication regimen review (MRR) for two of five residents sampled (Resident (R) 67 and R110). The attending physician did not document in the medical record that the identified irregularities had been reviewed, nor did he/she document the rationale for the no change in medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's food preference/request was followed for one of four residents sampled (Resident (R) 106). R106 requested white bread for every meal and did not get white bread for every meal.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on 1 of 32 residents sampled, that were accurately documented. As a result of this deficient practice, Resident (R)313 was placed at risk for a decrease in quality and competency of care. In addition, based on observation, interview, and record review, the facility failed to keep a resident's Electronic Health Record (EHR) confidential. This deficient practice places residents' EHRs at risk for violations of the Health Insurance Portability and Accountability Act (HIPAA).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Binding Arbitration Agreements ([NAME]) they asked the residents (or their representatives) to enter into, were explained in a form and manner that they could understand. This is evidenced by 1 of 3 residents or resident representatives (of Resident 63) sampled stating she did not have the BAA explained to her in a way that she understood what it meant.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for two of six residents sampled for infection control (Resident (R) 126 and R85). R85's humidifier bottle was not properly secured to the oxygen concentrator. During R126 sacral wound dressing change, the nurse didn't sanitize hands after removing dirty gloves and before putting on clean gloves. This failure could place the resident at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to maintain a medical record that was accurately documented for one of three residents in the sample. Two entries documented in the electronic medical record stated the resident's fractured shoulder was the right shoulder when the injury occurred in the left shoulder. A third entry documented the resident was transferred to the wrong acute care hospital. The deficient practice has the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview, and policy review, the facility failed to protect and promote quality of life for 4 of 5 residents sampled (Residents (R)29, 52, 75, and 1) by making sure that they were treated with respect and dignity. Specifically, the facility failed to ensure that English was consistently spoken in all resident care areas, exposing R1 to frustrating situations. R29 handling R29 roughly while providing care despite resident's request to be gentle. R52 and R75 both reported having to wait 30 minutes to 1 hour for staff to respond and/or acknowledge the resident after activating their call light. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review (RR), the facility failed to accommodate the needs of 3 of 5 residents sampled (Residents (R)1, 74, and 100) by ensuring that their call lights were always placed within reach. As a result of this deficient practice, the residents were placed at risk of not having their needs identified and met in a timely manner. This deficient practice has the potential to affect all the residents at the facility who can activate a call light, or have it activated on their behalf.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was stored and prepared in accordance with standards for food safety. As a result of this deficient practice, all resident have the potential to be affected and experience harm.

Inspectors wroteBased on observations and staff interview, the facility failed to secure an electrical panel on Nursing Unit 4. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards.

Inspectors wroteBased on interview and record review (RR), the facility failed to identify and support 2 of 2 residents sampled (Residents (R)1 and 65) preference to be gotten up out of bed daily. As a result of this deficient practice, these residents did not have their needs met and were placed at risk of not attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, homelike environment for one out of 49 residents sampled (Resident (R) 88). This deficient practice has a negative effect on resident's quality of life and places her at risk for psychosocial harm. Findings Include: R88 is a [AGE] year-old female admitted to the facility on [DATE]. Observation and interview were conducted on 08/07/23 at 02:11 PM. R88 stated, My neighbor's snacks are all over the place. I don't like seeing it all! The curtains need to be washed. It has not been washed since I have been here. It smells bad. An observation was made on a tear in the curtain that created a 5inch-by-5inch hole. To the right of R88's television are shelves, tables, large plastic storage bins, and stackable trays. These items contained food, packing boxes, plants, pillows, blankets, paper goods, and drinks. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to document ongoing re-evaluation of the need for restraints for one out of four residents sampled (Resident (R) 429). This deficient practice places the resident at risk for psychosocial harm. Findings Include: R429 is a [AGE] year-old male admitted to the facility on [DATE]. Observations were conducted at various times between the dates 08/07/23-08/10/23. R429 had his mitten restraint on throughout the four-day span. Interview was conducted with Registered Nurse (RN) 25 on 08/09/23 at 01:34 PM near the nurse's station. RN25 stated that R429's mitten is supposed to be released every two hours. RN also mentioned that she only completes the flowsheet and has not charted in the progress notes regarding R429's restraint use. Interview was conducted with Unit Manager (UM) 3 on 08/09/24 at 02:58 PM. [...]

