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 fully cover urinary drainage and leg bags: A resident using a urinary drainage bag and later a urinary leg bag was observed with the bag only partially covered or not covered by a privacy/dignity bag while out of the room and in the dining area. The resident stated concern that the bag should always be covered and that the exposed leg bag made the resident uncomfortable because it was visible to others. RN and DON both confirmed that urinary bags should always be fully covered with privacy or dignity bags.
A resident with a catheter was observed with the catheter bag and tubing exposed outside the privacy bag and resting directly on the floor, and the resident moved the wheelchair over the bag. An RN later confirmed that catheter bag and tubing should not be in direct contact with the floor.
A pill cutter in the station 1C med cart was observed with large amounts of white and brown sediments inside it during survey. An RN administering meds from the cart confirmed the contamination and stated it was from not cleaning the cutter, adding that it should be cleaned after each use.
Failure to Provide Ordered AROM Program: A resident with weakness, pain, and a history of falls did not receive the ordered AROM restorative program 6 times a week as care planned. Record review showed some weeks with fewer than the required interventions, with treatments sometimes refused and sometimes not offered. The MDSC confirmed the frequency was not met and that refusals were not being addressed in the RNA program.
Failure to Provide Ordered AROM Program: A resident admitted with weakness, pain, and a history of falls was ordered AROM exercises 6 times a week to maintain mobility and strength. Documentation showed repeated missed sessions, refusals, and days marked not applicable or not done, and the MDS coordinator, RNA, and DON confirmed the program was not consistently carried out. Staff reported that staffing shortages, other assigned duties, and lack of time prevented them from completing the ROM program, revisiting the resident, or providing ongoing encouragement when the resident refused.
Failure to Protect Resident from Physical Abuse: A CNA willfully pushed a resident’s head without a care-related purpose after frustration during toileting and transfer assistance. Another CNA directly witnessed the resident being struck on the head, and the resident later stated he had been slapped and was shocked because he had a good relationship with the CNA. The DON confirmed the action was not related to care and the facility determined the incident was physical abuse.
Failure to fully cover urinary drainage and leg bags
Penalty
Summary
The facility failed to ensure the resident's right to a dignified existence for 1 of 2 residents sampled for dignity, involving a resident who used a urinary drainage bag and later a urinary leg bag. During an observation, the resident was seen self-propelling to the dining area from Physical Therapy with a urinary drainage bag hanging under the wheelchair and only about one-third of the bag covered by a privacy/dignity bag. When asked about it, the resident stated concern that the drainage bag was not fully covered and said the bag should always be covered; the resident then tried to adjust the privacy bag but was unable to fully resolve the issue. During a later observation in the dining room, the resident had a urinary leg bag securely attached to the right leg and stated that the RN had changed the urinary bag to a leg bag and instructed that it be changed every time the resident left the room. The resident said the leg bag did not have a privacy bag covering it, that the resident preferred to wear short pants, and that the exposed leg bag made the resident uncomfortable because it was visible to others outside the room. RN11 and the DON both stated that urinary bags should always be fully covered with privacy or dignity bags, and the DON said the facility was in the process of ordering new urinary leg bags with dignity or privacy bags. The facility policy stated that the resident has a right to be treated with respect and dignity.
Catheter Bag and Tubing Left in Contact With Floor
Penalty
Summary
Appropriate catheter care was not provided for Resident R144, who was observed seated in a wheelchair in the entrance of the resident's assigned room with the catheter bag outside of the privacy bag. Approximately the bottom third of the catheter bag and the tubing were resting directly on the floor, and the resident moved the wheelchair and ran over the exposed catheter bag. When the situation was brought to RN15's attention, RN15 secured the catheter bag and tubing off the floor. RN15 confirmed that appropriate treatment and care of the catheter bag and tubing was to ensure it was not in direct contact with the floor.
