Hale Ola Kino By Arcadia
1314 Kalakaua Ave Second Floor, Hon, HI 96826 · For profit - Corporation · 32 certified beds · (808) 983-4444 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (13% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.8% | 16.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.5% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.4% | 1.0% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.0% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 1.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.9% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 10.8% | 20.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 2.1% | 9.1% | 18.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with pressure ulcers | 0.0% | 3.4% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 30.3% | 17.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.4% | 11.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.0% | 84.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.2% | 19.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 18.1% | 10.3% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
63.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 125 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 64 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.64 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.0%CMS range 55.6–70.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.7–14.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 43.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 40.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.8–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 32 beds and averages 30.1 residents a day — about 94% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.54 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.41 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.67 hrs/resident/day on weekends vs 5.85 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.83 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 13% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · D2025-02-21 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity by protecting and promoting the rights of one of one resident (Resident (R) 4) reviewed for resident rights. R4's personal property was taken from his room without his knowledge or proper communication. This deficient practice has the potential to affect R4's dignified existence. Findings include: On 02/19/25 at 12:55 PM, an interview and observation of R4 was done. R4 was lying down in his room on his bed and complained that a friend brought him a bottle of TUMS yesterday morning and he does not know what happened to them. R4 reported he wanted TUMS and even asked the facility to get him a bottle, but no one helped him get it, so he asked his friend who was able to get him some and had put it in his drawer. R4 raised his voice and loudly stated .they took it from me. I don't know what happened .it's my personal property! I got it, someone brought it for me, and it disappeared. Nobody can find it! Should I call the police? It disappeared; they use it for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement the comprehensive person-centered care plan for two of 15 residents (Resident (R) 4 and R21) care plan reviewed. The facility did not develop a dietary care plan for R4 and did not implement R21's care plan for edema. This deficient practice has the potential to negatively affect R4 and R21's health and well-being. Findings include: R4 was admitted to the facility on [DATE] with diagnosis of, but not limited to, unspecified severe protein-calorie malnutrition. Review of R4's weight since admission found on 01/14/25, the resident weighed 175.6 pounds (lbs.) and on 02/11/25, a month later, he weighed 166.2lbs. which is a 5.35% weight loss. Review of the initial interdisciplinary team (IDT) care plan meeting notes, dietary services documented PO [by mouth] intake has been poor, eating 25% or less at meals. No c/o [complaints of] food or menu. Likes ice cream and crispy bacon, however, currently on a minced diet. Wt [weight] 165.1#…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure one of two residents (Resident (R) 3) sampled for limited range of motion received appropriate treatment for left foot contracture. This deficient practice put R3 at risk of further decrease in range of motion. Findings include: R3 was admitted to the facility on [DATE] with diagnoses of dementia, hemarthrosis to right knee, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, cognitive communication deficit, vitamin D deficiency, and osteoarthritis. Review of R3's care plan documented R3 has limited physical mobility related to contractures to left foot. Interventions included Splint as ordered. Review of R3's physician orders for splint one time a day for left foot contracture Apply left foot splint on 4 hours/day; ON at 1200 and OFF at 1600 as tolerated and remove per schedule. On 02/18/25 at 12:37 PM, observed splint for left foot on the chair in R3's room, not being used. At 02:26 PM, R3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure one of three residents (Resident (R) 84) sampled for pain management was consistent with professional standards of practice. R84's pain management was ineffective and not followed up on which has the potential result of discomfort and continued pain. Findings include: R84 was admitted to the facility on [DATE] with diagnoses of, but not limited to, insomnia, encounter for surgical aftercare following surgery on the nervous system, and chronic pain syndrome. On 02/19/24 at 08:59 AM interviewed R84 in his room. R84 reported he has constant pain and discomfort on his left shoulder. He requests for oxycodone about every four hours, and it helps the pain go from a 9 to a 7 in the pain index scale (a 0-10 scale where 0 represents no pain and 10 represents the worst possible pain). Nursing staff check on him and ask if the medication is effective and he informs them he is at a pain level of 7. Inquired if nursing staff follow up with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure resident menus were followed for one of one