Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Samuel Mahelona Memorial Hospital during CMS and state inspections, most recent first.
A resident with advanced dementia and a recent hip fracture was placed on 1:1 monitoring after a prior fall, but staff did not remain continuously with her and instead tagged other staff or worked other assignments. The resident later had an unwitnessed fall from her wheelchair, and subsequent x-rays showed a new right greater trochanter fracture with ongoing pain and difficulty ambulating. Interviews with CNA staff and the DON confirmed the 1:1 coverage was not consistently maintained and that the facility had no policy for 1:1 monitoring for fall prevention.
Failure to develop individualized dementia care plans for three residents was identified. Two residents with dementia diagnoses and psychotropic medication use had no dementia care plans in their EHRs, and a third resident coded with non-Alzheimer's dementia on the MDS also lacked a dementia care plan; the DON confirmed the omissions and stated the plan should have been included.
Food Storage and Ice Machine Sanitation Deficiencies: Surveyors observed expired uncooked rice and multiple expired, unlabeled food items in the walk-in freezer, and the HEC confirmed food containers should be properly labeled and expired food discarded. Surveyors also observed hardened brown sediment on the kitchen ice machine; the HEC stated an outside vendor was responsible for PM and cleaning, but the PM log showed no 2026 PM documented.
A resident was prescribed trazodone 50 mg every morning, but the EHR contained no documented informed consent before the medication was given. The DON confirmed the facility did not obtain consent for the trazodone administration.
Failure to provide required discharge/transfer notification. A resident was transferred and discharged to the hospital, but the facility could not locate a written discharge/transfer notice for the resident, the resident's representative, or the Ombudsman. The DON confirmed the notice was not provided, despite facility policy requiring notice to the resident and representative and a copy to the Hawaii LTC Ombudsman.
Unlocked medication and treatment carts were left unattended in the hallway. An RN left a treatment cart unsecured after retrieving a band aid for a resident's wound, and an LPN left a medication cart unlocked after responding to a resident who yelled for help. The DON confirmed carts should always be locked when not in use, and facility policy required medications and supplies to remain locked when unattended.
A facility failed to provide required education and the CDC VIS about influenza vaccine benefits, risks, and potential side effects before obtaining consent or declination from five residents or their representatives. Record review showed four residents consented to the vaccine and one resident declined, but all five forms indicated education had not been provided; the IP confirmed the requirement was in facility policy.
A resident’s COVID-19 vaccine consent form showed consent was obtained, but staff marked that education and the CDC VIS about the vaccine’s benefits, risks, and potential side effects were not provided before consent. The IP stated she tracks vaccine dates but was not aware nurses were documenting no education, and confirmed the resident or representative is to receive the education and CDC sheet per facility policy.
The facility failed to manage food storage and disposal properly, with expired mustard and milk found during a kitchen inspection. Additionally, a box of peas and carrots was improperly stored on the floor of the walk-in freezer, violating the facility's policy. The Hospital Executive Chef acknowledged these issues and removed the items.
A resident was found in an LTC facility with a blanket covering his entire body due to cold air blowing directly onto him from the AC. The resident and his family member reported the room was too cold, and the DON confirmed the temperature was colder than the set 72 degrees Fahrenheit. The air from the AC was strong enough to move privacy curtains, and the resident expressed discomfort, stating it caused him a headache.
A facility failed to discard expired Melatonin medication stored in a medication cart for a resident, potentially placing residents at risk. During an inspection, a registered nurse confirmed the expired medication should have been removed. The resident's MAR documented the administration of expired Melatonin tablets, with the last dose given the previous night. The facility's pharmacy policy requires outdated medications to be immediately removed and disposed of, which was not adhered to.
A facility failed to ensure a resident's preferences on the Advance Health Care Directive (AHCD) were accurately documented on the Physician Order for Life-Sustaining Treatment (POLST). The resident's AHCD indicated a preference for life-prolonging treatment, but the POLST stated Do Not Resuscitate (DNR). This inconsistency was confirmed by the resident's physician, who found no additional documentation explaining the discrepancy, placing residents at risk for more than minimal physical harm.
