The Care Center of Honolulu

In the surveyor’s words

From the most serious findings on record at The Care Center of Honolulu, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Mar 15, 2021

  Based on observations, record review, and interviews, the facility failed to ensure the resident's environment remained free from accident hazards and residents received adequate supervision and assistance to prevent accidents. As a result of this deficiency, as evidenced by for R75, who's wheelchair was placed in a position that restricted the resident from freely moving, adequate supervision was not provided and hot water temperatures were not checked after repair work was completed and were found to be unsafe for the residents, staff and visitors. […]

• Actual harm, isolatedF585Aug 15, 2024

  Based on interview and record review, the facility failed to support the resident's right to voice a complaint without the fear of reprisal or retaliation for one resident (Resident (R) 31) sampled. R31 reported an allegation of mistreatment by the Alleged Perpetrator (AP) to the Assistant Administrator (AADM). Initially, R31 reported he did not want to file a formal grievance due to being fearful what AP's reaction would be, and that R31 would not receive assistance from staff, or care would be withheld. During the facility's investigation, the facility informed R31 and AP that there should not be any form of contact between the two individuals. […]

• Actual harm, isolatedF600Aug 10, 2023

  Based on interviews and record review, the facility failed to protect Resident (R)52 from physical harm. Facility Staff (FS)7 confirmed pulling R52's right arm to repositioned in bed, no other staff were present at the time. Immediately after pulling R52's arm the resident reported pain and swelling to his/her right shoulder as a result of the incident. R52 was assessed by nursing staff which also noted redness to the resident's right shoulder. X-ray results confirmed R52 sustained a subluxation (partial dislocation) of the right (R) shoulder. R52 experienced pain and a decline in the resident's mobility ability which affected the resident's ability to achieve and maintain her highest level of physical well-being and had a decline in functional status. […]

• Actual harm, isolatedF684Aug 10, 2023

  Based on record reviews and interviews, the facility failed to provide the required care and needed treatment for one resident, whose family prefers to be anonymous, (RA), out of a sample of 36 residents. This deficient practice resulted in the potentially avoidable death of RA and could pose harm to other residents who have complex medical conditions. Finding includes: Record review of the Intake Information document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) 10464. RA was admitted to the facility in August 2022 for rehabilitation, did not improve with rehabilitation, and was transferred to long term care. RA's health status significantly declined and needed to be emergently transferred to the emergency room (ER) on 12/06/22. […]

• Actual harm, isolatedF686Apr 9, 2021

  Based on observation, record review (RR), and interview, the facility failed to ensure one resident (R)41 in the sample received the appropriate treatment and services to prevent pressure-related skin conditions from occurring. This was evidenced by a stage II (a shallow, open sore) pressure ulcer (PU) on R41's ischium (lower back portion of his hip bone), and a deep tissue injury (DTI), or a closed pressure sore with signs of underlying tissue damage, on his left ear. Despite the resident being identified as at-risk for pressure ulcer development upon admission, and multiple interventions being incorporated to prevent them, the facility failed to ensure those interventions were consistently implemented. This deficient practice has the potential to affect all the residents at the facility. […]