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Complaint Investigation

Oahu Care Facility

March 25, 2025 · Honolulu, HI · 1808 South Beretania Street
Citations 1
CMS Rating 5/5
Beds 82
Provider ID 125042
Healthcare Facility
Oahu Care Facility
Honolulu, HI  ·  View full profile →
Inspection Summary

OAHU CARE FACILITY in HONOLULU, HI — inspection on March 25, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF655
pad. Surveyor asked CNA2, to open up R2's chart to see if Some there was none as she wasn't assigned to R2 yesterday. CNA2 checked another date, 03/11/2025 to see if affected

Review of Wound Care Nurse (WCN) notes, dated 05/13/2024, indicated, wound on coccyx is necrotic and malodorous with large, purulent drainage. R1's care plan for unstageable ulcer, initiated on 05/16/2024, included tasks to assist R1 to turn/reposition at least every 2 hours.

There was no documentation in R1's TAR that repositioning/turning every 2 hours was completed.

3)

Record review of R2s MDS noted that R2 was admitted to the facility on [DATE] with multiple PUs. R2 had a Stage 3 PU on the right buttocks, unstageable wound left buttocks, Stage 2 coccyx, and left ankle ulcers.

Review of WCN notes dated 03/21/2025, indicated wounds located on bilateral buttocks and left posterior thigh are smaller in size while the right posterior thigh is healed. R2's care plan initiated on 02/28/2025, included tasks that R2 needs assistance to turn/reposition at least every 2 hours, more often as needed or requested.

There was no documentation in R2's TAR that repositioning/turning every 2 hours was completed.

4) On 03/25/2025 at 10:25 AM, interview with Certified Nurse Assistant (CNA)1 inquired how often they would check on the residents with PUs. CNA1 stated, We check up on them every time they have bowel movement, at least three times a day, in the morning after breakfast, again at lunch, and after dinner.

When asked about peri care and repositioning, CNA1 replied, We clean them and would report any findings to the charge nurse. We change their position every two hours and document that in the I-pad, under Activities of Daily Living (ADLs), repositioning and sign our name. At 10:30 AM, CNA1 showed surveyor, where in the I-pad, they would document repositioning was completed.

125042

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 125042 B.

Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oahu Care Facility 1808 South Beretania Street Honolulu, HI 96826

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HONOLULU, HI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAHU CARE FACILITY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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