Cycle 1
Health 2024-11-15 · Fire 2024-11-15
5 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wailuku, HI
Hale Makua - Wailuku
5-star overall rating with 4-star inspections with $22,887 in total fines with 5 recent health deficiencies
1540 Lower Main Street, Wailuku, HI
(808) 243-1722
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
90
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-11-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.37
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
0.98
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.33
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,793
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0087
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.44
Performance 19.38% · Measure score 4.44 · Achievement 4.44 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.40
Performance 6.52% · Measure score 4.40 · Achievement 4.40 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
10
Baseline 33.33% · Performance 20.59% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.75
Baseline 3.71 hours · Performance 3.86 hours · Measure score 2.75 · Achievement 2.75 · Improvement 0.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.07% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 3.88% · Lower 95% interval 5.81% |
| Discharge to community | 68.08% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 100 · Observed rate 67% · Lower 95% interval 61.26% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 93.9% |
95.27%
1.4 pts worse
|
Numerator 77 · Denominator 82 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 82 |
| Discharge self-care score | 43.84% |
53.69%
9.8 pts worse
|
Numerator 32 · Denominator 73 |
| Discharge mobility score | 43.84% |
50.94%
7.1 pts worse
|
Numerator 32 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 82 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 4.35% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 22.5% |
8.2%
14.3 pts better
|
Numerator 27 · Denominator 120 |
| Staff flu vaccination coverage | 20.28% |
42%
21.7 pts worse
|
Numerator 29 · Denominator 143 |
| Discharge function score | 58.9% |
56.45%
2.4 pts better
|
Numerator 43 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 68 · Denominator 68 |
| 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 | 11.43% |
25.2%
13.8 pts worse
|
Numerator 4 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
96.3%
1 pts worse
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 91.1% · Q3 96.7% · Q4 100.0% · 4Q avg 95.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
95.4%
1.9 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
1.9%
2.4 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.6% · Q3 3.3% · Q4 5.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
1.4%
0.9 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
4.9%
1 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 1.9% · Q3 1.7% · Q4 5.3% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
8.2%
0.1 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.4% · Q3 8.6% · Q4 10.5% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
11.3%
2.8 pts worse
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 15.7% · Q3 15.4% · Q4 13.5% · 4Q avg 14.1% · 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 | 23.5% |
23.4%
0.1 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
16.8%
2.9 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 19.1% · Q3 14.9% · Q4 21.7% · 4Q avg 19.7% · 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 2.1% · Q3 1.7% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.4%
0.2 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
17.8%
1.4 pts worse
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 20.7% · Q3 13.9% · Q4 22.4% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
3.6%
2.6 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.1% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
82.8%
7.2 pts better
|
81.7%
8.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.9% · Q2 91.2% · Q3 92.5% · Q4 92.4% · 4Q avg 90.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
10.9%
2.3 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 8.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.0%
0.5 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.4% |
84.7%
1.7 pts better
|
79.7%
6.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
19.6%
1.1 pts worse
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 18.7% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
9 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 3
Health 2023-11-08 · Fire 2023-11-08
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-15
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 2024-12-20
F · Potential for more than minimal harm
2024-11-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
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 2024-12-20
D · Potential for more than minimal harm
2024-11-15
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 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-05-03
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 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
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 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
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 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-06-12
D · Potential for more than minimal harm
2023-11-08
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 2023-12-20
D · Potential for more than minimal harm
2023-11-08
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 2023-12-20
D · Potential for more than minimal harm
2023-11-08
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 2023-12-20
D · Potential for more than minimal harm
2023-11-08
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 2023-12-20
D · Potential for more than minimal harm
2023-11-08
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 2023-12-20
D · Potential for more than minimal harm
2023-11-08
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 2023-12-20
D · Potential for more than minimal harm
2023-11-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-08
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-12-20
Penalties and ownership
What sits behind the stars
$10,348
2023-05-12
Fine
Fine · fine $10,348
Fine
$12,539
2023-05-12
Fine
Fine · fine $12,539
Fine
Ownership
Chun, Grant
Corporate Director · Individual
Dorheim, Tracy
Corporate Director · Individual
Kishaba, Richard
Corporate Director · Individual
Lo, Wesley
Operational/Managerial Control · Individual
Lo, Wesley
Corporate Director · Individual
Lo, Wesley
Corporate Officer · Individual
Lore, Andrew
Operational/Managerial Control · Individual
Mattfeld, Paul
Operational/Managerial Control · Individual
Mcbarnet, Alexander
Corporate Director · Individual
Mcclennon, Pamela
Operational/Managerial Control · Individual
Morikuni, Suanne
Operational/Managerial Control · Individual
Munekiyo, Michael
Corporate Director · Individual
Nishita, Josiah
Corporate Director · Individual
Ohana Pacific Management Company Inc
Operational/Managerial Control · Organization
Romson, Edward
Corporate Director · Individual
Sakamoto, Roy
Corporate Director · Individual
Wachi, Eileen
Corporate Director · Individual
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