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
Failure to assess, document, and report resident pain: Staff reported that a resident grimaced, became loud, and appeared to have hip pain during turning and care, but the RN did not document an assessment or notify the MD. Family also reported facial grimacing and pain concerns during a video call, yet no EHR note reflected the concerns or follow-up. The MAR showed pain recorded as 0 on the affected shifts, with no PRN pain medication documented.
The facility failed to provide written transfer/discharge notices, bed-hold notices, and documentation of Ombudsman notification for multiple residents sent to the ED or hospital. Records for several residents showed transfers for conditions such as low BP, hypoxia, pain, and difficulty breathing, but the EHRs lacked proof that the resident or RRP received the required notices, and the DON confirmed the written notices were not being provided.
Failure to document a new admission’s nausea, vomiting, and mild pain led to a deficiency. A resident admitted for rehab after a brain bleed complained of swallowing difficulty, could not eat dinner, received antiemetic medication, and was reported to have vomited clear secretions and food particles; MAR/TAR also showed Ondansetron doses and mild pain, but no health note was entered for the day and there was no explanation for why Tylenol was not given. The DON, RN, and EC confirmed the missing documentation and stated that significant findings, treatment response, and changes in condition should have been charted.
Incomplete post-fall investigations and missing fall assessments were identified for two residents. One resident with dementia and a prior femur fracture was found on the floor, complained of hip pain, and was later hospitalized with a hip fracture, but the post-fall investigation packet could not be found. Another resident with multiple diagnoses and repeated falls had no admission fall risk assessment, no fall risk assessment after a prior fall, and no event report for a later unwitnessed fall. The DON confirmed the missing documentation, and the facility policy required admission fall risk assessments, incident reports, and post-fall assessments/debriefings.
Three residents had incomplete physician documentation in their records. One resident admitted for rehab after sepsis secondary to a UTI had unsigned admission orders, a missing initial H&P in the EMR at review, and a delayed discharge summary signature; two other residents had admission orders signed by nursing but not by the MD, and each had a physician visit note that was signed late. The facility policy required physician orders and progress notes to be maintained per State and Federal regulations.
Failure to Respond to Family Grievance: The facility did not respond to a family member’s email grievance about a resident’s PT/OT, toileting, CNA mobility assistance limits, physician visits, and an inaccurate PMH entry. The ADM initially reported no grievances, later found the email in spam, and acknowledged there was no documented investigation, resolution, or timely follow-up communication despite OT notes showing repeated complaints from the family member.
Failure to assess, document, and report resident pain
Penalty
Summary
The facility failed to ensure that Resident 9 received treatment and care in accordance with professional standards when staff reported pain during repositioning in bed on the night shift and again on the day shift. Resident 9 was an elderly female with advanced Alzheimer’s dementia, dependent for all ADLs, and limited speech. Nursing documentation in the record did not show a timely assessment of the resident’s pain, documentation of the resident’s status, or notification to MD 2 after CNAs reported that the resident grimaced, became loud, and appeared to have pain when turned or touched at the hip. The DON confirmed that no progress note was charted regarding the pain reports and that no note documented RN 22 assessing the resident or notifying the physician. The record also showed that the resident’s family member observed facial grimacing, clenched jaw, facial drooping, and concerns about pain during a video call, but no documentation could be found in the EHR regarding the family member’s concerns, any nursing assessment, or physician notification. The April 2026 MAR documented pain as 0 on the affected shifts, and there was no entry showing administration of any ordered PRN pain medication on those dates. The facility’s documentation policy stated that changes in condition and any indication of illness or injury should be documented in the medical record, but the resident’s pain status was not documented from 04/27/26 through 05/01/26.
Failure to Provide Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to the resident or resident representative, failed to document that a copy of the notice was sent to the Office of the State Long-Term Care Ombudsman, and failed to provide written bed-hold notice for 5 of 6 residents reviewed for the discharge process, including R2, R3, R4, R9, and R10. The record review showed that R4 was transferred to the ED on 02/25/26, returned later that evening, and was transferred again on 02/26/26, but no completed discharge/transfer notice or bed-hold notice was found in the EHR or provided by the facility. For R9, a facility form showed a discharge notice date of 05/03/26 after transfer to the ED and hospital admission on 05/02/26, but there was no documentation showing how the written notice was provided to the RRP and no bed-hold notice was found. For R10, a discharge notice form showed a notice date of 03/09/26 after transfer to the ED and hospital admission, but there was no documentation that written notice was provided to the RRP, no documentation that the form was sent to the Ombudsman, and no bed-hold notice was found. Additional record review showed R3 was transferred to the ED on 05/15/26 for low blood pressure and hypoxia, and there was no written bed-hold or discharge/transfer notification given to the resident or RRP. R2 was transferred to the ED on 02/16/26 for right lower quadrant pain and difficulty breathing, and there was no written discharge notification given to the resident or RRP. During interview, the DON stated that the nurse sending the resident to the ED should complete the Discharge/Transfer Notice and that the nurse calling the family or RRP should ask about the bed-hold, but also stated that the written notice for both the discharge/transfer notice and bed-hold notice was not currently being provided or sent to the resident or resident representative.
