Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kauai Veterans Memorial Hospital during CMS and state inspections, most recent first.
A facility failed to ensure safe food storage when several transferred food items were found without required labels. In the pantry, plastic containers holding egg noodles and shiitake mushrooms had no labels, and later minced garlic and toasted bread were observed in the refrigerator without an expiration date or employee number. The HEC, a cook, and the RDN all confirmed that transferred food items should be labeled with the date of expiry and employee number.
Confidential resident information was left visible on an unattended laptop during medication administration. An RN took medications from the cart, entered the activity room, and administered meds to a resident while the laptop on the cart remained open and displayed the resident's EHR. Three staff members, including housekeeping, had the opportunity to view the screen. The RN later confirmed the laptop should not have been left open, and the DON agreed the resident's confidential information should have been secured.
A medication cart was observed unattended and unlocked during med pass while an RN administered medications to multiple residents. Multiple staff were in the hallway with access to the cart, and the RN confirmed the cart should have been locked while unattended. Facility policy stated all medications on all units shall be locked securely.
Failure to Review Infection Prevention Policies Annually: The facility failed to ensure its IPCP was reviewed annually. During an interview, the IP reviewed internal policy records and confirmed that the Hospital-Wide Infection Prevention plan, LTC Antimicrobial Stewardship Program, and Infection Surveillance and Prevention policies had not been reviewed within the required 12-month timeframe, and the RCQCO was made aware of the lapse.
The facility failed to ensure proper sanitization in the kitchen, using expired test strips and not maintaining the required dishwasher rinse temperature. The dishwasher's thermometer was broken, and logs showed inadequate temperatures without corrective actions, risking foodborne illnesses for residents, staff, and visitors.
A resident experienced a decline in ADLs, requiring more assistance with mobility and dressing. Despite these changes being documented in MDS assessments, the facility failed to submit a Significant Change in Status assessment to CMS within the required timeframe. The MDS Coordinator confirmed the oversight during an interview.
The facility inaccurately documented the health status of two residents. One resident was incorrectly noted as taking insulin, while another was wrongly identified as having Alzheimer's Disease instead of severe vascular dementia. These errors were confirmed by the MDS Coordinator and could potentially affect all residents if not addressed.
The facility failed to develop and implement comprehensive care plans for two insulin-dependent diabetic residents. One resident had her diabetes care plan discontinued and not re-initiated after a stroke, while another resident's care plan was outdated with no active interventions. This deficiency placed both residents at risk for a decline in their quality of life.
A resident with a history of falls and a recent stroke was not provided with adequate safety measures during transfers. Despite requiring maximum assistance and being unable to bear weight, staff attempted a manual transfer without using a mechanical lift, as required by facility policy. Additionally, the resident's care plan did not address her mobility and transfer needs.
The facility failed to ensure medications were labeled according to professional standards, leading to discrepancies between pharmacy labels and provider orders. A nurse was observed preparing medications with outdated hold parameters for two residents, despite changes in orders over a month prior. The facility's policy requires verification of orders, highlighting a lapse in ensuring accurate medication labeling.
Unlabeled Food Stored in Kitchen and Refrigerator
Penalty
Summary
The facility failed to ensure safe storage of perishable foods. During an initial kitchen observation, two plastic containers in the walk-in pantry held curly egg noodle and dried shiitake mushroom, and neither container had labels. The Hospital Executive Chef confirmed that once original food packages are opened and contents are transferred to plastic containers, the containers should be labeled with the date of expiry and the employee number of the staff member who printed the label. During a follow-up observation, minced garlic was seen in a plastic container inside the refrigerator without a proper label, including no expiration date or staff employee number. Toasted bread was also stored in a pan covered with clear plastic wrap in the refrigerator with no label, including no employee number and no date. A cook stated that the containers should have the date of expiry written on them and the staff employee number once the package was opened. The Regional Director of Nutrition later confirmed that food transferred from original packaging to another container should be labeled with an expiration date and employee number, and the facility policy titled Food Preparation and Storage states that items will be labeled with the date and food service employee number.
