Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Legacy Hilo Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A high-risk, immobile resident with multiple comorbidities and a Braden score indicating elevated PU risk was totally dependent on staff for positioning and bed mobility, yet there was no documentation that staff frequently repositioned her. On admission she had MASD to the buttocks but no PU, and her care plan lacked specific interventions to prevent PU development and was not revised promptly after a Stage III coccyx PU was discovered during nurse management skin rounds. The resident later complained of buttock pain, family reported a sacral PU, and the RCM confirmed the absence of a PU at admission, the presence of a Stage III PU, and the lack of documented repositioning.
The facility did not adhere to its kitchen sanitation and dietary dress code policies, leading to improper food handling practices. A scooper utensil was left inside a sugar container instead of being properly stored, and kitchen staff were observed working near food preparation areas without required hair restraints, despite policies mandating effective hair restraints and proper utensil storage. The Dietary Director acknowledged that these practices did not comply with established procedures, contributing to an increased risk for foodborne illness and reduced quality of service.
Surveyors found that the facility did not develop or timely update baseline care plans to address the immediate needs of several newly admitted residents. One resident with sepsis, pneumonia, multiple comorbidities, total ADL dependence, and a PICC line for IV antibiotics did not have her specific ADL deficits, interventions, or PICC care reflected in the baseline CP until later. Another resident admitted for rehab after falls and weakness, with CAD, CKD, insulin‑dependent DM, toe amputations, and a hand contracture, used side‑rail enablers and insulin, but his baseline CP omitted the enablers, insulin, and detailed ADL assistance needs. A third resident with DM on insulin, CAD, HTN, a left BKA, and a PICC line for a prolonged IV antibiotic course had neither the PICC line nor the enablers documented in the baseline CP until well after admission. A fourth resident with Afib on apixaban, prior CVA, DM on insulin, lower extremity weakness, and enabler bars had provider orders to closely monitor for side effects of duloxetine and apixaban, yet the baseline CP did not initially include these high‑alert medications or the enablers. The DON confirmed these omissions in the baseline care plans.
Surveyors found that the facility used U‑shaped bed enablers for four residents to assist with bed mobility and transfers without a governing policy, without documented assessments of each resident’s cognition and understanding of the device, and without properly signed informed consent forms. Residents with conditions such as sepsis, stroke, diabetes, coronary artery disease, chronic kidney disease, lower extremity weakness, and a below‑knee amputation were observed with enablers attached to both sides of their beds, while their Side Rail/Enabler/Grab Bar Observation and Consent forms contained only typed names in the signature fields and no actual resident or representative signatures. The ADM confirmed there was no restraint policy and no specific policy or criteria for enabler use.
A resident with multiple comorbidities, including ESRD on dialysis, developed urinary retention during a rehab stay and was discharged home with an indwelling Foley catheter and a mechanical lift. The resident’s son, designated as caregiver, had previously assisted her at home but had not managed a urinary catheter before. Nursing documentation at discharge noted follow-up with a PCP and home health and described the transfer to the son’s car, but recorded education/training as not applicable and contained no evidence of Foley catheter care teaching. During interviews, staff indicated that a vendor trains caregivers on the mechanical lift but could not confirm any nursing education on catheter care, and the Administrator acknowledged nursing’s responsibility to assess, provide, and document caregiver training and capacity, which was not done in this case.
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, including those at high risk for pressure injuries, with existing heel and foot wounds, with documented negative behaviors, and with significant histories of thromboembolic disease on anticoagulants. One resident who was immobile, cognitively impaired, and recently hospitalized for pulmonary emboli and DVTs had only generic pressure injury risk statements in the care plan, with no specific turning or positioning interventions, while family reported the resident was not turned over multiple days. Another resident with heel and foot wounds had a care plan requiring a protective boot, yet surveyors repeatedly observed the resident without the boot, with no documentation of refusals despite staff claims of frequent refusal, and behavior issues such as throwing items at staff were not initially care planned or specifically monitored. Two residents on apixaban for serious clotting histories had no care plan focus or interventions related to anticoagulant use, despite visible bruising and bleeding and staff acknowledgment that such care plans should have been in place.
