Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

A
Grade
69
Score
CMS Ratings
16.9/22
Staffing Quality
16.2/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
10.0/10

Current Availability Estimate

Occupancy Rate67.6%
93
Total Beds
63
Occupied
30
Available

Basic Information

Address:

84-390 JADE STREET

WAIANAE, HI 96792

Number of Beds:

93

Estimated Occupancy:

68% (~30 available)

Chain:

OHANA PACIFIC MANAGEMENT CO.

Quality Ratings

Overall Rating:4/5 Stars
Health Inspection:4/5 Stars
Staffing Rating:4/5 Stars
Quality Measures:3/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

125046

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Above Average

This Facility

1.06

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Average

This Facility

4.26

hours

National Avg

3.89

hours

Breakdown:

RN: 1.06hLPN: 0.51hAide: 2.69h

Staff Turnover Rate

Annual nursing staff turnover

Below Average

This Facility

27.6%

National Avg

46.6%

RN Turnover: 31.3%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

76

Inspections

4

High

4

Jul 26, 2024 - Health Survey

18 deficiencies cited

Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Sep 4, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Sep 4, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Sep 4, 2024
Medium - PatternTag F0790

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Corrected: Sep 4, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 4, 2024
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 4, 2024
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 4, 2024From Complaint
Medium - PatternTag F0675

Quality of Life and Care Deficiencies

Honor each resident's preferences, choices, values and beliefs.

Corrected: Sep 4, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 4, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Sep 4, 2024
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Sep 4, 2024
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Sep 4, 2024
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 4, 2024From Complaint
Medium - PatternTag F0675

Quality of Life and Care Deficiencies

Honor each resident's preferences, choices, values and beliefs.

Corrected: Sep 4, 2024From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 4, 2024From Complaint
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 4, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 4, 2024
Medium - PatternTag F0790

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Corrected: Sep 4, 2024

Aug 31, 2023 - Health Survey

6 deficiencies cited

Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 18, 2023From Complaint
High - Widespread PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 23, 2023From Complaint
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Sep 18, 2023From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 18, 2023From Complaint
High - Widespread PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 23, 2023From Complaint
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Sep 18, 2023From Complaint

Jul 28, 2023 - Health Survey

34 deficiencies cited

Medium - PatternTag F0882

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected: Oct 28, 2023
Medium - PatternTag F0882

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected: Oct 28, 2023
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Oct 17, 2023
Medium - PatternTag F0919

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected: Oct 17, 2023
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Oct 17, 2023From Complaint
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Oct 17, 2023
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Oct 17, 2023
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Oct 17, 2023
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

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: Oct 17, 2023
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Oct 17, 2023
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

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: Oct 28, 2023
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Oct 17, 2023
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Oct 17, 2023
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Nov 8, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Oct 28, 2023
Medium - PatternTag F0865

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected: Oct 28, 2023
Medium - PatternTag F0865

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected: Oct 28, 2023
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Oct 17, 2023
Medium - PatternTag F0919

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected: Oct 17, 2023
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Oct 17, 2023From Complaint
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Oct 17, 2023
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Nov 8, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Oct 28, 2023
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Oct 17, 2023
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

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: Oct 28, 2023
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Oct 17, 2023
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

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: Oct 17, 2023
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Oct 17, 2023
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Oct 17, 2023
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Oct 17, 2023
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Oct 28, 2023
Medium - PatternTag F0577

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected: Oct 17, 2023
Medium - PatternTag F0577

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected: Oct 17, 2023
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Oct 28, 2023

Aug 10, 2022 - Health Survey

18 deficiencies cited

Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Sep 16, 2022
Medium - PatternTag F0626

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Corrected: Sep 16, 2022
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Sep 16, 2022
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 16, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 16, 2022
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Sep 16, 2022
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 16, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 16, 2022
Medium - PatternTag F0921

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected: Sep 16, 2022
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 16, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 16, 2022
Medium - PatternTag F0921

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected: Sep 16, 2022
Medium - PatternTag F0626

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Corrected: Sep 16, 2022
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Sep 16, 2022
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 16, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 16, 2022
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Sep 16, 2022
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Sep 16, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

No penalties or payment denials in the past 3 years

Key Highlights

High CMS Rating
4 out of 5 stars from Medicare
👨‍⚕
Above Average RN Staffing
1.06 RN hours per resident/day (national avg: 0.64)
Low Staff Turnover
27.6% (national avg: 46.6%)
🛏
Beds Available
Approximately 30 beds potentially available
🏆
Clean Safety Record
No recent penalties or high-severity deficiencies
🏢
Part of Healthcare Chain
OHANA PACIFIC MANAGEMENT CO.

Frequently Asked Questions

What is the quality rating for PU'UWAI 'O MAKAHA?

PU'UWAI 'O MAKAHA has an overall CMS rating of 4 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

PU'UWAI 'O MAKAHA has 93 certified beds. The facility averages 63 residents per day, with an occupancy rate of approximately 68%.

What type of ownership does this facility have?

This facility is for profit - limited liability company owned. It is part of the OHANA PACIFIC MANAGEMENT CO. network.

How can I contact PU'UWAI 'O MAKAHA?

You can call PU'UWAI 'O MAKAHA at (808)695-9508. The facility is located at 84-390 JADE STREET, WAIANAE, HI 96792.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: