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Legacy Hilo Rehabilitation & Nursing Center

563 Kaumana Drive, Hilo, HI 96720 · Hawaii County · (808) 498-0184

100 certified beds, about 89 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2016

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 125065 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on February 27, 2026, inspectors cited 10 health deficiencies (the Hawaii average is 9.5, the national average 9.2).

Of 34 health citations since October 2023, 1 was rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $10,628 in the last three years; the largest was $10,628, and the latest is dated February 27, 2026.

Nurses and nurse aides worked 3.72 hours per resident per day, against 4.97 across Hawaii and 3.86 nationally. Registered nurses accounted for 0.95 of those hours.

62.3% of nursing staff left within the year CMS measured (Hawaii average 36.4%).

CMS links it to Ohana Pacific Management Co., an affiliated group of 6 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 34 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
27D
4E
2F
Potential for minimal harm
0A
0B
0C
February 27, 2026Standard inspection, Complaint inspection · 10 citations
  1. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on observation, interviews and record review, the facility failed to provide the needed care in accordance to standard of practice to prevent a pressure ulcer (PU) in one Resident (R)88 of a sample size of three. R88 was at high risk of developing a new PU due to her immobility. She was totally dependent on staff for positioning to prevent a PU. There was no evidence in the medical record that staff frequently repositioned R88. As a result, she suffered harm and developed a Stage III (3) coccyx/sacral PU, which increased the risk of infection and complications. This deficient practice has the potential to affect any resident at risk of PU.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on observations, staff interview and review of policy, the facility did not follow proper sanitation practices in the kitchen. As a result of this deficiency, there was an increase risk for foodborne illness and quality of service.
  3. E
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 9, 2026
    Inspectors wroteBased on observations, record review and interviews, the facility failed to develop baseline care plans (CP) and update with them to provide effective and person centered care to meet the immediate needs of four Resident's ((R)1, R2, R3,R4) of a sample size of five. As a result of this deficient practice, there is an increase risk of adverse events and lack of continuity of care. This has the potential to affect all new admissions to the facility.
  4. E
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 9, 2026
    Inspectors wroteBased on observation, document, record review and interviews, the facility failed to have a policy based on professional standards of practice that addressed the use of enablers (device attached to bedframe that assists the resident with turning, repositioning and getting in and out of bed) to ensure residents are assessed to ensure effective and safe use. Four of a sample size of five Residents (R)1, R2, R2, R4)) reviewed had enablers attached to the bed. The facility failed to provide evidence of an assessment that included the the Resident's level of cognition and that they understood the use of the enabler to prevent injury. In addition, the consent forms are not signed by the Resident/Representative. r. As a result of this deficient practice, there is increased risk of injury to a Resident with impaired cognition.
  5. D
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    F627 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on interviews, record and document review, the facility failed to develop and implement a discharge plan for the transition of post discharge care for one Resident (R)107 of a sample size of three. R107 had an indwelling urinary catheter (a medical device that helps drain urine from your bladder) at the time of discharge. The facility was not able to provide evidence that the Care Giver (CG) had the capacity, capability, or received education on how to preform catheter care. As a result of this deficient practice, there was increased risk of infection and complications related to the urinary catheter. This deficient practice could affect any discharged resident if the CG is not properly trained and capable to provide the after care needed.
  6. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for four of 21 residents (Resident (R) 6, 9, 88 and 104) in the active sample. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.
  7. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on interviews, observations and record/document review, the facility failed to ensure that the comprehensive care plan was reviewed and revised in a timely manner to reflect the current condition of two residents (R)2 and R88 of a sample size of three. As a result of this deficient practice, the care team does not have the current information needed to care for the resident's to ensure they reach their highest potential. Finding's include: 1) R2 was a long-term resident at the facility and requires 24-hour care. His medical history included End Stage Renal Disease requiring hemodialysis, Diabetes Type 2, Congestive Heart Failure, and stroke with left side weakness. He is dependent on staff for all Activities of Daily Living (ADL) and is a two-person transfer. On 02/25/26 at 08:10 AM, observed R2 in bed. He appeared comfortable and breathing easily. R2 was non interviewable. [...]
  8. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on observation and interview the facility failed to ensure one of three residents (Resident (R) 62) sampled was free from accident hazards as evidenced by over the counter (OTC) medication, brought in by Family Member (FM)3, being stored in R62's room and administered by FM3 without notifying staff. This deficient practice created a risk for injury to R62 due to inappropriate and unsafe administration of the OTC medications by an unauthorized person.
  9. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two of 21 residents (Resident (R) 74 and R109) in the active sample were free from significant medication errors as evidenced by R74 being administered an inappropriate dose of short acting insulin via insulin pen and R109 was administered an insulin dosage via insulin pen based on a blood sugar taken after a meal. As a result of this deficient practice, R74's and R109's health and safety were jeopardized.
  10. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2026
    Inspectors wroteBased on observation and interview, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper labeling of medications is necessary to promote safe administration practices, decrease the risk for medication errors, and decrease the risk for the diversion of resident medications. This deficient practice has the potential to affect all residents in the facility who take medications.