Surveyors found that staff failed to timely review and revise comprehensive care plans for two residents. One resident’s care plan continued to list active COVID isolation precautions and related interventions even though the resident no longer had COVID, while observations showed no isolation signage at the room. Another resident, who was at high risk for pressure ulcers due to immobility and multiple comorbidities, developed a Stage 3 pressure ulcer at the coccyx documented in nursing notes, but the care plan was not updated to include this new wound and related interventions until several days after its discovery.
A resident’s room contained OTC Tussin cough syrup and Tylenol Extra Strength capsules that had been brought in and administered by a family member without notifying staff. The family member reported giving these medications on several occasions in the past when the resident appeared uncomfortable. The RCM later confirmed the medications were present in the room and stated that this resident had not been assessed as able to self-administer and that medications should only be kept in a locked box if self-administration is approved. The DON also stated that medications may only be stored in a resident’s room when the resident is assessed as safe to self-administer and the medications are locked.
Two residents experienced significant medication errors when an LPN administered the wrong type of insulin to a resident despite checking the MAR and having the dose visually confirmed, and another LPN checked a resident’s blood glucose after a meal, administered insulin per sliding scale based on that post-prandial value, and failed to give a scheduled mealtime oral phosphate binder, incorrectly documenting the resident as absent from home without meds.
Surveyors found that an eye drop medication on a unit medication cart was in use but lacked a documented open date on its label, despite instructions to discard 42 days after opening. An RN confirmed the drops were being used and acknowledged that staff could not determine when the 42-day discard period would end because the open date had not been recorded, indicating noncompliance with professional labeling standards for medications.
The facility failed to notify the Ombudsman of resident transfers or discharges for four residents, as required by policy. Despite having a policy in place, the facility did not send notifications to the Ombudsman for residents transferred or discharged to hospitals, as confirmed by the Administrator.
A resident's call bell was repeatedly found out of reach, limiting their ability to request assistance. Observations showed the call bell dangling from the bed, and the resident expressed difficulty in accessing it. A CNA acknowledged the issue and repositioned the call bell. The facility's policy requires call lights to be conveniently positioned for residents, which was not followed in this case.
A resident reported missing supplements, but the facility failed to initiate an investigation due to a lack of communication between staff. The resident's psychosocial wellbeing was affected as he felt his concerns were not taken seriously, and the facility did not follow its policy on handling missing items.
A resident with a history of hemiplegia, hemiparesis, aphasia, and low back pain experienced frequent pain, which was not addressed in her care plan. Despite the resident's pain being documented in her MDS, the facility failed to include pain management strategies in her care plan. The DON confirmed the oversight, acknowledging that a care plan should have been developed according to the facility's Pain Management Policy.
A resident with a urinary catheter was found with tubing on the ground, and a nurse performed a catheter flush without a physician's order, failing to follow proper hand hygiene protocols. The resident's medical history includes hemiplegia, diabetes, and chronic kidney disease. The nurse later confirmed the absence of a required order, which was documented after the deficiency was noted.
The facility failed to properly reconcile controlled medications, as nursing staff pre-signed the Controlled Medication Reconciliation Log before conducting the actual count with the on-coming shift nurse. This was observed during an inspection of a medication cart, where a nurse pre-signed the log, claiming she would work a double shift, but the schedule showed otherwise. The Resident Care Manager confirmed that the facility's policy requires the log to be signed in the presence of another licensed nurse during shift change, which was not followed.
The facility failed to ensure proper storage of medications, as two medication carts were found unlocked and unattended on separate occasions. An LPN and an RN confirmed that the carts should have been secured, as per the facility's policy, which mandates that medication carts remain locked when not in use or attended by authorized personnel.
The facility failed to maintain proper infection control practices for two residents. A resident's urinary catheter tubing was observed on the ground, and an RN did not perform hand hygiene during catheter flushing. Another resident's dressing change was conducted without proper hand hygiene between glove changes, violating the facility's policy.
A resident in hospice care received morphine sulfate on a routine basis due to a data entry error, which was not questioned by nursing staff until the family intervened. The LPN and RN involved lacked proper competency verification, as their checklists were incomplete and missing assessments. This deficiency placed the resident at risk of decreased physical well-being.
