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Maunalani Nursing And Rehabilitation Center

5113 Maunalani Circle, Honolulu, HI 96816 · Non profit - Other · 100 certified beds · (808) 732-0771 Medicare & Medicaid certified

Call the home — (808) 732-0771 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations$32,133 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $32,133 in federal fines (most recent 2025-08-14)
  • nursing-staff turnover (97%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3846 Noeau St
Pharmacy
3221 Waialae Ave · (808) 735-2811 · Call to confirm hours
Grocery
2402 10th Ave · (808) 737-8952 · Call to confirm hours
Park
4625 Sierra Dr · (808) 733-7372 · Typically dawn to dusk
Place of worship
2117 Palolo Ave · (808) 735-0117

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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.0%16.8%15.4%better
Long-stay residents who lose too much weight5.0%4.9%5.4%typical
Long-stay residents with a catheter left in their bladder0.8%1.0%0.9%better
Long-stay residents with a urinary tract infection2.8%2.4%2.0%worse
Long-stay residents with depressive symptoms0.5%1.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.3%1.9%3.3%better
Long-stay residents whose ability to walk worsened10.3%20.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication3.0%9.1%18.9%better than state — see note marked double-dagger below the table
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers1.9%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control17.8%17.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.2%11.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine90.7%84.7%79.4%better
Short-stay residents rehospitalized after admission17.9%19.4%22.6%better
Short-stay residents with an outpatient ER visit4.9%10.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.021.091.67better
Long-stay outpatient ER visits per 1,000 resident days0.870.881.80typical for the state — see note marked double-dagger below the table

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.

73.0% 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 274 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

73.0%U.S. median 51.5%
Got home and stayed home
8.3%U.S. median 10.7%
Went back to hospital
58.0%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 58.0% 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 138 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF73.0%CMS range 67.1–78.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.3%CMS range 6.2–10.910.7%Oct 2022–Sep 2024no 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 discharge58.0%56.6%Oct 2024–Sep 2025CMS 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 discharge55.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge67.4%50.0%Oct 2024–Sep 2025CMS 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 identified99.4%98.7%Oct 2024–Sep 2025CMS 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 setting95.8%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 4.1–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS 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

1.62
RN hours/ resident / day
0.32
LPN hours/ resident / day
3.57
Aide hours/ resident / day
5.51
Total nurse hours/ resident / day
1.14
RN hoursweekends
97.4%
Total nursing turnover
93.9%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 86.5 residents a day — about 86% occupied, or roughly 14 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 1.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.57 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 4.86 hrs/resident/day on weekends vs 5.77 on weekdays — 16% thinner on weekends. RN hours go from 1.82 to 1.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 97% is well above 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