resident (Resident (R)10) sampled for food and two of 10 residents (R135 and R28) food trays and menus sampled in the kitchenette during food tray line. This deficient practice has the potential to put R10 and R135 at risk of not maintaining their weight and R28 at risk of low sodium with history of hospitalization. Findings include: On 02/18/25 at 12:31 PM, an observation of R10 and interview with resident representative (RR) 1 was done. R10 was observed to eat lunch (fresh cantaloup, fish, steamed cauliflower, and mashed potatoes with gravy) with assistance from RR1. RR1 reported R10 is supposed to get half the amount of starch on her plate but depending on who plates the food R10 will get the full amount. RR1 stated today the mashed potato was not half the amount but the full amount. RR1 pointed to the mashed potatoes on her plate and the menu which indicated the mashed potatoes were supposed to be half the amount. On 02/20/25 at 08:09 AM, observed R10…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure opened food was discarded by the use by date for one of five food items sampled in the walk-in refrigerator. Failure to appropriately label stored food has the potential to affect residents that receive food from the kitchen, and visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness. Findings include: During the initial tour of the main kitchen at 02/18/25 at 08:03 AM observed contracted facility [NAME] (C) 1 in the walk-in refrigerator gathering food items. C1 stated she is the designated cook for the facility and was gathering food items to make a salad from the top two shelves on the back left of the refrigerator with a little sign HCC. C1 confirmed those two shelves are food items for the facility, as well as a rolling food tray rack to the right. As C1 exited the walk-in refrigerator, this surveyor (Surveyor (S) 1) and S2 found a small metal container of food, covered with saran wrap, labeled Olive HCC S1 and S2 observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-07 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff competency in safe transfers and perineal care (peri care) for two residents in the sample (Residents 131 and 13). This deficient practice placed the residents at risk for avoidable injuries and decreased quality of care, and has the potential to affect all the residents at the facility requiring assistance with transfers and/or peri care. Findings include: 1) Cross-reference to F689 Accident Hazards. Based on interview and record review, the facility failed to ensure staff were trained for safe transfers as evidenced by an unsafe transfer of Resident (R)131 placing him at risk for avoidable injuries. 2) On 03/04/24 at 03:21 PM, observations were done of Certified Nurse Aide (CNA)11 performing perineal care (peri care) on Resident (R)13 after a bowel movement in her adult incontinence brief. After donning a pair of gloves, CNA11 prepared to clean R13 with two dry 4x4 disposable cloths and one 4x4 disposable cloth moistened with water. As he wiped her gluteal fold, CNA11 was observed having…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-07 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement a food and hydration program that recognizes and addresses the preferences of each resident. This is evidenced by a failure to provide fresh water throughout the day, despite repeated requests, to one resident (Resident 132), and a failure to offer and provide an alternate menu item when residents found their meal tray unappetizing. This deficient practice has the potential to affect all residents at the facility. Findings include: 1) On 03/04/24 at 09:56 AM, a concurrent observation and interview was done with Resident (R)132 at her bedside. R132 eating her breakfast, stated that last week when she went to the bathroom her urine was very dark like that [pointing to color of the brown bedside table] and burned. When she reported it, she was told she needed to drink more water. Water pitcher on the bedside table noted to be completely empty. At 11:36 AM, observation made that R132's water pitcher still completely empty. R132 stated that she did ask for water several times and was told by multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store food in accordance with professional standards. The walk-in refrigerator contained boxes of food sitting on the floor. The deficient practice has the potential to affect many residents living in the facility who eat foods prepared in the kitchen. Findings include: During a return visit to the kitchen on 03/06/24 at 12:04 PM, observation in the walk-in refrigerator/ freezer on B1 floor noted several cardboard boxes of food resting on metal trays on the floor in the walk-in refrigerator. Verified with the Dietary supervisor (DS) that the boxes of food are required to be stored off the floor. Verified that the food inside the walk-in fridge is for the residents who dine in the facility (since the main kitchen provides food for the assisted living facility within the building. The DS notified another kitchen staff in the area to move the food off of the floor. The DS also notified the Kitchen manager. Interview with the head chef (HC) from the kitchen on 03/07/24 at 1:55 PM. The surveyor shared survey findings and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, although informed of concerns regarding an unsafe transfer and poor positioning in bed, the facility failed to identify and document the verbalized complaint as such, and failed to provide a prompt resolution of the complaint/grievance for one resident (Resident 131) and his family representative(s). As a result of this deficient practice, the resident experienced a decreased quality of life, feeling as if the concerns he and his family representatives voiced were not being taken seriously, or acknowledged. This deficient practice has the potential to affect all the residents at the facility who voice a concern. Findings include: Resident (R)131 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include, but are not limited to, unspecified convulsions, left hemiplegia [paralysis on one side of the body] and left hemiparesis [one-sided