Based on observations, record review and interviews, the facility failed to develop baseline care plans (CP) and update with them to provide effective and person centered care to meet the immediate needs of four Resident's ((R)1, R2, R3,R4) of a sample size of five. As a result of this deficient practice, there is an increase risk of adverse events and lack of continuity of care. This has the potential to affect all new admissions to the facility. Findings include: 1) R1 was a [AGE] year-old female admitted to the facility on [DATE]. Her admitting diagnosis included sepsis (infection), pneumonia, diabetes, hypertension and transient ischemic attack. Reviewed R1's Admission/readmission Observation and Baseline Care Plan (nursing admission assessment) dated 04/02/26. …
F655 citations in Hawaii
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F655 more often than its own record predicts
2.58 times the share F655 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F655 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 | 1.90% | 2.38× |
| 2024 | 0.22% | 0.32× |
| 2025 | 1.69% | 2.58× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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