Kauai Veterans Memorial Hospital

Based on observations, interviews, and record review, the facility failed to ensure safe storage of perishable foods. As a result of this deficient practice, all residents have to potential to be exposed to harmfulfood-borne illnesses.Findings Include: On 02/24/26 at 08:29 AM, conducted a concurrent initial observation of the facility's kitchen and interview with the Hospital Executive Chef (HEC). The walk-in pantry (dry storage room) there were two (2) plastic containers, one contained curly egg noodle and the second one had dried shiitake mushroom; both plastic containers did not have labels. HEC was queried if containers should be labeled, after the original food packages were opened and the contents of the packages transferred to the plastic containers. HEC confirmed both plastic containers should have been labelled with the date of expiry written and employee number of the staff that printed the label when the packages were initially opened. On 02/26/2026 at 11:22 AM, conducted a follow-up interview and observation with [NAME] (C) 4. Observed minced garlic inside a plastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, the facility failed to protect the confidential health information for one (Resident (R) 6) of six residents sampled for medication administration. This defecient practice has the potential to negatively impact the psychosocial well-being of residents.Findings Include: On 02/26/26 at 07:44 AM, observed Registered Nurse (RN) 2 take medications from the medication cart (located in the hallway), enter into the activity room, and give medications to R6. Observed the laptop computer on top of the medication cart had been left open and unattended, displaying R6's confidential health information from the resident's Electronic Health Record (EHR). While RN2 was administering the medication, observed three (3) staff, including non-direct care (i.e. housekeeping), with the opportunity to view R6's confidential health information. After RN2 administered the medication to R6, he/she proceeded back to the medication cart and prepare the next resident's medications, then signed off (locking) the laptop computer before walking away from the medication cart. At…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe storage of medications. During medication administration, the medication cart was observed to be unattended, unlocked, and accessible to unauthorized individual(s).Findings Include: On 02/26/26 at 07:41 AM to 08:17 AM, observations conducted of medication administration with Registered Nurse (RN) 2 on the unit. Observed medication administration for Resident (R) 3, R10, R12, R13, R18, and R19. RN2 prepared a resident's medications, then left the medication cart unlocked as he/she went to administer the medication(s) to the resident. Observed multiple staff in the hallway with the opportunity to access the medications in the cart. After the last medication pass was completed, inquired with RN2 if the medication cart should have been locked prior to leaving the medication cart. RN2 confirmed the medication cart had not been locked prior to walking away from it and the medication cart should have been locked while unattended. Review of the facility's policy and procedure for Medications Security…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the Infection Prevention Control Program (IPCP) was reviewed annually. An interview with the Infection Preventionist (IP) was conducted and it was determined that the facility had not been reviewed and exceeded the annual (i.e. 12 months) requirement.Findings Include: On 02/26/26 at 02:20 PM, conducted an interview with the IP and the Regional Chief Quality and Compliance Officer (RCQCO) in the IP's office. Inquired 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) were last reviewed. IP reviewed the facility's internal policy review records and confirmed that the annual review of these policies and procedures had not yet been reviewed, and it has been more than 12 months since the last review. RCQCO was present during the review and became aware that these policies and procedures have not been reviewed annually, as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to identify and report, within 14 days, a significant change and decline in activities of daily living (ADLs) for 1 of 12 residents sampled (Resident (R) 11). This deficient practice has the potential to affect other residents who have a decline in health status. Findings include: On 09/05/24 record review of R11's Electronic Health Record (EHR) Minimum Data Set (MDS) Annual assessment dated [DATE] and Quarterly review dated 04/26/24 revealed she had the following declines in functional limitations: limitations progressing from one lower extremity to two lower extremities, now requires substantial/maximal assistance with upper body dressing when she was previously partial/moderate assistance, and went from being able to roll left and right with partial/moderate assistance to roll left and right requiring substantial/maximal assistance. Review of R11's MDS assessments submitted to the Centers for Medicare and Medicaid Services (CMS) revealed no Significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately document the health status of two residents reviewed, Residents (R)20 and 11. R20 was incorrectly identified as taking insulin for one day and R11 was incorrectly identified as having a diagnosis of Alzheimer's Disease when she has a diagnosis of severe vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety. This deficient practice has the potential to affect all the residents at the facility if their health status is not correctly identified. Findings include: 1) On 09/05/24 record review of R20's Electronic Health Record (EHR) revealed R20's Minimum Data Set (MDS) admission assessment dated [DATE] identified her taking insulin for 1 day. Review of R20's EHR medication orders did not find any insulin orders. On 09/06/24 at 09:33 AM, interviewed Minimum Data Set Coordinator (MDSC) who confirmed resident does not take insulin and confirmed this was an error. MDSC believes it might have been a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement a resident-centered Comprehensive Care Plan (CP) for 2 of 13 residents (Residents 5 and 1) in the sample. Both residents (R) are insulin-dependent diabetics, yet neither had an active diabetes care plan. