Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 21, 2025
Visit Reason
The inspection was conducted following a complaint regarding a privacy breach and possible neglect involving a resident at the facility.
Complaint Details
The complaint involved a video recorded on 09/30/25 showing a resident's uncovered buttocks and soiled incontinence brief without consent. The video was shared during shift reports. The staff member who recorded the video admitted to the act and was counseled. The complaint was substantiated.
Findings
The facility failed to maintain a resident's privacy and dignity when a video was taken without consent during personal care and shared among staff. The video showed the resident with a soiled incontinence brief, and the staff member who recorded it was counseled for violating facility policies.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to dignity and privacy by allowing a video to be taken of a resident during personal care without consent and sharing it among staff. This violated policies prohibiting recording without consent and compromised resident privacy.
Report Facts
Residents Affected: 1
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 20, 2025
Visit Reason
The inspection was conducted as the annual survey of Arcadia Retirement Residence to assess compliance with regulatory requirements.
Findings
The facility failed to update the service plan for Resident #1 as required, specifically not including added tasks following readmission and interventions related to nutrition and fluid status as ordered.
Deficiencies (1)
Service plan for Resident #1 was not updated to include added tasks following readmission and interventions related to nutrition and fluid status.
Report Facts
Inspection dates: 2
Inspection Report
Routine
Deficiencies: 6
Date: Oct 4, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Arcadia Retirement Residence.
Findings
The facility was found deficient in multiple areas including failure to obtain proper informed consent for psychotropic medications for several residents, inconsistent code status documentation with advance directives, failure to update care plans after resident falls, improper food sanitation practices, inaccurate resident care plan information regarding shared rooms, and unsecured electrical panels posing safety hazards.
Deficiencies (6)
F 0552: The facility failed to provide information on the risks and benefits of psychotropic medications to three of five sampled residents, resulting in incomplete or missing consent forms for antidepressant and antipsychotic medications.
F 0578: The facility failed to ensure that the code status was consistent with the Advance Health Care Directive for one resident, risking unnecessary cardiopulmonary resuscitation.
F 0657: The facility failed to revise the care plan for one resident after two falls, missing new interventions to prevent future falls.
F 0812: The facility did not follow proper sanitation practices in the kitchen, including unclean stove areas and expired food items, increasing risk for foodborne illness and fire hazards.
F 0842: The facility failed to correctly identify in a resident's care plan that she would be residing with her husband in a shared room, potentially affecting all residents in shared rooms.
F 0921: The facility failed to secure an electrical panel on the third-floor nursing unit, exposing residents and the public to accident hazards.
Report Facts
Residents sampled: 18
Residents affected by psychotropic medication consent deficiency: 3
Falls sustained by resident R63: 2
Expired food items observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding psychotropic medication consent forms and care plan updates | |
| Director of Nursing | Interviewed regarding care plan revisions after resident falls | |
| Kitchen Supervisor | Acknowledged unclean kitchen area and committed to cleaning | |
| Licensed Practical Nurse (LPN)10 | Confirmed expired food items should have been discarded | |
| Licensed Practical Nurse (LPN)11 | Confirmed expired cranberry juice should have been discarded | |
| Social Worker (SW)1 | Acknowledged code status inconsistency and planned correction | |
| Maintenance Staff 2 | Acknowledged unsecured electrical panel and need for locking |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 6, 2024
Visit Reason
The inspection was conducted in response to complaints and allegations including failure to honor resident medication preferences, failure to properly handle grievances, delayed reporting of alleged abuse, and failure to promptly notify physicians of significant radiology findings.
Complaint Details
The investigation was complaint-driven, involving substantiated issues including medication administration against resident/family wishes, inadequate grievance handling, delayed abuse reporting, and failure to notify physicians of critical radiology results.
Findings
The facility failed to honor a resident's and family member's request to discontinue melatonin, failed to establish an adequate grievance policy and timely investigate grievances, delayed reporting alleged sexual abuse to proper authorities, and did not promptly notify the ordering physician of significant radiology findings. These deficiencies posed minimal harm but had potential to affect residents' rights and safety.
