Legacy Hilo Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Legacy Hilo Rehabilitation & Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 27, 2026

  Based on observation, interviews and record review, the facility failed to provide the needed care in accordance to standard of practice to prevent a pressure ulcer (PU) in one Resident (R)88 of a sample size of three. R88 was at high risk of developing a new PU due to her immobility. She was totally dependent on staff for positioning to prevent a PU. There was no evidence in the medical record that staff frequently repositioned R88. As a result, she suffered harm and developed a Stage III (3) coccyx/sacral PU, which increased the risk of infection and complications. This deficient practice has the potential to affect any resident at risk of PU. […]

• No harm, potential for more than minimal, widespreadF812Feb 27, 2026

  Based on observations, staff interview and review of policy, the facility did not follow proper sanitation practices in the kitchen. As a result of this deficiency, there was an increase risk for foodborne illness and quality of service. Findings include:During observation of the kitchen on 02/24/26 at 10:15 AM, a scooper utensil was left in the sugar container. Observation of the kitchen on 02/25/26 at 01:15 PM, Kitchen Staff (KS)1 and KS2 were not wearing hair restraints when working near the food preparation area. Staff interview, on 02/25/26 at 01:20 PM, Dietary Director (DD) acknowledged that the scooper utensil should have been taken out of the container and that the kitchen staff should have been wearing hair restraints at all times. Review of policy on Kitchen Sanitation read; . […]

• No harm, potential for more than minimal, widespreadF623Oct 25, 2024

  Based on interview and Record Review (RR), the facility failed to ensure a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman for four residents (Resident (R)41, R57, R35, and R56) sampled. Requested a copy of the sampled resident's transfer or discharge notice that was sent to a representative of the Office of the State Long-Term Care Ombudsman and the Administrator confirmed the facility has not been sending any copies of the notices to the Ombudsman. This deficient practice has the potential to affect all the residents who are transferred or discharged from the facility. Findings Include: 1) On 10/23/24 at 11:04 AM during interview with R41 he stated he went to the hospital this year to have my leg amputated. […]

• No harm, potential for more than minimal, widespreadF679May 10, 2021

  Based on observations, interview with residents, resident representative and staff members, record review and a review of the facility's policy and procedures, the facility failed to assure based on a comprehensive assessment and care plan, 8 of 9 (Residents 36, 219, 226, 224, 10, 29, 27, and 28) residents in the sample and randomly observed residents were provided with an ongoing activity program to support residents in their choice of activity, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. […]

• No harm, potential for more than minimal, patternF655Feb 27, 2026

  Based on observations, record review and interviews, the facility failed to develop baseline care plans (CP) and update with them to provide effective and person centered care to meet the immediate needs of four Resident's ((R)1, R2, R3,R4) of a sample size of five. As a result of this deficient practice, there is an increase risk of adverse events and lack of continuity of care. This has the potential to affect all new admissions to the facility. Findings include: 1) R1 was a [AGE] year-old female admitted to the facility on [DATE]. Her admitting diagnosis included sepsis (infection), pneumonia, diabetes, hypertension and transient ischemic attack. Reviewed R1's Admission/readmission Observation and Baseline Care Plan (nursing admission assessment) dated 04/02/26. […]