Cycle 1
Health 2025-05-23 · Fire 2025-05-23
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pearl City, HI
Pearl City Post Acute
4-star overall rating with 4-star inspections with 8 recent health deficiencies
919 Lehua Avenue, Pearl City, HI
(808) 453-1919
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-11-17
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
Hours and turnover
RN hours / resident day
1.92
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
3.23
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
5.80
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.57
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
5.14
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.45
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.28
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
2.05
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,119
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9992
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.35
Performance 19.88% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.35
Performance 6.54% · Measure score 4.35 · Achievement 4.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.95
Baseline 88.23% · Performance 41.03% · Measure score 6.95 · Achievement 5.54 · Improvement 6.95
Adjusted total nurse staffing
3.72
Baseline 4.31 hours · Performance 4.14 hours · Measure score 3.72 · Achievement 3.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.8% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 225 · Observed rate 8.89% · Lower 95% interval 8.06% |
| Discharge to community | 71.51% |
50.57%
20.9 pts better
|
Better than the National Rate · Eligible stays 247 · Observed rate 65.59% · Lower 95% interval 65.29% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 44.72% |
95.27%
50.5 pts worse
|
Numerator 110 · Denominator 246 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 246 |
| Discharge self-care score | 60.11% |
53.69%
6.4 pts better
|
Numerator 107 · Denominator 178 |
| Discharge mobility score | 62.36% |
50.94%
11.4 pts better
|
Numerator 111 · Denominator 178 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 246 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 202 · Observed rate 5.94% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 29.82% |
8.2%
21.6 pts better
|
Numerator 34 · Denominator 114 |
| Staff flu vaccination coverage | 77.12% |
42%
35.1 pts better
|
Numerator 91 · Denominator 118 |
| Discharge function score | 60.67% |
56.45%
4.2 pts better
|
Numerator 108 · Denominator 178 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | 99.44% |
96.28%
3.2 pts better
|
Numerator 178 · Denominator 179 |
| Resident COVID-19 vaccinations up to date | 30.48% |
25.2%
5.3 pts better
|
Numerator 32 · Denominator 105 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
96.3%
1.1 pts worse
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.5% · Q3 94.3% · Q4 91.2% · 4Q avg 95.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
95.4%
1 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| 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 | 4.3% |
1.4%
2.9 pts worse
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.8% · Q3 3.6% · Q4 4.2% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.9%
2.2 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 11.1% · Q3 7.7% · Q4 1.6% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
8.2%
3.5 pts worse
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 9.5% · Q3 10.6% · Q4 12.3% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
11.3%
1.2 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.4% · Q3 8.2% · Q4 16.7% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 7.4% |
0.3%
7.1 pts worse
|
0.1%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 6.1% · Q3 4.3% · Q4 7.4% · 4Q avg 7.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.6% |
23.4%
9.8 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.8%
7.5 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 4.2% · Q3 12.5% · Q4 8.7% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.3%
0.9 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.1% · Q3 2.2% · Q4 2.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
2.4%
3.6 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.5% · Q3 10.1% · Q4 9.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.0% |
17.8%
8.8 pts better
|
19.8%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 7.2% · Q3 6.5% · Q4 13.5% · 4Q avg 9.0% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
3.6%
7.7 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 12.5% · Q3 16.2% · Q4 10.2% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.9% |
82.8%
10.9 pts worse
|
81.7%
9.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.8% · Q2 69.7% · Q3 73.0% · Q4 70.3% · 4Q avg 71.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
10.9%
3.5 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 13.6% · Expected 10.6% · 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 0.4% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.6% |
84.7%
24.1 pts worse
|
79.7%
19.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
19.6%
2.2 pts worse
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 21.0% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-05-12 · Fire 2023-05-12
24 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-10
D · Potential for more than minimal harm
2023-07-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-08
D · Potential for more than minimal harm
2023-05-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-23
C · Minimal harm
2023-05-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-23
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 2025-06-05
D · Potential for more than minimal harm
2025-05-23
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 2025-06-05
D · Potential for more than minimal harm
2025-05-23
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 2025-06-05
D · Potential for more than minimal harm
2025-05-23
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 2025-06-05
D · Potential for more than minimal harm
2025-05-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-23
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 2025-06-05
D · Potential for more than minimal harm
2025-05-23
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 2025-06-05
D · Potential for more than minimal harm
2025-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-05
D · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-04-25
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-25
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 2024-05-10
D · Potential for more than minimal harm
2024-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-25
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 2024-05-10
D · Potential for more than minimal harm
2024-04-25
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 2024-05-10
D · Potential for more than minimal harm
2024-04-25
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 2024-05-10
D · Potential for more than minimal harm
2024-04-25
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 2024-05-10
D · Potential for more than minimal harm
2024-02-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
D · Potential for more than minimal harm
2023-07-07
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 2023-08-08
F · Potential for more than minimal harm
2023-05-12
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 2023-06-05
E · Potential for more than minimal harm
2023-05-12
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 2023-06-23
E · Potential for more than minimal harm
2023-05-12
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-05-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-05-12
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 2023-06-05
E · Potential for more than minimal harm
2023-05-12
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 2023-06-06
E · Potential for more than minimal harm
2023-05-12
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 2023-06-05
D · Potential for more than minimal harm
2023-05-12
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 2023-06-08
D · Potential for more than minimal harm
2023-05-12
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 2023-06-07
D · Potential for more than minimal harm
2023-05-12
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 2023-06-01
D · Potential for more than minimal harm
2023-05-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-12
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 2023-05-31
D · Potential for more than minimal harm
2023-05-12
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 2023-06-07
D · Potential for more than minimal harm
2023-05-12
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 2023-06-09
D · Potential for more than minimal harm
2023-05-12
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 2023-06-06
D · Potential for more than minimal harm
2023-05-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-05-12
F756 · Pharmacy Service Deficiencies
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 2023-05-30
D · Potential for more than minimal harm
2023-05-12
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-12
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-06-03
D · Potential for more than minimal harm
2023-05-12
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 2023-06-06
C · Minimal harm
2023-05-12
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 2023-06-05
Penalties and ownership
What sits behind the stars
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
Lefler, Tyrus
Operational/Managerial Control · Individual
Lefler, Tyrus
Corporate Officer · Individual
Olsen, Spencer
Corporate Officer · Individual
Yoshida, Cynthia
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Kulana Malama
Ewa Beach, HI
5-star overall rating with 4-star inspections with $14,069 in total fines with 12 recent health deficiencies
#2
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
#3
Nuuanu Hale
Honolulu, HI
1-star overall rating with 1-star inspections with $27,310 in total fines with 17 recent health deficiencies
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