Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Yukio Okutsu State Veterans Home during CMS and state inspections, most recent first.
The facility did not ensure that Binding Arbitration Agreements included a clause allowing residents or their representatives to rescind the agreement within 30 days of signing. This was discovered during a review of a resident's EHR and confirmed by the Administrator, affecting 42 out of 60 residents.
A resident with a history of cerebral infarction and other conditions experienced respiratory distress with low oxygen saturation levels. Despite this, nursing staff did not promptly seek a higher level of care, only increasing oxygen supply with minimal effect. Family members observed the resident's struggle to breathe and requested ER transfer, which was delayed. The DON confirmed that action should have been taken sooner.
A facility failed to uphold a resident's right to dignity when an RN referred to residents needing meal assistance as 'feeders' in front of a resident with intact cognition. The resident expressed discomfort with the term and subsequently refused a meal. The DON confirmed that such language is inappropriate.
A resident's food preferences were not honored, leading to the serving of disliked foods such as milk and fish, despite clear documentation of these preferences. The resident experienced diarrhea and suspected lactose as a contributing factor, yet continued to receive milk with meals. The dietitian confirmed the error, and the DON acknowledged the oversight.
The facility failed to provide written notification of transfer or discharge to two residents and their representatives, as well as to the Ombudsman. One resident was transferred to a hospital due to difficulty breathing without notifying the Ombudsman, and another resident was transferred after a fall without any written notification to the resident or his representative. The facility's policy requires such notifications, which were not adhered to.
A facility failed to include non-pharmacological interventions in a resident's care plan for pain management, relying solely on medications like Oxycodone and Morphine. The resident, with conditions including low back pain and gangrene, did not receive standard multimodal pain relief approaches. The DON confirmed the absence of non-pharmacological interventions in the care plan.
A resident experienced diarrhea for six days without appropriate management by the facility. Despite having loose stools, the facility attempted to administer MiraLAX, and a stool sample was not taken promptly to rule out conditions like C. difficile. The attending physician conducted a brief assessment without ordering necessary tests, and contact precautions were delayed. The resident, with a history of chronic conditions, felt emotionally down due to the lack of attention and person-centered care.
A facility failed to follow fluid restrictions for a resident with ESRD receiving hemodialysis, as ordered by the physician. The resident's fluid intake exceeded the prescribed 1,200 ml per day on several occasions, potentially leading to complications. A nurse acknowledged the oversight and noted that fluids were provided by staff, with possible additional intake from visiting family members.
A facility failed to maintain a medication error rate below 5%, with errors involving an LPN improperly administering Mucinex and Flonase to two residents. The LPN cut a Mucinex tablet against package instructions and did not follow proper Flonase administration procedures, placing residents at risk.
The facility failed to maintain sanitary conditions in food service areas, risking foodborne illness. A food warmer was found with an uncovered soup container and dust buildup, and expired test strips were used for dishwasher solution testing. Staff confirmed these issues, violating the facility's sanitation policy.
A resident initially consented to receive the influenza vaccine but later refused it. The facility failed to document the refusal and the education provided about the vaccine's benefits and risks. Despite the refusal, the EHR inaccurately recorded that the vaccine was administered, highlighting a significant documentation error.
Failure to Include Rescission Clause in Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the Binding Arbitration Agreements (BAA) adhered to all regulatory requirements. Specifically, the agreements did not include language granting residents or their representatives the right to rescind the agreement within 30 calendar days of signing. This deficiency was identified during a review of a resident's Electronic Health Record (EHR) and the document titled Patient and Facility Arbitration Agreement. It was found that 42 out of 60 residents had entered into such agreements without the option to rescind within the specified timeframe. During an interview and record review with the Administrator, it was acknowledged that the agreements lacked the necessary language to allow rescission within 30 days.
