Cycle 1
Health 2024-12-13 · Fire 2024-12-13
22 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Honolulu, HI
The Ching Villas
4-star overall rating with 2-star inspections with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2230 Liliha Street, Honolulu, HI
(808) 547-6000
Overall
4 / 5
CMS overall stars
Health inspections
2 / 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
163
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ohana Pacific Management Co.
Operator or chain grouping
Approved since
2015-07-23
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
2.50
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.99
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
6.03
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
3.04
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
5.45
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.78
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.08
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
224
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
77.28
Composite VBP score used to determine payment impact.
Payment multiplier
1.0252
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.44
Baseline 18.64% · Performance 17.52% · Measure score 8.44 · Achievement 8.44 · Improvement 6.45
Healthcare-associated infections
8.45
Baseline 6.33% · Performance 5.31% · Measure score 8.45 · Achievement 8.45 · Improvement 7.15
Total nurse turnover
7.07
Baseline 49.12% · Performance 34.78% · Measure score 7.07 · Achievement 7.07 · Improvement 5.41
Adjusted total nurse staffing
6.95
Baseline 4.98 hours · Performance 5.06 hours · Measure score 6.95 · Achievement 6.95 · Improvement 0.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.22% |
10.72%
3.5 pts better
|
Better than the National Rate · Eligible stays 776 · Observed rate 5.67% · Lower 95% interval 5.91% |
| Discharge to community | 77.24% |
50.57%
26.7 pts better
|
Better than the National Rate · Eligible stays 853 · Observed rate 69.87% · Lower 95% interval 74.25% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 674 · Denominator 674 |
| Falls with major injury | 0.74% |
0.77%
About the same
|
Numerator 5 · Denominator 674 |
| Discharge self-care score | 46.22% |
53.69%
7.5 pts worse
|
Numerator 232 · Denominator 502 |
| Discharge mobility score | 49.2% |
50.94%
1.7 pts worse
|
Numerator 247 · Denominator 502 |
| Pressure ulcers or injuries, new or worsened | 1.34% |
2.29%
0.9 pts better
|
Numerator 9 · Denominator 674 · Adjusted rate 1.51% |
| Healthcare-associated infections requiring hospitalization | 5.31% |
7.12%
1.8 pts better
|
Better than the National Rate · Eligible stays 583 · Observed rate 4.63% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 26.5% |
8.2%
18.3 pts better
|
Numerator 84 · Denominator 317 |
| Staff flu vaccination coverage | 58.33% |
42%
16.3 pts better
|
Numerator 203 · Denominator 348 |
| Discharge function score | 53.39% |
56.45%
3.1 pts worse
|
Numerator 268 · Denominator 502 |
| Transfer of health information to provider | 91.78% |
95.95%
4.2 pts worse
|
Numerator 491 · Denominator 535 |
| Transfer of health information to patient | 93.2% |
96.28%
3.1 pts worse
|
Numerator 96 · Denominator 103 |
| Resident COVID-19 vaccinations up to date | 32.66% |
25.2%
7.5 pts better
|
Numerator 114 · Denominator 349 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
96.3%
1.4 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 97.7% |
| 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 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
4.9%
5.6 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
8.2%
8.2 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
11.3%
7.9 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
16.8%
5.8 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.3%
1.4 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 14.0% |
2.4%
11.6 pts worse
|
1.7%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
17.8%
0.3 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 14.1% |
3.6%
10.5 pts worse
|
5.1%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
82.8%
16 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.4% · Q3 98.8% · Q4 98.1% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
10.9%
1.4 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 9.9% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.0%
0.5 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.2% · Q2 0.5% · Q3 0.4% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
84.7%
14.5 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
19.6%
1.5 pts worse
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 22.8% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-22 · Fire 2023-12-22
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
B · Minimal harm
2024-12-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-06
D · Potential for more than minimal harm
2023-12-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
E · Potential for more than minimal harm
2022-12-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-16
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-16
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.
Not marked corrected
E · Potential for more than minimal harm
2025-10-09
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 2025-12-16
E · Potential for more than minimal harm
2025-10-09
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 2025-12-16
D · Potential for more than minimal harm
2025-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-10-09
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 2025-12-16
D · Potential for more than minimal harm
2025-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-16
E · Potential for more than minimal harm
2024-12-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-23
E · Potential for more than minimal harm
2024-12-13
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 2025-01-23
D · Potential for more than minimal harm
2024-12-13
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 2025-01-23
D · Potential for more than minimal harm
2024-12-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-13
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-13
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 2025-01-23
D · Potential for more than minimal harm
2024-12-13
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 2025-01-23
D · Potential for more than minimal harm
2024-12-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-13
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 2025-01-23
D · Potential for more than minimal harm
2024-12-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-13
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 2025-01-23
D · Potential for more than minimal harm
2024-12-13
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 2025-01-23
D · Potential for more than minimal harm
2024-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-05-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-07
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
D · Potential for more than minimal harm
2023-12-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
D · Potential for more than minimal harm
2023-12-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
D · Potential for more than minimal harm
2023-12-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-22
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 2024-01-31
D · Potential for more than minimal harm
2022-12-09
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 2022-12-27
D · Potential for more than minimal harm
2022-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-12-09
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 2022-12-27
D · Potential for more than minimal harm
2022-12-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-12-09
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 2022-12-27
Penalties and ownership
What sits behind the stars
Ownership
Ohana Pacific Management Company Inc
5% Or Greater Direct Ownership Interest · Organization
Brewer, Stephen
Contracted Managing Employee · Individual
Davis, Dusty
Contracted Managing Employee · Individual
Hata, Randall
Corporate Officer · Individual
Kishaba, Richard
Corporate Director · Individual
Kishaba, Richard
Corporate Officer · Individual
Morikuni, Suanne
Corporate Officer · Individual
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