Above average — CMS composite of the measures below.
The next survey window likely opens around June 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 Life Care Center Of Hilo during CMS and state inspections, most recent first.
Opened Resident Mail Delivered: A resident reported receiving several pieces of mail, including bank statements and personal letters with checks, already opened before delivery. Staff stated the business office receives resident mail and that mail is not opened except for residents for whom the facility is the rep payee; the resident was not listed as one of those residents. The DON and Administrator confirmed resident mail is supposed to be delivered unopened.
The facility did not show proof of written discharge notification for a resident transferred to the hospital. The record showed the resident's representative was notified by phone, and the SSD said the form was mailed but could not provide verification. The facility policy required transfer/discharge notice to the resident or responsible party in accordance with federal regulations.
Failure to develop care plans for two residents’ skin conditions. One resident had left shin cellulitis with orders for saline cleansing, Mupirocin, and a dressing after a fall-related injury, but no care plan was in place. Another resident with PVD, malnutrition, and polycythemia vera had reddened, shiny feet with small open wounds; although staff were cleansing the feet with saline, applying Aquaphor, and covering them with gauze in bed, no care plan was found. An RN, an LPN, and the DON confirmed the missing care plans.
A resident receiving Citalopram, Trazodone, and Risperidone for dementia-related conditions had a partially completed Medication Informed Consent form. Blank sections included ineffective non-drug approaches, the reason for the medication, expected benefits, and the proposed course of treatment, and the DON confirmed the form should have been completed before telephone consent was obtained from the resident’s representative.
A resident with a left shin wound and cellulitis was not placed on EBP despite facility policy indicating EBP for residents with wounds and requiring a gown for wound care. During observed wound care, no EBP signage was posted at the room entrance and the RN did not wear a gown while applying ordered mupirocin and changing the dressing. The DON confirmed the resident should have been on EBP.
A resident who had not tolerated wheelchair use for years was placed in a w/c, later reporting 10/10 lower back pain. The resident received 650 mg acetaminophen despite reporting it was usually ineffective and requesting stronger pain control. Pain remained severe at 8/10 on reassessment, yet no non-pharmacological interventions were documented. Although a physician ordered hydrocodone-acetaminophen 5-325 mg early in the afternoon, it was not administered until about seven hours later, during which time the resident continued to experience severe pain. Subsequent documentation noted the resident as pale and lethargic with extensive bruising and deformity of the RLE, and the resident later expired in the ED. The report states that, due to this deficient practice, residents are at risk of physical harm.
A resident was admitted with documented skin issues but no right lower extremity (RLE) bruising. By the next day, staff notified the POA of new bruising to the RLE, later documented as a large bruise below the knee, with the resident unable to recall how it occurred. A photo showed extensive dark red and yellow/purple bruising from below the knee to the shin. Despite the injury being of unknown origin and resulting in serious bodily harm, the facility did not conduct a formal investigation or submit a Facility Reported Incident to the State Agency. The Administrator stated the facility believed the injury might have occurred during transport, while a family member and an audio recording showed the family questioning how the injury occurred and expressing concern about the resident’s worsening condition, without attributing the injury to transport.
A resident was admitted with documented skin issues but no bruising or swelling to the right lower extremity (RLE). The next day, staff documented a new, large bruise to the RLE of unknown origin, and the resident could not recall how it occurred. Despite the injury’s severity and the need for x‑rays, facility leadership did not initiate an abuse investigation, relying instead on an assumption that the family believed it was related to the admission transfer. A family member later reported they had not attributed the injury to transport and provided an audio recording showing they focused on the severity of the new injury and the need for prompt imaging, with no mention of transport as the cause.
A resident with severe cognitive impairment and multiple medical conditions was left alone in a facility transport van after returning from dialysis. The resident, who required extensive assistance and used a wheelchair, reported being left unattended by the van driver. Staff interviews and documentation confirmed that only one staff member was present on the van at times, and the driver admitted to leaving the resident alone while attending to personal needs. The resident was found to be emotionally distressed but physically stable upon return to her unit.
Opened Resident Mail Delivered
Penalty
Summary
The facility failed to provide unopened mail to one of four residents sampled for mail delivery. During a resident council interview, the resident stated that approximately six months earlier she received four bank statements from her credit union and two personal letters with checks that had been delivered opened to her. She reported that the mail included checks made out to her for her to sign and give to the facility. Staff interviews and record review showed that the business office receives resident mail when it is delivered to the facility. The Accounts Receivable staff stated the facility does not open residents’ mail, except for residents for whom the facility is the representative payee. She provided a list of residents for whom the facility was the representative payee, and the resident who reported the opened mail was not on that list. The DON and Administrator also confirmed that resident mail is supposed to be delivered unopened.