A facility failed to ensure accurate reconciliation and accounting of controlled medications for a resident in hospice care. Discrepancies were found between the MAR and the controlled drug log for morphine sulfate, with doses administered not properly documented. The RCM admitted to not reviewing the narcotic logs as required, leading to the deficiency.
Failure to Reposition High-Risk Resident and Update Care Plan Resulting in Stage III Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer (PU) prevention and care for a long-term female resident with Guillain-Barre syndrome, paraplegia, spinal stenosis, neurogenic bladder, and cognitive impairment, who was totally dependent on staff for positioning and mobility. On readmission from the hospital, she had moisture-associated skin damage (MASD) to the buttocks treated with zinc oxide cream and no documented PU. Her MDS documented total dependence for bed mobility and inability to roll, and a Braden Scale score of 12 indicated high risk for pressure injury. Despite this, there was no evidence in the medical record that staff frequently repositioned her to prevent a PU. The resident later reported pain in her buttocks, and family members stated she had a PU on her sacrum. A nursing note documented that during nurse management skin rounds, staff discovered a Stage III coccyx PU and entered treatment orders. The Resident Care Manager confirmed that the resident did not have a PU at admission, that she currently had a Stage III PU on her coccyx, and that there was no documentation of positioning to prevent a PU. Additionally, the comprehensive care plan developed at initial admission did not include specific interventions to meet her needs and prevent a new PU, and the care plan was not revised in a timely manner after the Stage III PU developed.
Failure to Follow Kitchen Sanitation and Hair Restraint Policies
Penalty
Summary
The facility failed to follow its kitchen sanitation and dietary dress code policies, resulting in improper food handling practices. During a kitchen observation on 02/24/26 at 10:15 AM, a scooper utensil was found left inside a sugar container instead of being properly stored, contrary to the facility’s policy requiring proper utensil storage and handling. A subsequent kitchen observation on 02/25/26 at 01:15 PM revealed that two kitchen staff members were working near the food preparation area without wearing required hair restraints, despite the dietary dress code policy stating that effective hair restraints must be utilized while working in the dietary department and that hairnets, beard guards, or bonnets are available at department entrances and exits. In a staff interview on 02/25/26 at 01:20 PM, the Dietary Director acknowledged that the scooper utensil should not have been left in the sugar container and confirmed that kitchen staff are required to wear hair restraints at all times while working in the department. The report notes that, as a result of these deficiencies, there was an increased risk for foodborne illness and impact on quality of service.
Failure to Develop and Update Baseline Care Plans for New Admissions
Penalty
Summary
The deficiency involves the facility’s failure to develop and timely update baseline care plans within 48 hours of admission to address new residents’ immediate needs. For one cognitively impaired female resident with sepsis, pneumonia, diabetes, hypertension, and a transient ischemic attack, the admission assessment documented extreme weakness, maximal assist needs for transfers, and total dependence for multiple ADLs, as well as the presence of a PICC line for IV ceftriaxone. However, the baseline care plan initiated several days after admission did not initially specify her ADL deficits or corresponding interventions, and these were only added later. The PICC line and its required specialized care and monitoring were also not included in the baseline care plan until it was revised and resolved on the same day, after the resident had already been receiving IV therapy. A male resident admitted for rehabilitation after hospitalization for pneumonia, multiple falls, progressive weakness, and functional decline had a history of coronary artery disease, chronic kidney disease, insulin‑dependent type 2 diabetes, spinal stenosis, toe amputations, and a left hand contracture. His admission assessment documented the use of side rail enablers to assist with transfer and bed mobility, but the baseline care plan did not include the enablers, did not specify interventions or levels of assistance for his ADL self‑care performance deficits, and did not reflect that he was on insulin. Another male resident with diabetes on insulin, coronary artery disease, hypertension, and a left BKA was admitted with a PICC line in place for a planned six‑week course of IV ceftriaxone and had or requested an enabler. His baseline care plan did not include the PICC line until several weeks after admission and did not include the enabler at all, despite observation of enablers on both sides of his bed. A further male resident admitted for rehabilitation after a fall related to generalized weakness and dizziness had a history of atrial fibrillation on apixaban, prior cerebrovascular accident, and diabetes managed with insulin, with documented lower extremity weakness and use of enabler bars. Provider orders directed staff to observe closely for significant side effects of duloxetine and apixaban, including drowsiness, blurred vision, dizziness, discolored urine, and black tarry stools. The baseline care plan initiated at admission did not include the high‑alert anticoagulant or the antidepressant that required close monitoring, and these medications were only added to the care plan several weeks later. The enabler bars used by this resident were also not included in the baseline care plan. During an interview and concurrent review of these residents’ care plans, the DON confirmed that the baseline care plans were missing these items and acknowledged they should have been included. The report states that, as a result of this deficient practice, there is an increased risk of adverse events and lack of continuity of care for all new admissions.
