Based on interviews and record review, the facility failed to ensure safe handling and modified dressing protocols were used to protect one resident (R) 6, who had severe bilateral upper extremity (BUE) contractures and was totally dependent on staff for care. As result of this deficient practice, R6 suffered harm, a dislocated left shoulder. This was a facility reported event (FRI) #2745775, which the facility identified the noncompliance and conducted a Root Cause Analysis (RCA) and implemented a comprehensive corrective action plan that was fully verified as corrected on 07/17/2026, therefore, past noncompliance was determined. …
F684 citations in Hawaii
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F684 less often than its own record predicts
0.79 times the national share — cited less often here than elsewhere.
Of every deficiency written in Hawaii in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F684 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 observation, interviews, document and record review, the facility failed to ensure three Residents ((R)16, R176 and R221 of a sample size of three received the treatment and care in accordance with professional standards of practice and their person-centered comprehensive care plan (CP). This deficient practice put these residents at increased risk of not meeting their highest practicable physical, mental and psychosocial wellbeing, and could affect any resident in the facility. Findings include:1) R16 was a [AGE] year-old female long-term resident at the facility. …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 2.53% | 0.70× |
| 2024 | 4.65% | 1.16× |
| 2025 | 3.39% | 0.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction