18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Honolulu, HI
3-star overall rating with 2-star inspections with $12,838 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1930 Kamehameha Iv Rd, Honolulu, HI
(808) 847-4834
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
108
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avalon Health Care
Operator or chain grouping
Approved since
1971-01-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 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
RN hours / resident day
1.91
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.20
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.59
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.42
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.69
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Program rank
1,665
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.91
Composite VBP score used to determine payment impact.
Payment multiplier
1.0098
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.57
Baseline 15.97% · Performance 19.78% · Measure score 3.57 · Achievement 3.57 · Improvement 0
Healthcare-associated infections
10
Baseline 5.47% · Performance 4.96% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
5.04
Baseline 40.57% · Performance 43.09% · Measure score 5.04 · Achievement 5.04 · Improvement 0
Adjusted total nurse staffing
3.35
Baseline 4.19 hours · Performance 4.03 hours · Measure score 3.35 · Achievement 3.35 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 250 · Observed rate 10.4% · Lower 95% interval 8.59% |
| Discharge to community | 72.71% |
50.57%
22.1 pts better
|
Better than the National Rate · Eligible stays 248 · Observed rate 68.55% · Lower 95% interval 66.21% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.51% |
95.27%
2.2 pts better
|
Numerator 196 · Denominator 201 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 201 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 82 · Denominator 123 |
| Discharge mobility score | 60.98% |
50.94%
10 pts better
|
Numerator 75 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 4 · Denominator 200 · Adjusted rate 1.46% |
| Healthcare-associated infections requiring hospitalization | 4.96% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 2.03% · Lower 95% interval 2.8% |
| Staff COVID-19 vaccination coverage | 7.78% |
8.2%
0.4 pts worse
|
Numerator 14 · Denominator 180 |
| Staff flu vaccination coverage | 38.57% |
42%
3.4 pts worse
|
Numerator 81 · Denominator 210 |
| Discharge function score | 65.04% |
56.45%
8.6 pts better
|
Numerator 80 · Denominator 123 |
| Transfer of health information to provider | 96.61% |
95.95%
0.7 pts better
|
Numerator 57 · Denominator 59 |
| Transfer of health information to patient | 97.48% |
96.28%
1.2 pts better
|
Numerator 116 · Denominator 119 |
| Resident COVID-19 vaccinations up to date | 33.7% |
25.2%
8.5 pts better
|
Numerator 31 · Denominator 92 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
96.3%
3.1 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
95.4%
0.2 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
1.9%
0.5 pts worse
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.4% · Q4 2.3% · 4Q avg 2.4% · 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 | 0.7% |
4.9%
4.2 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.2% |
8.2%
6 pts better
|
19.6%
17.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 2.9% · Q4 2.6% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.8% |
11.3%
10.5 pts better
|
16.7%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 | 23.4% |
23.4%
About the same
|
16.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
16.8%
3.9 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 15.0% · Q4 7.7% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.3%
1.1 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.3% · Q3 2.6% · Q4 1.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
2.4%
1.8 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.0% |
17.8%
4.8 pts better
|
19.8%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 14.6% · Q3 14.4% · Q4 5.2% · 4Q avg 13.0% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
3.6%
0.1 pts worse
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.5% · Q3 4.3% · Q4 2.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
82.8%
2.1 pts better
|
81.7%
3.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 84.8% · Q3 84.1% · Q4 81.3% · 4Q avg 84.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
10.9%
1.3 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.3% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.0%
0.6 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.3% · Q3 0.7% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.6% |
84.7%
6.9 pts better
|
79.7%
11.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
19.6%
0.1 pts worse
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 18.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Rights (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Rights (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-07
Fire Safety
Meet other general requirements.
Corrected 2023-08-08
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-03-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-01
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-16
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 2025-05-16
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-16
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-16
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-16
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 2025-05-16
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-16
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 2025-05-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-16
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-16
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-16
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-16
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 2025-05-16
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-16
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 2025-05-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-07
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 2024-05-07
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-07
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-05-07
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-07
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-05-07
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 2024-05-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-07
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 2024-05-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-07
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 2024-05-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-07
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 2024-05-07
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 2024-05-07
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-07
Health
Keep all essential equipment working safely.
Corrected 2024-05-07
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-01
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-05-01
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-01
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-01
Health
Post nurse staffing information every day.
Corrected 2023-05-01
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 2023-05-01
Health
Keep all essential equipment working safely.
Corrected 2023-05-01
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 2023-05-01
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 2023-05-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-01
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 2023-05-01
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-05-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-01
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 2023-05-01
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-01
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-01
Penalties and ownership
Fine · fine $12,838
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
Nearby options
Honolulu, HI
1-star overall rating with 1-star inspections with $27,310 in total fines with 17 recent health deficiencies
Honolulu, HI
5-star overall rating with 4-star inspections with $8,278 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Honolulu, HI
2-star overall rating with 2-star inspections with $11,170 in total fines with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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