Lack of Policy, Assessment, and Signed Consent for Bed Enabler Use
Penalty
Summary
The deficiency involves the facility’s failure to have and implement a policy, based on professional standards of practice, governing the assessment and use of bed enablers (U‑shaped devices attached to the bedframe to assist with turning, repositioning, and transfers). Surveyors found that four residents had enablers attached to their beds without evidence of appropriate assessment of cognitive status to ensure understanding and safe use, and without properly executed informed consent forms. The Administrator confirmed that the facility did not have a restraint policy because they do not use restraints and also had no policy or criteria for the use of enablers. One resident was an elderly female admitted with sepsis, pneumonia, diabetes, hypertension, and stroke, whose admission assessment and MDS documented cognitive impairment, extremity weakness, and total dependence on staff for multiple ADLs, including rolling from side to side. Her admission documentation indicated side rails/enablers were in use, and the Side Rail/Enabler/Grab Bar Observation and Consent form listed bed mobility as the reason for use. During observation, she was lying in bed with U‑shaped enablers on both sides and was non‑interviewable due to cognitive status. There was no documented assessment of her cognitive ability to understand and safely use the enabler, and the consent form had her name typed in the signature area but lacked an actual resident or representative signature. Three additional residents were also found with enablers in use without complete assessment and consent documentation. One male resident with coronary artery disease, chronic kidney disease, insulin‑dependent diabetes, spinal stenosis, left eye blindness, and a right toe amputation had enablers on both sides of the bed; his admission assessment showed he was alert and oriented with no upper or lower extremity impairment aside from a left hand contracture, and his form cited transfer and bed mobility as the reason for use, but the consent area contained only a typed name and no signature. Another male resident with diabetes, coronary artery disease, hypertension, and a left BKA had enablers for transfer and bed mobility with the same lack of signed consent. A further male resident admitted for rehab with a history of multiple falls, impaired memory, disorientation, lower extremity weakness, and prior PT with walker use also had enabler bars on both sides of the bed; his documentation indicated a grab bar request, but again, the enabler consent form only had a typed resident/representative name without a signature and no documented cognitive assessment specific to enabler use.