Failure to Provide Competent Nursing Services for Resident in Respiratory Distress
Penalty
Summary
The facility failed to provide competent nursing services for a resident, identified as R166, who was experiencing respiratory distress. R166 was admitted with diagnoses including hemiplegia/hemiparesis following a cerebral infarction, dysphagia, and hypertension, and was receiving therapy services. On the morning of the incident, R166's oxygen saturation levels were recorded as low, dropping to 83% and 84% while on oxygen via nasal cannula. Despite these low levels, which require immediate medical attention, the nursing staff did not take prompt action to seek a higher level of care. Instead, they increased the oxygen supply from 2 liters to 4 liters, resulting in only a 1% increase in saturation. Family members visiting R166 observed that the resident was struggling to breathe, appeared pale, and was coughing excessively. They requested that R166 be sent to the emergency room (ER) for further evaluation and treatment. However, the nursing staff, including RN3, did not perceive R166 as being in distress and attempted to administer oral medication, which R166 was unable to swallow. The Director of Nursing confirmed that the normal range for oxygen saturation is 90% to 100% and acknowledged that action should have been taken sooner. The delay in transferring R166 to the ER placed the resident at risk of more than minimal physical harm.
Resident Dignity Compromised by Staff Language
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence and to be treated with respect and dignity. During an interview with a resident, a Registered Nurse (RN) referred to residents who require assistance with meals as 'feeders' in the presence of the resident, who also required meal assistance. The resident, who had an intact cognitive status as indicated by a Brief Interview for Mental Status (BIMS) score of 15, expressed discomfort with being referred to in such a manner. Following the incident, the resident refused the meal. The Director of Nursing confirmed that staff should not refer to residents as 'feeders.'
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which is a violation of the resident's right to self-determination. A resident, identified as R58, reported that despite informing the facility staff of his dislike for certain foods, such as milk and fish, he continued to receive them. During an interview, R58 mentioned that he had been experiencing diarrhea and suspected that lactose in milk might be contributing to this issue. Despite his request to avoid milk, he was still served cereal with milk for breakfast, and his personal refrigerator contained six containers of milk that he had received with his meals. Additionally, during a lunch observation, R58 was served salmon, even though his meal ticket clearly indicated a dislike for fish. The dietitian confirmed that this was a mistake by the kitchen staff. The Director of Nursing was informed of the oversight and acknowledged that R58 should not have been served fish. This failure to respect the resident's food preferences poses a risk of more than minimal physical and/or psychosocial harm to the resident.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to two residents and their representatives, as well as to the Office of the State Long-Term Care Ombudsman. In the case of one resident, identified as R7, the facility did not send a copy of the Transfer/Discharge Notice to the Ombudsman when the resident was transferred to an acute hospital due to difficulty breathing. This was confirmed during an interview with Social Service staff, who acknowledged that the notice should have been sent but was not. For another resident, identified as R43, the facility did not provide any written notification of transfer to the resident or his representative when he was transferred to the hospital after falling out of his wheelchair. This was confirmed by the facility Administrator during an interview. The facility's policy requires that residents and their representatives be notified in writing of any transfer or discharge, including the reasons for the move, in a language and manner they understand. The failure to adhere to this policy was noted as a deficiency.
Failure to Implement Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident experiencing pain, which did not include non-pharmacological interventions. This deficiency was identified for a resident who was admitted with diagnoses including low back pain, cellulitis, and gangrene, and was under hospice care. The resident's care plan lacked multimodal approaches for pain relief, such as cold, heat, repositioning, exercise, and stretching, which are standard practices according to the American Nurses Association. The review of the resident's electronic health record and medication administration record showed that the resident received multiple doses of Oxycodone and Morphine for pain management. During an interview and record review with the Director of Nursing, it was confirmed that non-pharmacological interventions should have been implemented prior to administering medications. However, the resident's care plan did not document any such interventions, and the facility could not provide evidence of implementing other modalities for treating the resident's pain besides medication.
Failure to Manage Resident's Bowel Regimen and Diarrhea
Penalty
Summary
The facility failed to provide appropriate medical care for a resident, identified as R58, by not managing his bowel regimen and diarrhea according to professional standards. R58 reported having diarrhea for six days without the facility taking a stool sample to rule out conditions like C. difficile. Despite having loose stools, the facility attempted to administer MiraLAX, an osmotic laxative, which could worsen his condition. R58 had to advocate for himself to receive Loperamide, a medication to control diarrhea, and expressed concerns about the lack of person-centered care and attention from the attending physician (AP1). During an observation, AP1 conducted a brief assessment of R58, which lasted less than five minutes and did not include auscultation of the abdomen. AP1 did not order a stool sample during the visit, and contact precautions were not implemented until six days after the onset of symptoms. The facility's Director of Nursing (DON) confirmed that the professional standard of practice was not followed, as the stool sample and contact precautions were delayed, and a care plan for bowel management was not developed until after the surveyor's visit. R58's medical history includes acute and chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, type 2 diabetes mellitus, hypertension, and atrial fibrillation. Despite having an intact cognitive status, as indicated by a BIMS score of 14, R58 felt emotionally down due to the lack of attention to his concerns. The facility's failure to manage R58's condition appropriately and in a timely manner resulted in potential psychosocial and physical harm to the resident.