3
deficiencies at the latest standard inspection (2024-08-29)
7
at the previous standard inspection (2023-08-31)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited beforedisputed · IDR2025-08-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 interview and record review, the facility failed to ensure residents were free from accidents for one of three residents (Resident (R) 2) sampled for falls and one of one resident (R1) sampled for accident hazards. 1) The facility failed to ensure two trained staff members operated a mechanical lift and upon analysis, indicated human error, which lead to R2's fall from the lift. During transfer with use of a mechanical lift, the left side lift sling straps slipped off the hanger bar as R2 was lifted causing R2 to fall. As a result, R2 was hospitalized with left side rib fractures with pneumothorax (collapsed lung) requiring a pigtail chest tube placement. 2) The facility failed to ensure R1 received care consistent with her physician orders. As a result, R1's safety was compromised, and she was placed at risk of an avoidable injury and/or adverse outcome in the event of a respiratory emergency. Findings Include:1) R2 was admitted to the facility on [DATE] with diagnoses, not limited to, resolved right…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-10-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 interviews, observation, record review, the facility failed to provide adequate supervision to one Resident (R)2. On 09/21/2024, R2 fell while in the Physical Therapy gym which resulted in harm. He was hospitalized with a subdural hematoma (bleeding near the brain) which required immediate surgical intervention. In addition, the facility failed to conduct a thorough investigation, document findings, and interventions taken to reduce the likelihood of a similar event. This deficient practice could affect any resident if the appropriate level of supervision is not provided. Findings include: 1) On 09/23/2024, the Office of Healthcare Assurance (OHCA) received an facility reported incident (ACTs # 11218) regarding a witnessed fall with injury. The report included: Resident is a [AGE] year-old-male who was admitted . on 09/12/2024 for PT/OT (physical/occupational services) after being hospitalized . following right foot necrotizing fasciitis status post angiogram and balloon angioplasty on 8/29/24, then…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-10 · tag F0712 — pattern
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 review of medical records, documents and policies, three Resident ((R)1, R2 and R3) of a sample size of three, had incomplete medical records. Physician visits and/or discharge summary and initial admission orders lacked timely signature by the attending physician as required by regulatory standards. In addition. one initial History and Physical (R)1 was not documented in the medical record (EMR). These deficiencies do not meet the requirements for timely and authenticated physician documentation to support continuity of care and compliance with federal regulations. Findings include:1) R1 was admitted to the facility on [DATE] for subacute rehabilitation and skilled nursing management following hospitalization for sepsis secondary to a urinary tract infection. Reviewed R1's medical records on 06/08/26, which revealed the following: - Initial admission orders were entered into the EMR by the nursing staff on the date of admission, 08/05/25. There was no evidence in the medical record 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-10 · tag F0585 — failed to handle grievances — isolated
    Honor 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

