Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
114% worse than Hawaii average
Hawaii average: 8.1 deficiencies/year
Deficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 24, 2025
Visit Reason
The inspection was conducted following notification of a possible Legionnaires' disease outbreak at The Care Center of Honolulu, triggered by a positive Legionella test in a resident (R1) hospitalized with Legionnaires' Disease.
Complaint Details
The complaint investigation was initiated after the Office of Health Care Assurance received notification on 12/17/25 regarding a possible Legionnaires' outbreak. The resident (R1) tested positive for Legionella antigen while hospitalized and had multiple hospitalizations related to septic shock and pneumonia. The facility was unable to provide a completed risk assessment or a fully compliant Water Management Program at the time of the investigation.
Findings
The facility failed to provide evidence of a comprehensive Water Management Program (WMP) essential to prevent the spread of Legionella and other waterborne pathogens. The existing WMP lacked a detailed risk assessment, comprehensive water system description, testing protocols, and acceptable control parameters, placing vulnerable residents at increased risk of exposure.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program related to water management to prevent Legionella and other waterborne pathogens.
Report Facts
Date of survey completion: Dec 24, 2025
Notification date of possible outbreak: Dec 17, 2025
Resident hospitalization dates: Resident hospitalized from 10/10/25 to 10/24/25 and again on 11/30/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist (IP) | Interviewed regarding the Water Management Program and Legionella case | |
| Facility Manager (FM) | Interviewed regarding water system risks and maintenance | |
| Administrator (ADM) | Interviewed regarding contracting consultant and WMP revisions |
Inspection Report
Routine
Deficiencies: 11
Date: Nov 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication management, infection control, nutrition, and other aspects of care at The Care Center of Honolulu.
Findings
The facility was found deficient in multiple areas including failure to inventory personal belongings upon admission, failure to accommodate resident needs such as call light placement, failure to timely report alleged abuse, inaccurate resident assessments, incomplete care plans, inadequate personal care and hydration, improper medication storage and labeling, failure to provide dental services timely, failure to honor resident food preferences, and lapses in infection prevention and control practices.
Deficiencies (11)
Failed to ensure personal belongings were inventoried upon admission, resulting in missing hearing aids and dentures for a resident.
Failed to accommodate resident's needs by not ensuring call light was always within reach.
Failed to timely report an allegation of abuse to the State Agency and Adult Protective Services.
Failed to accurately assess residents' status including restraint use, medication coding, and pressure ulcer risk.
Failed to develop and implement a comprehensive care plan including use of bedrails and interventions to prevent rehospitalizations.
Failed to provide adequate personal care, maintain comfortable room temperature, and provide hydration for a resident receiving hospice care.
Failed to provide adequate hydration and encourage fluid intake for a resident at risk of dehydration.
Failed to ensure all drugs and biologicals were stored in locked compartments and properly labeled, including medication left unattended and unlabeled insulin pens.
Failed to promptly refer a resident with lost dentures for dental services, resulting in downgraded diet and lack of dental consult.
Failed to ensure residents received food consistent with their documented preferences, serving disliked foods to multiple residents.
Failed to implement infection prevention and control measures including improper use of PPE and hand hygiene during resident care.
Report Facts
Rehospitalizations: 7
Medication carts unlocked: 1
Expired medication bottles: 3
Insulin pens unlabeled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN25 | Registered Nurse | Left medications on resident R57's bedside table unattended. |
| ADON | Assistant Director of Nursing | Confirmed medication administration and storage deficiencies; confirmed insulin pen labeling issues. |
| RN20 | Registered Nurse | Observed medication cart unlocked and insulin pens unlabeled. |
| NS2 | Nurse Supervisor | Informed dietary staff about missing dentures of resident R150. |
| DDS2 | Director of Dietary Services | Confirmed food preference discrepancies and missing dental referral. |
| RT5 | Respiratory Therapist | Failed to change gloves and perform hand hygiene during tracheostomy care. |
| RTM | Respiratory Therapist Manager | Confirmed infection control lapses during tracheostomy care. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to reasonably accommodate the needs and preferences of a resident by not ensuring the call light was always within reach or positioned for activation.
Complaint Details
The visit was complaint-related concerning the facility's failure to accommodate Resident 78's needs regarding call light accessibility. The nursing home is disputing this citation.
Findings
The facility failed to ensure that the call light was consistently placed within reach of Resident 78, placing the resident at risk of not having emergent needs met timely. Observations and interviews confirmed the call light was often out of reach despite the resident's ability to activate it.