Inspectors wroteBased on interviews and document review, the facility failed to report one reportable event of suspected resident (Resident (R)52) abuse event to the State Agency (SA) and Adult Protective Services (APS) within 2 hours of the incident if serious bodily injury is present, as mandated by state law. On 03/28/23 it was reported to the facility that R52 had an injury to the right shoulder which was red, swollen, and could not move his/her arm. R52 was allegedly abuse by Facility Staff (FS)4. As a result of this deficient practice the SA did not have information to determine if an investigation by their agency was needed, and there is the potential incidents are not thoroughly investigated, putting all residents of potential abuse at risk.

Inspectors wroteBased on interviews and record review, the facility failed to ensure further potential for abuse was prevented and a completed report was submitted to the State Agency (SA) within 5 days of the incident. Facility Staff (FS)7 partially dislocated Resident (R)52's right (R) shoulder while attempting to reposition the resident. Applying the federal and state definitions of willful and abuse, the SA found the facility to not be in compliance with regulations and identified the incident as abuse. The facility did not identify the incident as abuse and therefore did not remove the staff from providing care and submitted the completed report 6 days after the incident.

Inspectors wroteBased on record review and interviews, the facility failed to properly document a transfer summary to be received by an acute care provider for one resident (R), R378, out of a sample of two residents. This deficient practice fails to inform the receiving acute care provider of the care needed by the resident and does not allow R378 a smooth transfer to the acute care provider from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely review and revision of the Resident's Comprehensive Care Plan (CP) included his family representative/healthcare surrogate for 1 of 3 residents (Resident (R)84) in the sample. As a result of this deficient practice, staff did not have all the information necessary to effectively address the resident's status, condition, and/or needs adequately so that he could meet his highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary care and services to ensure two residents' abilities in activities of daily living are not diminished. Facility Staff (FS)7 repositioned R52 by pulling the resident's arm resulting in a subluxation (partial dislocation) of the resident's right (R) shoulder. Prior to the incident, R52 could walk approximately 100 feet with minimal assistance and was in the process of finding appropriate discharge placement after the incident the resident is unable to walk and is not receiving restorative services to help maintain his/her strength to walk. As a result of this deficient practice, all residents needing restorative services are at a for potential risk of harm.

Inspectors wroteBased on observations, record review and staff interview, the facility failed to provide appropriate services to prevent urinary tract infection for one out of four residents (Resident (R) 43) sampled. This deficient practice exposes the resident to possible infection causing contaminants and has the potential to affect all residents with urinary catheters. Findings Include: On 08/07/23 at 09:58 AM, during initial observations, R43 was lying supine in bed with head elevated watching television. Observed R43 had a urinary catheter draining light yellow urine into a covered drainage bag that was on the floor. After initial observation of all 47 residents in the unit was completed, noted the drainage bag was still on the floor at the following times: 11:12 AM, 11:44 AM, 12:29 AM, 01:33 PM and 2:42 PM. On 08/08/23 at 08:20 AM, observed urinary catheter drainage bag was on the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate treatment and services to assess an identified complication, and prevent further potential complications related to enteral tube-feedings (TF) for 1 of 3 residents sampled (Resident (R)84). As a result of this deficient practice, the facility placed the resident at risk for continued avoidable complications. This deficient practice has the potential to affect all residents at the facility receiving enteral feedings.

Inspectors wroteBased on observation, interview, and record review (RR), the facility failed to ensure nurse competency in medication administration as evidenced by an extended release tablet being crushed and administered to a resident. This deficient practice places the residents at risk for avoidable declines in health status and decreased quality of care and has the potential to affect all the residents at the facility receiving crushed medications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that records for controlled medications are in order and that an accurate account is maintained and reconciled. The staff did not document the actual amount of medication in the container and signed off on medications not yet administered. As a result of this deficiency, there is a potential for the diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medication regimen irregularities were identified, reported, and addressed for 1 of 5 residents sampled (Resident (R)74). As a result of this deficient practice, the resident was placed at risk of avoidable complications related to his documented medication allergies. This deficient practice has the potential to affect all residents at the facility receiving medications.

Inspectors wroteBased on record review, the facility failed to maintain medical records on 1 of 36 residents sampled (Resident (R)25) that were complete and accurately documented. As a result of this deficient practice, the medication administration record (MAR) for R25 was incorrect until the state agency (SA) pointed out the discrepancy. Timely and accurate medical record documentation, especially of medications administered, is essential for the care of any resident. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to perform proper hand hygiene and follow infection control processes. This deficient practice places the residents and visitors at risk for the development and transmission of communicable disease and infections. Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), as well as follow standard precautions by performing hand hygiene in between glove changes. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.