Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lanai Community Hospital during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete the required annual review and evaluation of its infection prevention and control plan. Policy language in the plan requires an annual assessment of all components for compliance, trends, and continued applicability, but document review showed the last review occurred more than a year prior. During interviews, the IP initially could not state when the plan was last reviewed and later confirmed that the most recent review was the prior year and that the plan was only then under review, resulting in a cited deficiency at the facility-wide infection control program level.
A resident’s EHR was left open and visible on a computer terminal located in a public activities room, displaying flowsheets, diagnoses, and other health information where it could be seen by passersby. A CNA reported that she forgot to exit the chart while passing food trays and acknowledged the importance of closing the record to comply with HIPAA. The DON confirmed that staff are expected to exit resident charts when not in use to meet HIPAA requirements. Facility policy on premises information security and privacy requires computing systems displaying non-public information to be positioned to minimize viewing by unauthorized persons and to use physical safeguards such as privacy screens as appropriate.
A resident with ESRD and dementia was transferred from the LTC unit to the ED and then admitted to an acute care hospital for evaluation of chest pain and possible PE. Review of the EHR and hospitalization information showed that the facility did not provide or document any written notice of this discharge to the resident’s representative or to the LTCO office. In an interview, the Administrator confirmed that no written notifications were sent, despite facility policy requiring family notification of changes in level and room.
A resident with a history of stroke, hemiplegia, aphasia, incontinence, recurrent skin issues, and documented dental problems did not have an individualized care plan that reflected her actual needs. Despite multiple documented skin issues and prescriptions for topical corticosteroids, these treatments were not included as care plan interventions. The MDS showed the resident was incontinent without an indwelling catheter, yet the care plan contained goals and interventions for catheter care. Oral assessment documented plaque and dental caries, but no dental goals or interventions were care planned. A CN acknowledged that a standardized bundled care plan was chosen on admission instead of tailoring the plan to the resident’s current clinical status, and the DON confirmed that care plans are expected to be individualized.
A resident with a history of stroke, right-sided hemiplegia, and aphasia had a right-hand contracture for which staff were applying a rolled towel to the hand, but the care plan—initiated months earlier—still stated that no splint was required and did not include the towel intervention. Observations showed the resident first without any splint or towel and later with a rolled towel in place, while record review and interviews with the CN and DON confirmed that the care plan had not been updated to reflect this current intervention, contrary to the facility’s care planning policy requiring regular revisions based on reassessed needs.
A resident with documented plaque and caries was referred for dental care and had a clinic appointment scheduled, but the clinic later reported it could not accommodate the visit and would provide a new date. Facility staff did not receive a follow-up call and failed to reschedule the dental appointment. The CN confirmed the resident had initially refused an appointment, that no subsequent appointment was secured, and that the resident’s dental issues and refusal were not incorporated into the care plan. Required follow-up oral assessments were also not documented, while the resident’s family reported worsening dental condition and concern about the impact on eating.
The facility failed to label insulin syringes and blood glucose testing supplies with open and discard dates, as observed during an inspection. One insulin syringe lacked the required dates, and glucometer test strips and control solutions were also missing these labels, contrary to facility policy. This oversight could impact medication safety and testing accuracy.
A facility failed to accurately complete a PASARR Level I screening for a resident with Dementia due to Pick's Disease. The screening incorrectly marked 'No' for the presence of dementia, despite the resident's diagnosis. This error, confirmed by the MDS Coordinator, Social Worker, and DON, could have prevented the necessary Level II evaluation to determine appropriate care.
A facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in monitoring adverse medication effects and post-hemodialysis care. A resident with chronic kidney disease lacked care plan interventions for anticoagulant monitoring and vascular access care. Two residents on escitalopram had no documented monitoring for adverse effects, with the MAR only noting behavior monitoring. The DON confirmed the need for proper documentation and care plan inclusion.
