F656 in Hawaii. Pick another state for the same tag.
Against expectation — 2025
Hawaii cites F656 more often than its own record predicts
Versus expected share1.48×
1.48 times the share F656 takes of citations nationally.
Share of Hawaii citations5.08%
Of every deficiency written in Hawaii in 2025, this is the portion that was F656.
Hawaii5.08%
National3.44%
Share of all citations that were F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F656 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.
G · Actual harm, isolatedSeptember 9, 2022
Based on observations, interviews, and record reviews, the facility failed to appropriately develop and implement the care plans (CP) for three residents (R), R75, R33, and R23, out of a sample of 21 residents. The deficient practices included:
1. Staff failed to implement the identified care needs for R75 that resulted in a facility-acquired stage 2 pressure ulcer (PU), and the facility also failed to develop a person centered CP with interventions to heal and/or prevent the worsening of R75's PU.
2. The facility failed to identify and develop an individual care need for R33, and
3. …
D · No harm, potential for more than minimal, isolatedJuly 2, 2026
Based on observations, interviews and record reviews, the facility failed to develop a written person-centered comprehensive care plan for two of three residents (Resident (R) 48 and R164) sampled for skin conditions. As a result of this deficient practice, staff did not have the information to adequately care for both resident's skin conditions. Findings include: 1) On 06/29/26 at 11:52 AM, observed R48 walking in the hallway with the assistance of the physical therapist. R48 had a dressing to his left shin. Queried R48 what happened to his shin. R48 said he had a wound that was slow to heal and was acquired before he was admitted to the facility on [DATE].Review of R48's Electronic Health Record (EHR) was conducted. …
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