Based on record review and staff interview the facility failed to identify and submit a significant change for one Resident (R) 21 of three sampled for Nutrition. This deficient practice placed the resident at risk for further functional decline. Findings Include: The facility failed to identify a significant weight loss of greater than 5% in a month, and a decline in Activities of Daily Living (ADLS) which resulted from a fall with major injury and subsequently a fall with dislocation of hardware placed in R21's right hip. During a record review of R21's Electronic Health Record (EHR) found the facility was in the process of reporting a Significant Change for R21 to Center of Medicaid and Medicare Services (CMS) with an Assessment Reference Date (ARD) of 02/05/25. …
F637 citations in Hawaii
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F637 more often than its own record predicts
1.41 times the share F637 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F637 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% | 0.69× |
| 2024 | 0.22% | 0.99× |
| 2025 | 0.34% | 1.41× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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