Deficiencies (1)
Failed to ensure the call light was always placed within reach or positioned so it could be activated for Resident 78.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA122 | Certified Nurse Aide | Acknowledged the call light was out of Resident 78's reach and repositioned it closer to the resident's head. |
| NS3 | Nurse Supervisor | Interviewed regarding observations of the call light being out of reach and confirmed staff are to ensure Resident 78 can reach the call light at all times. |
Inspection Report
Routine
Deficiencies: 14
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, environment, grievance handling, abuse prevention, assessment accuracy, care planning, medication management, staffing, food service, and infection control at The Care Center of Honolulu.
Findings
The facility was found deficient in multiple areas including failure to provide resident privacy, ensure a homelike environment, support residents' rights to voice grievances without fear, protect residents from verbal abuse, timely report and investigate abuse allegations, accurately assess and code pressure ulcers, implement care plans for mobility and pressure ulcer care, maintain medication security and proper disposal, post nurse staffing information clearly, ensure pharmacist recommendations are acted upon, follow resident food preferences, maintain confidentiality of electronic health records, and implement infection prevention and control practices.
Deficiencies (14)
Failed to provide privacy for a resident during personal care, exposing the resident to others in the hallway.
Failed to ensure a homelike environment by not removing resident meal trays after serving meals.
Failed to support a resident's right to voice grievances without fear of reprisal, resulting in psychosocial harm.
Failed to protect a resident from verbal abuse and intimidation by a staff member.
Failed to timely report suspected abuse and investigate allegations appropriately.
Failed to accurately document a stage three pressure ulcer in the Resident Assessment Instrument.
Failed to implement care plans for repositioning residents to promote healing and maintain mobility.
Failed to ensure nurses and nurse aides have appropriate competencies, including proper medication disposal.
Failed to post nurse staffing information in a clear, identifiable, and prominent place for residents and visitors.
Failed to ensure pharmacist recommendations during monthly medication regimen reviews were acted upon and documented.
Failed to ensure a resident's food preference for white bread was consistently followed.
Failed to store and serve food in accordance with professional standards, including discarding expired food and monitoring dishwasher sanitizer.
Failed to maintain accurate medical records and safeguard resident electronic health records confidentiality.
Failed to provide infection prevention and control, including improper securing of oxygen humidifier and hand hygiene during wound care.
Report Facts
Residents observed during dining: 12
Residents observed during dining: 5
Residents observed during dining: 3
Residents in sample: 32
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA62 | Certified Nurse Aide | Named in privacy deficiency for failing to adjust curtains to provide privacy |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding privacy and abuse investigations |
| Assistant Administrator | Assistant Administrator (AADM) | Involved in grievance and abuse complaint handling |
| Registered Nurse 40 | Registered Nurse (RN) | Interviewed regarding homelike environment and meal trays |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding grievance and abuse investigations |
| Registered Nurse 24 | Registered Nurse (RN) | Observed disposing medication improperly and leaving EHR open |
| Registered Nurse 10 | Registered Nurse (RN) | Observed leaving EHR open |
| Unit Manager 8 | Unit Manager (UM) | Interviewed regarding medication disposal and EHR confidentiality |
| Licensed Practical Nurse 2 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration via feeding tube |
| Dietary Director | Dietary Director (DD) | Interviewed regarding food preferences and food safety |
| Restorative Nurse Aide 4 | Restorative Nurse Aide (RNA) | Interviewed regarding restorative care for resident |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control practices |
| Director of Medical Records | Director of Medical Records (DMR) | Interviewed regarding missing medication regimen reviews and binding arbitration agreement |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 3, 2024
Visit Reason
The inspection was conducted based on a complaint investigation regarding inaccurate documentation in the medical records of residents.
Complaint Details
Complaint investigation with findings of inaccurate medical record documentation; substantiation status not explicitly stated.
Findings
The facility failed to maintain accurate medical records for one of three residents reviewed, including incorrect documentation of a fractured shoulder location and transfer to the wrong acute care hospital. The deficient practice had the potential to affect all residents.
Deficiencies (1)
Failed to maintain a medical record that was accurately documented for one of three residents in the sample, including incorrect documentation of fractured shoulder and transfer details.
Inspection Report
Routine
Deficiencies: 17
Date: Aug 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, medication administration, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity and respect, inadequate response to call lights, improper handling of restraints, failure to timely report and investigate suspected abuse, incomplete transfer documentation, failure to maintain residents' functional abilities, improper catheter care, medication administration errors, inadequate infection control practices, and unsafe environmental conditions.
Deficiencies (17)
Failed to protect and promote quality of life by ensuring residents were treated with respect and dignity, including consistent use of English in resident care areas and timely response to call lights.
Failed to ensure call lights were always placed within reach for residents, placing them at risk of unmet needs.
Failed to support resident self-determination by not meeting residents' preferences to be gotten up out of bed daily.
Failed to provide a safe, homelike environment due to clutter and obstruction in resident rooms affecting wheelchair accessibility.
