Based on record reviews and interviews, the facility failed to prevent Resident, (R)34's alleged sexual abuse by R52, and did not monitor R52's sexual behavior, and failure to report R52's behavior to R52's physician. The facility failed to protect R34, who was a vulnerable resident from sexual abuse. This deficient practice has the potential to affect all vulnerable residents residing in the facility. Findings include: On 05/18/22 at 11:59 AM, reviewed the completed Event Report dated 05/13/22 retrieved from the Aspen Complaints/Incidents Tracking System (ACTS), intake number 9520. The Event Report was completed by the facility's Administrator and described an alleged sexual abuse incident between R34 and R52 that occurred on 05/12/22 at 12:06 AM. The physician was notified on 05/12/22. …
F600 citations in Hawaii
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F600 less often than its own record predicts
0.39 times the national share — cited less often here than elsewhere.
Of every deficiency written in Hawaii in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F600 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 observation, interview, and record review, the facility failed to protect the residents' right to be free from abuse, specifically resident-to-resident physical abuse, for 9 of 9 residents (Residents (R)10, R7, R8, R3, R1, R2, R4, R5, and R6) sampled for this type of abuse. The facility failed to provide sufficient protection to prevent resident-to- resident abuse from occurring or recurring once aware of aggressive behaviors. As a result of this deficient practice, at least one resident (R10) sustained physical injuries and experienced pain related to those injuries. …
Based on observations, interviews, and record review, the facility failed to ensure that residents were free from abuse by failing to adequately protect one of three residents reviewed for abuse allegations (R) 12). Specifically, a staff member willfully pushed R12's head without a care related purpose. This failure placed residents at risk of abuse and harm.Findings Include: Cross reference to F609, Reporting of Alleged Violations. The facility failed to ensure that a staff member who witnessed an incident involving another staff member willfully hitting a resident in the head immediately reported the incident to the administrator. On 05/04/26, the facility submitted a completed event report to the State Agency (SA), Intake #2999087. …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 0.63% | 0.36× |
| 2024 | 1.77% | 0.75× |
| 2025 | 1.02% | 0.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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