muscle weakness] following a stroke, and constipation. On 03/04/24 03:37 PM an interview was done…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2024-03-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one Resident (R)82 of four in the sample. R82's care plan was generalized, written as the resident instead of resident's name; the interventions for pain management were not followed as written on the care plan. The deficient practice placed the resident with ineffective pain control, cross reference (cr) to F697 pain management. Findings include: R82 is a [AGE] year-old male admitted to the facility on [DATE] for rehabilitation services after suffering from a fall with a lumbar fracture, cr to F697 pain management. Electronic health record (EHR) reviewed. Minimum data set (MDS) with Assessment reference date (ARD) 02/26/2024 reviewed. Active Diagnoses: Includes musculoskeletal wedge compression fracture of third lumbar vertebrae. Other low back pain and muscle weakness. Section J - Health Conditions: Pain Assessment interview. Pain Presence- Yes. Pain frequency: 2. Occasionally. Pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to adequately monitor, care plan, and manage, an elevated risk of constipation for 1 of 1 resident (R131) sampled. As a result of this deficient practice, Resident (R)131 experienced abdominal discomfort and difficulty defecating. This deficient practice has the potential to affect all the residents at the facility at risk of constipation. Findings include: Resident (R)131 is a [AGE] year-old male admitted to the facility on [DATE] with admitting diagnoses that include, but are not limited to, unspecified convulsions, left hemiplegia [paralysis on one side of the body] and left hemiparesis [one-sided muscle weakness] following a stroke, and constipation. On 03/05/24 at 09:18 AM, during an interview with R131's Family Representative (FR)1, FR1 reported that R131 had hard stools that he has difficulty pushing out every time he goes. FR1 continued on to explain that R131 had felt constipated the other day and had asked for a suppository, but was told that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents hazards, both in the Therapy Room, as evidenced by Resident 23 sustaining an injury on an exposed end of the wooden parallel/balance bars, as well as during transfers for Resident 131. This deficient practice has the potential to affect all residents using the Therapy Room or requiring assistance during transfers. Findings include: 1) Resident (R)23 is a [AGE] year-old female admitted on [DATE] with admitting diagnoses that include, but are not limited to, unspecified convulsions, history of syncope (fainting) and collapse, unspecified pain and shortness of breath, muscle weakness, and difficulty in walking. On 02/08/24, the facility conducted a Brief Interview for Mental Status (BIMS) exam and found R23 to be cognitively intact with a score of 15 out of 15. On 03/04/24 at 09:13 AM, during an interview with R23 at her bedside, observed she was wearing a geri sleeve skin protector on her left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to recognize and evaluate when the resident experienced pain; and manage pain consistent with the comprehensive assessment, the plan of care, current professional standards of practice, and the resident's goals for one resident (R) 82 in the sample. R82's pain level was not consistently evaluated by the nursing staff, and analgesics were not available to the resident as ordered by the physician. The deficient practice resulted in increased pain for R82. Findings include: R82 is a [AGE] year-old male admitted to the facility on [DATE] for rehabilitation services after suffering from a fall that resulted in a lumbar fracture. During an observation on 03/04/24 at 11:05 AM in R82's room who was observed sitting in the Geri chair next to his bed. The surveyor asked him how he was doing today. R82 stated terrible when I was living at home, I slipped and fell on the floor on my tailbone. I have a fracture in my spine and went to the hospital for a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adequately assess for and identify past traumas experienced by 1 of 1 residents (Resident 132) sampled for Trauma-Informed Care. As a result of this deficient practice, Resident 132 did not have her triggers identified, placing her at increased risk of re-traumatization, and was hindered from attaining her highest practicable mental and psychosocial well-being. Findings include: Resident (R)132 is a [AGE] year-old female admitted on [DATE] with admitting diagnoses that include, but are not limited to pain, muscle weakness, difficulty in walking, and history of falling. On 02/28/24, the facility conducted a Brief Interview for Mental Status (BIMS) exam and found R132 to be cognitively intact with a score of 15 out of 15. On 03/05/24 at 08:18 AM, during an interview with R132 at her bedside, she described how she was experiencing post-traumatic stress from the incident(s) that took her to the hospital and then here to the skilled nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-02-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interviews, and record reviews (RR), the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Finding includes: On 02/21/23 at 08:22 AM, an initial brief tour of the kitchen was done. Four kitchen staff were preparing food and not wearing hair nets. On a follow-up visit to the kitchen on 02/23/23 at 10:13 AM, noted three staff preparing food and not wearing hair nets On 02/23/23 at 11:12 AM, an interview with dietary supervisor (DS) was done. DS stated that staff stated they had just returned from a break. Explained that SA saw them prepping food and three staff were without hair nets. SA informed DS that, on 02/21/23 at 08:22 AM was the first event seen. The supervisor nodded with acknowledgement. RR of Standard Operating Procedure (SOM) for infection control policy indicates (1) All food service employees shall wear clean outer garments and utilize hair restraints as indicated, maintain a high degree of personal cleanliness, and conform to good hygienic practices while on duty.