Failed to document ongoing re-evaluation of the need for restraints, placing resident at risk for psychosocial harm.
Failed to timely report suspected abuse of a resident and conduct a thorough investigation within required timeframes.
Failed to ensure further potential for abuse was prevented and completed report submitted timely to State Agency.
Failed to properly document transfer summary to be received by acute care provider, lacking specific resident needs and facility efforts.
Failed to provide necessary care and services to prevent loss of residents' abilities in activities of daily living, including lack of restorative services after injury.
Failed to provide appropriate catheter care to prevent urinary tract infections, including allowing catheter drainage bag to rest on the floor.
Failed to provide appropriate treatment and services to assess and prevent complications related to enteral tube-feedings, including failure to assess leakage and notify physician timely.
Failed to ensure nurse competency in medication administration as evidenced by crushing an extended release tablet and administering it via gastric tube.
Failed to ensure records for controlled medications were accurate and reconciled, including pre-signing of medication count sheets and inaccurate documentation of medication amounts.
Failed to maintain accurate medical records for a resident, including timely and accurate documentation of medication administration.
Failed to ensure proper infection prevention and control practices, including improper use of personal protective equipment and hand hygiene.
Failed to ensure all medications were labeled in accordance with professional standards, including unlabeled bottles and insulin pens.
Failed to secure an electrical panel on Nursing Unit 4, posing a safety hazard to residents and visitors.
Report Facts
Residents sampled: 5
Residents affected: 4
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
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 |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Crushed extended release potassium chloride tablet and administered it via gastric tube |
| RN18 | Registered Nurse | Confirmed discrepancy in controlled medication amount and documentation |
| UM3 | Unit Manager | Confirmed medication administration and documentation deficiencies, and controlled medication audit issues |
| DON | Director of Nursing | Conducted abuse investigation and confirmed failure to identify abuse and timely report |
| Administrator | Interviewed regarding abuse investigation and electrical panel safety | |
| AA | Assistant Administrator | Interviewed regarding abuse investigation |
| CNA6 | Certified Nurse Aide | Observed not wearing gown during care and changing resident's brief |
| CNA7 | Certified Nurse Aide | Observed not wearing gown and gloves during care of ventilator-dependent resident |
| CNA8 | Certified Nurse Aide | Observed changing resident's brief with CNA6 |
| LPN25 | Registered Nurse | Documented medication administration for another nurse |
| RN25 | Registered Nurse | Documented medication administration for another nurse |
| UM1 | Unit Manager | Interviewed regarding transfer summary documentation |
| DRS | Director of Rehab Services | Interviewed regarding lack of restorative services for resident |
| UM | Unit Manager | Interviewed regarding medication allergy discrepancy |
| IP | Infection Preventionist | Observed improper glove use during Covid testing |
| LPN18 | Licensed Practical Nurse | Observed medication cart and confirmed medication amount discrepancy |
| NS34 | Nursing Staff | Pre-signed controlled medication count sheet |
| UM3 | Unit Manager | Confirmed medication labeling deficiencies |
| DD1 | Dietary Director | Confirmed freezer burn on food items |
| KS2 | Kitchen Staff | Confirmed improper holding temperature of cooked chicken |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility regulations, including resident rights, abuse reporting, transfer documentation, medication administration, pharmaceutical services, and safety.
Findings
The facility was found deficient in multiple areas including failure to protect residents' rights and dignity, delayed reporting and investigation of suspected abuse, inadequate transfer documentation, improper medication administration practices, inaccurate controlled medication records, and unsecured electrical panels posing safety risks.
Deficiencies (7)
Failed to protect and promote quality of life by not ensuring residents were treated with respect and dignity, including language barriers and delayed staff response to call lights.
Failed to timely report suspected abuse and conduct a thorough investigation within required timeframes for a resident injury caused by staff.
Failed to respond appropriately to alleged violations by not identifying an incident as abuse, not removing involved staff, and submitting reports late.
Failed to properly document a transfer summary to inform the receiving acute care provider of the resident's specific needs.
Failed to ensure nurse competency in medication administration as evidenced by crushing an extended release tablet against pharmacy instructions.
Failed to maintain accurate and reconciled records for controlled medications, including pre-signing medication counts and not documenting actual medication amounts.
Failed to secure an electrical panel on Nursing Unit 4, creating a safety hazard for residents and visitors.
Report Facts
Residents sampled: 5
Wait time for staff response: 30
Wait time for staff response: 60
Date of injury report: Mar 28, 2023
Date of report to State Agency: Mar 30, 2023
Date of completed report: Apr 4, 2023
Date of transfer: Dec 6, 2022
Medication dose: 10
Medication amount observed: 245
Medication amount documented: 200
Medication amount received: 320
Medication doses remaining: 16
Electrical circuit switches: 35
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