SAMUEL MAHELONA MEMORIAL HOSPITAL
Open-data reference.
SAMUEL MAHELONA MEMORIAL HOSPITAL is a government - state facility in KAPAA, HI with 66 certified beds and a 5-star overall CMS rating. The facility has 17 deficiency records on file.
4800 KAWAIHAU ROAD, KAPAA, HI 96746
Phone: 8088224961
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 125029
- Ownership
- Government - State
- Provider Type
- Medicare and Medicaid
- Beds
- 66
- Residents
- 46
- In Hospital
- Yes
- County
- Kauai
- Last Inspection
- Nov 22, 2024
Staffing Data
- RN Hours
- 2.24 (nat'l avg: 0.68)
- LPN Hours
- 0.37
- CNA Hours
- 3.47
- Total Nursing Hours
- 6.08 (nat'l avg: 3.89)
- PT Hours
- 0.02
- Nursing Turnover
- 7.3%
- RN Turnover
- 9.1%
What the CMS Record Reveals About SAMUEL MAHELONA MEMORIAL HOSPITAL
SAMUEL MAHELONA MEMORIAL HOSPITAL operates 66 certified beds in KAPAA, HI with approximately 46 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (5★), staffing levels (5★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 17 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 6.08 total nursing hours per resident day (national average 3.89), with RN coverage at 2.24 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Government - State" ownership and operating as a "Medicare and Medicaid" provider embedded within a hospital campus, SAMUEL MAHELONA MEMORIAL HOSPITAL falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 7.3%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (17 most recent)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 27, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 20, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Dec 27, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jan 3, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jan 5, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Jan 5, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 5, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 5, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jan 5, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Jan 5, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Nov 11, 2022
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Category: Infection Control Deficiencies
Corrected: Nov 11, 2022
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Nov 11, 2022
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 11, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 11, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 11, 2022
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 11, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.1% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.7% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.5% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 95.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | N/A | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | N/A | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 23.7% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 6.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 17.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 3.8% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for SAMUEL MAHELONA MEMORIAL HOSPITAL?
What are the staffing levels at SAMUEL MAHELONA MEMORIAL HOSPITAL?
How many beds does SAMUEL MAHELONA MEMORIAL HOSPITAL have?
Does SAMUEL MAHELONA MEMORIAL HOSPITAL have any deficiencies on record?
Has SAMUEL MAHELONA MEMORIAL HOSPITAL received any fines or penalties?
Who owns SAMUEL MAHELONA MEMORIAL HOSPITAL?
When was SAMUEL MAHELONA MEMORIAL HOSPITAL last inspected?
What quality measures are tracked for SAMUEL MAHELONA MEMORIAL HOSPITAL?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.