Waimea, HI

Kauai Veterans Memorial Hospital

2-star overall rating with 1-star inspections with Special Focus status with $34,300 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

4643 Waimea Canyon Drive, Waimea, HI

(808) 338-9431

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

20

Certified beds

Average residents

21

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Hawaii Health Systems Corporation

Operator or chain grouping

Approved since

1973-04-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.54

Registered nurse staffing

LPN hours / resident day

0.09

Licensed practical nurse staffing

Aide hours / resident day

0.88

Nurse aide staffing

Weekend hours

1.24

Weekend nurse staffing

RN turnover

13%

Annual RN turnover

Total nurse turnover

10%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
96.3%
3.7 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95.0%
95.4%
0.4 pts worse
95.5%
0.5 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 0.0%
1.9%
1.9 pts better
3.3%
3.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.0%
1.4%
1.4 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 2.8%
4.9%
2.1 pts better
5.4%
2.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 11.3%
8.2%
3.1 pts worse
19.6%
8.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 9.7%
11.3%
1.6 pts better
16.7%
7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.3%
0.3 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 11.7%
23.4%
11.7 pts better
16.3%
4.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 25.5%
16.8%
8.7 pts worse
14.9%
10.6 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.0%
1.3%
0.3 pts better
1.0%
About the same
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 1.3%
2.4%
1.1 pts better
1.7%
0.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 6.5%
17.8%
11.3 pts better
19.8%
13.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 1.1%
3.6%
2.5 pts better
5.1%
4 pts better
Long Stay · 2024Q4-2025Q3

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-10 · Fire 2024-09-10

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-09-22 · Fire 2023-09-22

4 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-09-02 · Fire 2022-09-02

11 health deficiencies

Top issue: Resident Rights (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-09-10

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-10-31

B · Minimal harm 2024-09-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-01

Inspection history

Recent health citations

L · Immediate jeopardy 2024-09-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-10-14

D · Potential for more than minimal harm 2024-09-10

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2024-10-14

D · Potential for more than minimal harm 2024-09-10

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-14

D · Potential for more than minimal harm 2024-09-10

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-10-14

D · Potential for more than minimal harm 2024-09-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-24

D · Potential for more than minimal harm 2024-09-10

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-10-14

F · Potential for more than minimal harm 2023-09-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-11-02

D · Potential for more than minimal harm 2023-09-22

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-11-06

D · Potential for more than minimal harm 2023-09-22

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2023-10-31

D · Potential for more than minimal harm 2023-09-22

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-11-06

G · Actual harm 2022-09-02

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-10-14

F · Potential for more than minimal harm 2022-09-02

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-11-24

E · Potential for more than minimal harm 2022-09-02

F574 · Resident Rights Deficiencies

Health

The resident has the right to receive notices in a format and a language he or she understands.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-02

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-02

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2022-09-02

E · Potential for more than minimal harm 2022-09-02

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-10-14

E · Potential for more than minimal harm 2022-09-02

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-10-14

E · Potential for more than minimal harm 2022-09-02

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-09-06

D · Potential for more than minimal harm 2022-09-02

F568 · Resident Rights Deficiencies

Health

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected 2022-09-29

D · Potential for more than minimal harm 2022-09-02

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2022-10-05

D · Potential for more than minimal harm 2022-09-02

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-09-09

Penalties and ownership

What sits behind the stars

$34,300 2024-09-10

Fine

Fine · fine $34,300

Fine

Ownership

Kauai Veterans Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 1996-07-01
Hawaii Health Systems Corporation

5% Or Greater Indirect Ownership Interest · Organization

20% 6 facilities 1996-07-01
Asato, Christine

Operational/Managerial Control · Individual

0% 2 facilities 2018-04-01
Asato, Christine

Corporate Officer · Individual

0% 2 facilities 2018-04-01
Franklin, Nicholas

Operational/Managerial Control · Individual

0% 2 facilities 2022-08-16
Segawa, Lance

Operational/Managerial Control · Individual

0% 2 facilities 2018-04-01
Segawa, Lance

Corporate Officer · Individual

0% 2 facilities 2018-04-01

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