Kahului, HI

Hale Makua - Kahului

0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $170,249 in total fines with 16 recent health deficiencies

472 Kaulana Street, Kahului, HI

(808) 877-2761

Compare this facility

Overall

0 / 5

CMS overall stars

Health inspections

0 / 5

Survey and complaint cycles

Staffing

0 / 5

RN + nurse staffing

Quality measures

0 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

252

Certified beds

Average residents

198

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

1.30

Registered nurse staffing · state 1.63 · national 0.68

LPN hours / resident day

0.83

Licensed practical nurse staffing · state 0.36 · national 0.87

Aide hours / resident day

2.83

Nurse aide staffing · state 2.73 · national 2.35

Total nurse hours

4.95

All reported nurse hours · state 4.71 · national 3.89

Licensed hours

2.12

RN + LPN hours · state 1.97 · national 1.54

Weekend hours

4.38

Weekend nurse staffing · state 4.19 · national 3.43

Weekend RN hours

0.90

Weekend registered nurse coverage · state 1.23 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.23

CMS adjusted RN staffing hours

Adjusted total hours

4.69

CMS adjusted total nurse staffing hours

Case-mix index

1.44

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 33% · national 45%

Total nurse turnover

31%

Annual nurse turnover · state 37% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,031

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.66

Composite VBP score used to determine payment impact.

Payment multiplier

0.9909

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.91

Baseline 15.76% · Performance 20.55% · Measure score 1.91 · Achievement 1.91 · Improvement 0

Healthcare-associated infections

2.33

Baseline 5.05% · Performance 7.14% · Measure score 2.33 · Achievement 2.33 · Improvement 0

Total nurse turnover

6.58

Baseline 33.97% · Performance 36.78% · Measure score 6.58 · Achievement 6.58 · Improvement 0

Adjusted total nurse staffing

4.24

Baseline 4.13 hours · Performance 4.28 hours · Measure score 4.24 · Achievement 4.24 · Improvement 0.43

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.54%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 209 · Observed rate 8.61% · Lower 95% interval 7.62%
Discharge to community	70.17%	50.57% 19.6 pts better	Better than the National Rate · Eligible stays 197 · Observed rate 65.99% · Lower 95% interval 64.36%
Medicare spending per beneficiary	0.86	1.02 0.2 pts better
Drug regimen review with follow-up	98.53%	95.27% 3.3 pts better	Numerator 134 · Denominator 136
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 136
Discharge self-care score	56%	53.69% 2.3 pts better	Numerator 56 · Denominator 100
Discharge mobility score	47%	50.94% 3.9 pts worse	Numerator 47 · Denominator 100
Pressure ulcers or injuries, new or worsened	1.47%	2.29% 0.8 pts better	Numerator 2 · Denominator 136 · Adjusted rate 1.28%
Healthcare-associated infections requiring hospitalization	7.14%	7.12% About the same	No Different than the National Rate · Eligible stays 88 · Observed rate 6.82% · Lower 95% interval 3.89%
Staff COVID-19 vaccination coverage	21.08%	8.2% 12.9 pts better	Numerator 74 · Denominator 351
Staff flu vaccination coverage	28.33%	42% 13.7 pts worse	Numerator 115 · Denominator 406
Discharge function score	59%	56.45% 2.5 pts better	Numerator 59 · Denominator 100
Transfer of health information to provider	89.89%	95.95% 6.1 pts worse	Numerator 80 · Denominator 89
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	17.39%	25.2% 7.8 pts worse	Numerator 12 · Denominator 69