Confidential Resident Information Left Visible on Unattended Laptop
Penalty
Summary
The facility failed to protect confidential health information for one resident during medication administration. On 02/26/26 at 07:44 AM, RN 2 took medications from the medication cart in the hallway, entered the activity room, and administered medications to R6 while the laptop computer on top of the medication cart was left open and unattended, displaying R6's confidential health information from the resident's EHR. During this time, three staff members, including non-direct care staff such as housekeeping, had the opportunity to view the information. After administering the medication to R6, RN 2 returned to the medication cart to prepare the next resident's medications and then signed off, locking the laptop computer before walking away. At 07:46 AM, RN 2 returned to the cart and confirmed the laptop should not have been left open to protect the resident's confidential health information. On 02/27/26 at 08:54 AM, the DON was informed of the observation and confirmed the laptop should have been secured and the resident's confidential health information safeguarded and protected. The facility policy titled Confidentiality/Privacy, effective 02/10/26, stated that the patient record shall be maintained at all times by keeping the record closed when not in use and ensuring no other individual can read the screen and logging off the computer when not in use.
Unattended Medication Cart Left Unlocked During Med Pass
Penalty
Summary
The facility failed to ensure safe storage of medications when a medication cart was observed unattended, unlocked, and accessible during medication administration. During observation of RN2 administering medications to multiple residents, RN2 prepared medications for a resident and then left the medication cart unlocked while walking away to administer the medications. Multiple staff were observed in the hallway with the opportunity to access the medications in the cart. When asked after the medication pass, RN2 confirmed the cart had not been locked before being left unattended and stated it should have been locked while unattended. The facility policy for Medications Security Maintenance on Nursing Units stated that all medications on all units shall be locked securely.
Failure to Review Infection Prevention Policies Annually
Penalty
Summary
The facility failed to ensure its Infection Prevention Control Program (IPCP) was reviewed annually. During an interview on 02/26/26 at 02:20 PM with the Infection Preventionist (IP) and the Regional Chief Quality and Compliance Officer (RCQCO) in the IP's office, surveyors asked when the Hospital-Wide Infection Prevention (Influenza, Pneumococcal and COVID Prevention Plan), Infection Control (LTC Antimicrobial Stewardship Program), and the Hospital-wide Infection Prevention (Infection Surveillance and Prevention) policies were last reviewed. The IP reviewed the facility's internal policy review records and confirmed that the annual review of these policies and procedures had not yet been completed, and that more than 12 months had passed since the last review. The RCQCO was present during the review and became aware that these policies and procedures had not been reviewed annually as required.
Deficiency in Kitchen Sanitization Practices
Penalty
Summary
The facility failed to ensure proper sanitization practices in the kitchen, leading to a deficiency in food safety standards. During an inspection, it was observed that the kitchen staff used expired Hydrion test strips to test the sanitizer level in the three-compartment sink, which is crucial for ensuring the effective cleaning and sanitization of dishware. Additionally, the kitchen dishwasher was not maintaining the required rinse temperature of 180 degrees Fahrenheit, as recommended by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code. The temperature logs for the dishwasher showed that the rinse cycle was recorded as 'P2' instead of the actual temperature, indicating a lack of proper monitoring and documentation. The inspection revealed that the thermometer on the dishwasher was broken, and maintenance staff had not yet replaced the necessary parts to fix it. The booster thermometer showed a temperature of 170 degrees Fahrenheit, which is below the required level for heat sanitization. The facility's dishwashing policy mandates that the supervisor maintain a temperature log to ensure compliance with established standards, but the logs from August and September showed temperatures below the required level without any corrective actions or notifications to maintenance. This deficiency in following proper sanitization practices put all residents, staff, and visitors at risk for foodborne illnesses.
Failure to Report Significant Change in Resident's Condition
Penalty
Summary
The facility failed to identify and report a significant change in condition for a resident within the required 14-day period. The resident, identified as R11, experienced a decline in activities of daily living (ADLs), including progressing from limitations in one lower extremity to both lower extremities, requiring substantial/maximal assistance with upper body dressing, and needing more assistance to roll left and right. These changes were noted in the resident's Minimum Data Set (MDS) assessments dated 01/28/24, 04/26/24, and 07/21/24, but a Significant Change in Status assessment was not submitted to the Centers for Medicare and Medicaid Services (CMS). The Minimum Data Set Coordinator confirmed the oversight during an interview, acknowledging that the significant change in the resident's ADLs should have been reported to CMS.