A resident receiving hemodialysis treatments had pressure dressings applied to her vascular access site, which were not removed within the recommended 24-hour period. The dressings, applied by the dialysis clinic staff, were observed by an RN to still be in place two days later. The DON and RN confirmed the oversight, acknowledging the risk of complications to the resident's vascular access.
The facility failed to document monitoring of medication effects for a resident on anticoagulants and two residents on antidepressants, as confirmed by a nurse and the DON. This lack of documentation put the residents at risk for adverse health complications.
Failure to Complete Annual Review of Infection Control Plan
Penalty
Summary
The facility failed to review its infection prevention and control plan on an annual basis as required by its own policy. Review of the facility’s Infection Control Plan 2024 on 04/01/26 showed the last review and revision date as 04/2024. The plan’s section 5.1, Plan Evaluation, specifically states that in preparation for the annual planning and revision of the Infection Control Plan, all components of the current plan will be evaluated to determine compliance, trends, and continued applicability. During an interview on 04/01/26 at 2:11 PM, the Infection Preventionist (IP) was unable to state when the Infection Control Plan was last reviewed and indicated he would need to check. In a follow-up interview at 2:46 PM the same day, the IP confirmed that the Infection Control Plan was last reviewed in 04/2024 and was only currently under review, demonstrating that the required annual evaluation and revision had not been completed within the specified timeframe, which the report states inhibits the facility’s ability to effectively implement its infection control prevention plan and has the potential to affect all residents by placing them at increased risk for illness. No specific residents or individual clinical conditions were identified in the report; the deficiency was cited at the facility-wide program level for infection prevention and control.
Failure to Protect Resident EHR Privacy on Public Computer Terminal
Penalty
Summary
Surveyors observed that the facility failed to protect the privacy and confidentiality of a resident’s personal and clinical information when a computer terminal in the activities room was left open with the resident’s electronic health record (EHR) visible and accessible to anyone passing by. On 03/31/26 at 01:00 PM, the computer screen displayed the resident’s flowsheets, diagnoses, and other health information, and was located in a public area on the left-side corner of the activities room. During a concurrent interview, CNA 1 stated she had left the EHR open and forgot to exit out while passing food trays, and acknowledged that closing out the chart is important for protecting residents’ health information and complying with HIPAA. In a separate interview at the same time, the DON confirmed that resident charts should be exited when not in use to comply with HIPAA requirements. Review of the facility’s Premises Information Security and Privacy policy, revised 09/2023, showed that computing systems displaying non-public information must be positioned to minimize viewing by unauthorized persons and that physical barriers such as privacy screens should be used as appropriate.
Failure to Provide Required Written Hospital Transfer Notice to Representative and LTCO
Penalty
Summary
The facility failed to provide required written notice of a transfer/discharge to the hospital to a resident’s representative and to the Long-Term Care Ombudsman (LTCO) office for one resident. The resident, an older female with end stage renal disease (ESRD) and dementia, developed chest pain and was seen in the Emergency Department (ED), where concern for a possible pulmonary embolism led to her transfer and admission to an acute care hospital. Record review on 03/31/26 showed that the resident was discharged to the ED and then admitted to the hospital, but the facility could not provide written notification of this discharge to the resident’s representative or to the LTCO office. In an interview, the Administrator confirmed there was no written documentation of such notifications, despite the facility’s “Patient Discharge – Long Term Care (LTC) Unit” policy stating that the family shall be notified of changes in level and room. This lack of written notification and documentation constituted a failure to provide the required discharge notice related to the resident’s needs, appeal rights, or bed-hold policies, and meant that the transfer and discharge were not communicated in writing to the resident’s representative or the LTCO office as required.
