Based on review of facility assessment and staff interview, the facility did not update the assessment annually, as required. As a result of this deficiency, the facility could not evaluate its resident population and identify resources needed to provide the necessary care and services.Findings include:During review of the facility assessment template on 01/14/26 at 02:10 PM, it showed the most recent review date of the following sections: Infection Prevention and Control 02/19/24, COVID-19 Resource Manual 02/19/24, Health Information Management 02/19/24, QAPI Manual 02/19/24, Wound Care Manual 02/19/24, Pharmacy Manual 05/23/23, Pharmacy Infusion Manual 05/23/23.During staff interview on 01/15/26 at 08:36 AM, Administrator said the facility assessment was recently discussed in their QAPI… …
F838 citations in Hawaii
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F838 more often than its own record predicts
1.34 times the share F838 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F838 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 policy review. The facility failed to meet the staffing needs of its resident population, and was determined by resident census, and not acuity of the residents, or other factors to be considered to determine number of staff meet the unique needs of its residents. Findings include: On 05/09/23 at 07:26 AM Initial tour of the fourth-floor unit. Noted a sign on the display board on the wall next to the nurse's station read: P2, P3, P4 Daily Nurse Staffing Posting. Dayshift: Four RNs; 5 plus 1 orientee CNA's. Evening shift 3 RN's, 5 CNA's. Night Shift 3 RN's and 3 CNA's (cross reference to F730 sufficient nurse staffing). …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 0.42% | 2.50× |
| 2024 | 0.44% | 2.27× |
| 2025 | 0.34% | 1.34× |
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