- Potential for harm · D2023-02-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to anticipate the needs for one of three sampled residents (R), R102. R102 was diagnosed with right hemiplegia (right sided paralysis) with the call device placed on R102's paralyzed side and not within reach of R102's functioning limb. Finding Includes: R102 was admitted with the diagnosis of aneurysm of artery of lower extremity, difficulty in communicating (read, speak, or write) following a stroke with paralysis of the right side. Observation and concurrent interview were made on 02/21/23 at 02:22 PM of R102. Observation revealed R102's call device was on the floor on the right side of the bed, while clipped to the bed sheet. Queried R102 if he could reach his call bell. R102 was able to follow command and move his left hand but could not move his right arm. R102 was able to open and close his left hand by demonstration to state agency (SA). On 02/22/23 at 08:15 AM, observed resident being fed puree breakfast by certified nurse aide (CNA)1. Call device was clipped to right side of bed and dangling from the bed sheet below…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-24 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations and interviews, the facility failed to allow one resident (R), R151, to have the freedom of choice. R151 was not informed of her therapy schedule and therefore was not able to plan her day because of this hindrance. This deficient practice affects all residents who are cognizant and want to plan their daily activities around their therapy schedule. Finding Includes: Reviewed R151's electronic health record (EHR). Read Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) of 02/10/23. R151's Brief Interview for Mental Status (BIMS) cognition assessment score was 15 or cognitively intact. On 02/21/23 at 1:33 PM, observed R151 sitting up at the edge of the bed in her room doing physical therapy (PT) with physical therapist assistant (PTA)2. On 02/22/23 at 09:30 AM, a concurrent observation and interview were done with R151 in her room. R151 sat up in her recliner watching television. R151 stated that she was unsure at what time she was receiving PT today and that it would be nice to know what time her appointment was. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-24 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop an appropriate person-centered baseline care plan that included a resident's R 151, goal(s) to be discharged from the facility. This deficient practice fails to identify what the resident needs to strive towards to be appropriately discharged from the facility and can potentially affect all residents admitted to the provider. Finding includes On 02/21/23 at 09:48 AM, interviewed R151 in her room. R151 stated that she does not know what her goals were for her discharge from the facility. Reviewed R151's health records. Read Clinical Notes and documentation on 02/03/23 at 5:26 PM by staff nurse (SN2) revealed that R151 was [AGE] years old discharged from the hospital with respiratory failure and being admitted to the facility for PT [physical therapy]/OT [occupational therapy]/RN [registered nurse] observation. SN2's Clinical Notes also revealed, .Baseline Careplan, medications, and admission consents reviewed with resident . Read BASELINE…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility did not individualize the care plans to identify the current treatment for two residents (R) 205 and R159, in a sample of four residents. This deficient practice has the potential for poorly managed care to be given to all residents in the facility. Findings include: 1) R205 is a [AGE] year old female, who was admitted on [DATE] with a foley catheter and diagnosis that include fractured sacrum, paroxysmal atrial fibrillation, hypertension, abnormal glucose, insomnia, pain, and malnutrition. On 02/24/23 at 10:10 AM, conducted an interview with R205. Inquired if the facility had discussed a trail void to discontinue the Foley catheter. R205 stated that Staff Nurse (SN)2 had discussed removing the Foley catheter this on 02/22/24, but she felt her pain level was still high and wanted to wait until next week, that way she will be better able to get up and use the bedside commode. On 02/24/23 at 10:33 AM, conducted a concurrent record review and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop an appropriate person-centered baseline care plan that included a resident's R 151, goal(s) to be discharged from the facility. This deficient practice fails to identify what the resident needs to strive towards to be appropriately discharged from the facility and can potentially affect all residents admitted to the provider. Finding includes On 02/21/23 at 09:48 AM, interviewed R151 in her room. R151 stated that she does not know what her goals were for her discharge from the facility. Reviewed R151's health records. Read Clinical Notes and documentation on 02/03/23 at 5:26 PM by staff nurse (SN2) revealed that R151 was [AGE] years old discharged from the hospital with respiratory failure and being admitted to the facility for PT [physical therapy]/OT [occupational therapy]/RN [registered nurse] observation. SN2's Clinical Notes also revealed, .Baseline Care plan, medications, and admission consents reviewed with resident . Read BASELINE…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review (RR), and interview, the facility failed to maintain treatment and services to maintain appropriate services for normal bladder function for two of two sampled residents (R)102 and R207). These deficient practices could have the potential to lead to urinary tract infections (UTI) and urinary incontinence of bladder function. Findings include: 1) On 02/24/23 at 11:02 AM, observation was made. R102 received maintenance of foley catheter (tubing inserted internally to remove urine) care. Observation of Certified Nurse Aide (CNA)1 used warm water to clean the foley tubing and glans penile area. Queried CNA1 what was in her disposable towel to clean catheter, CNA1stated that she just uses warm water. RR on 02/24/23 was done. RR of policy and procedure titled Care of the resident with a urinary catheter, under maintenance (2) for foley care indicated clean with soap and water, rinse well. (3) Retract the foreskin on male adult resident and clean glans, return the foreskin. Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) R206 was admitted to the facility on [DATE], with diagnosis that include rheumatoid lung disease, pneumonia, acute respiratory failure, and shortness of breath. Multiple observations (02/21/23 at 11:44 AM; 02/22/23 at 08:35 AM, 09:13 AM; ) were made of R206's oxygen concentrator humidifier solution and oxygen tubing with no label (date and time). On 02/21/23 at 11:44 AM, conducted an interview with R206. Inquired with R206 regarding when the oxygen tubing and humidifier solution is changed and if he had noticed it labeled. R206 stated that he has two tubing, one for when he is in bed and another for when he is walking with physical therapy. Inquired if the oxygen tubing for both oxygen sources were changed. R206 stated that it is the same tubing since he was admitted . On 02/23/23 at 12:21 PM, conducted a record review of R206's Electronic Health Record (EHR). Review of the physician orders documented an order to change oxygen tubing every one week. Based on observation, interview and record review, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents are free of any medication error for one of two residents (R) 103 sampled. As a result of this deficiency, residents are at risk of the potential for harm and adverse effects of medications. Findings include: On 02/23/23 at 08:20 AM, conducted an observation of staff nurse (SN)1 administering medication for R103. SN1 administered: Furosemide 20 milligram (mg) (2 Tab) Sodium Bicarbonate (1 Tab) Pravastatin 20 mg (1 Tab) Amlodipine 10 mg (1 tab) Nebivolol 10 mg (1 Tab) Omeprazole 40 mg (1 Tab) Irbesartan 300 mg (1 tab) Multiple Vitamin (1 Tab) Calcium 600 mg D3 (1 Tab) Allopurinol 100 mg (1 Tab) Gabapentin 100 mg (1 Capsule) On 02/23/23 at 09:16 AM, conducted a review of R103's Electronic Health Record (EHR). R103 is an [AGE] year-old female admitted to the facility on [DATE], with diagnosis that include acute and chronic respiratory failure, hypertension, diabetes mellitus type 2, chronic kidney disease, and chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ARCADIA COMMUNITY SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2022 |
| BUNN, ANDREW | Individual | CORPORATE DIRECTOR | — | since 11/01/2022 |
| CHANG, CORLIS | Individual | CORPORATE DIRECTOR | — | since 11/01/2022 |
| KOEHL, ALBERT | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| MAGANA, RAOUL | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| POPHAM, DAVID | Individual | CORPORATE DIRECTOR | — | since 11/01/2022 |
| REICHHARDT, LAURA | Individual | CORPORATE DIRECTOR | — | since 11/01/2022 |
| REINKER, KENT | Individual | CORPORATE DIRECTOR | — | since 11/01/2022 |
| SAYIN, LUCAS | Individual | CORPORATE DIRECTOR | — | since 11/01/2022 |
| SINNADURAY, RUSHAN | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| ZORN, MARTIN | Individual | CORPORATE DIRECTOR | — | since 11/01/2022 |
| LAI, VIVIAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 07/27/2022 |
| SCHULBERG, SUZIE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 07/27/2022 |
| ARCADIA ELDER SERVICES | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/27/2025 |
| KOMAGOME, BREE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| SALON, ROSELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/16/2024 |
| YAZAWA, KIYOTAKA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/27/2025 |
CMS files one row per role, so the 23 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in HI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Hawaii Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 125069. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.