Kauai Veterans Memorial Hospital

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to assure kitchen staff used non-expired Hydrion test strips to test the kitchen's three-compartment sink for proper sanitizer level to assure sufficient concentration of sanitizing solution is present to effectively clean and sanitize dishware and failed to assure the kitchen dishwasher water temperature was used and logged at 180 degrees Fahrenheit (F) or more during the rinse cycle, failing to assure dishware and silverware were heat sanitized. This deficient practice puts all residents, staff, and visitors, who eat their meals at the facility, at risk for foodborne illness. The State Agency (SA) identified an Immediate Jeopardy (IJ) at 483.60 (F812) on 09/03/24 at 10:12 AM. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.