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life and were prevented from attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Cross-reference to F689 Accident Hazards. A review of R5's CP revealed no active care plan developed for Activities of Daily Living (ADLs), which would include interventions addressing her mobility and transfer needs. Resident (R)5 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her active diagnoses include insulin-dependent diabetes, and chronic kidney disease. A review of R5's electronic health record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 13 residents sampled (Resident 5) was free from accident hazards. Despite having a history of falls, an identified recent stroke with functional decline, and requiring a two-man assist for transfer, staff failed to lower Resident (R) 5's bed until her feet were touching the floor prior to manually transferring her from her bed to a shower chair, placing her at risk for an avoidable fall and/or injury. In addition, the facility failed to develop and implement a care plan for R5 that included/addressed her mobility and transfer needs. This deficient practice has the potential to affect all residents at the facility who require assistance to stand or transfer. Findings include: Resident (R)5 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her diagnoses include diabetes (added to diagnosis list at admission), chronic kidney disease (last updated on diagnosis list [DATE]), recurrent falls (last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards, including medication parameters for administration. Proper labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications. Findings include: 1) On 09/06/24, beginning at 08:00 AM, medication pass observations were done with Registered Nurse (RN)6. At 08:01 AM observed RN6 preparing medications for Resident (R)11, who had a blood pressure that morning of 82/45 and when rechecked, 88/51. Observed the Metolazone 10 milligrams (mg) that RN6 prepared had a medication label on the blister pack that read: HOLD FOR SBP [systolic blood pressure] < [less than] 100 OR SYMPTOMATIC HYPOTENSION [low blood pressure]. Handwritten in red pen next to that was the following: SBP<80. Observed the Furosemide 40 mg that RN6 prepared had a medication label on the blister…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide safe storage for delivered food items placed into the kitchen's chiller and the dietary aides failed to perform appropriate hand hygiene while delivering meal trays to residents. These deficient practices have the potential to cause harm to their residents, staff, and visitors due to the possibility of contracting a food borne illness. Findings include: 1) On 09/19/23 at 10:32 AM, conducted a concurrent observation and interview with the kitchen chef (KC) of the kitchen's chiller located outside, across from the freezer. The chiller contained a box of sour cream tubs on the floor to the left and the right side contained crates with gallons of milk and juice. KC stated that they received the delivery of those items at 10:00 AM. On 09/19/23 at 10:45 AM, conducted a concurrent observation and interview with the Director of Food Services (DFS) of the same chiller. DFS stated that the delivery personnel will alert staff that the items were placed into the chiller. DFS further confirmed that the kitchen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the family or resident representative of one resident (R)19, out of three residents sampled, was notified of R19's transfer to the emergency room (ER) for an acute condition. This deficient practice fails to protect residents from possible inappropriate facility-initiated discharges from the facility. Finding includes: On 09/21/23 at 11:54 AM, progress notes revealed that R19 was transferred to the ER due to a low blood count. On 09/22/23 at 11:11 AM, conducted a concurrent observation of R19's electronic health record (EHR) and interview with the MDS Coordinator (MDSC) at the nursing station. MDSC confirmed that R19 was transferred to the ER on [DATE] as evidenced by an ER physician note documented on 08/13/23 at 09:21 AM that R19 refused her hemodialysis treatments (medical process to clean toxins out of the blood and to remove excess fluids) on Friday and Saturday. Progress notes revealed further that R19 was transferred from the ER to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that quarterly comprehensive assessments were completed no less frequently than once every 3 months for 2 of 2 residents (R) in the sample. As a result of this deficient practice, the facility placed R1 and R16 at risk of not having their needs met. This deficient practice has the potential to affect all the residents at the facility for long-term care. Findings include: On 09/21/23 at 03:00 PM, during a review of Resident (R)1's electronic health record (EHR), it was noted that R1's last quarterly Minimum Data Set (MDS) assessment had been completed on 05/20/23. The most recent MDS assessment showed an assessment reference date (ARD) or target date of 08/17/23, but had not been completed. On 09/21/23 at 03:24 PM, an interview was done with the MDS Coordinator (MDSC) at the Nurses' Station. Reviewing a Final Validation Report provided by the MDSC, it showed the assessment due on 08/17/23 had a Completion Date of 09/21/23. The MDSC confirmed that some of the care area assessments had been completed more than 14 days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (R) in the sample was free from accident hazards. Despite being unsteady on her feet and requiring at least a two-man assist to stand, staff failed to lock R11's shower chair before having her stand for a transfer, placing her at risk for an avoidable fall and/or injury. This deficient practice has the potential to affect all residents at the facility who require assistance to stand or transfer. Findings include: Resident (R)11 is an [AGE] year old female admitted to the facility on [DATE] with admitting diagnoses that include age-related physical disability, Diabetes, Hypertension (high blood pressure), Heart Failure, and Morbid Obesity. A review of R11's most recent quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 08/13/23, shows that for Balance During Transitions and Walking, as well as Surface-to-Surface Transfer (transfer between bed and chair or wheelchair), R11 was marked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.