Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Kula Hospital during CMS and state inspections, most recent first.
The facility failed to report two incidents to APS as required by law. One resident was found with large forearm lacerations, and another was diagnosed with a broken finger, both with unknown origins. The facility's internal investigations did not substantiate abuse, leading to a failure to report these incidents to APS, resulting in a deficiency in the facility's reporting protocol.
A resident with dementia suffered physical injuries due to inappropriate handling by a CNA, while another resident with an intellectual disability experienced non-consensual sexual contact from a fellow resident. Despite having policies in place, the facility failed to protect these residents from abuse.
The facility did not have a full-time Director of Nursing (DON) dedicated to the LTC facility. The same staff member served as the DON for the LTC, CAH, and ICF/IID facilities, each with distinct certification and licensing requirements. During an interview, the DON and Administrator confirmed the lack of a waiver for a full-time DON. The LTC facility had 105 beds with 89 occupied, while the CAH and ICF/IID had 9 beds each, with varying occupancy.
The facility failed to adhere to professional standards for food storage, leading to deficiencies observed by surveyors. Improperly stored beef patties and sweet yams were found in the kitchen, while expired and unlabeled food items were discovered in the nutrition room and small kitchen. The Food Service Manager and staff acknowledged these issues, which violated the facility's food storage policies.
The facility failed to secure storage rooms on the second and fourth floors, where hazardous chemicals were kept, placing residents at risk. On the second floor, the clean utility room was unlocked, with liquid bleach and dish soap inside, and the keys were missing. On the fourth floor, the soiled utility room was unsecured, containing a cleaning solution labeled as harmful. The DON confirmed the need for locked storage, and the CN acknowledged the oversight.
Two residents experienced a lack of dignity and timely assistance in an LTC facility. One resident faced long waits for toileting help, leading to soiling incidents, despite notifying the nursing supervisor. Another incident involved a hospital aide using disrespectful language, referring to a resident as a "feeder". These actions violated the facility's Resident Rights policy.
A resident and her representative were not involved in the care plan development due to a lack of notification for a care conference. The resident reported not attending a meeting for months, and records confirmed no documentation of her or her representative's presence at a recent conference. The facility's process requires notification and documentation, which was not followed.
A facility failed to ensure proper interventions for a resident with a pressure ulcer on the left heel. Despite a care plan requiring repositioning every two hours and floating of feet/heels, documentation was inconsistent, with numerous missed entries in the Treatment Administration Record over several months. This deficiency was confirmed by staff interviews, indicating a potential risk for all residents needing repositioning.
A nurse administered a laxative to a resident who had a large, watery bowel movement earlier, failing to check the bowel movement spreadsheet as required. The nurse also did not document medication administration promptly, contrary to facility policy, placing residents at risk for health declines.
A resident on anticoagulant therapy for atrial fibrillation was not adequately monitored for bleeding signs, as required by their care plan. Despite instructions to assess and report bleeding symptoms, no documentation was found in the MAR or progress notes. The DON confirmed the monitoring should have been documented every shift.
A facility failed to follow proper infection control practices during a wound dressing change. An RN was observed wearing two pairs of gloves and not performing hand hygiene between glove changes, contrary to facility policy. The Infection Preventionist confirmed the breach, noting the absence of a specific dressing change policy.
A facility did not follow the manufacturer's maintenance schedule for a Perfecto2 V Oxygen Concentrator used by a resident. The cabinet filter, observed to have lint and/or dirt, was cleaned monthly instead of the recommended weekly schedule. The DON acknowledged the oversight, which put the resident at risk for communicable diseases and infections.
Failure to Report Incidents to APS
Penalty
Summary
The facility failed to report two incidents that met the criteria for reporting to the Department of Human Services, Adult Protective Services (APS) as required by law. The first incident involved a resident who was found with two large forearm lacerations and bruising, with no known origin. The facility conducted an internal investigation and concluded that the injury was the result of an accident during patient repositioning. However, the facility did not report the incident to APS, as they believed the investigation did not substantiate abuse. The second incident involved another resident who was diagnosed with a broken finger. The resident alleged that the injury was caused by a CNA pulling on his hand. The facility's investigation suggested that the injury likely occurred when the resident was swinging a toy at the CNA, which struck the bedside table multiple times. Despite the resident's allegations and the severity of the injury, the facility did not report this incident to APS either. Both incidents highlight a deficiency in the facility's reporting protocol, as they failed to notify APS of potential abuse or neglect. The facility's policy requires that any alleged incident be reported to APS, but in both cases, the facility did not comply with this requirement. This resulted in the State Agency not being aware of the incidents and not conducting external investigations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of two residents, R1 and R2, from abuse. R1, a male resident with a history of dementia, bipolar disorder, and depression, suffered physical injuries on June 11, 2024, when a CNA did not appropriately respond to his aggressive behavior. The CNA continued to interact with R1, resulting in bruising and scratches on his forehead, temple, and chest. The CNA claimed the injuries were accidental, occurring while she was defending herself from R1's aggression. However, the injuries were inconsistent with her account, and there were no witnesses to the incident. In a separate incident, R2, a female resident with an intellectual disability and legal blindness, was subjected to non-consensual sexual contact by another resident, R3, on August 10, 2024. A staff member witnessed R3 with his hand inside R2's blouse, and R2 was unable to consent due to her condition. The facility conducted an investigation, and the allegation of abuse was substantiated. R3 was provided with 1:1 supervision and later transferred to a different unit to prevent further incidents. The facility had policies and procedures in place for preventing and reporting abuse, including mandatory staff education and background checks. Despite these measures, the incidents occurred, indicating a failure in protecting residents from abuse. The facility followed its policy by removing the alleged perpetrators and notifying the appropriate authorities, but the deficiencies highlight a lapse in ensuring resident safety.
Failure to Provide Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide a Director of Nursing (DON) on a full-time basis, as required. The same staff member was serving as the DON for three separate facilities: the long-term care (LTC) facility, the Critical Access Hospital (CAH), and the Intermediate Care Facility for the Intellectually Disabled (ICF/IID). Each of these facilities has its own specific certification and licensing requirements. During an entrance interview for the CAH recertification, the DON confirmed her full-time employment status and her role as the DON for all three facilities. Both the DON and the Administrator acknowledged that they did not have a waiver for a full-time DON. A review of the Office of Health Care Assurance (OHCA) Licensed Beds and Location form indicated that the CAH had 9 beds with 4 occupied, the LTC facility had 105 beds with 89 occupied, and the ICF/IID facility had 9 beds, all occupied. This staffing arrangement did not meet the regulatory requirement for a full-time DON dedicated to the LTC facility.
Deficiencies in Food Storage and Expired Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, posing a risk of foodborne illness to residents. During an inspection, surveyors observed several deficiencies in food storage practices. In the kitchen, a standing freezer contained a small metal pan of beef patties that were poorly covered with plastic wrap, visibly freezer burned, and intended for resident consumption. The Food Service Manager (FSM) acknowledged the improper storage and removed the patties for disposal. Additionally, in the walk-in refrigerator, a large metal pan of sweet yams was stored next to a pan of raw meat, both loosely covered with plastic wrap. The FSM initially justified the storage arrangement but later acknowledged that the yams were ready-to-eat food and should not have been stored next to raw meat. Further observations revealed expired and unlabeled food items in the third-floor nutrition room and the fourth-floor small kitchen room. The fridge contained yogurt and ice cream past their expiration dates, and the freezer had an English muffin breakfast sandwich without an expiration date. Charge Nurse 1 confirmed that these items should have been discarded. On the fourth floor, six packets of tea bags were found to be expired, and the Dietitian acknowledged they should have been removed. The facility's policies on food storage and monitoring were not adhered to, leading to these deficiencies.
Failure to Secure Hazardous Chemical Storage
Penalty
Summary
The facility failed to secure storage rooms on the second and fourth floors where hazardous chemicals were kept, placing residents at risk for accident hazards. On the second floor, the clean utility room door was observed to be unlocked, and hazardous chemicals such as liquid bleach and dish soap were found inside. The keys to the room, which were supposed to be kept in a small keypad lock container outside the door, were missing. The Director of Nursing confirmed that all hazardous chemicals need to be stored in a locked cabinet or room. On the fourth floor, the soiled utility room was also found to be unsecured, with no staff present to prevent unauthorized entry. The room contained a bottle of cleaning solution labeled as an eye irritant and harmful if swallowed. The Charge Nurse acknowledged that the room should have been locked and stated that it would be secured immediately.
Failure to Uphold Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect, which negatively impacted their quality of life. One resident, an elderly individual with functional mobility and self-care deficits related to lower extremity weakness, morbid obesity, and osteoarthritis, reported experiencing long waits for assistance with toileting. This resident expressed frustration over having to wait up to three hours for help, resulting in instances where they soiled themselves before staff could assist. Despite bringing this concern to the attention of the nursing supervisor, the issue persisted, indicating a lack of timely response to the resident's needs. Another incident involved a hospital aide referring to a resident as a "feeder" in the dining room, which was deemed disrespectful and not in line with the facility's policy on treating residents with dignity. The aide later acknowledged the inappropriate language and expressed regret, stating that they should have used a more respectful term. These incidents highlight the facility's failure to uphold the residents' rights to dignity and respect, as outlined in their own Resident Rights document.
Failure to Involve Resident and Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure the participation of a resident and her representative in the development and review of the resident's care plan. The resident, a [AGE] year-old female, reported not attending a care conference meeting for months and could not recall having one in the past year. She mentioned that her son, who is her representative, would have attended if notified. A review of her medical records showed a care conference meeting was held, but there was no documentation of the resident or her representative's presence. Further investigation revealed that the facility's process involves the social worker notifying the resident's representative of the care conference date and time, and documenting the representative's response. However, the Minimum Data Set Coordinator and the Director of Nursing confirmed that there was no documentation indicating that the resident's representative was notified of the care conference. This lack of documentation and notification is contrary to the facility's established process, as outlined in their IDT Process document.
