Kula Hospital
Kula, Hawaii · CCN 125003
14 surveys since 2011, 7 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 90
- Surveys
- 14
- Harm or worse
- 7
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 105
- Ownership
- Non profit - Corporation
- Chain
- Independent
- County
- Maui
- Medicare-certified since
- 1967
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 1
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 43 facilities in Hawaii.
Last survey on record
Jan 8, 2025
670 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Annual nurse turnover | 53.9% | 24.7% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G13.1% | H— | I— |
| No harm, potential for more than minimal | D2268.8% | E515.6% | F412.5% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F8803×
Provide and implement an infection prevention and control program.
- F5502×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F6002×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6562×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6772×
Provide care and assistance to perform activities of daily living for any resident who is unable.
In the surveyor’s words
From the most serious findings on record at Kula Hospital, in the surveyor’s own words.
- Actual harm, isolatedF600Sep 19, 2024
Based on observation, interviews, record and document review, the facility failed to protect the rights of two Resident's (R )1 and R2 to be free from abuse. R1 suffered physical injuries on 06/11/2024 when a Certified Nurse Assistant (CNA)1 did not react and respond appropriately to R1's aggressive behavior. CNA1 did not leave the room, but willfully continued to interact and react with unnecessary physical contact which resulted in R1 suffering harm. R1 had bruising to the Left (L) forehead, L temple and scratch type injury to his chest. The injuries are not justifiably explained. In addition, on 08/10/2024, staff witnessed non-consensual sexual contact when R3 was observed with his hand inside R2's blouse. R2 does not have the capacity to consent. […]
- No harm, potential for more than minimal, widespreadF727Jun 6, 2024
Based on interview and record review, the facility failed to provide a Director of Nursing (DON) on a full-time basis. The same staff member covers the long-term care (LTC), the Critical Access Hospital (CAH), and the Intermediate Care Facility for the Intellectually Disabled (ICF/IID) facilities as the DON. Findings include: On 06/03/24 at 11:04 AM, an entrance interview for the Critical Access Hospital (CAH) recertification was done in the first-floor conference room with the DON and the Administrator. The DON confirmed that she was employed full-time, and was the DON for the CAH, the LTC facility, and the ICF/IID facility, each with their own facility-specific certification and licensing requirements. […]
- No harm, potential for more than minimal, widespreadF812Jun 6, 2024
Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food storage/handling practices represent a potential source of pathogen exposure for all residents at the facility who consume food or drink prepared at the facility. Findings include: 1) On [DATE] at 10:00 AM, while conducting an initial tour of the kitchen with the Food Service Manager (FSM), observed a standing freezer next to the ice machine containing a small metal pan of approximately ten (10) poorly covered beef patties. […]
- No harm, potential for more than minimal, widespreadF838Jun 5, 2023
Based on observations, interviews, and record reviews the facility failed to update their facility assessment as required annually or when there is a change that would require a substantial modification to any part of the assessment (i.e. staffing shortage, COVID-19 outbreak). The facility assessment provides a comprehensive inventory of resources that are necessary to care for its residents competently during day-to-day operations and during emergencies. This deficient practice renders the administrative and management staff the inability to assess for potential system failure(s). Findings include: Cross reference to F725 Sufficient Nursing Staff. […]
- No harm, potential for more than minimal, widespreadF880Jun 5, 2023
Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for COVID-19, linen is processed as to prevent the spread of communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), as well as follow standard precautions by consistently performing hand hygiene. In addition, the facility failed to track and monitor that staff's COVID-19 testing was consistently conducted to minimize the risk of continued transmission of COVID-19 during a facility outbreak. […]
Read 26 findings in full →The most serious and the most recent: 26 of 90 on record.
Every survey on record
FindingsAt actual harm or above
- Jan 8, 2025Complaint1 finding
- Sep 19, 2024Complaint1 finding · 1 harm
- Jun 6, 2024Standard10 findings
- Jun 5, 2023Standard and complaint12 findings
- Jun 30, 2022Standard and complaint8 findings
- May 28, 2020Complaint2 findings
- May 31, 2019Standard3 findings · 1 harm
- Jun 22, 2018Standard and complaint6 findings
Show the 6 earlier surveys
- Apr 21, 2017Standard14 findings · 1 harm
- Mar 11, 2016Standard9 findings
- Apr 24, 2015Standard2 findings
- Sep 10, 2014Standard1 finding
- Jul 11, 2014Standard14 findings · 3 harm
- Sep 16, 2011—7 findings · 1 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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