Cycle 1
Health 2025-05-15 · Fire 2025-05-15
38 health deficiencies
Top issue: Resident Rights (10 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Honolulu, HI
Hale Nani Rehabilitation And Nursing Center
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $27,885 in total fines with 38 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1677 Pensacola Street, Honolulu, HI
(808) 537-3371
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
288
Certified beds
Average residents
271
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Volare Health
Operator or chain grouping
Approved since
1974-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
1.33
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.17
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
3.11
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
4.28
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.03
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.29
CMS adjusted RN staffing hours
Adjusted total hours
4.50
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,273
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.53
Composite VBP score used to determine payment impact.
Payment multiplier
1.0047
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.29
Baseline 15.37% · Performance 20.37% · Measure score 2.29 · Achievement 2.29 · Improvement 0
Healthcare-associated infections
5.31
Baseline 5.68% · Performance 6.25% · Measure score 5.31 · Achievement 5.31 · Improvement 0
Total nurse turnover
8.78
Baseline 30.10% · Performance 27.80% · Measure score 8.78 · Achievement 8.78 · Improvement 3.89
Adjusted total nurse staffing
3.84
Baseline 4.06 hours · Performance 4.17 hours · Measure score 3.84 · Achievement 3.84 · Improvement 0.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 361 · Observed rate 8.31% · Lower 95% interval 7.54% |
| Discharge to community | 69.2% |
50.57%
18.6 pts better
|
Better than the National Rate · Eligible stays 376 · Observed rate 61.44% · Lower 95% interval 63.89% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 88.27% |
95.27%
7 pts worse
|
Numerator 143 · Denominator 162 |
| Falls with major injury | 0.62% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 162 |
| Discharge self-care score | 56.67% |
53.69%
3 pts better
|
Numerator 68 · Denominator 120 |
| Discharge mobility score | 47.5% |
50.94%
3.4 pts worse
|
Numerator 57 · Denominator 120 |
| Pressure ulcers or injuries, new or worsened | 1.85% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 162 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 6.25% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 174 · Observed rate 5.75% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 10.82% |
8.2%
2.6 pts better
|
Numerator 41 · Denominator 379 |
| Staff flu vaccination coverage | 41.42% |
42%
0.6 pts worse
|
Numerator 157 · Denominator 379 |
| Discharge function score | 53.33% |
56.45%
3.1 pts worse
|
Numerator 64 · Denominator 120 |
| Transfer of health information to provider | 98.61% |
95.95%
2.7 pts better
|
Numerator 71 · Denominator 72 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 61 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 14.86% |
25.2%
10.3 pts worse
|
Numerator 11 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
0.9
0.5 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · 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 97.1% · Q2 98.6% · Q3 100.0% · Q4 99.5% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
95.4%
2.8 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| 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 3.4% · Q2 3.3% · Q3 1.8% · Q4 1.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
1.4%
0.2 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.5% · Q4 3.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
4.9%
0.6 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.8% · Q3 7.0% · Q4 5.1% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.9% |
8.2%
5.3 pts better
|
19.6%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.2% · Q3 3.5% · Q4 2.6% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
11.3%
0.1 pts worse
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.2% · Q3 12.1% · Q4 13.2% · 4Q avg 11.4% · 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 | 23.1% |
23.4%
0.3 pts better
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 24.4% · Q3 29.1% · Q4 21.2% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
16.8%
3.7 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 14.4% · Q3 13.8% · Q4 7.0% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.3%
0.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.8% · Q3 0.3% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.4%
0.9 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.5% · Q3 1.8% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.4% |
17.8%
1.4 pts better
|
19.8%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 16.0% · Q3 19.4% · Q4 16.6% · 4Q avg 16.4% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
3.6%
2.6 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.5% · Q3 6.3% · Q4 4.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
82.8%
10 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 93.4% · Q3 95.3% · Q4 92.9% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
10.9%
1.1 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.0%
0.4 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.4% · Q3 0.0% · Q4 1.5% · 4Q avg 0.6% · 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 | 22.7% |
19.6%
3.1 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 22.8% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2024-07-19
29 health deficiencies
Top issue: Resident Rights (9 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-07-14 · Fire 2023-07-14
25 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-15
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 2025-07-08
E · Potential for more than minimal harm
2025-05-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-08
F · Potential for more than minimal harm
2024-07-19
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2024-08-19
E · Potential for more than minimal harm
2023-07-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-19
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 2026-01-02
F · Potential for more than minimal harm
2025-11-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-11-19
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 2026-01-02
F · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-05-15
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-05-15
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 2025-06-27
E · Potential for more than minimal harm
2025-05-15
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 2025-06-27
E · Potential for more than minimal harm
2025-05-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-05-15
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F756 · Pharmacy Service Deficiencies
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
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 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-27
G · Actual harm
2025-04-25
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 2025-06-05
F · Potential for more than minimal harm
2025-04-25
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-06-02
E · Potential for more than minimal harm
2025-04-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-04-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-04-25
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 2025-06-02
D · Potential for more than minimal harm
2025-04-25
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-04-25
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 2025-06-02
D · Potential for more than minimal harm
2024-10-22
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 2024-11-26
D · Potential for more than minimal harm
2024-10-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-07-19
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 2024-09-02
F · Potential for more than minimal harm
2024-07-19
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 2024-09-02
F · Potential for more than minimal harm
2024-07-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-07-19
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 2024-09-02
E · Potential for more than minimal harm
2024-07-19
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 2024-09-02
E · Potential for more than minimal harm
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F726 · Nursing and Physician Services Deficiencies
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
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 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-03-22
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 2024-05-05
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F726 · Nursing and Physician Services Deficiencies
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 2023-10-27
E · Potential for more than minimal harm
2023-07-14
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-14
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-14
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 2023-08-22
E · Potential for more than minimal harm
2023-07-14
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 2023-08-18
E · Potential for more than minimal harm
2023-07-14
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 2023-08-18
E · Potential for more than minimal harm
2023-07-14
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 2023-08-18
E · Potential for more than minimal harm
2023-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-14
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-18
D · Potential for more than minimal harm
2023-07-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-14
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 2023-08-25
D · Potential for more than minimal harm
2023-07-14
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-08-18
Penalties and ownership
What sits behind the stars
$27,885
2025-04-25
Fine
Fine · fine $27,885
Fine
Ownership
Pac 12 Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Blanchette, Patricia
Operational/Managerial Control · Individual
Hagar, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Hagler, Alexander
5% Or Greater Indirect Ownership Interest · Individual
Hale Nani Propco LLC
5% Or Greater Mortgage Interest · Organization
Knox Healthcare Pac 12 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Knox, Donald
5% Or Greater Indirect Ownership Interest · Individual
Knox, Donald
Operational/Managerial Control · Individual
Knox, Donald
Corporate Officer · Individual
Pac 12 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Pac 12 Pinnacle Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Schwartz, Eliezer
Operational/Managerial Control · Individual
Smith, Brian
Corporate Officer · Individual
Volare Health LLC
Operational/Managerial Control · Organization
Young, Rebecca
Operational/Managerial Control · Individual
Nearby options
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Arcadia Retirement Residence
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5-star overall rating with 3-star inspections with $12,854 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Islands Skilled Nursing & Rehabilitation
Honolulu, HI
2-star overall rating with 2-star inspections with Special Focus status with $89,206 in total fines with 14 recent health deficiencies
#3
Oahu Care Facility
Honolulu, HI
2-star overall rating with 2-star inspections with $8,278 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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