Based on observation, interviews and record review, the facility failed to complete a comprehensive assessment for one resident sampled for being a smoker. As a result of this deficient practice, the facility failed to identify resident (R) 38 as a smoker and no plan of care was developed to address the health and safety risks associated with smoking. Findings Include: On 07/15/24 at 12:24 PM, observed R38 up in his wheelchair in the hallway at Unit 4, propelling himself to one of the doors that open to the parking lot. R38 stopped to talk to Registered Nurse (RN) 6 as she was preparing medications. R38 then proceeded to exit Unit 4 and went to the parking lot unsupervised. Asked RN6 where R38 was going, she said he was going to the parking lot to smoke. …
F636 citations in Hawaii
Comprehensive assessments · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Hawaii cites F636 more often than its own record predicts
1.51 times the share F636 takes of citations nationally.
Of every deficiency written in Hawaii in 2024, this is the portion that was F636.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F636 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 | 0.21% | 0.53× |
| 2024 | 0.44% | 1.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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