October 25, 2024Standard inspection · 8 citations
  1. F
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on interview and Record Review (RR), the facility failed to ensure a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman for four residents (Resident (R)41, R57, R35, and R56) sampled. Requested a copy of the sampled resident's transfer or discharge notice that was sent to a representative of the Office of the State Long-Term Care Ombudsman and the Administrator confirmed the facility has not been sending any copies of the notices to the Ombudsman. This deficient practice has the potential to affect all the residents who are transferred or discharged from the facility. Findings Include: 1) On 10/23/24 at 11:04 AM during interview with R41 he stated he went to the hospital this year to have my leg amputated. [...]
  2. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on observations, resident interview, staff interview, and review of policy, the facility did not have the call bell in reach for one Resident (R)14 out of six Residents sampled. As a result of this deficiency, R14s ability to call out for help was limited and the deficient practice has the potential to affect all the residents that uses the call bell for assistance. Findings Include: During observation and interview on 10/22/24 at 10:18 AM, R14's call bell was attached to the bed but was dangling and out of reach. R14 said that he/she had hard time finding the call bell to call out to staff. Observation and interview on 10/23/24 at 02:30 PM, R14's call bell was dangling over head of the bed and out of reach. R14 wanted to call to ask staff a question. [...]
  3. D
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on interviews and record review, the facility failed to exercise reasonable care for the protection of the property from loss or theft for one out of 22 sampled residents (Resident (R) 9). As a result of this deficiency, R9's psychosocial wellbeing was negatively affected. R9 did not think the facility took his statement seriously. This deficient practice has the potential to affect all the residents whose property is lost or missing. Findings Include: Interview was conducted with R9 on 10/22/24 at 01:45 PM in his room. R9 stated that a couple of months ago, five bottles of supplements went missing after taking just one pill. R9 explained that a family member had ordered the supplements for him and had it delivered to the facility. R9 had informed a couple of the facility staff of the missing items and staff had helped him search for it. [...]
  4. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one out of 22 sampled residents (Resident (R) 66). R66 experienced frequent pain and the facility failed to develop a care plan for R66's pain. The deficient practice has the potential to negatively affect R66's wellbeing and has the potential to affect all the residents who experiences pain in the facility. Findings Include: R66 is a [AGE] year-old female admitted to the facility on [DATE]. R66 has medical diagnosis that includes, but not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, aphasia, low back pain, and pain. Observation and interview were conducted with R66 on 10/23/24 at 09:53 AM in R66's room. R66 was observed rubbing/massaging her left thigh area. [...]
  5. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on observation, interview and Record Review (RR) the facility failed to assure one of the sampled residents (Resident (R) 132) received appropriate treatment and services with care for his urinary indwelling catheter. The deficient practice included R132's urinary catheter tubing being left on the ground, urinary catheter flush for blood in the tubing performed by licensed staff without a physician order, and licensed staff not performing proper hand hygiene before flushing R132's urinary catheter. This deficient practice has the potential to affect all the resident with urinary catheter. Findings Include: Cross-reference to F880 Infection Prevention & Control On 10/22/24 at 11:30 AM R132 was observed sitting in his wheelchair near his bed with his urinary catheter tubing on the ground. Interview was conducted with the Certified Nurse Assistant (CNA) 1 who was working with R132. [...]
  6. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on interviews and record review, the facility failed to ensure controlled medication was reconciled for one of four medication carts sampled. Review of the Controlled Medication Reconciliation Log (CMR Log) documented on 10/02/24, nursing staff did not sign the log with the on-coming evening shift nurse indicating all controlled medications for medication cart was reconciled at change of shift and on 10/24/24 and 10/25/24, nursing staff pre-signed the CMR Log prior to reconciling and verifying the controlled medications count with the on-coming evening shift. As a result of this deficient practice, the facility is at potential risk for diversion of controlled medications. Findings Include: On 10/24/24 at 08:40 AM, conducted an inspection of medication cart # 4 with Nursing Staff (NS)3. [...]
  7. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. This deficient practice has the potential to affect all the residents in one of the four units in the facility. Findings Include: Concurrent observation and interview were conducted on 10/22/24 at 11:00 AM. One of the facility's medication carts was observed unlocked and unattended. The cart was assigned to Licensed Practical Nurse (LPN) 10, who was observed in one of the resident's rooms. Once LPN 10 exited the resident's room, she was asked about the unlocked and unattended medication cart. LPN10 confirmed that the medication cart should not have been left unlocked and unattended. [...]
  8. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on observation, Record Review (RR) of Resident's Electronic Health Record (EHR) and interview, the facility failed to assure one of the sampled resident's (Resident (R) 132) urinary catheter tubing did not rest on the ground, failed to have staff remove dirty gloves, perform hand hygiene and put on clean gloves before flushing R132's urinary catheter, and perform hand hygiene after disposing of dirty gloves before putting on clean gloves during a dressing change for R58. The deficient practice puts the residents at risk for facility acquired infections. Findings Include: 1) On 10/22/24 at 11:30 AM R132 was observed returning to his room in his wheelchair with staff pushing his wheelchair. R132 was observed in his wheelchair near his bed and his urinary catheter tubing was observed resting on the ground. [...]
July 10, 2024Complaint inspection · 2 citations
  1. D
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 9, 2024
    Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing services that assured resident (R) safety for 1 of 6 residents sampled (R1). As a result of this deficient practice, R1 was placed at risk of a decrease in her physical well-being related to receiving morphine sulfate (a strong narcotic most commonly used to treat moderate to severe pain) on a routine basis, scheduled every one hour, as opposed to being used as needed.
  2. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 9, 2024
    Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy services included a thorough process to assure accurate reconciliation and accounting for all controlled medications in order to promptly identify loss or potential diversion.
October 30, 2023Standard inspection, Complaint inspection · 14 citations
  1. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observations, record review (RR) and staff interview the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 19 residents sampled (Residents 8, 57, 68 and 69), to meet and maintain their needs for indwelling catheter care, dementia care, and activities of daily living (ADL). As a result of these deficient practices, these residents were placed at risk for a decline in their quality of life and were prevented from attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility.
  2. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label food in accordance with professional standards for food service safety as evidenced by the following observed practices: the facility failed to maintain a clean standing fan in the kitchen, correctly test the temperatures on the tray line, correctly test the sanitizer level of their three-compartment sink in the kitchen, failed to maintain a clean refrigerator in 1 of 2 resident nourishment rooms, and failed to maintain the proper temperature for food safety in the refrigerator of the other resident nourishment room. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility able to consume food orally.
  3. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observation, interview, and record review (RR), the facility failed to accommodate 1 of 3 Residents' (Resident 69) needs by not ensuring that his whiteboard (for communication), and remote for the TV, was always placed within his reach on his left side (the mobile side). As a result of this deficient practice, R69 was prevented from achieving independent functioning with regards to the TV, and he was hindered from attaining his highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with deficits in mobility.
  4. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on record review (RR), staff interview and facility policy review, the facility failed to notify the physician when Resident (R)70 became COVID positive and had a significant change in physical condition becoming unresponsive requiring transfer to hospital emergency room. The deficient practice has the potential to affect all residents in the facility that has a significant change in physical condition that could be life threatening.
  5. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on interviews and facility document review, the facility failed to implement their written abuse policy and procedure for an alleged physical abuse of one of the facility residents (Resident (R) 23). This deficient practice had the potential to compromise the safety of the resident and places all residents in the facility at risk for potential physical and psychosocial harm.
  6. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for one Resident (R)35 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication.
  7. D
    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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to provide written notice of bed-hold policy for one Resident (R)35 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication of the bed-hold policy.
  8. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately record that one Resident (R)65 of two residents sampled was receiving Hospice Services in the RAI, Minimum Data Set (MDS). As a result of this deficiency, the facility put R65 at risk for further RAI, MDS inaccuracy.
  9. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a baseline care plan that provided effective and person-centered care for 2 of 7 residents (Residents 89 and 16) reviewed for falls. As a result of this deficient practice, the facility placed these residents at risk for avoidable declines and injuries. This deficient practice has the potential to affect all the residents at the facility.
  10. D
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    F676 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observation, record review, and interview, the facility failed to provide the necessary care and services to meet the activities of daily living (ADLs) needs of 2 of 3 residents (Residents 57 and 69) sampled for ADLs. Specifically, the facility did not ensure Resident (R)57's hygiene needs were met, and failed to provide the proper care and treatment to improve or maintain the communication abilities of R69. As a result of this deficient practice, these residents were not having their needs met, and were placed at risk of a decline in their physical well-being, psychosocial well-being, and quality of life. This deficient practice has the potential to affect all residents at the facility with hygiene or communication needs.
  11. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an ongoing resident-centered activities program that fully identified and met the resident's needs, for 1 of 3 residents sampled for activities (Resident 69). As a result of this deficient practice, Resident 69 was placed at risk of experiencing a decline in his psychosocial well-being and quality of life. This deficient practice has the potential to affect all residents at the facility.
  12. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 10 residents (Resident 89) sampled for accidents was free from accident hazards. Specifically, after identifying a newly admitted resident as a Falls Risk, the facility failed to ensure his bed was kept in the lowest position, in alignment with his Baseline Care Plan. As a result of this deficient practice, Resident (R)89 was placed at an increased risk of an avoidable injury, should he suffer a fall out of bed.
  13. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on interviews and record review, the facility failed to provide Gradual Dose Reduction (GDR) to one out of five sampled residents (Resident (R) 27) who is currently on a psychotropic medication. This failed practice has the potential to negatively affect all residents on psychotropic medications which may be clinically contraindicated at a higher dose.
  14. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure proper glove use procedures were followed by a staff member. This deficient practice places the residents at risk for the development and transmission of communicable diseases and infections.