Failure to Individualize Care Plan for Skin, Incontinence, and Dental Needs
Penalty
Summary
Surveyors identified a failure to develop a person-centered, comprehensive care plan for a female resident with a history of stroke, right-sided hemiplegia, and aphasia. On observation, the resident was in bed, awake, with a flaccid right hand and contracture, wearing a brief and with no visible indwelling catheter. Interview with a family member revealed concerns that the resident was prone to skin issues and had been experiencing skin problems for several months, as well as worries about worsening dental condition and its impact on eating. Record review showed that the facility’s Alert Charting list documented at least 16 skin issues over several months, and the resident was prescribed Clobetasol 0.05% ointment twice daily and Triamcinolone Acetonide 0.1% ointment for rash and itching, yet these topical corticosteroids were not included as interventions in the resident’s care plan. Further record review showed that the resident’s MDS documented bowel and bladder incontinence and no indwelling catheter on admission, but the care plan nonetheless contained goals and interventions for indwelling catheter care. Additionally, a Basic Oral Assessment flowsheet documented plaque and dental caries, but the care plan did not include any goals or interventions addressing dental care. In interviews, the charge nurse confirmed that the topical corticosteroid treatments and dental care plan were missing from the care plan and acknowledged that catheter care should not have been included because the resident never had an indwelling catheter. The charge nurse also stated that a bundled, standardized care plan had been selected on admission instead of an individualized plan based on the resident’s current needs, and the DON confirmed that care plans were expected to be individualized and reflect current needs, consistent with the facility’s written care planning policy.
Failure to Revise Care Plan for Hand Contracture Intervention
Penalty
Summary
The deficiency involves the facility’s failure to revise an existing care plan to reflect the current intervention being used for a resident with a right-hand contracture. The resident is an adult female admitted with diagnoses including stroke, right-sided hemiplegia, and aphasia. On one observation, she was seen in bed with right arm flaccidity and a right-hand contracture, and no hand or towel splint was applied. On a subsequent observation, the same right-hand contracture was noted, this time with a rolled towel in place on the right hand. Record review showed that the resident’s care plan, initiated several months earlier, addressed contractures but did not include the intervention of applying a towel to the right hand and stated that the resident did not require a splint. The Charge Nurse confirmed that the care plan had not been revised to include the towel application, despite staff using the towel to prevent moisture and sweat accumulation in the resident’s right hand. The Charge Nurse acknowledged the importance of revising the care plan to reflect current resident needs, and the DON confirmed that care plans are expected to be individualized and updated based on reassessment, consistent with the facility’s written Care Planning policy.
Failure to Reschedule Dental Appointment and Update Care Plan After Missed Clinic Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and ongoing dental services for a resident with documented oral health issues. A family member reported that the resident’s teeth were worsening and expressed concern about the impact on the resident’s eating. Record review showed that a Basic Oral Assessment documented plaque on the resident’s teeth and a referral for dental consultation, with a dental appointment scheduled for 06/15/25, and subsequent assessments noting plaque and caries while still referencing the same scheduled appointment. A nursing note indicated that the dental clinic later emailed that they could not accommodate the appointment and would call back with a new date, but no follow-up call was received and facility staff did not reschedule the appointment. The Charge Nurse confirmed that the resident initially refused an appointment, that a subsequent follow-up appointment could not be accommodated by the clinic, and that staff failed to reschedule the dental visit. The Charge Nurse also acknowledged that the resident’s refusal and dental issues were not incorporated into the resident’s care plan, and there was no documentation of the next scheduled oral assessment being completed. This deficient practice was identified for one resident sampled for dental services and was determined to have the potential to affect all residents residing in the facility.
Failure to Label Medications and Testing Supplies
Penalty
Summary
The facility failed to ensure that all medications and blood glucose testing supplies were labeled according to professional standards, which is necessary to promote safe administration practices and decrease the risk of medication errors. During an inspection of the medication cart, it was observed that three insulin syringes were in use, but one of them did not have the open and discard dates written on the red sticker as required. The Registered Nurse (RN1) confirmed that the dates should be written on the sticker to ensure the medication is still usable. The Director of Nursing (DON) also confirmed that staff are supposed to write these dates on the insulin syringes. Additionally, the inspection revealed that the glucometer test strips and control solutions at the nurse's station were not labeled with open and discard dates. RN1 stated that the glucometer is tested once a day and confirmed that the test strips and control solutions in use should have had the open and discard dates written on them. According to the facility's policy, test strips are good for 120 days and control solutions for 90 days once opened, but these dates were not recorded, which could affect the accuracy of blood glucose testing.
