Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies/skills sets to provide nursing and related services to ensure each resident received care that was safe, and able to maintain their highest practicable physical, mental, and psychosocial well-being. It was found there was an insufficient number of licensed staff with a lack of competency training required to provide quality care for their residents who were all ventilatory dependent and required total care by staff. As a result, an immediate jeopardy (IJ) was identified for the systemic problems and potential for serious harm to occur to all their residents. …
F725 citations in Hawaii
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F725 less often than its own record predicts
0.88 times the national share — cited less often here than elsewhere.
Of every deficiency written in Hawaii in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F725 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, record review and interview, the facility failed to ensure there was sufficient nursing staff to provide adequate supervision and care to prevent a potentially avoidable accident for one resident (Resident (R) 31). This deficient practice, including the lack of adequate supervision of CNA25 by the charge nurse that night, was a contributing factor for R31 sustaining serious injury and harm. This deficient practice also has the potential to cause serious harm to other residents residing in the facility, as the facility failed to complete their in-service education/training for hoyer lifts after the accident, and failed to monitor ADL activity/care provided to the residents during the night shift. …
Based on observations, interviews, and record reviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services necessary to meet residents' needs in a safe manner and in a manner that promoted each resident's rights and physical, mental, and psychosocial well-being for five Residents (R) 170, 187, 222, Anonymous 1, Anonymous 2 of thirty five residents sampled. These failures placed residents at risk for unmet care needs, delays in assistance, decline in hygiene and psychosocial well-being, and diminished quality of life.Findings Include: 1) On 04/28/26 at 08:51 AM, an interview was conducted with R170. …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 1.27% | 1.57× |
| 2024 | 0.89% | 1.10× |
| 2025 | 0.68% | 0.88× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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