Failure to Adhere to Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident receiving hemodialysis, specifically by not following the fluid restrictions ordered by the attending physician. The resident, who was admitted for short-term rehabilitation and diagnosed with End Stage Renal Disease (ESRD), was supposed to have a fluid intake limited to 1,200 milliliters per day. However, records showed that on multiple occasions, the resident's fluid intake exceeded this limit, with recorded intakes of 1,680 ml, 3,360 ml, 1,338 ml, and 1,318 ml on various days in November. During an interview, the resident mentioned experiencing drops in blood pressure during dialysis treatments when weight gains between treatments were high, indicating potential complications from excess fluid intake. A registered nurse acknowledged the failure to follow the fluid restrictions and noted that fluids were provided by staff, with the possibility of additional fluids being given by visiting family members. The nurse emphasized the importance of adhering to fluid restrictions due to the resident's inability to remove excess fluid from the body, highlighting the facility's lapse in monitoring and managing the resident's fluid intake as ordered.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.67% error rate. This was evidenced by two medication errors observed out of 30 opportunities. The first error involved an LPN administering Mucinex Extended Release, 600 mg, to a resident. The LPN cut the tablet into two pieces before administration, despite the package instructions clearly stating not to crush, chew, or break the tablet. There was no physician order to alter the medication, which the LPN confirmed upon reviewing the electronic health records. The second error occurred when the same LPN administered Flonase nasal spray to another resident. The LPN did not follow the manufacturer's administration directions, which included specific steps such as blowing the nose, closing one nostril, and wiping the nasal applicator after use. The LPN failed to provide these instructions to the resident and did not follow the proper procedure as outlined in the package insert. These deficiencies placed the residents at risk of negative outcomes due to improper medication administration.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain food serving equipment, dishes, and utensils in a sanitary condition, which poses a risk for foodborne illness to residents. During an observation and interview, a food warmer was found with an uncovered container of soup, and the warmer had a worn-down rubber seal with a buildup of dust and lint directly above the soup. Both the cook and the dietitian confirmed that the soup should have been covered and the warmer cleaned. Additionally, during another observation and interview, a dietary assistant was seen testing the dishwasher solution with test strips from a bottle that had expired. Both the dietary assistant and the dietitian acknowledged that the expired test strips should not have been used. The facility's policy on cleaning and sanitation of dining and food service areas was reviewed, which requires maintaining cleanliness and sanitation.
Failure to Document Resident's Refusal of Influenza Vaccine
Penalty
Summary
The facility failed to ensure proper documentation of a resident's refusal to receive the influenza immunization, which was a part of the facility's infection control program. A resident, who had initially signed a consent form to receive the influenza vaccine, later refused it when the staff attempted to administer it. However, the refusal and the education provided to the resident regarding the benefits and risks of the vaccination were not documented in the resident's medical record or Electronic Health Record (EHR). This lack of documentation was confirmed during an interview and record review with the Director of Nursing (DON) and the Registered Nurse (RN) responsible for obtaining consents and refusal forms. Despite the resident's refusal, a progress note in the EHR later indicated that the influenza vaccine was administered to the resident's left deltoid, and the resident was placed on alert for monitoring adverse effects. This discrepancy between the resident's refusal and the recorded administration of the vaccine highlights a significant documentation error, placing the resident at risk for more than minimal harm due to the lack of accurate medical record-keeping.
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Illustrative
What surveyors actually found near you
We read the 23 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) |
|---|---|---|---|---|
| Hilo Benioff Medical Center | 0 mi | ★★★★★ | 0 | 0 |
| Hale Anuenue Restorative Care | 0 mi | ★★★★★ | 0 | 0 |
| Legacy Hilo Rehabilitation & Nursing Center | 0.9 mi | ★★★★★ | 15 | 0 |
| Life Care Center Of Hilo | 2.7 mi | ★★★★★ | 8 | 0 |
| Honoka'a Hospital & Skilled Nursing | 34.1 mi | ★★★★★ | 0 | 0 |
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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.