Inaccurate PASARR Level I Screening for Dementia
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately for a resident, potentially affecting the determination of whether a Level II evaluation was necessary. The resident was admitted for long-term placement with a diagnosis of Dementia due to Pick's Disease. Upon review, it was found that the PASARR Level I Screen incorrectly marked 'No' for the question regarding the presence of dementia, despite the resident's primary diagnosis indicating otherwise. This error was confirmed during an interview and record review with the MDS Coordinator, Social Worker, and Director of Nursing, who acknowledged that the correct response should have been 'Yes'. This inaccuracy in the PASARR Level I could have prevented the necessary steps to trigger a Level II evaluation, which is crucial for determining the appropriate care and services for the resident's mental condition.
Deficient Care Planning and Monitoring in LTC Facility
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in monitoring for adverse effects of medications and post-hemodialysis care. Specifically, the care plans for a resident with stage 5 chronic kidney disease and atrial fibrillation did not include interventions for monitoring signs and symptoms of bleeding or bruising due to the use of an anticoagulant, nor did they include instructions for the care of vascular access after hemodialysis treatments. This oversight was confirmed during an interview with a registered nurse, who acknowledged the absence of these critical interventions in the resident's care plan. Additionally, two other residents, both on escitalopram for depression, had care plans that included monitoring for adverse effects of the medication. However, there was no documentation of such monitoring in the medical records. The registered nurse confirmed that the monitoring was only documented in the medication administration record (MAR) as behavior monitoring, without specific attention to adverse effects. The Director of Nursing also confirmed the need for documentation of medication side effects in the MAR and the inclusion of post-hemodialysis care instructions in the comprehensive care plan.
Failure to Remove Hemodialysis Pressure Dressing
Penalty
Summary
The facility failed to provide post-hemodialysis treatment care consistent with professional standards for a resident who received hemodialysis treatments. The resident, who underwent hemodialysis on Mondays, Wednesdays, and Fridays, had pressure dressings applied to her vascular access site by the dialysis clinic staff. These dressings were observed to remain in place beyond the recommended 24-hour period, as noted in a communication from the hemodialysis facility dated 08/08/24, which instructed the removal of the pressure dressing after 24 hours. On 10/15/24, a Registered Nurse (RN) observed the dressings on the resident's left upper arm, which were applied after her treatment on 10/14/24. The dressings were still present on 10/16/24, indicating they had not been removed within the recommended timeframe. The Director of Nursing (DON) and the RN confirmed that the dressings should have been removed on 10/15/24 to prevent possible complications to the resident's vascular access. This oversight in care could result in preventable vascular access complications, posing serious health risks to the resident.
Failure to Monitor Medication Effects for Residents
Penalty
Summary
The facility failed to ensure adequate monitoring of medication effects for three residents, leading to a deficiency in their care. Resident 3, who was on Eliquis, an anticoagulant, did not have documentation in their chart indicating monitoring for signs and symptoms of bleeding. Similarly, Residents 4 and 6, both on escitalopram for depression, lacked documentation of monitoring for adverse effects of the antidepressant medication. This lack of documentation was confirmed during a review of the medication administration records (MAR) with a registered nurse, who acknowledged the absence of such records. During an interview with the Director of Nursing, it was confirmed that the monitoring for signs and symptoms of bleeding for Resident 3 and adverse effects of antidepressants for Residents 4 and 6 should have been documented in the MAR every shift. The failure to document these critical monitoring activities put the residents at risk for avoidable adverse health complications related to their medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lanai City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hale Makua - Wailuku | 28.1 mi | ★★★★★ | 3 | 0 |
| Hale Makua - Kahului | 28.6 mi | ★★★★★ | 13 | 0 |
| Kula Hospital | 37.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lanai Community Hospital.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.