Legacy Hilo Rehab and Nursing Center Abuse and Neglect Lawyers

To protect the public, the Centers for Medicare and Medicaid Services (CMS) and the State of Hawaii routinely inspect and survey every nursing facility on all the islands. Their efforts involving unscheduled visits and unannounced investigations help identify serious violations and deficiencies occurring at the nursing home.

When problems are identified, the nursing facility is given the opportunity to make improvements promptly to ensure the health and well-being of every resident are protected and maintained.

However, not every facility has the ability to make improvements. Some nursing homes have major underlying issues that require extensive corrections and ongoing efforts so that even the most minimal changes are permanent.

If corrections are not made in a timely fashion, the federal and state nursing home regulatory agencies might force the nursing home to sell their company to others that remain in good standing in providing quality nursing home care to the community.

In recent months, Legacy Hilo Rehabilitation & Nursing Center was designated a Special Focus Facility (SFF) by the CMS, because it provided substandard medical and nursing care to the residents. Receiving this undesirable designation means that the nursing center will undergo extensive, unannounced surveys and inspections throughout the year to check for improvements made to correct serious violations.

Likely, the facility will remain on the federal watch list for one or more years until surveyors and investigators have been assured that the quality of life of every resident is being protected by providing a higher level of quality care.

Legacy Hilo Rehabilitation and Nursing Center

The 100-certified bed for-profit Medicare/Medicaid-participating nursing facility provides care and services to the residents of Hilo and Hilo County, Hawaii. The Home is located at:

563 Kaumana Drive
Hilo, HI 96720
(808) 498-0184


The state of Hawaii and the Centers for Medicare and Medicaid Services (CMS) issue citations and monetary fines to ensure immediate improvements are made at the facility to protect the health and well-being of every resident.

Within the last three years, Legacy Hilo Rehabilitation and Nursing Center received one major monetary fine that was issued on September 19, 2016, for $136,555. During that same time frame, Medicare denied a request for payment due to unacceptable service that resulted in harm to residents.

Current Nursing Home Resident Safety Concerns

Both the Centers for Medicare and Medicaid Services (CMS) and the State of Hawaii update their nursing home information into the national Medicare.gov database to keep the public informed.

This information is used by families and individuals interested in placing a loved one in a facility that provides the best nursing care and hygiene assistance. In addition to providing details of violations and deficiencies, the site can also be used as a comparative analysis tool through their Star Rating Summary System.

Currently, Legacy Hilo Rehabilitation & Nursing Center maintains a below average two out of five stars overall rating compared all the facilities in the United States.

This ranking includes one out of five stars for health inspections, four out of five stars for staffing, and two out of five stars for quality measures. Some of the major concerns involving deficiencies and violations at this facility are listed below.

  • Failure to Provide Necessary Care and Services to Ensure Every Resident Maintains Their Highest Well-Being

  • In a summary statement of deficiencies dated September 22, 2017, the state investigator noted that the facility “failed to obtain and maintain the highest practicable physical and psychosocial well-being of [two residents].” In one incident, a resident reported having “difficulty swallowing due to a loss of teeth and can only eat certain foods as it gets stuck in her throat when swallowing.”

    The surveyor noted that 1:41 PM on September 20, 2017, the resident “reported she had difficulty eating her lunch today and had to ask a staff member to [chop her food finely]. She further stated she had difficulty swallowing the chicken that was in the chicken and long rice [meal] that was served at lunch. The resident also reported she needs gravy on all her food to aid in swallowing.”

    On the morning of September 21, 2017, the resident “was observed with her breakfast tray on the bedside table. The resident responded she had eggs and toast. The toast was not cut into pieces; she reported she didn’t eat one piece of toast as it was wet. Subsequent observations on September 21, 2017, at 5:15 PM, another resident was served regular texture of chicken with gravy, Rice and a slice of cake. The food items were not observed to be chopped [or cut into tiny] pieces for consumption.”

    The state investigator reviewed a September 20, 2017, record with physician’s orders for “speech therapy five times a week for three weeks for swallowing therapy, cognitive communication deficit and dysphagia [swallowing discomfort or difficulties].”

  • Failure to Provide Adequate Treatment to Prevent the Development of a Bedsore or Allow an Existing Sore to Heal

  • In a summary statement of deficiencies dated September 22, 2017, the state investigator noted the facility’s failure “to provide one resident with the necessary care and services to avoid a stage IV pressure ulcer.” Findings generated by the state investigation revealed that the resident “was admitted to the facility from an acute care facility.”

