Based on interview and record review, the facility failed to ensure the resident's (R)12's physician was notified after an incident that occurred resulted in an injury for one resident sampled. On 02/08/24, R12 reported that during physical therapy he experienced a loud crack and sharp pain to his hip when physical therapist (PT)1 pushed R12's left knee to the resident's chest. R12's physician and his treatment team were not notified of the incident which resulted in a left hip fracture that was delayed in diagnosis and treatment. On 02/26/24, R12 was transferred to a hospital for a surgical repair of the fracture. As a result of this deficient practice, R12 suffered pain, continued to decline and sustained harm. …
F580 citations in Hawaii
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F580 less often than its own record predicts
0.46 times the national share — cited less often here than elsewhere.
Of every deficiency written in Hawaii in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F580 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.
Based on record review and interview, the facility failed to notify the physician when one Resident (R) 10 of three sampled for hospitalizations, had an acute change in condition that resulted in a transfer to the Emergency Department (ED). Findings include: Cross reference to F684 Quality of Care. Review of R10's Electronic Health Record (EHR) on 04/22/26. R10 was admitted to the facility on [DATE] for diagnosis including severe anemia dependent on blood transfusions. 03/01/26 04:37 Type: Health Status Note. Resident to be admitted to Hospital for septic Shock. Signed by RN36.Care plan reviewed. Focus. R10 is at risk for rehospitalization due to chest pain, shortness of breath (SOB) and acute pneumonia and other comorbidities revision 02/23/26. Interventions. …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 0.84% | 0.59× |
| 2024 | 0.44% | 0.29× |
| 2025 | 0.68% | 0.46× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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