Based on interview and record review, 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 for one of three residents (Resident (R) 12) reviewed for allegations of abuse. This failure had the potential to delay the facility's response to allegations of abuse and place residents at risk for harm.Findings Include: Cross reference to F600, Free from Abuse and Neglect. The facility failed to ensure that R12 remained free from abuse when a staff member was witnessed willfully pushing/hitting the resident's head without a care-related purpose. On 04/29/26, the facility submitted an initial event report to the State Agency (SA), Intake #2999087. …
F609 citations in Hawaii
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F609 more often than its own record predicts
1.11 times the share F609 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F609 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 | 1.69% | 0.85× |
| 2024 | 2.21% | 0.97× |
| 2025 | 2.71% | 1.11× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction