7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Honolulu, HI
1-star overall rating with 1-star inspections with Special Focus status with $83,236 in total fines with 7 recent health deficiencies
347 North Kuakini Street, Honolulu, HI
(808) 547-9357
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
187
Certified beds
Average residents
126
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-07-01
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
RN hours / resident day
1.33
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.11
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
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Program rank
2,427
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.83
Composite VBP score used to determine payment impact.
Payment multiplier
1.0039
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.75
Baseline 16.27% · Performance 19.70% · Measure score 3.75 · Achievement 3.75 · Improvement 0
Healthcare-associated infections
5.89
Baseline 5.75% · Performance 6.08% · Measure score 5.89 · Achievement 5.89 · Improvement 0
Total nurse turnover
8.88
Baseline 23.08% · Performance 27.38% · Measure score 8.88 · Achievement 8.88 · Improvement 0
Adjusted total nurse staffing
1.42
Baseline 3.70 hours · Performance 3.48 hours · Measure score 1.42 · Achievement 1.42 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 7.55% · Lower 95% interval 6.74% |
| Discharge to community | 71.45% |
50.57%
20.9 pts better
|
Better than the National Rate · Eligible stays 155 · Observed rate 66.45% · Lower 95% interval 63.73% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 75.86% |
95.27%
19.4 pts worse
|
Numerator 88 · Denominator 116 |
| Falls with major injury | 1.72% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 116 |
| Discharge self-care score | 60.92% |
53.69%
7.2 pts better
|
Numerator 53 · Denominator 87 |
| Discharge mobility score | 58.62% |
50.94%
7.7 pts better
|
Numerator 51 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 1.72% |
2.29%
0.6 pts better
|
Numerator 2 · Denominator 116 · Adjusted rate 1.8% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 4% · Lower 95% interval 3.52% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 145 · Denominator 145 |
| Staff flu vaccination coverage | 65.41% |
42%
23.4 pts better
|
Numerator 87 · Denominator 133 |
| Discharge function score | 60.92% |
56.45%
4.5 pts better
|
Numerator 53 · Denominator 87 |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 21 · Denominator 23 |
| Transfer of health information to patient | 85.37% |
96.28%
10.9 pts worse
|
Numerator 70 · Denominator 82 |
| Resident COVID-19 vaccinations up to date | 5% |
25.2%
20.2 pts worse
|
Numerator 3 · Denominator 60 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.3
0.8 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
0.9
0.1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
96.3%
5.7 pts worse
|
93.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.1% · Q2 95.1% · Q3 91.2% · Q4 91.1% · 4Q avg 90.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.3% |
95.4%
16.1 pts worse
|
95.5%
16.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
1.9%
0.8 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
1.4%
About the same
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 1.3% · Q4 1.3% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
4.9%
2.6 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.6% · Q3 10.4% · Q4 10.3% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
8.2%
1.2 pts worse
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.5% · Q3 9.1% · Q4 15.4% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
11.3%
0.2 pts worse
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 12.9% · Q3 12.5% · Q4 13.0% · 4Q avg 11.5% · 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 | 35.0% |
23.4%
11.6 pts worse
|
16.3%
18.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 31.2% · 4Q avg 35.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.7% |
16.8%
7.9 pts worse
|
14.9%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 17.9% · Q3 32.1% · Q4 25.0% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
1.3%
1.6 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.9% · Q3 3.7% · Q4 2.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
2.4%
2.8 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.5% · Q3 11.0% · Q4 1.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
17.8%
0.4 pts worse
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 23.4% · Q3 17.6% · Q4 21.3% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
3.6%
0.5 pts worse
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.8% · Q3 5.3% · Q4 3.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.3% |
82.8%
10.5 pts worse
|
81.7%
9.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.1% · Q2 64.8% · Q3 76.7% · Q4 83.9% · 4Q avg 72.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
10.9%
1.1 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 8.4% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.0%
0.5 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 1.6% · Q4 2.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 49.5% |
84.7%
35.2 pts worse
|
79.7%
30.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 49.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
19.6%
3.8 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 18.9% · Expected 19.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (9 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-16
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-07
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-02-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-06
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-06
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-04
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-04
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-04
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 2024-10-04
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 2024-10-04
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-04
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 2024-02-29
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 2024-04-08
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 2024-02-29
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-16
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 2024-02-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-16
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-02-16
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 2024-02-16
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 2024-02-16
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 2024-02-16
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 2024-02-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-16
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 2023-02-28
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-02-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-28
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 2023-04-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-28
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-02-28
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 2023-02-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-19
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 2023-02-28
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-19
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-28
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-28
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 2023-02-28
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-02-28
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-02-28
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-28
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-28
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 2023-04-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-28
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 2023-02-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-28
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-02-28
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-28
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 2023-02-28
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 2023-02-28
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-28
Penalties and ownership
Fine · fine $52,781
Fine
Fine · fine $30,455
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
Honolulu, HI
2-star overall rating with 2-star inspections with $11,170 in total fines with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Honolulu, HI
5-star overall rating with 4-star inspections with $8,278 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Honolulu, HI
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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