Based on observation, record review and interview, the facility failed to maintain a homelike environment in six Resident rooms (Rm (110, 114, 115, 116, 118 and 119) on the unit Pensacola 1. An unhomelike environment could significantly affect their physical, mental and social well-being and affect any resident in the facility. Findings include:On 04/28/26, the following observations were made: Room (Rm) 110 A: Wall clock broken (large piece missing), and several white patches on the wall. RM [ROOM NUMBER] A/B: Multiple large brown marks on the wall of unknown substance, visible immediately on entry. Immediately brought to staff's attention and observed being cleaned on 04/29/26. RM [ROOM NUMBER]: Loud constant buzzing noise when light in bathroom is turned on. …
F921 citations in Hawaii
Safe, clean, comfortable environment · Environmental Deficiencies
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Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Hawaii cites F921 more often than its own record predicts
1.20 times the share F921 takes of citations nationally.
Of every deficiency written in Hawaii in 2025, this is the portion that was F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Hawaii surveyors wrote
F921 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 | 1.05% | 1.23× |
| 2024 | 1.11% | 1.39× |
| 2025 | 1.02% | 1.20× |
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