Inadequate supervision during one-to-one monitoring led to an unwitnessed fall and hip fracture
Penalty
Summary
The facility failed to provide adequate supervision to prevent an accident for one resident who had been placed on one-to-one monitoring after a prior fall and right hip surgery. The resident had advanced dementia, was a medium fall risk at the time of the first fall, and had a floor alarm that was not heard because the room door had to be closed due to COVID isolation. After returning to the facility following surgical repair of an acute comminuted right femoral neck fracture, the resident remained on one-to-one monitoring because of her fall history and need for standby assistance. On 07/14/25, the resident had an unwitnessed fall from her wheelchair when she attempted to stand. Facility staff later reported that the resident was sitting in her wheelchair with footrests on when a loud thud was heard and she was found on the floor. Interviews with CNAs and the DON showed that the staff assigned to one-to-one monitoring did not remain continuously with the resident. CNA62 stated she was not actually assigned one-to-one that day, had a regular caseload, and had tagged RN29 to take over so she could go home. CNA47 also confirmed she worked as one of the one-to-one staff but did not remember who relieved her, and both CNAs denied being with the resident when she fell. The DON stated the CNAs assigned to the resident were also helping on the floor because of a COVID outbreak and that staff would tag another staff member to watch the resident, especially near the end of the shift. The DON confirmed the facility did not have a policy for one-to-one monitoring for residents being monitored for falls and acknowledged the staff should have waited for the next shift to hand off care. After the fall, the resident later complained of pain with ambulation, and repeat x-rays showed a new slightly displaced fracture of the right greater trochanter that appeared new since the prior x-ray. The record also documented ongoing pain and difficulty ambulating after the fall.
Failure to Develop Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized dementia care plans for three residents reviewed for dementia care: R4, R6, and R7. R6, a female admitted for LTC with diagnoses including high blood pressure, vascular dementia, type 2 diabetes, and motor speech disorder, was prescribed psychotropic medications and had a dementia diagnosis, but her EHR contained no care plan related to dementia care. On 05/13/26, the DON confirmed that R6 did not have a dementia care plan. R4 was admitted with diagnoses including dementia with mood disturbance, major depressive disorder, borderline personality disorder, and obstructive sleep apnea. Her EHR showed she was prescribed psychotropic medications and had a dementia diagnosis, but no dementia care plan was found. On 05/13/26, the DON confirmed that R4 did not have a dementia care plan. R7's record showed diagnoses including peripheral neuropathy, atrial fibrillation, and chronic constant pain due to injury, and his MDS coded him as having active non-Alzheimer's dementia. When a printed copy of R7's dementia care plan was requested, the DON provided other care plans but stated R7 did not have a care plan for dementia care and confirmed it should have been included.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to store and label food in accordance with professional standards for food service safety. During an initial tour of the kitchen on 05/11/26 at 08:29 AM, surveyors observed a large plastic container of uncooked rice with an expired use-by label dated 04/07/26. Multiple food items stored in the walk-in freezer were also observed to be expired and without proper labels. When asked about labeling food after transfer from original containers and discarding expired foods, the Hospital Executive Chef confirmed that food containers should be properly labeled and expired food should be discarded. The facility also failed to keep the kitchen ice machine in a clean and sanitary condition. During continued observation on 05/11/26 at 08:37 AM, surveyors observed a buildup of hardened brown sediment/material around the bottom edge and side panel of the ice machine. The Hospital Executive Chef stated that an outside vendor, [NAME] Refrigeration Kauai, was responsible for preventive maintenance and cleaning of the ice machine and that the vendor had been scheduled to perform this work in February 2026 but rescheduled it for 05/11/26 due to staffing issues. The kitchen ice machine quarterly PM log showed preventive maintenance was completed on 08/12/25 and 11/17/25, with no PM documented for 2026.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident or the resident representative was informed of treatment and provided consent for the use of psychotropic medication for one resident, R40, who was reviewed for unnecessary medications. Review of R40’s physician orders showed trazodone, an antidepressant medication, 50 mg every morning beginning on 11/10/25. Review of the resident’s EHR showed no documented informed consent for trazodone 50 mg before the medication was administered. During an interview on 05/13/26 at 02:01 PM, the DON confirmed that the facility did not obtain consent for the administration of trazodone 50 mg.
