Cycle 1
Health 2024-06-06 · Fire 2024-06-06
10 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Kula, HI
Kula Hospital
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
100 Keokea Place, Kula, HI
(808) 878-1221
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
91
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
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.06
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.10
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
3.25
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
5.41
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
4.52
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.34
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.18
CMS adjusted RN staffing hours
Adjusted total hours
5.75
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
682
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0196
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
5.59
Baseline 93.97% · Performance 51.91% · Measure score 5.59 · Achievement 2.88 · Improvement 5.59
Adjusted total nurse staffing
7.49
Baseline 4.05 hours · Performance 5.21 hours · Measure score 7.49 · Achievement 7.49 · Improvement 6.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 4 · 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 3 · 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 Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| 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 | 6.15% |
8.2%
2 pts worse
|
Numerator 11 · Denominator 179 |
| Staff flu vaccination coverage | 71.15% |
42%
29.2 pts better
|
Numerator 111 · Denominator 156 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
0.9
0.3 pts worse
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.8 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
96.3%
1 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 97.8% · Q3 97.8% · Q4 94.5% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
95.4%
3.5 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
1.9%
1.1 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.3% · Q3 2.2% · Q4 3.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.3% |
1.4%
4.9 pts worse
|
11.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.0% · Q3 7.1% · Q4 6.0% · 4Q avg 6.3% |
| 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 5.8% · Q2 4.8% · Q3 3.6% · Q4 1.3% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
8.2%
1 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.9% · Q3 7.0% · Q4 8.2% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
11.3%
14 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 23.0% · Q3 24.3% · Q4 26.0% · 4Q avg 25.3% · 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 | 13.9% |
23.4%
9.5 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 4.1% · Q3 15.4% · Q4 13.1% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
16.8%
2.9 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 8.0% · Q3 13.7% · Q4 17.1% · 4Q avg 13.9% · 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 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.1% |
17.8%
2.7 pts better
|
19.8%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 10.6% · Q3 12.3% · Q4 16.1% · 4Q avg 15.1% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
3.6%
1.1 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.5% · Q3 4.5% · Q4 5.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.0% |
82.8%
2.8 pts worse
|
81.7%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 80.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-05 · Fire 2023-06-05
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-06-30 · Fire 2022-06-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-06
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 2024-06-18
C · Minimal harm
2023-06-05
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-06-15
B · Minimal harm
2022-06-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-08
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 2025-02-28
G · Actual harm
2024-09-19
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 2024-09-19
F · Potential for more than minimal harm
2024-06-06
F727 · Nursing and Physician Services Deficiencies
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 2024-07-21
F · Potential for more than minimal harm
2024-06-06
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 2024-07-21
E · Potential for more than minimal harm
2024-06-06
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 2024-07-21
D · Potential for more than minimal harm
2024-06-06
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 2024-07-21
D · Potential for more than minimal harm
2024-06-06
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 2024-07-21
D · Potential for more than minimal harm
2024-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-06
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 2024-07-21
D · Potential for more than minimal harm
2024-06-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-21
F · Potential for more than minimal harm
2023-06-05
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 2023-07-31
F · Potential for more than minimal harm
2023-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-05
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 2023-07-31
E · Potential for more than minimal harm
2023-06-05
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 2023-07-31
D · Potential for more than minimal harm
2023-06-05
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 2023-07-31
D · Potential for more than minimal harm
2023-06-05
F578 · Resident Rights Deficiencies
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 2023-07-31
D · Potential for more than minimal harm
2023-06-05
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 2023-07-31
D · Potential for more than minimal harm
2023-06-05
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 2023-07-31
D · Potential for more than minimal harm
2023-06-05
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 2023-07-31
D · Potential for more than minimal harm
2023-06-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-05
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 2023-07-31
D · Potential for more than minimal harm
2023-06-05
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-07-31
E · Potential for more than minimal harm
2022-06-30
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-14
D · Potential for more than minimal harm
2022-06-30
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 2022-08-14
D · Potential for more than minimal harm
2022-06-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-14
D · Potential for more than minimal harm
2022-06-30
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 2022-08-14
D · Potential for more than minimal harm
2022-06-30
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 2022-08-14
D · Potential for more than minimal harm
2022-06-30
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 2022-08-14
D · Potential for more than minimal harm
2022-06-30
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-08-14
D · Potential for more than minimal harm
2022-06-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-14
Penalties and ownership
What sits behind the stars
Ownership
Kaiser Foundation Hospitals
5% Or Greater Direct Ownership Interest · Organization
Cartwright, Debra
Operational/Managerial Control · Individual
Cartwright, Debra
Corporate Officer · Individual
Choucair, Bechara
Corporate Officer · Individual
Decosta-Galdeira, Shelby
Corporate Officer · Individual
Ebersole, Wade
Operational/Managerial Control · Individual
Ebersole, Wade
Corporate Officer · Individual
Fulton, Lynn
Operational/Managerial Control · Individual
Fulton, Lynn
Corporate Officer · Individual
Goodfellow, Tamar
Corporate Director · Individual
Hanenburg, Thomas
Corporate Officer · Individual
Hew, Mary
Corporate Director · Individual
Kaiser Foundation Hospitals
Operational/Managerial Control · Organization
Koval, Penny
Operational/Managerial Control · Individual
Koval, Penny
Corporate Officer · Individual
Scott, Kenneth
Operational/Managerial Control · Individual
Shitamoto, Barry
Corporate Officer · Individual
Sutherland, Richard
Corporate Director · Individual
Takitani, Anthony
Corporate Director · Individual
Yamamoto, John
Corporate Director · Individual
Nearby options
Other facilities in reach
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Hale Makua - Kahului
Kahului, HI
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
#2
Hale Makua - Wailuku
Wailuku, HI
5-star overall rating with 4-star inspections with $22,887 in total fines with 5 recent health deficiencies
#3
Lanai Community Hospital
Lanai City, HI
5-star overall rating with 5-star inspections with 5 recent health deficiencies
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