Cycle 1
Health 2024-06-06 · Fire 2024-06-06
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ewa Beach, HI
Kulana Malama
5-star overall rating with 4-star inspections with $14,069 in total fines with 12 recent health deficiencies
91-1360 Karayan Street, Ewa Beach, HI
(808) 681-1200
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
33
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
5.71
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
5.08
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
11.10
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
6.02
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
10.45
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
5.04
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.14
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
3.65
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,346
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9899
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
5.22
Baseline 84.71% · Performance 50.47% · Measure score 5.22 · Achievement 3.23 · Improvement 5.22
Adjusted total nurse staffing
2.08
Baseline 3.92 hours · Performance 3.67 hours · Measure score 2.08 · Achievement 2.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| 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 Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 6.47% |
8.2%
1.7 pts worse
|
Numerator 9 · Denominator 139 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| 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 |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
96.3%
0.5 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.7% · Q3 96.9% · Q4 97.0% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
95.4%
1.4 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.9%
1.9 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.0% |
1.4%
1.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.9%
0.1 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 13.3% · Q3 3.1% · Q4 0.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 57.6% |
8.2%
49.4 pts worse
|
19.6%
38 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.0% · Q2 60.0% · Q3 53.1% · Q4 57.6% · 4Q avg 57.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
11.3%
11.3 pts better
|
16.7%
16.7 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 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 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 | 1.6% |
2.4%
0.8 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.3% |
17.8%
14.5 pts better
|
19.8%
16.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
3.6%
3 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 20.0% |
82.8%
62.8 pts worse
|
81.7%
61.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 20.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-23 · Fire 2023-06-23
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-15 · Fire 2022-07-15
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-26
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 2025-11-07
J · Immediate jeopardy
2025-06-18
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 2025-06-20
D · Potential for more than minimal harm
2025-06-18
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 2025-06-20
D · Potential for more than minimal harm
2025-06-18
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 2025-03-30
D · Potential for more than minimal harm
2025-06-18
F713 · Nursing and Physician Services Deficiencies
Health
Provide or arrange emergency care by a doctor 24 hours a day.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-20
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 2024-07-28
D · Potential for more than minimal harm
2024-06-06
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 2024-07-28
D · Potential for more than minimal harm
2024-06-06
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 2024-07-28
D · 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 2024-07-28
D · Potential for more than minimal harm
2024-06-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-07
D · Potential for more than minimal harm
2024-06-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-07-28
D · Potential for more than minimal harm
2024-06-06
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 2024-07-28
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 2024-07-28
F · Potential for more than minimal harm
2023-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-23
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 2023-07-14
D · Potential for more than minimal harm
2023-06-23
F693 · Quality of Life and Care Deficiencies
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 2023-07-14
D · Potential for more than minimal harm
2023-06-23
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 2023-07-14
D · Potential for more than minimal harm
2023-06-23
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-07-14
E · Potential for more than minimal harm
2022-07-15
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 2022-08-26
E · Potential for more than minimal harm
2022-07-15
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 2022-08-26
E · Potential for more than minimal harm
2022-07-15
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 2022-08-26
D · Potential for more than minimal harm
2022-07-15
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 2022-08-26
D · Potential for more than minimal harm
2022-07-15
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 2022-08-26
Penalties and ownership
What sits behind the stars
$14,069
2025-06-18
Fine
Fine · fine $14,069
Fine
Ownership
Pacific Skilled Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Olsen, Spencer
5% Or Greater Indirect Ownership Interest · Individual
Mayer, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Sorensen, Kristen
5% Or Greater Indirect Ownership Interest · Individual
Ito, Randall
Operational/Managerial Control · Individual
Ito, Randall
Corporate Officer · Individual
Ito, Randall
W-2 Managing Employee · Individual
Lefler, Tyrus
Corporate Officer · Individual
Olsen, Spencer
Corporate Officer · Individual
Pang, Brian
Corporate Officer · Individual
Yoshida, Cynthia
Corporate Officer · Individual
Nearby options
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Ka Punawai Ola
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4-star overall rating with 4-star inspections with 8 recent health deficiencies
#3
Avalon Care Center - Honolulu, LLC
Honolulu, HI
3-star overall rating with 2-star inspections with $12,838 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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