Fire safety inspections

5 fire safety citations on file: 5 on February 27, 2026.

Every fire safety citation5 citations
  1. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · February 27, 2026 · Corrected (the home has a date of correction)
  2. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 27, 2026 · Corrected (the home has a date of correction)
  3. F
    Have simulated fire drills held at unexpected times.
    K 712 · February 27, 2026 · Corrected (the home has a date of correction)
  4. D
    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
    K 362 · February 27, 2026 · Corrected (the home has a date of correction)
  5. D
    Have proper medical gas storage and administration areas.
    K 923 · February 27, 2026 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
February 27, 2026Fine $10,628

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeHawaiiUnited States
All nursing staff (RN, LPN and aides)3.724.973.86
Registered nurses0.951.750.69
All nursing staff on weekends3.204.413.42
Nurse aides2.18
Licensed practical nurses0.59
Nursing staff turnover (share who left in a year)62.3%36.4%45.8%
Registered nurse turnover45.5%31.5%42.9%
Administrators who left0

CMS expects 4.00 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.93 on weekdays and 3.20 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.44 in April to June 2025 to 3.72 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.720.953.933.20 1.1%0 of 9089
Oct to Dec 20253.851.174.043.37 4.9%0 of 9280
Jul to Sep 20253.610.963.753.26 13.7%0 of 9286
Apr to Jun 20253.440.863.563.12 16.3%0 of 9191
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Hawaii, Jan to Mar 20264.631.604.864.086.9%0% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Hawaii

JobMedianMiddle halfEmployed
Hawaii, all employers
CNAs (nursing assistants)$21.80$19.26 to $24.255,050
LPNs and LVNs$34.20$30.03 to $36.18840
Registered nurses$65.54$48.65 to $69.3012,940
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For Legacy Hilo Rehabilitation & Nursing Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeHawaiiUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
10.516.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.81.00.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.72.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
1.31.93.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.61.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
30.120.414.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
4.33.44.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
8.811.915.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
24.719.423.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
13.710.312.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.71.11.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.90.91.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Legacy Hilo Rehabilitation & Nursing Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (68.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

68.1% this home

Better than the national rate

US median of homes 51.5% · Hawaii: 24 better, 0 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 145 eligible stays.

Potentially preventable readmissions

10.3% this home

No different from the national rate

US median of homes 10.7% · Hawaii: 1 better, 0 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 137 eligible stays.

Infections that led to a hospital stay

8.0% this home

No different from the national rate

US median of homes 7.1% · Hawaii: 1 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 93 eligible stays.

Self-care and mobility at discharge

24.6% this home

Median of homes: Hawaii52.5% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 69 residents counted.

Falls with major injury

0.0% this home

Median of homes: Hawaii0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 107 residents counted.

New or worsened pressure ulcers

1.0% this home

Median of homes: Hawaii2.0% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 107 residents counted.

Medication list given at discharge

97.6% this home

Median of homes: Hawaii99.6% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 41 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: HILO SNF LLC. CMS links this home to Ohana Pacific Management Co., a group of 6 nursing homes averaging 3.3 stars overall.

NameRoleTypeShareSince
Ohana Pacific Management Company IncDirect ownership interestOrganization01/01/2020
Richard S. Kishaba 2010 Dynasty TrustIndirect ownership interestOrganization07/30/2010
Kishaba, RichardIndirect ownership interestIndividual01/01/2020
First Hawaiian Bank5% or greater mortgage interestOrganization12/27/2019
Kishaba, RichardCorporate officerIndividual09/04/2019
Ohana Pacific Management Company IncOperational/managerial controlOrganization01/01/2020
Hata, RandallOperational/managerial controlIndividual01/01/2020
Kishaba, RichardOperational/managerial controlIndividual01/01/2020
Lore, AndrewOperational/managerial controlIndividual02/01/2022
McClennon, PamelaOperational/managerial controlIndividual04/01/2025
Morikuni, SuanneOperational/managerial controlIndividual01/01/2020
Pitcher, KerryOperational/managerial controlIndividual04/03/2023
Kishaba, SandraIndividual is an owner, partner or trustee of any ADP of the SNFIndividual11/12/2025
Ohana Pacific Management Company IncAdp of the SNFOrganization01/01/2020
Richard S. Kishaba 2010 Dynasty TrustAdp of the SNFOrganization01/01/2020
Hata, RandallAdp of the SNFIndividual01/01/2020
Kishaba, RichardAdp of the SNFIndividual01/01/2020
Lore, AndrewAdp of the SNFIndividual02/01/2022
McClennon, PamelaAdp of the SNFIndividual04/01/2025
Morikuni, SuanneAdp of the SNFIndividual01/01/2020
Pitcher, KerryAdp of the SNFIndividual04/03/2023
Smith, TobyAdp of the SNFIndividual11/01/2023

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 8 problems in this area, most recently on February 27, 2026: "Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge."
  2. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 7 problems in this area, most recently on February 27, 2026: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
  3. When is the care plan meeting, and can family attend it?Inspectors cited 7 problems in this area, most recently on February 27, 2026: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on February 27, 2026: "Ensure that residents are free from significant medication errors."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.20 hours per resident per day, below the Hawaii average of 4.41.

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Common questions

What is Legacy Hilo Rehabilitation & Nursing Center's Medicare star rating?
CMS rates Legacy Hilo Rehabilitation & Nursing Center 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Legacy Hilo Rehabilitation & Nursing Center get at its last inspection?
10 health deficiencies at the standard inspection on February 27, 2026. The Hawaii average is 9.5.
Has Legacy Hilo Rehabilitation & Nursing Center been fined?
Yes. CMS lists 1 fine totaling $10,628 in the last three years.
Does Legacy Hilo Rehabilitation & Nursing Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Legacy Hilo Rehabilitation & Nursing Center?
CMS lists 22 owners and managers, and links the home to Ohana Pacific Management Co.. Legal business name: HILO SNF LLC.

Sources

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