Citations in Hawaii
Statistics, citations and compliance trends for long-term care facilities in Hawaii.
Statistics for Hawaii (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Hawaii
Multiple failures to maintain resident dignity and timely care were identified, including a resident left waiting over an hour for assistance to urinate despite documented mobility deficits, and two residents with indwelling urinary catheters whose drainage bags were left uncovered and visible from the hallway contrary to facility policy. During a Resident Council meeting, residents reported that certain CNAs did not consistently provide basic morning hygiene, ignored or delayed responses to call lights, and sometimes turned off call lights after learning a request involved incontinence care without returning, resulting in residents remaining soiled for extended periods and care being left for the next shift.
Staff failed to keep call systems within reach for three LTC residents who were incontinent and dependent on staff for ADLs, including residents with arthritis, bipolar disorder, chronic pain, stroke with one-sided impairment, and hemiplegia/hemiparesis. Surveyors observed call lights and call pads placed toward the head of the bed, behind the bed on a light fixture, or hanging on the wall above the bed, all out of the residents’ reach during multiple observations. These practices did not follow the facility’s policy requiring call lights to be within reach and accessible while residents are in bed.
Multiple rooms on one unit were found with environmental deficiencies, including broken and unsecured electrical outlets, damaged and stained walls and ceilings, improvised extensions on light cords using a plastic bag and a washcloth, dripping and constantly running sink faucets with discolored grout, and a strong urine odor in one room. A review of work orders and an interview with the Facilities Director showed that only two work orders had been submitted for this unit, both generated after surveyor observations, indicating that unit staff had not routinely initiated maintenance requests for these conditions.
The facility failed to adequately inform and assist multiple residents with Advance Health Care Directives (AHCDs). One resident requested an AHCD form but received no documented follow-up or assistance, and this issue was not addressed in later interdisciplinary team meetings. Another resident had a Five Wishes AHCD document on file that lacked required witness signatures, despite clear instructions that witnessing was necessary for validity. A third resident initially declined an AHCD, but the facility did not periodically revisit the discussion, and the resident later reported that no one had discussed AHCDs with him and expressed a desire to complete one.
Surveyors observed that the lab specimen refrigerator had brown stains on the door and bottom shelves and multiple small dead bugs on the door shelf, demonstrating that staff failed to maintain a clean environment in an area used for specimen storage. The Infection Prevention Nurse acknowledged the refrigerator was dirty.
Surveyors found that the facility failed to develop and maintain comprehensive care plans for two residents, one receiving an anticoagulant and psychotropic meds for vascular dementia with agitation, and another with a history of sacral pressure ulcers and a high Braden risk score. The first resident’s care plan did not address anticoagulant use or dementia-related care despite active orders and facility policy requiring individualized dementia care planning. The second resident’s care plan lacked any pressure ulcer prevention or management interventions, even though prior sacral ulcers had healed with documented preventive measures in place and the ulcer later reopened; staff confirmed the resident’s high risk and the absence of an active pressure injury prevention care plan during that time.
Failure to Maintain Resident Dignity, Privacy, and Timely Response to Care Needs
Penalty
Summary
The deficiency involves multiple failures to honor residents’ rights to dignity, respect, and timely assistance with care needs. One resident reported that after an activities session she informed staff she needed to urinate but was told to wait; staff did not return for over an hour, and it was the next shift that ultimately assisted her. She stated she did not feel treated with respect or dignity. Her electronic health record showed diagnoses including diabetes, chronic kidney disease, chronic pain, borderline personality, and schizoaffective disorder, and her care plan documented mobility and self-performance deficits due to significant muscle weakness and debility. Surveyors also observed two residents with indwelling urinary catheters whose drainage bags were positioned facing the bedroom door and visible from the hallway without privacy bags in place, despite multiple observations over several hours. The RN and DON both confirmed that catheter drainage bags should always be covered with privacy bags, and facility policy on catheter care and promoting/maintaining resident dignity required catheter bags to be covered at all times while in use and that staff maintain resident dignity and respect resident rights. During a Resident Council meeting, residents reported that certain CNAs did not consistently respond to care needs, did not provide basic morning hygiene such as wiping faces and hands, and sometimes turned off call lights after asking if the need involved urine or bowel movement without returning to provide incontinence care, leaving care for the next shift. Two residents reported remaining in their bowel movements for about one and a half hours after lunch when staff did not return after call lights were activated, and one resident stated staff respond more quickly when the bathroom call light is used.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failing to ensure that resident call systems were within reach for multiple residents who were dependent on staff for activities of daily living. One resident with arthritis, bipolar disorder, chronic pain, and total bowel and bladder incontinence was observed in bed with her call light cord positioned toward the head of the bed and out of her reach; when asked, she confirmed she could not reach it and requested that it be moved closer. Another resident with a history of stroke and one-sided impairment, who was incontinent and dependent on staff for ADLs, was observed lying in bed without access to the gray call pad, which was hanging on a light fixture behind the bed; he stated he was able to use the call pad, but it was not placed where he could reach it until a CNA later repositioned it. A third resident with hemiplegia and hemiparesis affecting the left non-dominant side, impaired left upper extremity, and functional limitation in upper extremity range of motion was repeatedly observed lying comfortably in bed while the call light was left hanging on the wall above the bed and out of reach. This resident was able to communicate verbally and move the right upper extremity, but the call light remained out of reach during multiple observations on different days and times. Review of the facility’s policy titled “Call Light: Accessibility and Response” showed that staff were required to ensure the call light was within reach of the resident and accessible while the resident was in bed, which was not followed in these instances.