Failure to Document New Admission’s Nausea, Vomiting, and Pain
Penalty
Summary
The facility failed to document pertinent findings and interventions for a resident admitted for rehabilitation after a brain bleed who later developed abdominal symptoms and was transferred to the ED. On 01/31/26, the resident complained of difficulty swallowing and could not eat dinner, was given medication for nausea, and was reported by a CNA to have vomited clear secretions and food particles and then felt better. The resident’s MAR/TAR also showed Ondansetron was given at 02:27 AM and 10:13 PM, and the pain record noted mild pain on the evening and night shift, but no Tylenol was administered. There was no health note documented for the entire day to show the resident’s nausea, vomiting, or pain, or to explain why Tylenol was not given. The DON confirmed there should have been daily charting for the new admission and stated it was important to document significant findings and issues for continuity of care. An RN confirmed no health note was created for that day and agreed the resident’s nausea, vomiting, and mild pain should have been documented, along with whether medications were effective and why Tylenol was not given, such as if the resident refused it. The RN also stated new admissions should be monitored and documented for at least 72 hours and that significant findings should be relayed if the assigned nurse could not chart. The EC confirmed nurses were trained to document head-to-toe assessments for newly admitted residents for at least 72 hours and to document changes in condition and pertinent findings, but noted there had been no audit to ensure documentation requirements were met. The facility policy stated that changes in condition, objective observations, and treatment details, including refusal and unusual findings, must be documented in the medical record.
Incomplete Post-Fall Investigations and Missing Fall Assessments
Penalty
Summary
The facility failed to complete a thorough post-fall investigation for 2 of 5 sampled residents, R10 and R4. For R10, who was admitted with diagnoses including a left femur fracture with repair and dementia, the record showed she was found on the floor by her daughter, complained of left hip pain, was sent to the emergency room, and was later admitted to the hospital with a hip fracture. After her return to the facility following open reduction and intramedullary nailing of the left femur and revision of prior left hip fracture repair, the Administrator and DON stated that the post-fall investigation packet for this fall could not be found, even though the packet was intended to include a falls checklist, neurological flow sheet, post-fall resident assessment, and staff interviews/statements. For R4, who was admitted with diagnoses including left knee pain, unspecified fall, atrial fibrillation, and muscle weakness, the record showed multiple falls after admission. One fall resulted in a laceration to the back of the head, and another unwitnessed fall occurred when the resident was found lying on the floor. The record review and DON interview confirmed that no initial fall risk assessment was completed on admission, no fall risk assessment was completed after the earlier fall event, and no event report was completed for the later fall. The facility policy stated that a fall risk assessment is to be completed at admission and that incident reports and post-fall assessments/debriefings are to be completed and used to implement fall prevention interventions.
Incomplete Physician Authentication and Missing H&P Documentation
Penalty
Summary
Timely physician authentication was not present in the medical records for three residents, and one resident’s initial H&P was missing from the EMR at the time of review. R1 was admitted for subacute rehabilitation and skilled nursing management following hospitalization for sepsis secondary to a UTI. Review of R1’s record showed the initial admission orders entered by nursing on the admission date had no evidence of MD1’s signature, the initial comprehensive H&P was not in the record when first reviewed, and the discharge summary was not electronically signed until much later than the encounter date. The H&P that was later provided was electronically signed and posted after the deficiency was identified, and it contained an incorrect transition-to-SNF date. The ADM and MD1 both described the admission-order process, and MD1 stated he had not been aware of the electronic signature feature until recently. R2 and R3 were both transferred from acute care and admitted to the facility, and their records also showed physician admission orders that were signed by nursing but not signed by MD1. In addition, each resident had a physician visit note that was not signed in a timely manner, with the electronic signature occurring well after the encounter date. The facility policy titled Physician Services stated that physician orders and progress notes were to be maintained in accordance with State and Federal regulations and facility policy.
Failure to Respond to Family Grievance
Penalty
Summary
The facility failed to respond to a family member’s email grievance regarding Resident 1’s stay at the facility. On survey entry, the facility was asked for its grievance log from September 2025 through June 8, 2026, and the Administrator initially stated there were no grievances during that period. During a later interview, the Administrator said she found an email in her spam folder from the resident’s family member that had also been copied to the Ombudsman and the Office of Healthcare Assurance, and she had been unaware of it until the night before. The family member’s concerns included PT/OT therapy, toileting, CNA restrictions related to mobility assistance, physician visits, and an inaccurate past medical history entry documenting a knee replacement. Record review showed OT notes documenting repeated complaints from the family member about the resident’s therapy and level of care, including dissatisfaction with the amount of therapy received, requests for more therapy, concerns about nurses walking the resident more with PT, and complaints about the time it took for the resident to reach that level of care. The facility policy required written grievances to be investigated, findings documented, reviewed by the Administrator, and a follow-up call made to the person who voiced the concern within 3 business days. The Administrator acknowledged the grievance should have been acknowledged, investigated, and responded to in a timely manner, but there was no follow-up documentation, resolution, or communication to the family member.
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Compliance trends in Hawaii
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 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: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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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