    Based on interviews, documents and record review, the facility failed to respond to a family member's (FM) email grievance regarding Resident (R)1's stay at the facility. The facility reported no grievances during period requested (September 2025 to June 8,20-26). There was no follow-up documentation, resolution, or communication to the FM. This failure resulted in several of the FM's concerns remaining unaddressed and caused ongoing dissatisfaction. Findings include:1) On survey entry, requested the facility grievance log from September 2025 to current. On 06/08/26 at approximately 01:00 PM, interviewed the Administrator (ADM) and the Director of Nursing (DON) about the facility process for grievances. At that time, interviewed the ADM, who said they did not have any grievances during the period the log was requested.2) On 06/09/25 at 09:38 AM during a second interview with the ADM, she stated she found an email the previous night in her spam file with a grievance from R1's FM that was sent to her and copied to the Ombudsman and the Office of Healthcare Assurance. She said she…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-18 · tag F0661 — pattern
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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, document and medical record review (RR), the facility failed to ensure appropriate discharge summaries were completed for two out of a sample size of three residents (R). R1 and R2 were transferred to the Hospital for a higher level of care, but when the Resident's families informed the facility the resident would not be returning to the facility, the discharge summaries are required to include a recapitulation of the resident's stay and treatment in the facility. R2's discharge summary was not accurate or complete, and R1's had not been completed prior to survey. As a result of these deficiencies, the provider did not have all the necessary information regarding the resident's clinical status. This deficient practice could affect all discharged resident's. Findings include: 1) R1 is a [AGE] year old female with significant past medical history that included, but not limited to Cerebral Vascular Accident (CVA/stroke) resulting in right lower extremity weakness, hypertension (high blood…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interviews, document and record review, the facility failed to recognize the seriousness of one Resident's (R)1 condition, of a sample size of three. Specifically, R1 exhibited a change in level of consciousness on two consecutive days, and on day two, the nursing staff determined her condition not serious enough to transport to the hospital by Emergency Medical Services (EMS/911). In addition, the facity failed to develop a comprehensive care plan for R1's multiple skin tears. As result of these deficiencies, R1 was 1) hospitalized for sepsis due to urinary tract infection (UTI), and 2) continued to get skin tears. These deficiencies may affect any resident, and has potential to delay transport to a higher level of care. Findings include: 1) Reviewed the facility grievance log, which included a complaint made by R1's daughter. The Complaint Report Form was dated 09/12/2024, and included Dtr (daughter) expressed concerns that staff did not contact EMS (Emergency Medical Services/011) timely to address…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 medical record review (RR), one physician's (MD)1 documentation of one Resident's (R)2 visit, did not meet regulatory requirements. MD1's visit note did not accurately reflect R2's total program of care, and included an inaccurate statement. Findings include: R2 was a [AGE] year old male with past pertinent history of diabetes (on insulin), hypertension, anemia of chronic renal failure, and end stage renal disease. He was incontinent of urine, had a urostomy (urinary bladder removed and opening in belly created to drain urine), and received dialysis three times a week. R2 has some memory issues at baseline and prior to hospitalization was dependant on daughter for care. He was hospitalized on [DATE], for sepsis due to cellulitis (bacterial infection) of the right lower extremity. His hospitalization was complicated by multiple debridements and necrotizing fasciitis (flesh-eating disease) and delirium. On 09/05/2024, R2 had an amputation above the right knee. On 09/12/2024, he was admitted…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family interviews, record review and staff interview, the facility failed to care for two Residents (R) 46 and 188 of eight residents reviewed, with respect and dignity. As a result of this deficiency, R46 and R188 were not given their right to the maintenance and/or enhancement of their quality of life. Findings include: 1) During an interview with R46's family (FAM) on 08/26/24 at 12:00 PM, FAM was concerned about several issues related to care and quality of life. FAM said that the showering was not being done three times a week as ordered. FAM said they would notice dirt or fecal like matter on the hands or fingernails after the supposed showering. FAM said they have not had any follow up from the physician about medications related to low blood pressure. During activities, FAM said that staff would speak loudly and scare R46. Review of Electronic Health Record (EHR) showed R46 was admitted on [DATE] with diagnosis including Cerebral Infarction (Stroke), Difficulty Walking,…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to accurately assess one Resident (R) 2 of three in the sample who had two pressure ulcer's that were acquired in the facility. The resident assessment coded one stage three pressure injury as present on admission. The deficient practice potentially affects the care plan which implements the goals and treatment outcomes. All residents in the facility may be affected. Findings include: Cross Reference to F696. Electronic Health Record (EHR) review of the Minimum Data Set (MDS) Annual assessment date 02/27/2024. R2 did not have any unhealed pressure ulcers. RR of MDS change of status assessment date 04/11/2024. R2 has a stage three pressure ulcer that was coded as present on admission. Review of the Minimum Data Set (MDS) quarterly review 07/12/24. R2 is cognitively intact with impairment on bilateral upper and lower extremities and dependent on staff for self-care and mobility. R2 is coded with having a stage three pressure ulcer that was present on admission. Interview and concurrent record review with the Director of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 provide care consistent with professional standards of practice to prevent the development of two stage three (full thickness skin loss) pressure ulcers (a localized damage to the skin and/or underlying tissue, as a result of intense pressure in combination with shear) while in the facility for one resident (R) 2 of three in the sample. The facility staff failed to turn and reposition R2 every 1-2 hours. The deficient practice placed the resident at an increased risk of infection and poor health outcomes. All residents who require assistance from staff for mobility are at risk. Findings include: R2 is a [AGE] year-old female. Primary diagnoses includes other neurological conditions, and coronary artery disease. R2 