Failure to Assess and Educate Caregiver on Foley Catheter Care Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate discharge plan and caregiver education for a resident who was discharged home with an indwelling urinary catheter. The resident, an older female admitted for short-term rehabilitation after an acute hospitalization, had multiple medical conditions including diabetes, spinal stenosis, chronic back pain, muscle weakness, gait and mobility abnormalities, and end-stage renal disease requiring dialysis. While in the facility, she developed urinary retention and required an indwelling urinary catheter, which remained in place at the time of discharge home with her son as the designated caregiver. The nursing progress note documented that the resident was discharged home with her son, to be followed by her primary care provider and home health services, and that staff assisted with transfer to the son’s car. The note also indicated “Education/Training Response as indicated: n/a,” and there was no documentation that the caregiver received education on Foley catheter care. Following a report of concern to the Office of Health Care Assurance that the resident did not have needed resources after discharge and that the caregiver could not safely manage the urinary catheter, surveyors reviewed records and interviewed staff. The Social Services Assistant, after consulting the Social Worker, reported that a vendor provides caregiver training on the mechanical lift when delivering the equipment to the home, but the Social Worker did not know if nursing had provided catheter care education. It was acknowledged that although the son had cared for the resident prior to hospitalization, she did not have a urinary catheter at home before this admission. In an interview, the Administrator confirmed that nursing was responsible for assessing caregiver training needs, providing and documenting the training, and documenting that the caregiver was willing, capable, and had the capacity to provide the required care. The facility was unable to provide evidence that such assessment and education on Foley catheter care were completed or documented for this caregiver.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable interventions for multiple residents. One resident with Guillain-Barre syndrome, paraplegia, neurogenic bladder, cognitive impairment, a recent hospitalization for saddle pulmonary embolus with bilateral pulmonary emboli and femoral DVTs, and a pressure ulcer was care planned only as being at risk for pressure injury with generic interventions to follow facility policies and obtain/monitor labs and diagnostics. The care plan did not include specific pressure injury prevention interventions such as positioning or turning, despite the resident being immobile and totally dependent on staff for positioning since admission. Family members reported that over three consecutive days they were present from morning to evening and did not see staff turn the resident, and they stated CNAs acknowledged responsibility for positioning and reported the pressure ulcer was getting bigger. Another resident with a traumatic brain injury, incontinence, limited mobility, and existing pressure and wound issues on the right heel and foot had a care plan intervention for heel protectors to the right lower extremity while in bed or in a wheelchair. Surveyors repeatedly observed this resident in bed without the protective boot, which was seen in the corner of the room, and later in a wheelchair without the boot. The Resident Care Manager stated the resident often refused or kicked off the boot and that CNAs were required to document application and refusals, but there was no documentation of refusals in the progress notes for the days observed, and the Treatment Administration Record showed the boot as applied, which did not match observations. This same resident exhibited negative behaviors, including throwing items at staff and agitation noted by staff, and nursing progress notes documented negative behaviors toward staff and a roommate; however, the care plan initially contained no behavior focus. Only later was a behavior problem of throwing items at staff added, and even then, interventions did not include monitoring the specific types or frequency of behaviors. Two additional residents admitted for short-term rehabilitation with significant histories of thromboembolic disease and use of anticoagulants were not care planned for anticoagulant use. One resident with atrial fibrillation, prior TIA, and cerebral infarction, who reported long-term anticoagulant use and had a small cut on the elbow with dried blood on bed sheets, was receiving apixaban 5 mg twice daily without any related care plan focus or interventions. Another resident with acute embolism and thrombosis of the left femoral vein and a history of falls, who also reported long-term anticoagulant use and had visible old bruises on the right wrist and hand, had an active order for apixaban 5 mg twice daily, but the comprehensive care plan did not address anticoagulant-related care or interventions. A reviewing RN confirmed that care plans addressing anticoagulant use should have been developed for both residents and were not.
Failure to Timely Update Care Plans for Infection Status and New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans in a timely manner to reflect residents’ current conditions. For one long-term male resident with end stage renal disease on hemodialysis, type 2 diabetes, CHF, and a history of stroke with left-sided weakness, the active care plan continued to list COVID isolation precautions and Special Droplet/Contact precautions, including full PPE with N95 and face shield, antiviral therapy if indicated, and other COVID-related interventions. During observation, the resident was in bed, appeared comfortable, and had no droplet/contact precaution signage on the door. When the resident care manager was interviewed, she stated the resident had been diagnosed with COVID months earlier but did not currently have COVID, and review of the care plan at that time showed it still reflected an active COVID infection and related precautions. The deficiency also includes a failure to timely revise the care plan for a female long-term resident with Guillain-Barre syndrome, paraplegia, spinal stenosis, neurogenic bladder, cognitive impairment, and high risk for pressure ulcers due to immobility. After readmission from the hospital, her admission summary documented MASD to the buttocks with zinc oxide cream applied and no pressure ulcer. A subsequent nursing note documented newly discovered skin breakdown at the coccyx identified during nurse management skin rounds, describing a Stage 3 pressure ulcer with orders entered. However, review of the resident’s care plan showed it was not revised to address the new Stage 3 pressure ulcer and associated interventions until several days later, indicating a delay between identification of the pressure ulcer and updating the comprehensive care plan.
Unauthorized OTC Medications Stored and Administered by Family Member
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided to prevent accidents, as over-the-counter (OTC) medications were stored in the resident’s room and administered by a family member without staff knowledge. On 02/24/26, surveyors observed bottles of Tussin Cough and Chest Congestion liquid and Tylenol Extra Strength 500 mg capsules on the resident’s corner table, and these medications remained there the following day. During an interview, the family member stated he had brought in the medications and had given the Tussin a couple of times approximately six months to a year earlier, and Tylenol Extra Strength about six to eight months earlier when the resident appeared uncomfortable, without informing nursing staff. On 02/26/26, the Resident Care Manager confirmed the presence of the medications in the room and stated that medications should not be stored in a resident’s room unless the resident had been assessed as able to self-administer and the medications were kept in a locked box, and further stated that this resident was not a candidate for self-administration. On 02/27/26, the DON similarly stated that medications could only be stored in a resident’s room if the resident was assessed as safe to self-administer and the medications were locked.
Significant Insulin Administration Errors and Missed Mealtime Medication
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when one resident was administered the wrong type of insulin and another resident received insulin based on a post-meal blood glucose reading and did not receive a scheduled oral medication. For one resident, an LPN prepared insulin at the medication cart after reviewing the MAR, stating that 15 units of Lantus insulin via pen were due based on a blood sugar of 143 mg/dl. The LPN removed an insulin pen from the cart, compared the label to the MAR, set the pen to 15 units, and had the Infection Preventionist visually confirm the dose setting. The LPN then administered the insulin and, upon returning to the cart, realized that 15 units of Novolog 100 u/ml flex pen had been given instead of Lantus, despite the MAR indicating that Novolog should have been held for a blood sugar of 70–150 mg/dl. The facility’s medication administration policy required verification of the correct medication three times before administration. In a separate incident, another resident’s family member reported that after the resident had eaten lunch, she informed an LPN that the resident needed his dialysis folder, lunchtime medications, and blood sugar check. The LPN, who stated she had been dealing with another resident emergency and had not passed lunch medications as scheduled, checked the resident’s blood sugar after the meal, obtained a result of 254 mg/dl, and administered insulin per the ordered sliding scale just before the resident left for dialysis. The resident’s lunchtime oral medication, a calcium acetate phosphate binder ordered to be given with meals and scheduled for 11:30, was not administered, and the MAR entry for that dose was marked with a code indicating the resident was absent from home without medications, even though he was still in the facility and received insulin from the LPN. Physician orders required blood glucose monitoring before meals and at bedtime, and facility policy required medications to be administered within 60 minutes of the scheduled time.
Improper Labeling of In-Use Eye Drop Medication on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were labeled in accordance with professional standards. During inspection of the [NAME] Unit medication cart with RN6, surveyors observed an eye drop medication stored in a plastic bag with a label instructing, “Refrigerate until opened. Discard 42 days after opening,” but the “Date opened” line on the label was left blank. When asked if the medication was currently being used and therefore considered open, RN6 stated that it was not their regular unit and consulted RN11. RN11 confirmed that the eye drops were currently being used and acknowledged that staff would not know when the 42-day discard period would be reached because the date the medication was opened had not been documented on the label. This deficient practice was cited under the requirement that drugs and biologicals be labeled in accordance with currently accepted professional principles, and it was noted as having the potential to affect all residents in the facility who take medications.
Failure to Notify Ombudsman of Resident Transfers or Discharges
Penalty
Summary
The facility failed to ensure that a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman for four residents. This deficiency was identified during interviews and record reviews. For Resident 41, the facility provided copies of the Notice of Transfer/Discharge, but it was confirmed that no notification was sent to the Ombudsman. Similarly, Resident 57 was transferred to the hospital after a fall, and although the Notice of Discharge/Transfer was signed, the facility did not send a notification to the Ombudsman. The Administrator confirmed that the facility had not been sending these required notifications. Further review of the records for Residents 35 and 56 revealed that both were discharged to acute hospitals, but there was no documentation of notification to the Ombudsman. The facility's policy, which was last updated in October 2022, requires that notices be sent to the Ombudsman in cases of transfer or discharge, especially in exceptional cases where immediate action is necessary. However, the facility did not maintain evidence that these notifications were sent, as required by their policy.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call bell was within reach, limiting the resident's ability to call for assistance. During multiple observations, the call bell for Resident 14 was found dangling and out of reach, attached to the bed but not accessible to the resident. On one occasion, the resident expressed difficulty in finding the call bell to request staff assistance. Another observation noted the resident attempting to get staff attention without success due to the call bell being out of reach. A Certified Nurse Assistant acknowledged the issue and repositioned the call bell closer to the resident. The facility's policy on call light use requires that call lights be positioned conveniently for residents and never placed on the floor or bedside stand, indicating a failure to adhere to this policy in the case of Resident 14.
Failure to Protect Resident's Property from Loss or Theft
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's property, resulting in a deficiency related to the loss or theft of personal items. Specifically, one resident reported that five bottles of supplements, ordered by a family member and delivered to the facility, went missing after he had taken just one pill. Despite informing several staff members about the missing items, the resident felt that his concerns were not taken seriously, and no investigation was initiated. The resident's psychosocial wellbeing was negatively affected as he believed the facility did not take his statement seriously. Interviews with facility staff revealed a breakdown in communication and procedure. A registered nurse acknowledged being informed of the missing supplements and participated in a search but did not notify the social worker. The social worker confirmed that she was unaware of the missing items and, as a result, did not initiate an investigation. A review of the facility's Theft and Loss Program policy indicated that a theft and loss form should be completed and forwarded to Social Services when an item is reported missing, a step that was not taken in this case.
Failure to Develop Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R66, who experienced frequent pain. R66, a female resident with a medical history including hemiplegia, hemiparesis, aphasia, and low back pain, was observed massaging her left thigh and reported experiencing constant pain in that area. Despite the resident's frequent pain being noted in her Minimum Data Set (MDS), her care plan did not include any strategies or interventions for managing her pain. The Director of Nursing confirmed the oversight and acknowledged that R66 should have had a care plan addressing her pain, as per the facility's Pain Management Policy, which mandates the development of an individualized care plan for residents experiencing pain.
Deficient Catheter Care and Lack of Physician Order
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary indwelling catheter, leading to several deficiencies. The resident, who has a medical history including hemiplegia, Type 2 diabetes, a history of prostate cancer, chronic kidney disease, and a urinary tract infection, was observed with his catheter tubing on the ground. A Certified Nurse Assistant confirmed that the tubing should not be on the ground and corrected the situation. Additionally, a Registered Nurse was observed flushing the resident's urinary catheter without a physician's order, which is required. The nurse also failed to perform proper hand hygiene before the procedure, using the same gloves throughout. Further record review revealed that there was no physician's order for the catheter flush at the time it was performed. The nurse later confirmed the absence of such an order and acknowledged the need for one. A verbal order was eventually documented, allowing catheter flushing under specific conditions, but this was after the deficiency was identified. These actions and inactions demonstrate a failure to adhere to proper catheter care protocols, potentially affecting all residents with urinary catheters in the facility.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled medications for one of the medication carts sampled. On multiple occasions, nursing staff pre-signed the Controlled Medication Reconciliation Log (CMR Log) before actually conducting the count of controlled medications with the on-coming shift nurse. Specifically, on 10/02/24, the nursing staff did not sign the log with the on-coming evening shift nurse, and on 10/24/24 and 10/25/24, the staff pre-signed the log before verifying the controlled medication count. This practice was observed during an inspection of medication cart #4, where a nurse pre-signed the CMR Log, claiming she would be working a double shift and would sign for both shifts. However, the unit schedule indicated she did not work the entire evening shift as reported. Further review of the CMR Log on 10/25/24 revealed that another nurse also pre-signed the log before conducting the count with the on-coming evening nurse. The Resident Care Manager confirmed that the facility's policy requires the CMR Log to be signed in the presence of another licensed nurse during the shift change, after confirming the accuracy of the controlled medication count. The failure to adhere to this policy was confirmed by the Resident Care Manager, who acknowledged that the staff should not have pre-signed the log and should have signed it in the presence of the on-coming nurse after verifying the count.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as required by their policy and professional principles. During an observation and interview on October 22, 2024, at 11:00 AM, a medication cart assigned to an LPN was found unlocked and unattended while the LPN was in a resident's room. Upon exiting the room, the LPN confirmed that the cart should not have been left in such a state. A similar incident occurred on October 23, 2024, at 03:17 PM, when another medication cart, assigned to an RN, was observed unlocked and unattended. The RN confirmed that the cart should have been secured. The facility's policy, reviewed on October 23, 2024, clearly states that medication carts should remain locked when not in use or attended by authorized personnel. This deficiency has the potential to affect all residents in one of the four units in the facility.
