Islands Skilled Nursing & Rehabilitation

Special Focus Facility candidate · CCN 125067 · ISLANDS SKILLED NURSING AND REHABILITATION, LLC · For profit - Limited Liability company · 42 certified beds · Honolulu · HI


Islands Skilled Nursing & Rehabilitation is a 42-bed nursing home in Honolulu, Hawaii. CMS has certified it for Medicare and Medicaid since 2020-04-30. It averages 36.4 residents a day.

What harm was found in the violations cited at Islands Skilled Nursing & Rehabilitation?

CMS lists 64 health-inspection deficiencies for Islands Skilled Nursing & Rehabilitation since 2023-05-25, 43 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2025-04-30.

Survey dateTagDeficiencySeverity
2025-04-30F0851, F0921Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.F
2025-04-30F0550, F0656Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E
2025-04-30F0584, F0641, F0655, F0684, F0689, F0756, F0761, F0812, F0842, F0880Honor 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. / Ensure each resident receives an accurate assessment. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Provide and implement an infection prevention and control program.D
2024-07-18F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.G
2024-07-18F0622, F0623, F0626, F0657, F0713Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. / Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide or arrange emergency care by a doctor 24 hours a day.D
2024-05-16F0732, F0838Post nurse staffing information every day. / Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.F
2024-05-16F0656, F0657, F0684, F0756, F0758, F0759, F0880Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / 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. / Ensure medication error rates are not 5 percent or greater. / Provide and implement an infection prevention and control program.E
2024-05-16F0550, F0551, F0582, F0609, F0610, F0623, F0641, F0655, F0677, F0695, F0761, F0842Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Give the resident's representative the ability to exercise the resident's rights. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / Ensure each resident receives an accurate assessment. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide safe and appropriate respiratory care for a resident when needed. / 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. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D
2023-09-06F0883, F0887Develop and implement policies and procedures for flu and pneumonia vaccinations. / 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.D
2023-05-25F0550, F0577, F0623, F0625, F0684, F0725, F0756, F0761, F0812, F0842, F0880Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. / Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / 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. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Provide and implement an infection prevention and control program.E
2023-05-25F0561, F0584, F0656, F0657, F0689, F0690, F0692, F0693, F0758, F0806Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / 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. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide enough food/fluids to maintain a resident's 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. / 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. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.D

Why was Islands Skilled Nursing & Rehabilitation fined?

DateTypeAmount
2024-05-16Fine$89,206

How is Islands Skilled Nursing & Rehabilitation staffed?

MeasureThis facilityHI average
Total nurse staffing hours per resident per day5.667474.97232
Total nursing staff turnover (%)40.036.4
Average number of residents per day36.481.9

Who owns Islands Skilled Nursing & Rehabilitation?

Islands Skilled Nursing & Rehabilitation is registered with CMS as For profit - Limited Liability company, operates under the legal business name ISLANDS SKILLED NURSING AND REHABILITATION, LLC.

RoleOwnerAssociation date
DIRECT OWNERSHIP INTERESTPACIFIC HEALTHCARE VENTURES LLCsince 12/31/2020
5% OR GREATER INDIRECT OWNERSHIP INTERESTACCORD HOLDINGS, LLCsince 12/31/2020
CORPORATE OFFICERLACKNER, CHRISTOPHER, SMITH, NICOLEsince 02/26/2020
OPERATIONAL/MANAGERIAL CONTROLMANUMALEUNA, EATHYN, YAZAWA, KIYOTAKAsince 07/24/2023
GENERAL PARTNERSHIP INTERESTACCORD HOLDINGS, LLCsince 12/31/2020
LIMITED PARTNERSHIP INTERESTACCORD HOLDINGS, LLCsince 12/31/2020
ADP OF THE SNFACCORD HOLDINGS, LLC, MANUMALEUNA, EATHYN, YAZAWA, KIYOTAKAsince 02/19/2025

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