Contaminated Pill Cutter Found in Medication Cart
Penalty
Summary
The facility failed to provide a safe and sanitary environment when a pill cutter in the station 1C medication cart was found with large amounts of white and brown sediments inside the cutter. On 06/03/26 at 08:10 AM, surveyors checked the top drawer of the medication cart and observed the contaminated pill cutter in 1 of 3 medication carts reviewed. RN6, who was administering medications from the cart at the time, confirmed seeing the white and brown sediments and stated that it was from not cleaning it. RN6 also stated that the cutter should be cleaned after each use.
Failure to Provide Ordered AROM Program
Penalty
Summary
The facility failed to implement the person-centered care plan for one resident who was admitted with diagnoses including weakness, pain, and a history of falling. The resident was identified as a fall risk and had mobility issues related to weakness. The care plan, initiated on 02/20/26, directed the RNA restorative program to encourage active range of motion (AROM) exercises to both upper extremities using 3-pound dowel weights for 10 repetitions times 3 sets, 6 times a week as tolerated. Record review of the resident’s AROM program from 02/20/26 through 05/20/26 showed that the resident received at most four interventions in some weeks, with some treatments refused and others not offered. During observation on 05/21/26, the resident was sitting on a rollator in the activities room and did not participate in a balloon toss activity; when asked why, the resident shook her head and motioned that she could not lift her arms. Interviews with the MDSC, who was responsible for the RNA program, confirmed that the resident was supposed to receive AROM 6 times a week and did not receive that frequency. The MDSC also stated that refusals were not being addressed and were being left to nursing staff because the RNAs were short-staffed and pulled to other duties.
Failure to Provide Ordered AROM Program
Penalty
Summary
The facility failed to implement the active range of motion (AROM) program for one resident who was admitted with weakness, pain, and a history of falling. The resident was identified as a fall risk and had mobility issues related to weakness. The care plan, initiated on 02/20/26, directed the restorative nurse aide (RNA) to encourage bilateral upper extremity ROM exercises using 3-pound dowel weights for 10 repetitions and 3 sets, 6 times a week as tolerated. Review of the resident’s AROM documentation showed that the ordered 6-times-a-week program was not consistently provided. Across multiple weeks, the record reflected days with no AROM intervention, days marked as resident refused, days marked as not applicable, and some days marked with an X. The MDS coordinator, who was also responsible for the restorative nursing program, confirmed that the resident should have been receiving AROM exercises 6 times a week and stated that NA meant the activity was not done. The coordinator also explained that Tuesdays were not used for AROM because the RNAs focused on resident weights. Interviews with the MDS coordinator, RNA, and DON confirmed that staffing shortages affected the restorative program and that RNAs were pulled to other duties, limiting their ability to complete ROM activities, revisit residents, or provide education and encouragement when residents refused. The RNA stated the resident often refused because she was tired and sleepy after breakfast and wanted the activity later, but staff did not have time to circle back. The DON confirmed that refusals should have been addressed and that the resident should have been revisited and encouraged to participate.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA willfully pushed the resident’s head without a care-related purpose. The incident involved R12, who was in his room with his roommate when CNA30 reportedly heard a back-and-forth conversation between R12 and CNA19 and then witnessed CNA19 strike R12 on the head. The event report stated CNA30 saw the resident struck twice on the head, once on the back of the head and once on the side of the head, and later assisted with transferring R12 back to bed. R12 later stated he was okay, but the report also documented that he told CNA30 CNA19 had slapped him the previous week. The facility’s investigation included interviews with CNA19, CNA30, R12, the IP, the DON, and the Administrator/Assistant Administrator. CNA19 stated she used one finger to push the back of R12’s head one time and said she was frustrated after assisting him to the toilet and having difficulty transferring him back to bed. CNA30 confirmed she directly witnessed CNA19 hit R12 on the back and side of the head with an open hand, causing his head to jerk forward slightly and making an audible sound. R12 stated CNA19 slapped him and said he was shocked because he had a good relationship with her. The DON stated CNA19 should not have placed her hands on the resident because the action was not related to providing care, and the facility concluded the incident was physical abuse.
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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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