Deficiencies (4)
F553: The facility failed to honor a resident's and family member's request to discontinue melatonin, resulting in continued administration despite refusal and lack of inclusion in the treatment plan.
F585: The facility's grievance policy lacked necessary elements such as anonymous filing, grievance official identification, and reasonable timeframes, and failed to timely investigate and communicate grievance resolutions.
F609: The facility failed to report alleged sexual abuse to Adult Protective Services and the Office of Healthcare Assurance within required timeframes, delaying investigation and notification.
F777: The facility failed to promptly notify the ordering physician of significant radiology findings due to an inefficient process and lack of policy on when to contact providers.
Report Facts
Residents Affected: 1
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in medication administration and communication deficiency |
| FM1 | Family member involved in complaints about medication and grievance handling | |
| Social Worker | Social Worker | Completed APS report and involved in abuse investigation |
| RN2 | Registered Nurse | Interviewed regarding radiology report handling and resident care |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 7, 2024
Visit Reason
Annual inspection of Arcadia Retirement Residence conducted on May 7, 2024.
Findings
No deficiencies were identified during the annual inspection; all rules and criteria were met with no plan of correction required.
Inspection Report
Deficiencies: 13
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, safety, medication management, and infection control at Arcadia Retirement Residence.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified care, accurate assessments, timely physician notification after falls, effective pain management, proper care planning, medication cart security, and infection control practices.
Deficiencies (13)
F 0550: The facility failed to ensure residents' right to a dignified existence as staff used force to make residents sit and reacted inappropriately to resident contact.
F 0551: The facility failed to ensure the resident representative's right to make decisions on behalf of a resident, as consent forms were signed by the resident instead of the health care POA.
F 0558: The facility failed to reasonably accommodate a resident's needs by not placing water within reach, causing the resident to have difficulty accessing water.
F 0580: The facility failed to immediately notify a resident's physician after a fall, delaying notification by 1 hour and 40 minutes despite the resident being on blood-thinning medications.
F 0584: The facility failed to maintain a safe, homelike environment as evidenced by building disrepair and staff noise disturbing residents' sleep.
F 0641: The facility failed to ensure accurate assessments for two residents, including misreporting pressure ulcers and cognitive status.
F 0655: The facility failed to include a newly admitted resident's advanced healthcare directives in the baseline care plan within 48 hours of admission.
F 0656: The facility failed to develop a complete care plan reflecting a resident's use of a walker and antidepressant medication.
F 0657: The facility failed to revise a resident's comprehensive care plan after a fall to address increased risk of injury related to anticoagulant medications.
F 0697: The facility failed to provide effective pain management for a resident, not offering stronger medication options despite resident's pain and preference.
F 0761: The facility failed to ensure a medication cart was locked when unattended, risking unauthorized access.
F 0842: The facility failed to maintain an accurate medical record for a resident, with care plan instructions conflicting with observed bed height.
F 0880: The facility failed to ensure proper glove use by a staff member, increasing risk of infection transmission.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding multiple deficiencies including resident rights, care planning, and pain management | |
| Advising Director of Nursing | Interviewed regarding multiple deficiencies including resident rights, care planning, and pain management | |
| Registered Nurse 5 | Observed leaving medication cart unlocked and interviewed about medication cart security | |
| Nursing Staff 42 | Interviewed regarding pain management and fall notification deficiencies | |
| Housekeeping Supervisor | Interviewed regarding building disrepair | |
| Infection Control Coordinator | Interviewed regarding improper glove use by housekeeping staff | |
| Certified Nurse Aides 63, 58, 12 | Interviewed regarding resident pain management | |
| Medical Director 8 | Interviewed regarding physician communication issues | |
| Physician 3 | Referenced in relation to delayed physician notification after resident fall |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 30, 2023
Visit Reason
Annual inspection of Arcadia Retirement Residence conducted to assess compliance with emergency care and disaster planning regulations.
Findings
The facility lacked documented evidence of quarterly rehearsal of emergency evacuation plans for staff and residents between June 2022 and October 2022.
Deficiencies (1)
Documented evidence of quarterly rehearsal of emergency evacuation plans unavailable between June 2022 and October 2022.