    The resident “had a history noted that he was admitted to the long-term care facility from an acute facility where he stayed from January 24, 2017, through May 1, 2017. The historical document further notes that the resident “was admitted to the acute care facility in septic shock due to multiple stage IV pressure injuries…” It was also stated that “the wounds were infected with bacteria and contained maggots. During his acute care state, [the resident’s] left lower leg was unsalvageable from complications of the wound on his left ankle…”

    The resident’s stay at the acute care facility was “further complicated with antibiotic-resistant bacterial infections which required management by the infectious disease specialist [before being] finally discharged from the acute care facility on May 1, 2017” when he was admitted to this nursing home.

    Before making a final report, the State surveyor interviewed the facility’s Wound Nurse who “was asked if a weekly skin assessment would demonstrate a breakdown and skin such as discoloration, redness, blanchiness, mushy feeling, or blisters prior to the development of stage II pressure injury. The Wound Nurse stated that the skin assessments would note such things …”.

    However, the Wound Nurse “was unable to explain how [the resident’s] right hip was discovered with a Stage II pressure injury without first having some visible skin breakdown prior to [the wound] opening. The Wound Nurse reported that Hospice agency was able to provide [the resident] with an air mattress at the end of June 2017, almost two months since his admission.

    When asked if the air mattress assisted with wound healing and potentially prevent the development of pressure injuries, the Wound Nurse replied ‘Yes.’” The Wound Nurse noted that “they did not provide an air mattress for [the resident] upon admission until he found out the Hospice would provide them.”

    The resident’s “history of multiple pressure injuries, emaciated stature, and deteriorating health placed him at high risk for skin breakdown. Despite these risk factors, the facility failed to implement all necessary interventions to maintain the integrity of [the resident’s] skin. The combination of [the resident’s condition] and the lack of vital interventions resulted in the development of three new pressure injuries. One of the three wounds progressed to a stage II and a stage IV in a matter of nine weeks.”

    “The physician failed to document any assessments or plans for the three facility-acquired wounds. The facility’s failure to maintain an aggressive approach to the prevention of additional skin breakdown resulted in [the resident] developing a stage IV pressure injury on his right hip and two deep tissue pressure injuries on his right foot.”

  • Failure to Implement Programs That Investigate, Control and Keep Infections from Spreading

  • The state investigator noted during a September 22, 2017, survey that the facility had failed to “ensure a safe and sanitary environment for residents.” An observation was made of a resident undergoing a dressing change in the morning of September 21, 2017, when a staff member was assisting the Wound Nurse.

    “The Wound Nurse set up his dressing change supplies on [the resident’s] bedside table by first laying down a waterproof barrier over the surface. The waterproof barrier extended over the sides of the bedside table [and] were folded over the edges.”

    During this observation, the surveyor noted that the Wound Nurse and other staff member failed to follow standard procedures properly involving clean and contaminating gloves while providing care to the resident.

  • Failure to Provide Protection of a Resident’s Funds and Personal Belongings

  • In a summary statement of deficiencies dated January 13, 2017, the state investigator noted during that the nursing home had failed to “ensure to provide sufficient and appropriate social services,” This deficiency involved a failure to maintain “contact with the resident’s family member to report the results of an investigation related to the resident’s missing items of value.”

    The state inspectors conducted “a complaint investigation based on an allegation that [a resident’s] personal item of value was missing upon the resident’s discharge to an acute care hospital from this facility on November 27, 2016. The missing personal item was alleged to have been a small satchel that had $3000 in cash, which the resident kept with him at all times, including when he slept.

    The missing cash and property were validated during an interview with [a Certified Nursing Assistant (CAN) at the facility], except that the CNA did not know the contents of the fanny pack.”

    A family member reported that the resident “was missing $3000 from a black pouch.” During the facility’s investigation, it was noted that the facility social worker “called the former employer/private caregiver for the resident and left messages on numerous occasions but to no avail. She also called the family member to discuss the findings of her investigation but failed to hear from the family member.”

Injured by Nursing Home Abuse and Neglect?

Is your loved one the victim of nursing home abuse, neglect or mistreatment? If so, you are likely entitled to file a claim for compensation on their behalf to ensure your family receives monetary recovery for their injuries. However, these cases are complex. Consider hiring a personal injury attorney who specializes in abuse and neglect cases.

Contact us today! There is no need for you to make any upfront payment. Personal injury attorneys typically handle wrongful death, medical malpractice, nursing home abuse and other cases involving injuries through contingency fee agreements. This means you will be provided immediate legal representation and counsel without the need of you making any upfront payment. Let our attorneys build, present and negotiate or resolve your case to ensure your family is fully compensated for the mistreatment.


Client Reviews

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric