The facility failed to ensure availability of a physician for emergency care for one Resident (R)1 of a sample size of three. R1 had a fall with a change of condition, and the facility was unable to reach the physician (MD)1 for over four and a half hours. In addition, the staff failed to transport R1 to the emergency room (ER) in a timely manner to obtain physician evaluation when they were unable to reach MD1. As a result of this deficient practice, there was a delay in transferring R1 to a higher level of care. …
F713 citations in Hawaii
Nursing and Physician Services Deficiencies
Provide or arrange emergency care by a doctor 24 hours a day.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F713 more often than its own record predicts
26.24 times the share F713 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F713.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F713 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 | 0.42% | 57.11× |
| 2024 | 0.22% | 44.90× |
| 2025 | 0.34% | 26.24× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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