Cycle 1
Health 2025-02-07 · Fire 2025-02-07
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Hilo, HI
Hilo Benioff Medical Center
4-star overall rating with 3-star inspections with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1190 Waianuenue Avenue, Hilo, HI
(808) 932-3000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
53
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Hawaii Health Systems Corporation
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
1.48
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
3.64
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
6.01
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.38
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
5.09
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.06
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.45
CMS adjusted RN staffing hours
Adjusted total hours
5.89
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
998
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.21
Composite VBP score used to determine payment impact.
Payment multiplier
1.0163
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
5.79
Baseline 25.00% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
6.45
Baseline 4.35 hours · Performance 4.91 hours · Measure score 6.45 · Achievement 6.45 · Improvement 3.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · 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 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.84% |
8.2%
3.4 pts worse
|
Numerator 3 · Denominator 62 |
| Staff flu vaccination coverage | 66.18% |
42%
24.2 pts better
|
Numerator 45 · Denominator 68 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| 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 2 · 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 | 1.9 |
1.3
0.6 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
0.9
0.4 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
96.3%
2.7 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
1.9%
0.1 pts worse
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 2.0% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.5% |
1.4%
8.1 pts worse
|
11.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.8% · Q3 4.7% · Q4 9.5% · 4Q avg 9.5% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
4.9%
1 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.3% · Q3 2.2% · Q4 2.3% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
8.2%
6.6 pts worse
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.9% · Q3 15.2% · Q4 19.6% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.0% |
11.3%
22.7 pts worse
|
16.7%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 35.0% · Q3 35.1% · Q4 29.7% · 4Q avg 34.0% · 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 | 38.5% |
23.4%
15.1 pts worse
|
16.3%
22.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
16.8%
4.3 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 20.0% · Q3 33.3% · Q4 5.4% · 4Q avg 21.1% · 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 | 0.5% |
2.4%
1.9 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.5% |
17.8%
6.3 pts better
|
19.8%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 14.1% · Q3 12.8% · Q4 7.6% · 4Q avg 11.5% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
3.6%
1.6 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.5% · Q3 5.2% · Q4 6.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.7% |
82.8%
17.1 pts worse
|
81.7%
16 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 65.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
1 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-24 · Fire 2022-10-24
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-07
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 2025-07-30
E · Potential for more than minimal harm
2025-02-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-30
E · Potential for more than minimal harm
2024-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-01-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-01-11
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 2024-03-26
D · Potential for more than minimal harm
2024-01-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-01-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-26
F · Potential for more than minimal harm
2022-10-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-10-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-10-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-12-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-02-07
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-03-24
E · Potential for more than minimal harm
2025-02-07
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 2025-03-24
E · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2025-02-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-07
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-07
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 2025-03-24
D · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-26
G · Actual harm
2022-10-24
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 2022-12-16
E · Potential for more than minimal harm
2022-10-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-10-24
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-10-24
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 2022-12-16
D · Potential for more than minimal harm
2022-10-24
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 2022-12-16
D · Potential for more than minimal harm
2022-10-24
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 2022-12-16
D · Potential for more than minimal harm
2022-10-24
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 2022-12-16
Penalties and ownership
What sits behind the stars
Ownership
Belcher, Daniel
Corporate Director · Individual
Brinkman, Daniel
Corporate Director · Individual
Farias, Chad
Corporate Director · Individual
Gomez, Lara
Corporate Director · Individual
Gray, Jerry
Corporate Director · Individual
Hawaii Health Systems Corporation
Operational/Managerial Control · Organization
Ho, Brenda
Corporate Officer · Individual
Ignacio, Jay
Corporate Director · Individual
Kurohara, Randall
Corporate Director · Individual
Nunokawa, Clarysse
Corporate Director · Individual
Sako, Deanna
Corporate Director · Individual
Skruch, Joseph
Corporate Director · Individual
Smith, Stephen
Corporate Director · Individual
Waltjen, Joni
W-2 Managing Employee · Individual
Wong, Yvonne
Corporate Director · Individual
Yamanaka, Rae
Corporate Director · Individual
Zelko-Schlueter, Jennifer
Corporate Director · Individual
Nearby options
Other facilities in reach
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3-star overall rating with 2-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
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Hilo, HI
3-star overall rating with 3-star inspections with $13,049 in total fines with 10 recent health deficiencies
#3
Legacy Hilo Rehabilitation & Nursing Center
Hilo, HI
3-star overall rating with 3-star inspections with 8 recent health deficiencies
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