Failure to Document and Implement Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement and document necessary interventions to prevent or improve pressure ulcers for a resident, identified as R50. Observations and record reviews revealed that R50, who had contractures in both lower extremities and was using an air mattress, had a pressure ulcer on the left heel that had reopened. The care plan required staff to reposition the resident every two hours and ensure the feet/heels were floated at all times. However, documentation in the Treatment Administration Record (TAR) for March, April, and May 2024 showed numerous missed entries, indicating that staff did not consistently document the floating of R50's feet/heel as required. The deficiency was further highlighted during interviews with RN2 and Nursing Supervisor (NS) 1, who confirmed that the expectation was for staff to document these interventions every shift. Despite this expectation, the logs for March and April 2024 were incomplete, with several missed entries, and the logs for May 2024 showed a total of 30 missed entries across all shifts. This lack of documentation and adherence to the care plan interventions potentially affected all residents dependent on staff for repositioning, as it indicated a systemic issue in ensuring proper pressure ulcer prevention and care.
Nurse Competency and Documentation Deficiencies in Medication Administration
Penalty
Summary
The facility failed to ensure nurse competency in medication administration, as evidenced by a registered nurse administering a laxative to a resident who had already experienced a large, watery bowel movement earlier that morning. The nurse did not check the bowel movement spreadsheet before administering the medication, despite a physician's order to hold the laxative in the event of loose stools. The nurse admitted to not checking the spreadsheet and relied on certified nurse aides to report bowel movements, which did not occur in this instance. Additionally, the nurse did not document the administration of medications in a timely manner. During a medication pass observation, it was noted that none of the medications given to the resident that morning were documented as administered. The nurse stated that she signs off on the medication administration record (MAR) after administering all medications to all residents, which is contrary to the facility's policy that requires immediate documentation. The nurse also failed to document the administration of the laxative the previous day, acknowledging that she missed it.
Failure to Document Monitoring of Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure adequate monitoring for a resident who was on anticoagulant therapy, specifically Apixaban, which is used to treat and prevent blood clots. The resident, who had a diagnosis of atrial fibrillation, was at risk for bleeding complications due to the lack of documented monitoring for signs and symptoms of bleeding. The care plan for the resident included instructions to assess, record, and report any signs of bleeding to the medical doctor, but there was no documentation found in the resident's chart to confirm that this monitoring was being conducted. During an interview and record review with a registered nurse and a nurse supervisor, it was revealed that the monitoring was supposed to occur every shift and be documented in the medication administration record (MAR). However, no such documentation was found in the MAR or the progress notes. The Director of Nursing confirmed that the monitoring should have been documented every shift, indicating a lapse in the facility's adherence to the care plan and documentation protocols.
Infection Control Breach During Wound Dressing Change
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during a wound dressing change for a resident. On the observed date, a registered nurse (RN) was seen changing the dressing of a resident's left foot wound. The RN gathered supplies, performed hand hygiene, and donned a gown and gloves before starting the procedure. However, after removing the old dressing, the RN was found to be wearing two pairs of gloves on each hand, which is against the facility's protocol. The RN then proceeded to clean the wound and apply ointment without performing hand hygiene between glove changes, which is a critical step in preventing the spread of infection. During an interview with the Infection Preventionist (IP) and the Director of Nursing (DON), it was confirmed that the facility's policy does not allow for wearing two pairs of gloves and requires hand hygiene between glove changes. The IP acknowledged the lack of a specific policy for dressing changes, although a hand hygiene policy was in place. The document provided by the facility outlined the correct procedure for wound dressing application, which includes performing hand hygiene and changing gloves at specific steps, but these were not followed by the RN during the observed dressing change.
Failure to Follow Maintenance Schedule for Oxygen Concentrator
Penalty
Summary
The facility failed to adhere to the manufacturer's recommended maintenance schedule for the cabinet filter of a Perfecto2 V Oxygen Concentrator, which was used by a resident. During an observation, it was noted that the cabinet filter of the oxygen concentrator appeared to have lint and/or dirt. The Director of Nursing (DON) stated that the cabinet filter was cleaned once a month, contrary to the service manual's recommendation of at least once a week. The DON acknowledged a previous change in oxygen concentrator equipment, which may have contributed to the oversight. This deficiency put the resident at risk for the development and transmission of communicable diseases and infections.
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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 Kula
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hale Makua - Kahului | 14.5 mi | ★★★★★ | 13 | 0 |
| Hale Makua - Wailuku | 15.7 mi | ★★★★★ | 3 | 0 |
| Lanai Community Hospital | 37.2 mi | ★★★★★ | 7 | 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.