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.3 0.1 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	0.9 1.1 pts worse	1.8 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.5 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.7%	96.3% 1.4 pts better	93.4% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 97.6% · Q3 99.4% · Q4 100.0% · 4Q avg 97.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.7%	95.4% 0.3 pts better	95.5% 0.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7%
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 1.8% · Q2 1.8% · Q3 2.4% · Q4 1.1% · 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	6.1%	4.9% 1.2 pts worse	5.4% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.8% · Q3 3.8% · Q4 4.3% · 4Q avg 6.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.9%	8.2% 1.7 pts worse	19.6% 9.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.4% · Q3 11.5% · Q4 11.0% · 4Q avg 9.9%
Percentage of long-stay residents who received an antipsychotic medication	12.5%	11.3% 1.2 pts worse	16.7% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 13.3% · Q3 11.7% · Q4 12.2% · 4Q avg 12.5% · 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	34.8%	23.4% 11.4 pts worse	16.3% 18.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 44.1% · Q2 49.8% · Q3 24.9% · Q4 23.7% · 4Q avg 34.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.1%	16.8% 5.3 pts worse	14.9% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 26.7% · Q3 15.8% · Q4 23.6% · 4Q avg 22.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	1.3% 0.7 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 0.4% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.4%	2.4% 1 pts worse	1.7% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.4% · Q3 1.8% · Q4 6.3% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.5%	17.8% 1.7 pts worse	19.8% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 20.7% · Q3 20.9% · Q4 16.0% · 4Q avg 19.5%
Percentage of long-stay residents with pressure ulcers	2.4%	3.6% 1.2 pts better	5.1% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.0% · Q3 3.0% · Q4 0.7% · 4Q avg 2.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.7%	82.8% 8.9 pts better	81.7% 10 pts better	Short Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 91.7% · Q3 93.6% · Q4 91.0% · 4Q avg 91.7%
Percentage of short-stay residents who had an outpatient emergency department visit	18.6%	10.9% 7.7 pts worse	12.0% 6.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 17.0% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.0% 0.1 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.5% · Q3 1.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	91.5%	84.7% 6.8 pts better	79.7% 11.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.0%	19.6% 0.4 pts worse	23.9% 3.9 pts better	Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 18.0% · Expected 21.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-18 · Fire 2024-10-18

16 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-10-19 · Fire 2023-10-19

34 health deficiencies

Top issue: Quality of Life and Care (13 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2022-07-22 · Fire 2022-07-22

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2023-10-19

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-11-24

E · Potential for more than minimal harm 2023-10-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-11-24

F · Potential for more than minimal harm 2022-07-22

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-09-09

F · Potential for more than minimal harm 2022-07-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-09-09

F · Potential for more than minimal harm 2022-07-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-09-09

F · Potential for more than minimal harm 2022-07-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-09-09

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-09

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.

Not marked corrected

D · Potential for more than minimal harm 2025-04-11

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 2025-05-16

E · Potential for more than minimal harm 2025-01-14

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 2025-02-14

D · Potential for more than minimal harm 2025-01-14

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 2025-02-14

D · Potential for more than minimal harm 2025-01-14

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 2025-02-14

D · Potential for more than minimal harm 2025-01-14

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 2025-02-14

G · Actual harm 2024-10-18

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 2024-08-21

G · Actual harm 2024-10-18

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-11-18

E · Potential for more than minimal harm 2024-10-18

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 2024-11-20

D · Potential for more than minimal harm 2024-10-18

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-11-18

D · Potential for more than minimal harm 2024-10-18

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-11-20

D · Potential for more than minimal harm 2024-10-18

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 2024-11-20

D · Potential for more than minimal harm 2024-10-18

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 2024-11-18

D · Potential for more than minimal harm 2024-10-18

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-11-18

D · Potential for more than minimal harm 2024-10-18

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-11-18

D · Potential for more than minimal harm 2024-10-18

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 2024-11-18

D · Potential for more than minimal harm 2024-10-18

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 2024-11-18

D · Potential for more than minimal harm 2024-10-18

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 2024-11-18

D · Potential for more than minimal harm 2024-10-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-18

D · Potential for more than minimal harm 2024-10-18

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 2024-11-18

G · Actual harm 2024-08-12

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 2024-09-16

D · Potential for more than minimal harm 2024-08-12

F563 · Resident Rights Deficiencies

Health

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-08-12

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 2024-09-16

D · Potential for more than minimal harm 2024-08-12

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-16

E · Potential for more than minimal harm 2024-04-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-25

L · Immediate jeopardy 2023-10-19

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 2023-12-08

G · Actual harm 2023-10-19

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 2023-12-08

G · Actual harm 2023-10-19

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-10-19

F574 · Resident Rights Deficiencies

Health

The resident has the right to receive notices in a format and a language he or she understands.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-10-19

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-10-19

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 2023-12-08

E · Potential for more than minimal harm 2023-10-19

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 2023-12-08

E · Potential for more than minimal harm 2023-10-19

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 2023-12-08

E · Potential for more than minimal harm 2023-10-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-12-08

E · Potential for more than minimal harm 2023-10-19