was readmitted to the facility after being discharged to the hospital on [DATE] per Electronic Health Record (EHR) review of the census and face sheet. Review of the facility matrix revealed that R2 had a stage three pressure…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-31 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 facility policy review, the facility failed to store and handle food items under sanitary conditions. This failed practice could place all facility residents at risk for food-borne illness. Findings include: Observation was conducted on 08/28/23 at 08:27 AM in the kitchen. A large freezer contained cake, six English muffins, and four bagels. All mentioned food items were wrapped in plastic and did not have a label. On the prep table, a half full bottle of thickener was observed without a label. Observation was conducted in the storage room on 08/28/23 at 08:40 AM. Six unopened boxes were placed directly on the floor. Large opened bags of penne pasta and macaroni noodles were wrapped in plastic with no labeled open dates. The freezer contained two large pork butt out of the box without dates, a package of edamame (soybeans) with an expiration date of 02/18/22, and unknown meat item in an unlabeled blue bag. Interview was conducted with Kitchen Manager (KM) on 08/28/23 between the times of 08:27 AM and 08:40 AM in the kitchen and storage room. KM…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-31 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 08/29/23 at 07:30 AM, six of seven rooms that had Airborne TBP signs outside were observed with the doors left wide open. Upon interview with the Infection Preventionist (IP), it was confirmed that the doors were left wide open to these rooms. Guidelines from the Centers for Disease Control and Prevention (CDC) state that doors will be closed when Airborne TBP are in place, to prevent spread of airborne-transmitted communicable diseases such as COVID. Seven residents were positive for COVID in these rooms and included rooms 214, 216, 217, 218 and 219. Further observations made on 08/29/23 included three wall-mounted fans outside of these open rooms, mounted high on the hallway walls to increase air circulation, were on. This observation was also confirmed with the IP. The wall-mounted hallway fans being on helps facilitate the spread of airborne microorganisms to other areas of the unit, putting all residents, visitors and staff at risk of the development and transmission of COVID. Two of the three…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Ecited before2023-08-31 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff, and visitors, as evidenced by the unlevel and/or multiple floor panels that are lifting in the hallways and dining room(s) of the resident floors, and in the elevator. As a result of this deficient practice, residents, staff, and visitors are placed in an uncomfortable environment and are at risk for avoidable injuries. Findings include: On 08/28/23 at 09:30 AM, during a tour of the third floor [NAME] wing, observed multiple areas of black tape on the floor panels along the hallway. When stepping in certain areas of the hallway, some floor panels were noted to give slightly when stepped on, causing an unlevel and unstable surface to walk on. On 08/29/23 at 10:39 AM, during an interview with Maintenance Staff (MS)1 near the third floor elevator, MS1 stated that the black tape on the floor is because the floor panels are lifting. MS1 continued on to explain that the facility had…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-31 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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: 1. Honor one Resident (R)2's wishes to refuse treatment per the advanced healthcare directive for one resident of one in the sample. 2. Did not honor the medical decision to stop medication that potentially prolong's life when the medical decision maker asked the nursing staff not to give the medication that would lower her blood pressure (BP). 3. Follow up with R2 and her medical decision maker about considering comfort care as an option. The deficient practice violates the rights of the resident and her representative to make treatment decisions. Findings include: Telephone interview with R2's Family member (FM)1 on 08/29/23 10:54 AM, who is the medical decision maker number one for R2. When asked if her aunt's choices are being honored by the facility stated. No, I don't think they are, they have been giving her a medication that she refuses to take, I can't remember what it is, but she has refused it a lot, and they do call me and ask if they can…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-31 · tag F0697 — failed to manage pain — isolated
    Provide 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 manage pain adequately for one of one resident (R) sampled for pain (R84). Specifically, the facility failed to ensure that R84's as needed (PRN) pain medication was kept in stock, failed to administer the PRN pain medication when asked for, failed to assess his pain level when needed, and failed to develop pain management goals with the Resident. As a result of this deficient practice, R84 was prevented from attaining or maintaining his highest practicable level of well-being. Findings include: Resident (R)84 is a [AGE] year-old male admitted on [DATE] for short-term rehab following surgical repair of a left lower leg fracture. On 08/30/23 at 07:57 AM, during an interview with Registered Nurse (RN)20 as she prepared medications for R84, RN20 stated the facility was having problems getting medications in from the pharmacy at times. As an example, RN20 reported that R84's as needed (PRN) pain medication, Oxycodone, was out and that she had…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-31 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and facility policy review, the facility failed to properly store medications in a manner that facilitates considerations of precautions and safe administration in one out of three medication carts sampled. This deficient practice has the potential to promote medication administration error to the residents in one unit in the facility. Findings include: Concurrent observation and interview were conducted on 08/30/23 at 10:28 AM on the third-floor hallway. An opened bottle of floor stock Acetaminophen was found in one of the facility's medication carts. The bottle of Acetaminophen did not have an expiration date. Licensed Practical Nurse (LPN)1 and Unit Manager (UM)1 both inspected the bottle for an expiration date. LPN1 and UM1 both could not locate an expiration date on the bottle. A review of the facility's policy titled, Medication Storage, with a review date of 07/08/23 was conducted. The facility's policy indicated, Medications will be discarded based on expiration date per facility protocol. If no open date or date of expiration is unknown,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-31 · tag F0806 — failed to honor food preferences — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to provide accommodation for food preferences for one of 20 residents sampled, Resident (R)60. Findings include: R60 is a [AGE] year-old female admitted to the facility on [DATE]. A review