Based on observation and interview, the facility failed to honor 1 of 1 resident's (Resident (R) 36) choice to eat lunch before doing therapy (physical and occupational). As a result of this deficient practice, R36's needs were not met and was placed at risk of not obtaining her highest practicable well-being.Findings include:On 04/28/26 at 12:15 PM, observed Certified Nurse Aide (CNA) 20 and CNA21 delivering meal trays to the resident rooms on the third floor. At 12:55 PM, observed physical therapy assistant (PTA) 1 finishing treatment to R36 and an uneaten lunch meal tray on R36's bedside table. At 01:00 PM, Respiratory Therapist (RT) 19, was suctioning R36 in preparation to deflate the tracheostomy cannula and attach the speaking valve to allow R36 to eat safely. …
F561 citations in Hawaii
Self-determination · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F561 more often than its own record predicts
2.65 times the share F561 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F561.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F561 findings written in Hawaii, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 1.27% | 2.42× |
| 2024 | 0.66% | 1.61× |
| 2025 | 1.02% | 2.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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