Inaccurate Resident Health Documentation
Penalty
Summary
The facility failed to accurately document the health status of two residents, which was identified during a record review and interview process. Resident 20 was incorrectly documented as taking insulin for one day in her Minimum Data Set (MDS) Admission assessment, despite no insulin orders being found in her Electronic Health Record (EHR). The Minimum Data Set Coordinator (MDSC) confirmed this was an error, possibly confusing it with another injection such as an immunization. Additionally, Resident 11 was inaccurately documented as having Alzheimer's Disease in her MDS Quarterly review, although her EHR indicated a diagnosis of severe vascular dementia without behavioral, psychotic, mood, or anxiety disturbances. The MDSC confirmed this was an error after reviewing the resident's MDS. These documentation errors have the potential to affect all residents if their health status is not correctly identified.
Failure to Implement Diabetes Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a resident-centered Comprehensive Care Plan (CP) for two residents who are insulin-dependent diabetics. Resident 5, a female with insulin-dependent diabetes and chronic kidney disease, had her diabetes care plan discontinued on June 4, 2024, and no active care plan was in place at the time of her stroke on August 5, 2024. Despite an entry for a diabetes care plan on August 15, 2024, it was never initiated, leaving her without an active plan. The MDS Coordinator confirmed the absence of an active diabetes care plan and stated that any licensed staff could initiate or discontinue care plans, but she reviews them every 90 days. Resident 1, who also receives daily insulin, did not have a current diabetes care plan. The MDS Coordinator provided a copy of Resident 1's care plan, which showed that the diabetes care plan was last updated in August 2023, with outcomes and interventions either discontinued or met. The lack of an active diabetes care plan for both residents placed them at risk for a decline in their quality of life and prevented them from attaining their highest practicable well-being.
Failure to Ensure Safe Transfers for Resident with Mobility Needs
Penalty
Summary
The facility failed to ensure that a resident, who had a history of falls and a recent stroke leading to functional decline, was free from accident hazards. The resident required maximum assistance for transfers due to right lower extremity weakness and was at an increased risk of falls. During an observation, two CNAs attempted to transfer the resident from her bed to a shower chair without lowering the bed sufficiently for her feet to touch the floor, which could have led to an avoidable fall. The CNAs did not use a mechanical lift, despite the resident's inability to bear weight, and instead performed a manual transfer. The facility also failed to develop and implement a comprehensive care plan addressing the resident's mobility and transfer needs. The resident's care plan did not include interventions for activities of daily living, such as transferring. The facility's policy required the use of mechanical lifts for residents who cannot assist with transfers, but this was not followed. Interviews with staff revealed a lack of consistent practice in using mechanical lifts, and the staff relied on manual transfers even when the resident could not assist, contrary to the facility's policy.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all medications were labeled in accordance with professional standards, which is necessary to promote safe administration practices and decrease the risk of medication errors. During a medication pass observation, a registered nurse (RN6) was seen preparing medications for a resident with low blood pressure. The Metolazone and Furosemide medications had labels with outdated parameters for holding the medication based on systolic blood pressure (SBP). The labels did not match the provider's orders, which had been changed over a month prior. The nurse confirmed that the medication blister packs were sent from the pharmacy after the order changes, but could not explain the discrepancy. Another observation involved the preparation of Losartan for a resident with a blood pressure reading of 145/58. The medication label indicated a hold parameter for SBP less than 100, whereas the original order specified a hold for SBP less than 110, and this parameter had never been changed. The nurse confirmed that the medication blister pack was sent from the pharmacy after the original order date, yet the label did not match the provider's order. The facility's Medication Administration policy requires the RN to verify orders in the Electronic Medical Record (EMR) and the pharmacist to independently verify the physician's order, indicating a failure in the process of ensuring accurate medication labeling.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waimea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kauai Care Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Hale Kupuna Heritage Home, Llc | 11.8 mi | ★★★★★ | 13 | 0 |
| Garden Isle Healthcare And Rehabilitation Center | 19.3 mi | ★★★★★ | 0 | 0 |
| Samuel Mahelona Memorial Hospital | 24.7 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.