Cycle 1
Health 2024-10-25 · Fire 2024-10-25
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hilo, HI
Legacy Hilo Rehabilitation & Nursing Center
3-star overall rating with 3-star inspections with 8 recent health deficiencies
563 Kaumana Drive, Hilo, HI
(808) 498-0184
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ohana Pacific Management Co.
Operator or chain grouping
Approved since
2016-01-20
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
0.96
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,450
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2
Baseline 17.13% · Performance 20.51% · Measure score 2 · Achievement 2 · Improvement 0
Healthcare-associated infections
0
Baseline 5.17% · Performance 8.03% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.29
Baseline 30.56% · Performance 37.97% · Measure score 6.29 · Achievement 6.29 · Improvement 0
Adjusted total nurse staffing
1.16
Baseline 4.30 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 9.49% · Lower 95% interval 7.02% |
| Discharge to community | 68.08% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 145 · Observed rate 60% · Lower 95% interval 57.71% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 114 · Denominator 115 |
| Falls with major injury | 0.87% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 115 |
| Discharge self-care score | 39.47% |
53.69%
14.2 pts worse
|
Numerator 30 · Denominator 76 |
| Discharge mobility score | 53.95% |
50.94%
3 pts better
|
Numerator 41 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 1.74% |
2.29%
0.6 pts better
|
Numerator 2 · Denominator 115 · Adjusted rate 1.78% |
| Healthcare-associated infections requiring hospitalization | 8.03% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 9.68% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 33.63% |
8.2%
25.4 pts better
|
Numerator 38 · Denominator 113 |
| Staff flu vaccination coverage | 44.44% |
42%
2.4 pts better
|
Numerator 52 · Denominator 117 |
| Discharge function score | 39.47% |
56.45%
17 pts worse
|
Numerator 30 · Denominator 76 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 63 · Denominator 70 |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 37 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 32.79% |
25.2%
7.6 pts better
|
Numerator 20 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.3
0.9 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
0.9
1.1 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
96.3%
0.1 pts worse
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 100.0% · Q3 96.7% · Q4 98.4% · 4Q avg 96.2% |
| 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 | 2.9% |
1.9%
1 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.3% · Q3 3.3% · Q4 1.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
1.4%
1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.9%
1.4 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.2% · Q3 1.7% · Q4 3.3% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
8.2%
4.3 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.4% · Q3 5.2% · Q4 4.9% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
11.3%
5.1 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.1% · Q3 6.0% · Q4 6.1% · 4Q avg 6.2% · 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 · 4Q avg 35.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
16.8%
2.5 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 7.5% · Q3 13.2% · Q4 17.9% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.3%
0.2 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.5% · Q3 1.3% · Q4 0.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
2.4%
1.8 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.0% · Q3 1.7% · Q4 3.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
17.8%
2.4 pts worse
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 21.9% · Q3 26.3% · Q4 15.1% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
3.6%
0.2 pts worse
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.3% · Q3 2.9% · Q4 4.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
82.8%
11.7 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 92.7% · Q3 95.4% · Q4 94.0% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
10.9%
2.8 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.9% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.0%
0.6 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
84.7%
10.1 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
19.6%
5 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 25.7% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-30 · Fire 2023-10-30
16 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-16 · Fire 2022-09-16
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-25
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F690 · Quality of Life and Care Deficiencies
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-07-10
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 2024-08-09
D · Potential for more than minimal harm
2024-07-10
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 2024-08-09
E · Potential for more than minimal harm
2023-10-30
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 2023-12-08
E · Potential for more than minimal harm
2023-10-30
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 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-30
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 2023-12-08
D · Potential for more than minimal harm
2023-10-30
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 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-30
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 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-30
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 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F758 · Pharmacy Service Deficiencies
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 2023-12-08
D · Potential for more than minimal harm
2023-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
E · Potential for more than minimal harm
2022-09-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-16
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 2022-09-28
Penalties and ownership
What sits behind the stars
Ownership
Ohana Pacific Management Company Inc
5% Or Greater Direct Ownership Interest · Organization
Hata, Randall
Corporate Officer · Individual
Kishaba, Richard
Corporate Director · Individual
Kishaba, Richard
Corporate Officer · Individual
Morikuni, Suanne
Corporate Officer · Individual
Pearce, Jennifer
Contracted Managing Employee · Individual
Pitcher, Kerry
Contracted Managing Employee · Individual
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