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
A resident with severe BUE contractures, paralysis of the left side from a stroke, and total dependence for ADLs did not have specific modified handling and dressing instructions in the care plan to protect the contracted UEs during care. A PT later observed the left shoulder out of alignment, and imaging confirmed a left anterior shoulder dislocation and anterior humeral head dislocation, requiring transfer for closed reduction.
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.
Failure to Use Safe Handling and Modified Dressing for Resident With Severe Contractures
Penalty
Summary
The facility failed to ensure safe handling and modified dressing protocols were used for a resident with severe bilateral upper extremity contractures who was totally dependent on staff for dressing, bed mobility, transfers, and range of motion care. The resident had severe cognitive impairment, limited range of motion due to contractures, and paralysis of the dominant left side from a stroke, and was unable to communicate at baseline. Prior to the incident, the resident’s care plan did not contain specific modified handling and dressing instructions to protect the resident’s severe upper extremity contractures during activities of daily living care. On 02/12/26, a physical therapist observed that the resident’s left shoulder was not in alignment before range of motion was performed. X-rays on 02/13/26 showed a left anterior shoulder dislocation and an anterior humeral head dislocation, and the resident was transferred to acute care for a closed reduction.
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.
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Compliance trends in Hawaii
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 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.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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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