of R60's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/13/23 revealed that R60 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, meaning she was found to be cognitively intact. Observation and interview were conducted on 08/29/23 at 07:42 AM in R60's room. R60 was up in bed having breakfast. R60's menu indicated, give cornflakes with brown sugar every breakfast, 1/2 tuna sandwich only for breakfast, no boiled eggs, omelet is fine or scrambled egg is fine, no oatmeal or cream of wheat. What R60 received from the kitchen was Portuguese sausage, rice, banana, and cream of wheat. She did not receive any of her chosen menu items. R60 stated that she often gets the wrong items…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of the facility's policy and procedures, and interview with staff members, the facility failed to ensure a contractor, injecting COVID-19 boosters at the facility, demonstrate proper hand hygiene between glove changes while vaccinating the residents. This deficient practice may increase the spread of infections and has the potential to affect the residents who are receiving vaccinations in the facility. Findings Include: On 10/13/22 at 10:38 PM observation and interview with Contractor (C)1 and Health Information Clerk (HIC)4 was done. Observed C1 and HIC4 in Resident (R)17's room as she expressed that she did not want to get the COVID-19 booster. C1 stated he is at the facility to administer COVID-19 boosters to facility staff members and residents. HIC4 stated he is assisting C1 to ensure C1 vaccinate residents who are eligible and consented to the booster. On 10/13/22 at 11:07 AM, during a second observation, observed C1 doff (take off) and don (put on) gloves without hand sanitizing and administering R82 with the booster injection, then continue to…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-14 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview and review of Product Safety Data Sheet, the facility failed to perform preventive maintenance on three Biohazard Response Spill Kits, Peroxide Multi Surface Cleaner and Disinfectant bottles located in hallway cabinets on the nursing units. As a result of this deficiency, the facility put the residents, staff, visitors at risk for exposure to hazardous solutions. Findings include: During observations of the three Biohazard Response Spill Kits on 10/13/22 at 01:00 PM, it was noted that the Peroxide Multi Surface Cleaner and Disinfectant bottles appeared wilted with spillage of yellow substances. The Spill kits contained labels which said Updated 5/26/17 and Updated 2/2/21. During staff interview on 10/13/22 at 01:20 PM, the Maintenance Manager (Maint Mgr) stated that they have not used and/or done preventive maintenance on any of the kits since it was installed. The labels on the kits showed when it was last checked; 5/26/17 and 2/2/21. Review of the Product Safety Data Sheet for Peroxide Multi Surface Cleaner and Disinfectant read as follows:…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 observations, interviews, and record review the facility failed to ensure the comprehensive person-centered care plan was implemented for one (1) of 19 residents sampled. R69's care plan was not implemented and the facility failed to monitor the efficacy of R69's pain management regimen. The deficient practice resulted in R69 experiencing unrelieved pain. R69 is at a potential risk for psycho-social harm. Findings Include: Cross reference to F697 Pain Management. R69 was admitted to the facility on [DATE] with diagnoses that included unspecified polyneuropathy, unspecified gout, and abrasion of lower back and pelvis. Review of the resident's care plan documents R69 to have pain in her right leg and to be managed with pain medication as needed. The care plan further documents she will be comfortable with current pain regimen. Tolerable pain level is 3. Interventions include Administer pain medication as needed for moderate to severe pain .Assist me to repositioning as needed to maintain proper body…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observations, record review and interviews, the facility failed to provide resident centered needed care and services for one (1) of 19 residents sampled, Resident (R)24. The facility did not follow the physicians order to treat diarrhea for R24. Findings Include: R24 was admitted to the facility on [DATE] with multiple diagnoses which includes, hypertiensive chronic kidney disease and Cauda Equina Syndrome, a rare disease affecting a bundle of nerves in the spine. Review of R24's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/22/22, R24's Brief Interview Mental Status (BIMS) scored her at a 15 (cognitively intact). On 10/11/22 at 12:25 PM interview with R24 was done, R24 reported having frequent loose stools, diarrhea, and her physician was to recommend medication but was never administered any medication to treat diarrhea. During a second observation and interview at 02:56 PM, R24 was observed to finish her lunch and stated she tries not to eat certain foods due to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-14 · tag F0697 — failed to manage pain — isolated
    Provide 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 evaluate the effectiveness of regularly scheduled pain medication for one of two residents sampled for pain management. As a result of this deficient practice, Resident (R)69 had unrelieved pain. Findings Include: Cross reference to F656, Develop/ implement comprehensive care plan. R69 was admitted to the facility on [DATE] with diagnoses that included unspecified polyneuropathy, unspecified gout, and abrasion of lower back and pelvis. Review of R69's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/28/22, R69's Brief Interview Mental Status (BIMS) scored her at a 15 (cognitively intact). Review of the physician's orders documented R69 was prescribed Gabapentin Capsule 300 milligrams (mg) give two capsules by mouth three times a day for Neuropathy, Tylenol Tablet 325 mg give two tablets by mouth three times a day for Pain Management for 14 days, and Tylenol Tablet give 650 mg by mouth every 4 hours as needed…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-14 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure one (1) of 19 residents sampled, Resident (R)24 who were served food according to preference. Findings Include: R24 was admitted to the facility on [DATE]. Review of R24's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/22/22, R24's Brief Interview Mental Status (BIMS) scored her at a 15 (cognitively intact). Review of R24's food allergies documented in R24's Electronic Medical Record (EMR) includes Basil and Broccoli. On 10/11/22 at 12:33 PM observation and interview with R24 was done during lunch. R24 stated the facility gives her the menu weekly and she can mark off her preferences, however, on the bottom of the menu she requests for a tuna sandwich and raisins every day just in case she doesn't like the food or is served with food she is allergic to. R24 stated the facility does not always follow her preference, If I don't order a toss salad, don't give me a toss salad. R24 further stated she…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$32,133 in federal fines across 2 penalties.

