Nuuanu Hale: Assessment Failures Left Wounds Untreated - HI
Federal inspectors who visited the facility on February 6 found that the man, identified in records only as Resident 21, had pressure ulcers on both heels when he returned from being hospitalized. Pressure ulcers, sometimes called bedsores, are wounds that develop when sustained pressure cuts off blood flow to skin and tissue. Left unmonitored and untreated, they can deepen through layers of skin and muscle, reach bone, and become life-threatening infections.
Nobody at Nuuanu Hale recorded the wounds on the required federal assessment.
The assessment in question is called a Minimum Data Set quarterly review, a standardized form that nursing homes are required to complete regularly for each resident. It is the foundation of care planning. If a wound does not appear on that form, it effectively does not exist in the facility's care system. Staff working from that record would have no reason to look for the ulcers, no protocol for dressing them, no schedule for checking whether they were getting worse.
That is what happened here. The facility not only failed to note the pressure ulcers on Resident 21's quarterly assessment after his return, it also failed to develop any care plan to treat or monitor the wounds on his heels. Inspectors cited the facility under F641, the federal tag governing the accuracy of resident assessments.
The failure is particularly striking because the moment of return from a hospital is one of the most documented and scrutinized transitions in nursing home care. Residents who have been hospitalized often arrive back at their facilities in worse condition than when they left, sometimes with new wounds, new medications, or new diagnoses. The reassessment process exists precisely to catch those changes.
Resident 21's heels were not caught.
How long the wounds went without a formal treatment plan is not specified in the inspection record. What the record does establish is that by the time federal inspectors arrived, the gap between what the assessment said and what the resident's body showed was wide enough to constitute a citable violation.
Pressure ulcers to the heels are among the more common wound sites in bedridden or mobility-limited residents. The heel has little soft tissue between skin and bone, which means wounds there can progress quickly and are difficult to heal. Standard care typically involves offloading pressure from the heel entirely, inspecting the wound regularly, and documenting any changes. Without a care plan, none of that is organized or assigned.
Nuuanu Hale is a nursing facility in Honolulu. The inspection that surfaced this finding was a health inspection, the type conducted to assess whether a facility is meeting basic federal standards of care.
The inspection report does not describe Resident 21's current condition, does not say whether the pressure ulcers worsened during the period they went undocumented, and does not name any staff member responsible for completing the quarterly assessment or initiating the care plan. It does not say whether the resident or his family was aware that the wounds had been missed on the official record.
What it says is that a man came back from the hospital with wounds on both heels, and the facility whose job it was to care for him wrote nothing down about those wounds and planned nothing to address them.
The assessment form moved forward without him in it, at least not the part of him that was injured. And without that documentation, whatever was happening to his heels, whether improving or deteriorating, was happening outside the formal system meant to track it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nuuanu Hale from 2025-02-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
NUUANU HALE in HONOLULU, HI was cited for violations during a health inspection on February 6, 2025.
Pressure ulcers, sometimes called bedsores, are wounds that develop when sustained pressure cuts off blood flow to skin and tissue.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.