Failure to Provide Required Discharge/Transfer Notification
Penalty
Summary
The facility failed to ensure that the discharge/transfer form was provided to the resident, the resident's representative, and the Ombudsman for one resident, R49. Record review showed that R49 was transferred and discharged to the hospital on [DATE] at 11:39 AM, but a written discharge/transfer notification could not be located in the EHR or provided by the DON. During an interview on 05/13/26 at 02:28 PM, the DON confirmed that written notification was not provided to the resident, the resident's representative, or the Ombudsman. The facility policy titled Resident Transfer and Discharge, effective 07/22/25, states that notice of discharge shall be provided to the resident and the resident's representative, and a copy of the notice shall also be provided to the Hawaii LTC Ombudsman at least 30 days prior to discharge.
Unlocked medication and treatment carts left unattended
Penalty
Summary
The facility failed to ensure that medications and treatment supplies were secured when unattended. During medication administration observation on 05/13/26 at 08:34 AM, a treatment cart containing prescribed topical medications and other resident supplies was observed in the hallway unlocked and unsecured. RN24 was asked whether the cart should be locked when not in use or before leaving it to administer medication to residents, and RN24 confirmed it should be locked and secured. RN24 stated the cart had been left unlocked after she grabbed a band aid to apply to a resident's wound. Later that same day at 11:28 AM, a medication cart was observed in the hallway near a resident's room unlocked with no nurses nearby. LPN4 came out of the resident's room and noticed the cart was unlocked, stating she had become distracted when a resident yelled out for help and she went to assist him. LPN4 confirmed she was supposed to lock the medication cart before leaving it. The DON also confirmed that treatment carts should always be locked and secured when not in use. The facility policy on Medication Storage stated that medications must be stored to prevent unauthorized access and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by authorized persons.
Failure to Provide Influenza Vaccine Education Before Consent or Declination
Penalty
Summary
The facility failed to provide education to five residents, or their representatives, regarding the risks and benefits and potential side effects of influenza immunization before obtaining consent or declination for the annual influenza vaccine. Record review showed that for four residents who consented to vaccination, the facility staff marked “No” on the consent/declination forms for having provided education and the CDC Vaccination Information Statement about the vaccine’s benefits, risks, and potential side effects. For one resident who declined vaccination, the form also indicated “No” for having received this education. During interview, the Infection Preventionist stated she tracks the dates of vaccines for all residents but was not aware that nurses were marking the forms this way. She confirmed that the resident or representative is to be given the education and CDC Vaccination Information Statement before consent or declination is obtained, and stated this requirement is included in the facility policy.
COVID-19 Vaccine Education Not Provided Before Consent
Penalty
Summary
The facility failed to provide education to one resident, or the resident’s representative, before offering and obtaining consent for the COVID-19 vaccine. Record review for the resident showed a consent/declination form dated 09/28/25 with consent given for COVID-19 vaccination, but the form also indicated that staff circled “N” for whether education and the CDC Vaccination Information Statement about the benefits, risks, and potential side effects associated with the vaccine had been provided. During interview, the Infection Preventionist stated she tracks vaccine dates but was not aware nurses were marking that education had not been given, and confirmed that the resident or representative is to receive the education and CDC sheet per facility policy.
