Cycle 1
Health 2025-02-28 · Fire 2025-02-28
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Kaneohe, HI
Ann Pearl Nursing Facility
3-star overall rating with 3-star inspections with 12 recent health deficiencies
45-181 Waikalua Road, Kaneohe, HI
(808) 247-8558
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ohana Pacific Management Co.
Operator or chain grouping
Approved since
1998-12-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.71
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.18
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.25
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.62
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,314
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.27
Composite VBP score used to determine payment impact.
Payment multiplier
1.0044
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.75
Baseline 33.80% · Performance 32.00% · Measure score 7.75 · Achievement 7.75 · Improvement 1.51
Adjusted total nurse staffing
2.30
Baseline 4.02 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 5.78% |
| Discharge to community | 66.97% |
50.57%
16.4 pts better
|
Better than the National Rate · Eligible stays 36 · Observed rate 77.78% · Lower 95% interval 55.35% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 37.65% |
8.2%
29.4 pts better
|
Numerator 32 · Denominator 85 |
| Staff flu vaccination coverage | 57.5% |
42%
15.5 pts better
|
Numerator 46 · Denominator 80 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
96.3%
2.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.3% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.9% |
95.4%
4.5 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
1.9%
0.1 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 0.0% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.4%
1.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.9%
1.2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.9% · Q3 0.0% · Q4 5.6% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
8.2%
4.4 pts worse
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.7% · Q3 9.4% · Q4 13.9% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
11.3%
1.6 pts worse
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 7.7% · Q3 12.0% · Q4 20.0% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.5% |
23.4%
7.1 pts worse
|
16.3%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
16.8%
4.8 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 21.4% · Q3 12.5% · Q4 9.7% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.3%
0.1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.8% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
2.4%
3.2 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 2.4% · Q3 5.1% · Q4 4.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
17.8%
9.2 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 32.7% · Q3 25.5% · Q4 29.7% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
3.6%
0.6 pts worse
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.2% · Q3 2.3% · Q4 4.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.9% |
82.8%
0.9 pts worse
|
81.7%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.8% · Q2 78.6% · Q3 82.7% · Q4 88.0% · 4Q avg 81.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.0%
1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.6% |
84.7%
6.1 pts worse
|
79.7%
1.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-22 · Fire 2024-03-22
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-03 · Fire 2023-03-03
25 health deficiencies
Top issue: Nursing and Physician Services (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-03-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-03-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
D · Potential for more than minimal harm
2024-07-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-01
G · Actual harm
2024-03-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-01-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-02-18
E · Potential for more than minimal harm
2024-01-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-18
D · Potential for more than minimal harm
2024-01-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-18
D · Potential for more than minimal harm
2024-01-19
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-02-18
G · Actual harm
2023-03-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-03
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-03-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-03-03
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-03
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-04-12
Penalties and ownership
What sits behind the stars
Ownership
Ohana Pacific Management Company Inc
5% Or Greater Direct Ownership Interest · Organization
Richard S. Kishaba 2010 Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Kishaba, Richard
5% Or Greater Indirect Ownership Interest · Individual
Beh, Gordon
Operational/Managerial Control · Individual
Canon-Fratis, Rebecca
Operational/Managerial Control · Individual
First Hawaiian Bank
5% Or Greater Mortgage Interest · Organization
Hata, Randall
Operational/Managerial Control · Individual
Hata, Randall
Corporate Director · Individual
Hata, Randall
Corporate Officer · Individual
Kishaba, Richard
Operational/Managerial Control · Individual
Kishaba, Richard
Corporate Director · Individual
Kishaba, Richard
Corporate Officer · Individual
Lo, Wesley
Operational/Managerial Control · Individual
Lore, Andrew
Operational/Managerial Control · Individual
Mcclennon, Pamela
Operational/Managerial Control · Individual
Morikuni, Suanne
Operational/Managerial Control · Individual
Ohana Pacific Management Company Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Harry And Jeanette Weinberg Care Center
Kaneohe, HI
5-star overall rating with 5-star inspections with 4 recent health deficiencies
#2
Aloha Nursing & Rehab Centre
Kaneohe, HI
3-star overall rating with 2-star inspections with $36,296 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Nuuanu Hale
Honolulu, HI
1-star overall rating with 1-star inspections with $27,310 in total fines with 17 recent health deficiencies
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