Infection Control Lapses in Catheter and Dressing Procedures
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with a urinary catheter. On two separate occasions, the resident's catheter tubing was observed resting on the ground, which is against standard infection control protocols. A Certified Nurse Assistant (CNA) acknowledged that the tubing should not be on the ground and adjusted it accordingly. Additionally, a Registered Nurse (RN) failed to perform hand hygiene after removing dirty gloves and before donning clean gloves while flushing the resident's urinary catheter. The RN admitted to not following proper hand hygiene procedures during the process. Another incident involved a dressing change for a different resident with a suprapubic catheter. The RN performed the dressing change but did not perform hand hygiene after removing dirty gloves and before putting on clean gloves. This was contrary to the facility's hand hygiene policy, which requires hand hygiene before and after direct resident contact and before donning and after doffing gloves. These lapses in infection control practices put residents at risk for facility-acquired infections.
Deficiency in Nursing Competency Leads to Medication Error
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe nursing services, resulting in a deficiency related to the administration of morphine sulfate to a resident. The resident, an elderly female admitted for end-of-life care, was given morphine sulfate on a routine basis every hour instead of as needed, due to a data entry error. This error was not questioned or clarified by the nursing staff until it was brought to their attention by the resident's family. The resident received multiple doses of morphine sulfate before the order was corrected, placing her at risk of decreased physical well-being. The investigation revealed that the Licensed Practical Nurse (LPN) who transcribed the order and the Registered Nurse (RN) who administered the medication lacked proper competency verification. The competency checklists for both nurses were incomplete, with missing assessments of individual skills and methods of evaluation. The Staff Development/Educator acknowledged these deficiencies, noting that the preferred assessment methods, such as observed practice or return demonstration, were not utilized. This lack of proper competency assessment contributed to the failure to question or clarify the incorrect medication order.
Failure in Narcotic Reconciliation and Accounting
Penalty
Summary
The facility failed to ensure proper pharmacy services for accurate reconciliation and accounting of controlled medications, specifically morphine sulfate, for a resident who was admitted for end-of-life care. The resident, an elderly female, was admitted to hospice care and later passed away at the facility. An anonymous complaint was received by the State Agency regarding the care provided to the resident, including concerns about the administration of morphine sulfate. Upon investigation, discrepancies were found between the medication administration record (MAR) and the controlled drug log. The MAR indicated a dose of morphine sulfate was administered without a corresponding sign-out on the log, and there were inconsistencies in the documentation of doses and refusals. During an interview, the Resident Care Manager (RCM) admitted that it was their responsibility to review and reconcile narcotic logs at the end of each month, but they failed to do so for the resident's morphine sulfate. The lack of reconciliation and accounting for the controlled medication led to the inability to promptly identify any loss or potential diversion, contributing to the deficiency in pharmaceutical services provided by the facility.
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What surveyors actually found near you
We read the 8 citations issued within 25 miles in the last 12 months — 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hilo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hale Anuenue Restorative Care | 0.9 mi | ★★★★★ | 0 | 0 |
| Hilo Benioff Medical Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Yukio Okutsu State Veterans Home | 0.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Hilo | 2 mi | ★★★★★ | 8 | 0 |
| Honoka'a Hospital & Skilled Nursing | 34.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.