Cycle 1
Health 2025-07-25 · Fire 2025-07-25
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Waianae, HI
Pu'uwai 'o Makaha
4-star overall rating with 4-star inspections with $65,455 in total fines with 8 recent health deficiencies
84-390 Jade Street, Waianae, HI
(808) 695-9508
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
93
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ohana Pacific Management Co.
Operator or chain grouping
Approved since
1997-07-03
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
1.10
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,587
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.51
Composite VBP score used to determine payment impact.
Payment multiplier
1.0105
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
7.96
Baseline 30.00% · Performance 31.15% · Measure score 7.96 · Achievement 7.96 · Improvement 0
Adjusted total nurse staffing
3.14
Baseline 3.95 hours · Performance 3.97 hours · Measure score 3.14 · Achievement 3.14 · 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 23 · 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 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 14.96% |
8.2%
6.8 pts better
|
Numerator 19 · Denominator 127 |
| Staff flu vaccination coverage | 65.54% |
42%
23.5 pts better
|
Numerator 97 · Denominator 148 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.0% |
1.9%
1.1 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.4% · Q3 1.8% · Q4 3.4% · 4Q avg 3.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.9%
1.2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 1.8% · Q3 0.0% · Q4 5.4% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
8.2%
1.3 pts worse
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 7.0% · Q3 11.5% · Q4 8.8% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.6% |
11.3%
14.3 pts worse
|
16.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.6% · Q3 28.6% · Q4 23.3% · 4Q avg 25.6% · 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 | 35.5% |
23.4%
12.1 pts worse
|
16.3%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
16.8%
5.7 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.8% · Q3 8.1% · Q4 15.4% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.3%
About the same
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 1.2% · Q4 1.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.4%
0.2 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 3.7% · Q4 1.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.0% |
17.8%
3.8 pts better
|
19.8%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 16.6% · Q3 7.5% · Q4 16.6% · 4Q avg 14.0% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
3.6%
0.7 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.5% · Q3 1.8% · Q4 2.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
82.8%
6.4 pts better
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 88.9% · Q3 85.1% · Q4 94.9% · 4Q avg 89.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.0%
3.2 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 4.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
84.7%
6.4 pts better
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-26 · Fire 2024-07-26
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-28 · Fire 2023-07-28
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-26
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 2024-08-25
D · Potential for more than minimal harm
2023-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
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 2025-09-08
D · Potential for more than minimal harm
2025-07-25
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 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
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 2025-09-08
D · Potential for more than minimal harm
2025-07-25
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 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-09-08
E · Potential for more than minimal harm
2024-07-26
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 2024-09-04
E · Potential for more than minimal harm
2024-07-26
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 2024-09-04
E · Potential for more than minimal harm
2024-07-26
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 2024-09-04
D · Potential for more than minimal harm
2024-07-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-26
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 2024-09-04
D · Potential for more than minimal harm
2024-07-26
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-26
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 2024-09-04
D · Potential for more than minimal harm
2024-07-26
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-26
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-09-04
G · Actual harm
2023-08-31
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 2023-08-23
D · Potential for more than minimal harm
2023-08-31
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 2023-09-18
D · Potential for more than minimal harm
2023-08-31
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-09-18
G · Actual harm
2023-07-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-17
F · Potential for more than minimal harm
2023-07-28
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-10-28
E · Potential for more than minimal harm
2023-07-28
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 2023-10-17
E · Potential for more than minimal harm
2023-07-28
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-10-17
E · Potential for more than minimal harm
2023-07-28
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 2023-10-28
E · Potential for more than minimal harm
2023-07-28
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 2023-11-08
E · Potential for more than minimal harm
2023-07-28
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 2023-10-28
D · Potential for more than minimal harm
2023-07-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-07-28
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 2023-10-17
D · Potential for more than minimal harm
2023-07-28
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 2023-10-17
D · Potential for more than minimal harm
2023-07-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-07-28
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 2023-10-28
D · Potential for more than minimal harm
2023-07-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-07-28
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 2023-10-17
D · Potential for more than minimal harm
2023-07-28
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 2023-10-28
D · Potential for more than minimal harm
2023-07-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-07-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-10-17
Penalties and ownership
What sits behind the stars
$65,455
2023-07-28
Fine
Fine · fine $65,455
Fine
$0
2023-07-28
Payment Denial
Payment Denial · denial start 2023-10-28 · 11 days
11 day denial
Ownership
Ohana Pacific Management Company Inc
5% Or Greater Direct Ownership Interest · Organization
Collins, Hannah
Contracted Managing Employee · Individual
Hata, Randall
Corporate Officer · Individual
Kishaba, Richard
Corporate Director · Individual
Kishaba, Richard
Corporate Officer · Individual
Morikuni, Suanne
Corporate Officer · Individual
Santoro, Mary
Contracted Managing Employee · Individual
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