Based on interviews and medical record review, the facility failed to ensure Resident #8 was served the correct specialized diet that resulted in the resident choking on his food and developing aspiration pneumonia. Findings: A medical record review was conducted on 08/15/2018 and the following was found documented in the record, that a speech therapist report dated 11/30/2017 had documented that Resident #8 required a puree diet with nectar thick fluids as he was at risk of aspiraton. The specialized diet ordered for this resident has not changed since the date of that report. A nursing note dated 07/21/2018 had documented that the Resident #8 had a continuous wet moist cough, gurgling, rales all four lobes, spitting whitish thick saliva after dinner. …
F800 citations in Hawaii
Nutritious diet · Nutrition and Dietary Deficiencies
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Hawaii cites F800 more often than its own record predicts
1.72 times the share F800 takes of citations nationally.
Of every deficiency written in Hawaii in 2024, this is the portion that was F800.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F800 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 residents dietary needs and preference were met. 1) Resident (R) 52 food preferences were not followed. 2) Staff members providing feeding assistance and/or passing meal trays to residents were not aware of residents' special dietary texture needs to ensure residents are receiving the proper diet texture on their meal trays. 3) R62's food preferences were not followed. 4.) R50's fluid preferences were not given. Findings include: 1) On 01/31/24 at 08:41 AM an observation and interview with R52 was done. Observed Certified Nurse Aide (CNA) 10 approach R52 while R52 was eating breakfast. …
What else Hawaii surveyors cite →
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