Cycle 1
Health 2024-10-18 · Fire 2024-10-18
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lanai City, HI
Lanai Community Hospital
5-star overall rating with 5-star inspections with 5 recent health deficiencies
628 7th Street, Lanai City, HI
(808) 565-8450
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
10
Certified beds
Average residents
10
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.3%
3.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
1.9%
0.7 pts worse
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 5.7% |
4.9%
0.8 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
8.2%
5.7 pts worse
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
11.3%
0.8 pts worse
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
16.8%
9.9 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.4%
2.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.7% |
17.8%
15.1 pts better
|
19.8%
17.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.6%
3.6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-27 · Fire 2023-10-27
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2023-10-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-01
D · Potential for more than minimal harm
2022-08-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-10-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-18
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 2024-11-19
D · Potential for more than minimal harm
2024-10-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-18
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 2024-11-19
D · Potential for more than minimal harm
2024-10-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-19
D · Potential for more than minimal harm
2023-10-27
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-10-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-10-27
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 2024-01-11
D · Potential for more than minimal harm
2023-10-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-10-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-10-27
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-01-11
F · Potential for more than minimal harm
2022-08-11
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 2022-09-01
E · Potential for more than minimal harm
2022-08-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-08-11
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 2022-08-11
D · Potential for more than minimal harm
2022-08-11
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
2022-08-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-11
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 2022-08-26
D · Potential for more than minimal harm
2022-08-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-25
Penalties and ownership
What sits behind the stars
Ownership
Kaiser Foundation Hospitals
5% Or Greater Indirect Ownership Interest · Organization
Ebersole, Wade
Operational/Managerial Control · Individual
Ebersole, Wade
Corporate Officer · Individual
Ebersole, Wade
W-2 Managing Employee · Individual
Goodfellow, Tamar
Corporate Director · Individual
Hew, Mary
Corporate Director · Individual
Kaiser Foundation Hospitals
Operational/Managerial Control · Organization
Lancaster, Kathryn
Corporate Director · Individual
Maui Health System A Kaiser Foundation Hospitals LLC
Operational/Managerial Control · Organization
Miller, Stephen
Corporate Director · Individual
Rembis, Michael
Operational/Managerial Control · Individual
Rembis, Michael
Corporate Officer · Individual
Rembis, Michael
W-2 Managing Employee · Individual
Smith, Bryan
Corporate Director · Individual
Sutherland, Richard
Corporate Director · Individual
Takitani, Anthony
Corporate Director · Individual
Yamamoto, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Hale Makua - Wailuku
Wailuku, HI
5-star overall rating with 4-star inspections with $22,887 in total fines with 5 recent health deficiencies
#2
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
#3
Kula Hospital
Kula, HI
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out