Deficient Food Storage and Disposal Practices
Penalty
Summary
The facility failed to properly manage food storage and disposal, leading to potential health risks for residents and staff. During an inspection of the kitchen, it was observed that three jars of mustard and an opened jar of mustard in the refrigerator were past their expiration dates. Additionally, ten one-quart jugs of milk in the walk-in refrigerator were also expired. The Hospital Executive Chef (HEC) acknowledged these items were past their expiration dates and removed them. Furthermore, a box of peas and cut carrots was found on the floor of the walk-in freezer, contrary to the facility's policy that food should be stored above floor level to prevent contamination. The HEC confirmed that the staff should have stored the box on shelves or plastic pallets and removed it from the floor.
Resident's Room Temperature Not Maintained at Comfortable Level
Penalty
Summary
The facility failed to maintain a comfortable temperature level for a resident, identified as R12, which compromised the resident's right to a safe and homelike environment. During the survey, it was observed that R12 was lying in bed with a blanket covering his entire body, including his face, due to the cold air blowing directly onto him from the air conditioner (AC). R12's family member, FM3, confirmed that the room was too cold, and R12 had to cover himself to avoid the cold air, even during visits. The Director of Nursing (DON) verified that the temperature in R12's room was colder than the set temperature on the AC controller, and the air blowing from the AC was not at a comfortable level for R12. The surveyor noted that the air from the AC was strong enough to move R12's privacy curtains, indicating a high rate of airflow. Despite the AC being set to 72 degrees Fahrenheit, the air felt colder, and the DON confirmed this discrepancy. R12 expressed discomfort, stating that the cold environment was causing him a headache. The observations and interviews highlighted the facility's failure to ensure a comfortable and safe environment for R12, putting the resident at risk for physical and psychosocial harm.
Expired Medication Not Removed from Medication Cart
Penalty
Summary
The facility failed to discard expired medication stored in the medication cart for one resident, which potentially places residents at risk for more than minimal harm. During an inspection of a medication cart with a registered nurse, an expired bottle of Melatonin, 5 mg, was observed. The bottle was labeled with the resident's name, and the registered nurse confirmed that the expired medication should have been removed from the cart. The resident currently resides in the facility and takes the medication every night. A review of the Electronic Health Record (EHR) showed that the resident's Medication Administration Record (MAR) documented the administration of two expired tablets of Melatonin 5 mg every evening, with the last dose given the previous night. The facility's pharmacy policy and procedure manual states that outdated medications should be immediately removed from stock and disposed of according to procedures, which was not followed in this instance.
Discrepancy Between AHCD and POLST for a Resident
Penalty
Summary
The facility failed to ensure that a resident's preferences documented on the Advance Health Care Directive (AHCD) were accurately reflected on the Physician Order for Life-Sustaining Treatment (POLST). Specifically, the AHCD for Resident 40 indicated a preference for medical treatment to prolong life, while the POLST contradicted this by stating that the resident should not receive Cardiopulmonary Resuscitation (CPR) and was marked as Do Not Resuscitate (DNR). This discrepancy was confirmed during a review of the resident's Electronic Health Records (EHR) and was acknowledged by the facility's Director of Nursing and Administrator. Further investigation involved a concurrent record review and interview with the resident's physician, who confirmed that both the AHCD and POLST were the most current forms and completed by the facility. The physician acknowledged the inconsistency between the two documents and verified that there was no additional documentation in the resident's EHR to explain the discrepancy. This failure to align the POLST with the resident's documented preferences on the AHCD placed residents at risk for more than minimal physical harm.
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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 Kapaa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Isle Healthcare And Rehabilitation Center | 8.4 mi | ★★★★★ | 0 | 0 |
| Hale Kupuna Heritage Home, Llc | 16.1 mi | ★★★★★ | 13 | 0 |
| Kauai Veterans Memorial Hospital | 24.7 mi | ★★★★★ | 8 | 0 |
| Kauai Care Center | 24.7 mi | ★★★★★ | 1 | 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.