  • $24,115 — penalty dated 2025-08-14
  • $8,018 — penalty dated 2024-10-18

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
THE MAUNALANI FOUNDATIONOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 03/16/1987
BLANCHETTE, PATRICIAIndividualCONTRACTED MANAGING EMPLOYEE; ADP OF THE SNFsince 06/01/2013
CHANTAVY, SAIIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/03/2024
FLORES, JEROMEIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 07/23/2018
CHOY, MELIndividualCORPORATE DIRECTORsince 11/07/2019
GOLDCAMP, JOSEPHIndividualCORPORATE DIRECTORsince 12/28/2015
HASEYAMA, KEVINIndividualCORPORATE DIRECTORsince 09/23/2022
HEIRAKUJI, LYNNIndividualCORPORATE DIRECTORsince 11/17/2019
PEROFF, RODERICKIndividualCORPORATE DIRECTORsince 12/28/2015
SOMBRERO, STEVEIndividualCORPORATE DIRECTORsince 11/07/2019
TODANI, DAVIDIndividualCORPORATE DIRECTORsince 12/28/2015
WRISTON, ARTHURIndividualCORPORATE DIRECTORsince 12/28/2015
YASUDA, NEALIndividualCORPORATE DIRECTORsince 05/11/2018

CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$18.6M
Net patient revenuemost recent cost report
-6.9%
Operating marginrevenue minus expenses
$768K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 6%Medicare 11%Other / private 82%

This home reported $768K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$620per resident / day
operating cost
$18,856per month
≈ monthly operating cost
$580per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

Paying with Medicaid

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.

Typical monthly cost in Hawaii
$15,473/mo
Nursing home (semi-private)
$16,395/mo
Nursing home (private)
$12,096/mo
Assisted living

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 125013. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-29, 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.

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