Missing Written Transfer/Discharge Notice
Penalty
Summary
The facility did not provide proof of written discharge notification for one resident, R11, who was transferred to the hospital. Record review showed that R11 was discharged to the hospital on [DATE], and the Notice of Resident Transfer or Discharge form documented that the resident's representative was notified by phone of the transfer or discharge. During an interview on 07/01/26 at 2:35 PM, the Social Services Director stated that the facility mailed R11's Transfer or Discharge form to the representative but could not provide any verification of that mailing. Review of the facility's Transfer and Discharge policy showed that the facility is to provide transfer/discharge notice to the resident or responsible party in accordance with federal regulations.
Failure to Develop Care Plans for Residents’ Skin Conditions
Penalty
Summary
The facility failed to develop written person-centered comprehensive care plans for two residents with skin conditions. One resident, admitted for short-term rehabilitation after a cervical fracture from a fall at home and with multiple bruises and wounds from that fall, had a left shin wound identified as cellulitis. A provider order dated 06/23/26 directed cleansing with normal saline, application of Mupirocin ointment, and a dressing to the wound, but no care plan was implemented for the cellulitis. During a concurrent interview and record review, an RN confirmed that no care plan had been developed for the management of the resident’s left shin cellulitis. The second resident, admitted for long-term placement and diagnosed with peripheral vascular disease, protein-calorie malnutrition, and polycythemia vera, had reddened, shiny feet with small open wounds observed during an interview. The resident stated that the feet had developed open sores after prior edema to both legs and that staff cleanse the feet with normal saline and apply Aquaphor. The EHR showed orders for saline wound wash every evening, Aquaphor application, and covering the feet with gauze when in bed, but no care plan was found for the management of the resident’s foot skin condition. An LPN reviewed the record and confirmed the absence of a care plan, and the DON confirmed that the care plans for both residents needed to be updated to include skin care.
Incomplete Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure that one of five residents reviewed, R10, had a completed Medication Informed Consent form for psychotropic medications that was shared with the resident’s representative by phone. Record review showed R10 was receiving Citalopram Hydrobromide for a mood disorder secondary to dementia, Trazodone at bedtime for sleep, and Risperidone twice daily for dementia with psychosis. The Medication Informed Consent form dated 07/17/2025 was only partially completed, with blank sections for the non-drug approaches that had proven ineffective, the reason the medication was prescribed, the expected benefits to the resident, and the proposed course of the medication not checked off. During interview, the DON confirmed that the consent form should have been filled out completely before the nurse obtained telephone consent from the resident’s representative.
Failure to Use EBP for Resident With Cellulitis Wound
Penalty
Summary
The facility failed to implement its infection control policy for Enhanced Barrier Precautions (EBP) for one resident with a wound and cellulitis on the left lower leg. The resident was admitted for short-term rehabilitation after a cervical fracture from a recent fall at home and had diagnoses including diabetes and a history of alcohol abuse. The resident also had multiple bruises and wounds to all extremities from the fall. During observation, the resident was seen walking in the hallway with physical therapy assistance and had a dressing on the left shin, and the resident stated the wound had been slow to heal and was present before admission. Review of the electronic health record showed treatment orders for mupirocin ointment to the left shin scab for cellulitis, with cleansing, ointment application, and dressing changes. When wound care was observed in the resident’s room, no signage was posted at the room entrance indicating EBP, and the RN providing wound care was not wearing a gown. The facility’s EBP policy stated that residents with wounds and/or indwelling medical devices are indicated for EBP and that wound care involving any skin opening requiring a dressing is a high-contact resident care activity requiring a gown. The DON confirmed that the resident should have been on EBP because the wound was identified as cellulitis.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and effective pain management for a resident with severe lower back pain. The resident, who had not tolerated wheelchair use for approximately two years due to dizziness and contractures, was placed in a wheelchair in the dining room and initially appeared comfortable. Later, the resident reported 10/10 lower back pain, and at 12:54 PM was given 650 mg of acetaminophen, despite having stated that acetaminophen usually did not work and requesting stronger pain medication. A follow-up pain assessment at 1:23 PM documented pain at 8/10, indicating severe debilitating pain, with no documentation of any non-pharmacological interventions attempted. At 1:47 PM, the physician ordered hydrocodone-acetaminophen 5-325 mg for pain, but this medication was not administered at that time. The resident’s pain remained severe, with a pain score of 8/10 documented at 5:00 PM, yet neither the ordered hydrocodone-acetaminophen nor additional acetaminophen was administered, and non-pharmacological interventions continued not to be implemented. Hydrocodone-acetaminophen 5-325 mg was finally administered at 9:00 PM, approximately eight hours after the initial acetaminophen dose and more than seven hours after the opioid was ordered, during which time the resident experienced unrelieved severe pain. Later, at 1:50 AM, a progress note documented the resident as pale and lethargic, with extensive bruising on the right lower extremity below the knee and pain with slight movement. Hospital records noted obvious deformities to the right tibia and right lower extremity of uncertain origin. The resident arrived at the emergency room at 2:39 AM and expired at 3:20 AM. The report states that, as a result of this deficient practice, residents are at risk of physical harm.
Failure to Report and Investigate Serious Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an injury of unknown source that resulted in serious bodily injury to the State Agency (SA) within the required 2-hour timeframe and to conduct a formal investigation into the origin of the injury. The resident was admitted on 02/02/26, and the Nursing Admission Tool completed that day documented several skin conditions, including a rash on the lower back, a scab on the tip of the nose, and toenail issues, but no bruising or swelling to the right lower extremity (RLE). A progress note entered at midnight on 02/03/26 documented that staff called the resident’s power of attorney to inform them of bruising to the RLE, which was not present on the admission assessment, indicating a new injury occurring after admission with no identified source at that time. A subsequent progress note on 02/03/26 at 5:00 PM described a bruise to the RLE below the knee measuring 20 cm by 7 cm, with the resident unable to recall how it occurred, and a photograph taken at 5:03 PM showed dark red bruising with additional yellow/purple bruising extending from below the knee to the shin. Despite the unknown origin and extent of the injury, the facility did not submit a Facility Reported Incident (FRI) to the SA, as confirmed by review of the IQIES database and by the Administrator, who stated the facility did not investigate or report the injury because the family later suggested it could have occurred during transport to the facility. However, an interview with a family member and a verified audio recording from the evening of 02/03/26 showed the family repeatedly asking staff how the resident sustained the injury, requesting an earlier x-ray due to the severity of the RLE injury, and reporting that the resident was vomiting and had a decline in cognition from normally alert and oriented to person, place, time, and situation to being oriented only to person. The family did not state that the injury occurred during admission transport in this recording. There was no documentation of an investigation by the facility to determine whether the injury was related to abuse or neglect, and the injury of unknown origin was not reported to the SA as required.
Failure to Investigate Serious Injury of Unknown Origin and Rule Out Abuse
Penalty
Summary
The facility failed to investigate an injury of unknown origin to rule out the potential for abuse for a resident identified as R10. On admission, the Nursing Admission Tool documented several skin conditions, including a rash on the lower back, a scab on the tip of the nose related to malignant neoplasm, and onychomycosis with an avulsed toenail on the left great toe, but there was no documentation of any significant bruising or swelling to the right lower extremity (RLE). The day after admission, a progress note documented a new bruise to the RLE below the knee measuring 20 cm by 7 cm, with the resident unable to recall how the bruise occurred. Review of the admission assessment confirmed that the bruise and swelling were not present at admission, indicating the injury occurred after the resident entered the facility and that the nature of the bruising and swelling was significant and warranted x‑rays. During an interview, the Administrator acknowledged that no investigation was conducted to determine the origin of the new bruise or to rule out abuse, explaining that the facility believed the family thought the injury might have occurred during the admission transfer by the transport company. However, in a separate telephone interview, a family member stated that they did not report the injury as being from the admission transfer and asserted it was a new bruise sustained after admission. The family provided a verified audio recording from the evening of the day the bruise was discovered, during which they repeatedly urged the facility to obtain x‑rays sooner due to the severity of the RLE injury and did not attribute the injury to the admission transport. As a result of the lack of investigation into this serious injury of unknown origin, the potential for abuse was not ruled out for this resident.
Resident Left Unsupervised in Transport Van After Dialysis
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, diabetes, and end stage renal disease, was left alone in the facility's transport van for an unknown period of time. The resident, who required extensive assistance for transfers and primarily used a wheelchair, was returning from an offsite dialysis appointment when the incident occurred. Upon arrival at the facility, the resident reported to staff that the van driver left her alone in the vehicle, and she did not know what to do. Documentation and interviews confirmed that the resident was left unsupervised in the van, with the exact duration remaining undetermined. The facility's records showed that, on the day of the incident, the post-dialysis vital signs were taken later than usual, suggesting a delay in the resident's return to her unit. Staff interviews indicated that, at times, only one staff member—the driver—was present on the van, as the transporter might stay with another resident at an appointment, leaving the driver alone to manage the return trip. On the day in question, the driver admitted to leaving the resident in the van while he attended to personal needs, only realizing afterward that the resident was still inside. The resident was found to be alert and verbal upon return to the unit, though she was described as flustered and emotional immediately after the event. Staff confirmed that her physical condition was stable, with no abnormal vital signs or signs of physical harm. The incident was reported through the facility's concern and comment process, and the resident's family was notified. The event highlighted a lapse in supervision and adherence to safe transport protocols, resulting in the resident being left in an unsafe environment.
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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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Nursing homes near Hilo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Hilo Rehabilitation & Nursing Center | 2 mi | ★★★★★ | 15 | 0 |
| Hale Anuenue Restorative Care | 2.7 mi | ★★★★★ | 0 | 0 |
| Hilo Benioff Medical Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Yukio Okutsu State Veterans Home | 2.7 mi | ★★★★★ | 0 | 0 |
| Honoka'a Hospital & Skilled Nursing | 36.8 mi | ★★★★★ | 0 | 0 |
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