Inspection Reports for Rose Hwang’s Care Home
1755 Palamoi Street, Pearl City, HI 96782, HI, 96782
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 27, 2025, identified multiple deficiencies related to operational policies, nutrition, medications, records, physical environment, fire safety, and case management services. Earlier inspections also noted various issues, including medication management, personnel clearances, documentation, and care planning. Common themes across reports involved medication administration discrepancies, incomplete assessments and care plans, and lapses in fire safety and personnel health clearances. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and no complaint investigations were noted. The facility’s inspection history shows recurring issues with medication and documentation, with no clear pattern of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Mar 27, 2025
Visit Reason
The inspection was conducted as the annual survey for Rose Hwang's Care Home to assess compliance with state licensing regulations.
Findings
Multiple deficiencies were identified related to general operational policies, nutrition, medications, records and reports, physical environment, fire safety, and case management services. The facility provided plans of correction for each deficiency, with future plans to prevent recurrence.
Deficiencies (13)
No signed EARCH policy for Resident #1.
Medication administration record showed nectar consistency liquid was provided without a physician order for this consistency.
Hospital discharge summary included medication orders without documentation of discontinuation in the medication administration record.
Hospital discharge summary medication order for Quetiapine did not match the medication administration record.
No documentation in progress notes that Resident #1's urine output was monitored as ordered.
Weight recorded on monthly weight log was not accurate; hospice RN used mid-arm circumference for weight check.
September 2024 fire drill did not include the time taken to safely evacuate residents.
No fire drill recorded for February 2025.
Three wheelchair residents needed assistance with evacuation; maximum allowed is two.
No comprehensive assessment completed by RN Case Manager prior to admission into the ARCH facility.
No interim care plan completed by RN Case Manager within 48 hours of admission.
Care plan did not identify ongoing issues including insomnia, fall risk, risk for UTI, risk for impaired skin integrity, and self-care deficit.
No documentation that Resident #1 or legal guardian was informed of resident's rights and responsibilities.
Report Facts
Deficiencies cited: 13
Maximum wheelchair residents allowed: 2
Wheelchair residents needing assistance: 3
Inspection Report
Annual Inspection
Deficiencies: 26
Date: Mar 25, 2024
Visit Reason
The inspection was conducted as the annual survey of Rose Hwang's Care Home to assess compliance with state licensing regulations.
Findings
Multiple deficiencies were identified related to personnel tuberculosis clearance, admission policies, nutrition orders, food sanitation, medication management, personal care services, records and reports, and resident health care standards. Plans of correction were submitted for each deficiency with specified completion dates.
Deficiencies (26)
Substitute caregiver (SCG) #1 had no current tuberculosis (TB) clearance.
Resident #2's level of care was not reevaluated/reassessed by the physician as required.
Resident #1 was taking nutritional supplements without a physician order.
Expired canned goods (chicken and beef stock) were noted in the kitchen pantry.
A tube of Calmoseptine cream and a bottle of Ammonium Lactate were found on resident #2's nightstand.
No label for several supplements found in resident #1's medication bin.
Unlabeled Latanoprost eye drop and Metamucil were noted in resident's medication cabinet.
Resident #2's diet order did not meet pureed texture diet and nectar thick liquids requirements.
Resident #1's medications were not timely renewed and signed by the physician every four months.
Resident #2's TB documentation showed no TB clearance signed by a physician or APRN.
Resident #2's PCG assessment was not completed upon readmission.
Resident #1's medication orders were not properly labeled or stored securely.
Resident #1's medication orders were not timely renewed and signed by the physician every four months.
Resident #1's telephone order to discontinue medication was not documented.
Resident #1's medication administration record did not reflect all medications given.
Resident #2's plan of care and schedule of activities were not updated upon readmission.
Resident #1's RN case manager did not conduct a comprehensive assessment.
Resident #1's care plan was not developed by RN case manager since readmission.
Unusual incidents involving residents were not documented in progress notes.
Resident #1's hospitalization and other unusual incidents were not documented.
Resident #1's permanent general register was not updated to reflect discharge and readmission.
Resident #1's progress notes did not reflect monitoring and responses to treatments and medications.
Resident #1's order for Fit Therapy for home PT was not carried out or documented timely.
Resident #2's physician was not timely notified of a fall and injury.
Resident #3's hospitalization was not documented.
Resident #2's medications were being crushed without physician's order.
Report Facts
Completion Date: Apr 12, 2024
Completion Date: Jul 16, 2024
Completion Date: May 24, 2024
Completion Date: Mar 25, 2024
Completion Date: Mar 5, 2024
Completion Date: Apr 20, 2024
Completion Date: Mar 28, 2024
Completion Date: Apr 18, 2024
Completion Date: Apr 24, 2024
Completion Date: Mar 25, 2024
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as the annual licensing inspection of Rose Hwang's Care Home to ensure compliance with state licensing requirements.
Findings
Multiple deficiencies were identified related to licensing, personnel requirements, medications, personal care services, records and reports, and resident accounts. The facility submitted plans of correction addressing each deficiency.
Deficiencies (16)
Current Fieldprint clearance unavailable for review for Primary Caregiver, Substitute Caregiver, and Household Member.
Current annual physical exam unavailable for Substitute Caregiver #1.
Current annual tuberculosis clearance unavailable for Substitute Caregiver #1.
Medication labeling deficiencies: bottles of Calcium-Vitamin D, BioTrue lubricating eye drops, and Vitamin D3 lacked dosage and frequency information.
Multiple medication cups labeled with residents' names found prefilled in medication cabinet.
Physician's order for Calcium-Vitamin D supplement did not match the dosage provided.
Discontinuation orders unavailable for several medications prescribed to Resident #1.
Medication administration record (MAR) did not reflect current orders for several medications including Melatonin and Quetiapine.
Medications have not been routinely reevaluated and signed by the resident's physician every four months as required.
Daily schedule of activities not followed; Resident #1 was observed lying on the couch watching television instead of engaging in scheduled activities.
No documented evidence that Resident #1 was offered influenza and pneumococcal vaccines or declined them.
Monthly progress note for Resident #1 did not include resident's response to medications and diet.
Medical visits for Resident #1 on multiple dates were not documented in progress notes.
Financial statement/agreement for Resident #1 unavailable for review.
Current inventory of Resident #1's possessions unavailable for review.
Continuing education certificates for Primary Caregiver were falsified and submitted in an attempt to meet training requirements.
Report Facts
Continuing education certificates falsified: 7
Continuing education hours required: 12
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 29, 2022
Visit Reason
Annual inspection conducted to assess compliance with personnel, staffing, family requirements, medication storage, and records and reports regulations.
Findings
Multiple deficiencies were identified including missing annual physical exams for substitute caregivers, unavailable tuberculosis clearances, lack of valid first aid and CPR certifications, unsecured medications, and missing annual physical examination and tuberculosis clearance documentation for residents. Plans of correction were submitted for all deficiencies.
Deficiencies (7)
Substitute Caregiver (SCG) #1,2,3 – Annual physical exam unavailable for review.
SCG #1 – Initial and annual TB clearance unavailable; SCG #2 – Annual TB clearance unavailable.
Residents were left unattended while all caregivers attended educational trainings on 1/15/22, 1/28/22, and 2/5/22.
SCG #1 – Valid first aid certification unavailable.
SCG #1 – Valid CPR certification unavailable.
Resident #2 – Two bottles of medicated eye drops stored unsecured on resident’s nightstand.
Resident #1 – Initial and annual TB clearance unavailable.
Report Facts
Dates of caregiver trainings: 1/15/22, 1/28/22, and 2/5/22
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