Report Facts
Inspection Date: May 30, 2023
Deficiency period: 4
Plan Completion Date: Jun 7, 2023
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Dec 22, 2022
Visit Reason
Annual inspection of Arcadia Retirement Residence to assess compliance with regulatory requirements related to resident rights, safety, care planning, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to document advance health care directives, unsafe environmental conditions due to mold exposure, improper use of physical restraints, failure to report injuries of unknown source, inadequate communication during resident transfers, lack of written bed-hold policy, incomplete implementation of care plans, malfunctioning exit door alarms leading to elopement risk, incomplete nurse staffing data, improper medication refrigerator temperature management, unsafe food storage temperatures, failure to adhere to COVID-19 PPE protocols, and dishwasher not maintaining proper sanitizing temperatures.
Deficiencies (13)
F 0578: The facility failed to document Resident 26's advance health care directive and did not provide periodic opportunities to formulate or update it.
F 0584: The facility failed to provide a safe, clean environment for Resident 32 exposed to mold from a water leak, risking adverse reactions.
F 0604: The facility failed to ensure Resident 47 was free from physical restraints as her posey belt was improperly placed behind her, preventing self-removal.
F 0609: The facility failed to timely report an injury of unknown source (fracture) of Resident 44 to Adult Protective Services as required by state law.
F 0622: The facility failed to communicate Resident 22's comprehensive care plan goals to the receiving hospital during transfer, risking suboptimal care.
F 0625: The facility failed to provide written information about bed-hold policy to Resident 22 or her representative upon hospital transfer.
F 0656: The facility failed to implement a complete care plan for Resident 47, including fall prevention interventions, resulting in multiple falls and injury.
F 0689: The facility failed to ensure functional exit door alarms, resulting in Resident 52 eloping and placing residents at immediate jeopardy; also failed to provide adequate supervision to prevent falls for Resident 47.
F 0732: The facility failed to update nurse staffing data daily and at the beginning of each shift for one of four units.
F 0761: The facility failed to maintain appropriate temperatures in two medication refrigerators, risking medication spoilage.
F 0812: The facility failed to ensure food was procured, stored, and served under sanitary conditions; observed uncovered raw chicken and refrigerator temperatures above 41°F.
F 0880: The facility failed to adhere to COVID-19 infection control protocols by not disinfecting face shields and changing N95 respirators after exiting a COVID-19 isolation room.
F 0908: The facility failed to maintain the dishwasher in safe operating condition as the dishwasher did not consistently reach the required sanitizing temperature of 180°F.
Report Facts
Falls: 4
Temperature reading: 46.7
Temperature reading: 46
BIMS score: 3
BIMS score: 3
Fall Risk Assessment score: 10
Fall Risk Assessment score: 13
Fall Risk Assessment score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding Resident 26's advance health care directive documentation. | |
| Director of Nursing | Acknowledged mold exposure risk to Resident 32 and posey belt restraint issues for Resident 47. | |
| Quality Assurance Nurse | Interviewed regarding posey belt use, injury reporting, and care plan implementation. | |
| Registered Nurse | Observed not disinfecting PPE properly after exiting COVID-19 isolation room. | |
| Environmental Services Manager | Interviewed about exit door alarms and their malfunction. | |
| Infection Preventionist | Interviewed about PPE protocols and nurse staffing data. | |
| Head Cook | Interviewed about refrigerator and dishwasher temperature issues. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 11, 2022
Visit Reason
The inspection was conducted as the facility's annual survey to assess compliance with state regulations for assisted living facilities.
Findings
The inspection identified deficiencies related to the facility's service plan and nursing services, including failure to update the resident's service plan to reflect ongoing blepharitis treatment and lack of documented comprehensive assessments and service plans prior to residents' admission.
Deficiencies (3)
Resident #1's service plan was not updated to reflect ongoing blepharitis treatment between 6/4/21 and 12/21/21.
No documented evidence of comprehensive assessments and service plans performed and developed prior to residents' admission into the facility.
No documented evidence physician was notified about unresolved eye redness between 6/4/21 and 11/30/21.
Report Facts
Deficiency correction completion date: May 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Shiraki | Licensee/Administrator | Signed the plan of correction document dated 5/23/22 |
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