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)
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
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
Chain footprint
6 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.09
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
0.88
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
1.51
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
0.63
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
1.24
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
1.69
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
10%
Annual nurse turnover · state 37% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 160 |
| Staff flu vaccination coverage | 46.91% |
42%
4.9 pts better
|
Numerator 76 · Denominator 162 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
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 · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 95.0% |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 2.8% |
| 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 · 4Q avg 11.3% |
| 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 · 4Q avg 9.7% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 11.7% · Used in QM five-star |
| 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 · 4Q avg 25.5% · Used in QM five-star |
| 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 · Q3 0.0% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q3 5.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q4 0.0% · 4Q avg 6.5% |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Hawaii Health Systems Corporation
5% Or Greater Indirect Ownership Interest · Organization
Asato, Christine
Operational/Managerial Control · Individual
Asato, Christine
Corporate Officer · Individual
Franklin, Nicholas
Operational/Managerial Control · Individual
Segawa, Lance
Operational/Managerial Control · Individual
Segawa, Lance
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Kauai Care Center
Waimea, HI
3-star overall rating with 3-star inspections with 10 recent health deficiencies
#2
Hale Kupuna Heritage Home, LLC
Koloa, HI
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Garden Isle Healthcare And Rehabilitation Center
Lihue, HI
5-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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