Cycle 1
Health 2025-02-21 · Fire 2024-02-23
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Lihue, HI
Garden Isle Healthcare And Rehabilitation Center
5-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3-3420 Kuhio Highway, Suite 300, Lihue, HI
(808) 245-1802
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ohana Pacific Management Co.
Operator or chain grouping
Approved since
1967-01-01
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
1.53
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.23
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.28
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
1.48
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
329
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0237
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.49% · Performance 16.79% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
7.44
Baseline 5.31% · Performance 5.61% · Measure score 7.44 · Achievement 7.44 · Improvement 0
Total nurse turnover
10
Baseline 28.41% · Performance 20.83% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.77
Baseline 4.07 hours · Performance 3.58 hours · Measure score 1.77 · Achievement 1.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.2% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 2.72% · Lower 95% interval 5.77% |
| Discharge to community | 76.64% |
50.57%
26.1 pts better
|
Better than the National Rate · Eligible stays 139 · Observed rate 76.26% · Lower 95% interval 70.12% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 68.52% |
53.69%
14.8 pts better
|
Numerator 37 · Denominator 54 |
| Discharge mobility score | 62.96% |
50.94%
12 pts better
|
Numerator 34 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 4.29% |
2.29%
2 pts worse
|
Numerator 3 · Denominator 70 · Adjusted rate 4.34% |
| Healthcare-associated infections requiring hospitalization | 5.61% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 2.33% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 20% |
8.2%
11.8 pts better
|
Numerator 30 · Denominator 150 |
| Staff flu vaccination coverage | 52.2% |
42%
10.2 pts better
|
Numerator 83 · Denominator 159 |
| Discharge function score | 70.37% |
56.45%
13.9 pts better
|
Numerator 38 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.63% |
25.2%
9.6 pts worse
|
Numerator 5 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
0.9
1.5 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| 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 96.8% · Q2 100.0% · Q3 100.0% · Q4 98.3% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
95.4%
1.6 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
1.9%
0.6 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 0.0% · Q3 1.7% · Q4 1.7% · 4Q avg 2.5% · 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 | 2.6% |
4.9%
2.3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.9% · Q3 1.8% · Q4 1.9% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
8.2%
1.2 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.6% · Q3 7.1% · Q4 7.5% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
11.3%
1.8 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 9.4% · Q3 8.5% · Q4 8.5% · 4Q avg 9.5% · 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 | 16.8% |
23.4%
6.6 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
16.8%
6.3 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 26.0% · Q3 22.7% · Q4 16.7% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.4%
0.7 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 3.4% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.6% |
17.8%
8.2 pts better
|
19.8%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.7% · Q3 9.4% · Q4 7.7% · 4Q avg 9.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
3.6%
1 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 7.9% · Q3 3.1% · Q4 3.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.0% |
82.8%
22.8 pts worse
|
81.7%
21.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.6% · Q2 67.4% · Q3 68.4% · Q4 52.9% · 4Q avg 60.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.6% |
10.9%
11.7 pts worse
|
12.0%
10.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 20.7% · Expected 10.2% · Used in QM five-star |
| 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 | 58.9% |
84.7%
25.8 pts worse
|
79.7%
20.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 6.1% |
19.6%
13.5 pts better
|
23.9%
17.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.2% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2023-02-10
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-02-10 · Fire 2022-02-17
18 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
B · Minimal harm
2024-02-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-15
D · Potential for more than minimal harm
2023-02-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-21
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 2025-04-07
D · Potential for more than minimal harm
2025-02-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-21
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 2025-04-07
D · Potential for more than minimal harm
2025-02-21
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-21
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-21
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 2025-04-07
D · Potential for more than minimal harm
2025-02-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-21
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-07
E · Potential for more than minimal harm
2024-02-23
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 2024-04-05
D · Potential for more than minimal harm
2024-02-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-23
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 2024-04-05
D · Potential for more than minimal harm
2024-02-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-23
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-07-07
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 2023-08-11
F · Potential for more than minimal harm
2023-02-10
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 2023-05-05
E · Potential for more than minimal harm
2023-02-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
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 2023-05-05
D · Potential for more than minimal harm
2023-02-10
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 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
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 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
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 2023-05-05
D · Potential for more than minimal harm
2023-02-10
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 2023-05-05
D · Potential for more than minimal harm
2023-02-10
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 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-05
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
Hata, Randall
Operational/Managerial Control · Individual
Ho, Bronson
Operational/Managerial Control · Individual
Kishaba, Richard
Operational/Managerial Control · Individual
Kop, Arnold
Operational/Managerial Control · 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
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#2
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3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
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2-star overall rating with 1-star inspections with Special Focus status with $34,300 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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