Based on interviews and record reviews, the facility failed to provide discharge instructions for Resident (R)1 that include special instructions for ongoing care to family member related to wound care dressing changes, toileting, medications, and failed to notify a physician before discharging R1 against medical advice (AMA). Findings include: On 09/21/22 at 3:00 PM a record review (RR) of the Minimum Data Set (MDS) stated that R1 was admitted to the facility on [DATE]. R1 has a history of delusional disorder, paranoid schizophrenia, right hemiplegia/hemiparesis following a cerebral infarction, history of amputation to multiple right toes, generalized muscle weakness. R1 required extensive assistance for toileting and required use of an indwelling Foley catheter. …
F622 citations in Hawaii
Transfer and discharge · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Hawaii cites F622 more often than its own record predicts
1.38 times the share F622 takes of citations nationally.
Of every deficiency written in Hawaii in 2024, this is the portion that was F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F622 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 provide Resident (R)107's completed Interact Nursing Home to Hospital Transfer Form to the hospital R107 was sent to when his condition changed and he became unstable, requiring a transfer and admission to an acute hospital. Findings Include: Record Review (RR) was done of R107's Electronic Health Record (EHR). On 11/17/24 Registered Nurse (RN) 25 documented R107 was sent to the emergency room (ER) because R107 complained of shortness of breath and could not breath and his Oxygen (O2) saturations were in the 70's. R107 was sent to the ER by 911 ambulance. Progress note dated 11/17/24 stated R107 was admitted to the hospital for diagnosis of AFib (Atrial fibrillation (AFib) is an irregular and often very rapid heart rhythm.). …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 1.05% | 4.18× |
| 2024 | 0.44% | 1.38× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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