Cycle 1
Health 2024-09-06 · Fire 2024-09-06
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Koloa, HI
Hale Kupuna Heritage Home, LLC
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4297a Omao Road, Koloa, HI
(808) 742-7591
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ohana Pacific Management Co.
Operator or chain grouping
Approved since
2011-06-07
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
1.35
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.49
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,827
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
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
2.23
Baseline 49.21% · Performance 54.55% · Measure score 2.23 · Achievement 2.23 · Improvement 0
Adjusted total nurse staffing
2.88
Baseline 4.24 hours · Performance 3.90 hours · Measure score 2.88 · Achievement 2.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 6.79% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · 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 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 17.07% |
8.2%
8.9 pts better
|
Numerator 14 · Denominator 82 |
| Staff flu vaccination coverage | 29.27% |
42%
12.7 pts worse
|
Numerator 24 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
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 0.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
0.9
0.6 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
96.3%
1.5 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 95.3% · Q3 97.8% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
95.4%
0.4 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
1.9%
0.9 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.7% · Q3 2.2% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
1.4%
0.5 pts worse
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.1% · Q4 2.3% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
4.9%
1.1 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 2.6% · Q3 2.6% · Q4 2.6% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.1% |
8.2%
5.1 pts better
|
19.6%
16.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 2.6% · Q4 5.1% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
11.3%
2.7 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 6.1% · Q3 8.1% · Q4 11.1% · 4Q avg 8.6% · 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 | 35.4% |
23.4%
12 pts worse
|
16.3%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.7% · Q2 32.9% · Q3 26.5% · Q4 36.0% · 4Q avg 35.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.1% |
16.8%
11.3 pts worse
|
14.9%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 18.4% · Q3 34.2% · Q4 35.1% · 4Q avg 28.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.3%
0.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.4%
0.2 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 2.2% · Q4 2.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
17.8%
4.9 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 24.4% · Q3 23.7% · Q4 12.5% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
3.6%
0.5 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.1% · Q3 3.1% · Q4 3.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.2% |
82.8%
3.4 pts better
|
81.7%
4.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 90.9% · 4Q avg 86.2% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-02 · Fire 2022-09-02
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-06
K223 · Egress Deficiencies
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 2024-10-15
D · Potential for more than minimal harm
2022-09-02
K223 · Egress Deficiencies
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 2022-10-28
D · Potential for more than minimal harm
2022-09-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-06
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 2024-10-21
F · Potential for more than minimal harm
2024-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-06
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 2024-07-17
D · Potential for more than minimal harm
2024-09-06
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 2024-10-21
D · Potential for more than minimal harm
2024-09-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-06
F625 · Resident Rights Deficiencies
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 2024-10-21
F · Potential for more than minimal harm
2023-09-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-09-22
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 2023-11-01
D · Potential for more than minimal harm
2023-09-22
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 2023-11-01
D · Potential for more than minimal harm
2023-09-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-22
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 2023-11-01
D · Potential for more than minimal harm
2023-09-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-22
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 2023-11-01
D · Potential for more than minimal harm
2023-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-22
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-01
F · Potential for more than minimal harm
2022-09-02
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-02
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 2022-10-17
D · Potential for more than minimal harm
2022-09-02
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 2022-10-17
D · Potential for more than minimal harm
2022-09-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-02
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 2022-10-17
D · Potential for more than minimal harm
2022-09-02
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 2022-10-17
D · Potential for more than minimal harm
2022-09-02
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 2022-10-17
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
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
Morikuni, Suanne
Corporate Officer · Individual
Ohana Pacific Management Company Inc
Operational/Managerial Control · Organization
Smith, Joel
Operational/Managerial Control · Individual
Nearby options
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5-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
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3-star overall rating with 3-star inspections with 10 recent health deficiencies
#3
Kauai Veterans Memorial Hospital
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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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