Failure to Maintain Homelike and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Pensacola 1 unit, as evidenced by multiple environmental deficiencies observed in six resident rooms. In one room, a wall clock was broken with a large piece missing and several white patches were visible on the wall. Another room had multiple large brown marks of unknown substance on the wall that were immediately visible upon entry. A separate room had a loud, constant buzzing noise whenever the bathroom light was turned on. Additional observations included several visible water marks on a ceiling, a broken electrical plug plate, and a heavily damaged wall behind a bed. Other rooms showed further environmental issues, including a wall light over a bed that had a cord extended with a plastic bag so the resident could reach it, and an electrical outlet at the head-of-bed wall that was not secure and was visibly coming out of the wall. One room had a dripping sink faucet and very discolored grout around the sink, while another had a strong smell of urine. Yet another room had a sink faucet that was constantly running, and one bed area had a washcloth attached to the light cord to extend its reach and six large screws or hooks in the wall. Interview with the Facilities Director revealed that unit staff were expected to complete work orders for needed repairs, but only two open work orders existed for this unit, both related to issues reported during the survey, indicating that routine work orders had not been submitted by unit staff for the observed problems.
Failure to Inform and Assist Residents With Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to properly inform and assist residents with formulating Advance Health Care Directives (AHCDs) and to ensure that existing AHCD documents were validly executed. For one resident (R17), the EHR showed that AHCD information was discussed and the resident requested a blank AHCD form on 04/14/25. However, there was no subsequent documentation that the resident completed an AHCD or that the facility provided follow-up assistance after that date. The Social Services Assistant (SSA) confirmed there was no follow-up documentation, and the most recent interdisciplinary team meeting record for this resident contained no reference to AHCD follow-up. For another resident (R170), the facility obtained a completed Five Wishes document intended to serve as an AHCD, but the document lacked required witness signatures, despite instructions on the form stating it must be signed and witnessed as directed to be legal and valid. The SSA confirmed the absence of witness signatures. For a third resident (R153), the EHR showed that AHCD information was last discussed on 12/10/24, at which time the resident declined to formulate an AHCD. There was no evidence that the facility revisited the discussion or reoffered assistance after that date. In a subsequent interview, this resident reported that the facility had not discussed an AHCD with him and stated he would like to complete one.
Unclean Lab Specimen Refrigerator Compromises Environmental Cleanliness
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when the lab specimen refrigerator was found to be unclean. During an observation of the refrigerator, brown stains were noted on the door shelf and bottom shelf, and multiple small dead bugs were present on the door shelf. In a subsequent interview, the Infection Prevention Nurse acknowledged that the lab specimen refrigerator was dirty. These conditions demonstrated that the facility failed to maintain a clean environment in the area where lab specimens are stored.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use, Dementia, and Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, individualized care plans addressing all identified needs for two residents. For one resident with vascular dementia and agitation, record review showed an active order for Eliquis 2.5 mg twice daily with instructions to monitor for adverse reactions, but the resident’s care plan did not address the use of this anticoagulant medication. During interview, the MDS RN confirmed that the anticoagulant should have been included in the care plan. The same resident had diagnoses including vascular dementia with agitation and was prescribed psychotropic medications, yet the care plan did not include dementia-related care. The MDS RN verified that dementia care should have been incorporated, despite the facility’s own dementia policy requiring individualized care plans that consider symptoms, disease progression, and co-existing conditions. The second resident had a history of sacral/buttocks pressure ulcers that had previously healed, with APRN documentation that preventive interventions such as scheduled repositioning, pressure-relieving devices, incontinence care, and protective dressings remained in place. A subsequent wound clinic note documented that the prior sacral ulcer site had broken down again, with fat layer exposed, and attributed contributing factors including moisture-associated skin damage and trauma from a shower chair. The resident reported that the wound may have reopened due to prolonged time in a wheelchair without repositioning assistance and stated that staff did not consistently assist with repositioning every two hours as recommended. Review of the care plan revealed no documented interventions for pressure ulcer prevention or management, despite a Braden Scale score of 11 indicating high risk. Nursing staff confirmed the resident was at high risk for pressure ulcer development and that the care plan did not include pressure ulcer prevention interventions, and the MDS RN reported that the pressure injury care plan had been discontinued after healing and was not reinitiated until after the wound reopened, leaving the resident without an active pressure injury prevention care plan during that period.
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Compliance trends in Hawaii
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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