Cycle 1
Health 2024-11-22 · Fire 2024-11-22
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Kapaa, HI
Samuel Mahelona Memorial Hospital
5-star overall rating with 5-star inspections with 4 recent health deficiencies
4800 Kawaihau Road, Kapaa, HI
(808) 822-4961
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
66
Certified beds
Average residents
46
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-07-15
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.24
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
3.47
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
6.08
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.61
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
5.62
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.86
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.18
CMS adjusted RN staffing hours
Adjusted total hours
5.92
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
7%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
82
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
87.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0270
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
10
Baseline 12.50% · Performance 7.27% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
7.53
Baseline 5.79 hours · Performance 5.22 hours · Measure score 7.53 · Achievement 7.53 · 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 | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 137 |
| Staff flu vaccination coverage | 42.75% |
42%
0.8 pts better
|
Numerator 59 · Denominator 138 |
| 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 | 95.7% |
96.3%
0.6 pts worse
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 88.9% · Q3 100.0% · Q4 100.0% · 4Q avg 95.7% |
| 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 | 2.2% |
1.9%
0.3 pts worse
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.1% · Q4 4.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
1.4%
0.7 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
4.9%
2.1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.7% · Q3 0.0% · Q4 2.2% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.0% |
8.2%
2.2 pts better
|
19.6%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 4.5% · Q3 4.3% · Q4 4.3% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
11.3%
7.5 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 3.0% · Q4 5.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.5% |
0.3%
0.2 pts worse
|
0.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.7% |
23.4%
0.3 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 17.3% · Q3 25.8% · Q4 32.0% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
16.8%
3.7 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 12.8% · Q3 9.8% · Q4 15.0% · 4Q avg 13.1% · Used in QM five-star |
| 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 | 1.1% |
2.4%
1.3 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.1% |
17.8%
0.7 pts better
|
19.8%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 16.0% · Q3 9.7% · Q4 16.3% · 4Q avg 17.1% |
| 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 0.0% · Q2 2.7% · Q3 2.3% · Q4 6.6% · 4Q avg 2.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-30 · Fire 2022-09-30
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-12-01
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 2024-01-14
E · Potential for more than minimal harm
2022-09-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-22
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 2024-12-20
D · Potential for more than minimal harm
2024-11-22
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 2025-01-03
D · Potential for more than minimal harm
2024-11-22
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 2024-12-27
D · Potential for more than minimal harm
2024-11-22
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 2024-12-27
F · Potential for more than minimal harm
2023-12-01
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 2024-01-05
D · Potential for more than minimal harm
2023-12-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-01
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 2024-01-05
D · Potential for more than minimal harm
2023-12-01
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 2024-01-05
D · Potential for more than minimal harm
2023-12-01
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 2024-01-05
D · Potential for more than minimal harm
2023-12-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-05
E · Potential for more than minimal harm
2022-09-30
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 2022-11-11
E · Potential for more than minimal harm
2022-09-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-09-30
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 2022-11-11
E · Potential for more than minimal harm
2022-09-30
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 2022-11-11
D · Potential for more than minimal harm
2022-09-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-09-30
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 2022-11-11
D · Potential for more than minimal harm
2022-09-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
Ownership
Samuel Mahelona Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Asato, Christine
Operational/Managerial Control · Individual
Asato, Christine
Corporate Officer · Individual
Franklin, Nicholas
Operational/Managerial Control · Individual
Samuel Mahelona Memorial Hospital
Operational/Managerial Control · Organization
Segawa, Lance
Operational/Managerial Control · Individual
Segawa, Lance
Corporate Officer · Individual
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#3
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