The incident on July 24 came just weeks after the facility investigated allegations that the man had inappropriately touched another female resident's private areas. Staff had promised to keep him supervised whenever vulnerable women were present.
Instead, federal inspectors found him unsupervised watching television with a female resident for at least 10 minutes. When they alerted the Administrator, she confirmed what they had observed: "He's supposed to be supervised and he was not."
The breakdown in supervision put female residents at risk in a facility already struggling with basic care coordination. Inspectors documented multiple failures during their July 26 visit, including a resident who missed a critical medical appointment because staff forgot to arrange transportation, and another resident who spent days in agitated distress without proper behavioral interventions.
The sexual assault investigation began June 29 when a certified nursing assistant entered the dining area and saw the male resident touching a female resident's private area over her clothing. No other residents or staff were present.
The assistant asked what he was doing and told him to stop. He laughed and backed his wheelchair away, saying he was doing nothing.
The female victim told staff the touching was not consensual. She said he had grabbed her breasts and touched her pubic area under her brief. She wanted police involved.
When questioned, the male resident admitted he had his hand on the woman's thigh but denied touching her "up there."
The man has a history of aggressive behavior dating back years. His care plan documents multiple incidents: slapping staff and spewing profanities in October 2023, pushing a nurse while she provided wound care, threatening to punch a nursing assistant, and grabbing another resident's hand to stop him from turning lights on and off.
Following the June sexual assault allegation, staff developed a detailed care plan. The resident was not to touch or intimidate another resident. He was not to be in the same area as the alleged victim or any vulnerable females unless supervised.
The plan was specific: "Keep R3 separated from other vulnerable females when out in the common area unless supervision is available. If vulnerable females come out into the common area, ask R3 to go to another area or his room unless he is supervised."
A psychiatrist who evaluated him July 5 recommended continued supervision in common areas "to deter pt from another inappropriate physical touch." The doctor noted the resident had sufficient insight regarding appropriateness and legal implications and had complied with boundary setting.
But supervision failed.
On July 22, inspectors observed him in the dining area with several other residents while staff played cards nearby. The next day, they found his room door open with curtains pulled around the bed, making it impossible to see if he was inside. When they called his name, no one responded. Minutes later, they found him alone outside on the lanai, an area with limited staff visibility.
The most serious lapse occurred July 24. Inspectors walked into the dining room at 3:50 PM and found him alone watching Family Feud with a female resident sitting at a table in the back. They observed for 10 minutes. No staff came to monitor him.
When they notified the charge nurse, she said staff took turns supervising him, with dietary and activity staff also helping. She was unaware he had been unsupervised and said, "I don't know how that happened."
Asked if she would consider the female resident vulnerable, the nurse hesitated and said the woman would yell if someone approached her and she didn't want them to.
The facility's other failures compounded risks to residents.
A woman with a fractured leg from a fall in May had her cast replaced with a different type in June, but staff never updated her care plan to reflect the change. The plan still referenced the original splint she had tried to remove, not the pink cast inspectors observed on her leg.
The same woman missed a critical appointment to have her cast removed July 15. The nursing staff had documented the appointment date and time when she returned from an orthopedic visit June 17, but they never informed the unit coordinator who arranges transportation. The missed appointment delayed her cast removal by three weeks.
Another resident spent four days in severe behavioral distress after his psychiatric medications were stopped due to a drug interaction. Inspectors found him in isolation for COVID-19, shaking his bed rails violently and appearing disheveled with tangled sheets around him.
His bed had been moved to the center of the room away from the windows because staff feared he might kick them out. Call lights hung on the wall out of his reach. A psychiatrist's order required staff to document his behavior frequency and intensity every shift, but no behavioral observations were recorded from January through July.
Staff documented his agitation in progress notes: "very restless, yelling, swearing, trying to damage mattress, ripping at it and bed, grabbing, and shaking parts violently, unable to redirect resident all shift." Another note described him "yelling loudly and shaking bed rails" throughout an entire night shift.
The Director of Nursing told inspectors she thought the physician was aware of his behavioral changes, but she couldn't find documentation that anyone had called the doctor. Staff didn't contact the physician about his escalating agitation until July 23, four days after his medications were stopped.
When asked about non-pharmacological interventions for his distress, the Director of Nursing said they place him on floor mats because "he likes it on the floor." His care plan listed no other behavioral interventions.
The Activity Director said no one was providing activities to the isolated resident, though nursing staff should turn on his television during room visits. During the inspection, his TV remained off despite DVDs being available in his room.
The facility also failed basic food safety protocols. Inspectors found clean dishes and pots stored on racks covered with rust-colored debris. The kitchen manager wore dirty gloves while moving between kitchen areas and handling food without changing them or washing her hands.
Temperature logs for refrigerators and freezers were missing entries for July 14. The kitchen manager acknowledged she had forgotten to record temperatures that day while covering for an absent cook.
Medical records contained significant gaps and inaccuracies. One resident's hospice certification had expired in January, but the facility had no updated certification, care plan, or progress notes from hospice nurses. When inspectors requested the missing documents, the Director of Nursing confirmed it was the first time the facility had received progress notes from hospice beyond a single page.
Another resident had physician orders and signed documents indicating she did not want resuscitation attempts, but a social services note incorrectly stated she was "full code status" and refused to complete advance directives.
The most serious documentation failure involved the resident with behavioral problems. Despite care plans and conference notes documenting his use of a bed alarm due to fall risks and behavioral issues, inspectors found no physician order authorizing the device. When questioned, the Director of Nursing searched his records and confirmed no order existed.
These systemic failures created an environment where residents faced multiple risks simultaneously. The male resident accused of sexual assault remained unsupervised around vulnerable women. The woman with the fractured leg endured weeks of unnecessary immobilization. The behaviorally distressed resident suffered in isolation without appropriate interventions or monitoring.
The Administrator's acknowledgment that supervision had failed represented more than a single oversight. It reflected broader breakdowns in communication, care coordination, and resident protection that put the facility's most vulnerable residents at continued risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pu'uwai 'o Makaha from 2024-07-26 including all violations, facility responses, and corrective action plans.