Based on observations, medical record review and staff interviews, the facility failed to maintain the highest practicable physical, mental and emotional well being for five of six residents (R) (R39, R33, R20, R41, R70) reviewed for behavior, with one resident (R39) who experienced actual harm from not receiving the necessary behavioral health care and services. Findings include: 1) Cross reference to F692 Cross reference to F676 Resident (R) 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of R39 on the morning of 01/29/19 at 10:41 AM found she activated her call light and was banging on the wall in her room and screaming: Help me. Help me. I need help. Surveyor went into R39's room and asked how she was doing. …
F740 citations in Hawaii
Behavioral health services · Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F740 more often than its own record predicts
1.29 times the share F740 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F740.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F740 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, interview and record review the facility failed to ensure the necessary behavioral health care services that were person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety were provided for one Resident (R) 201 of four residents in the sample. This deficient practice has the potential to affect all of the residents residing on the unit. Findings include: Cross reference to F641 Interview on 05/12/25 at 12:30 PM with R2 and R103 on the Piikoi 2 dining area. R2 referred to R201 and said to the surveyor that she was upset because sometimes R201 goes into other people's rooms and takes their food. …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 0.84% | 3.20× |
| 2024 | 0.22% | 0.89× |
| 2025 | 0.34% | 1.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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