Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kauai Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke, encephalopathy, gait abnormalities, incontinence, and insulin-dependent Type 2 DM was discharged home alone with only a private hire caregiver for two hours per day, despite provider orders for 24-hour care and therapy recommendations for 24/7 or extensive caregiver support. Interdisciplinary documentation inaccurately indicated the resident had family and a wife as primary caregiver, and there was no evidence that the facility discussed with the resident his limitations, the risks of minimal supervision, or that the provider was informed of the reduced supervision at discharge. The discharge MDS documented full continence despite multiple recorded episodes of incontinence, and the facility did not verify or document that the resident could self-inject insulin or that a qualified caregiver was trained to do so. Additionally, an ordered stool culture for persistent diarrhea was not completed due to improper specimen handling, and there was no documentation that the provider, PMD, or resident was notified that the test was not performed.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility failed to designate a full-time Director of Nursing (DON) who works 40 or more hours a week, as the DON was also responsible for the Infection Prevention and Control Program (IPCP). This dual role affected the DON's ability to fulfill her responsibilities, potentially impacting the quality of care and resident outcomes. The Administrator confirmed that corporate resource staff do not assist with daily duties related to infection prevention, leading to the deficiency.
The facility failed to establish a water management program as part of its infection prevention and control program, necessary to prevent diseases associated with water-borne pathogens. A maintenance staff member confirmed that the facility had not completed an assessment of the building's water system and did not have a plan for monitoring for Legionella and other pathogens.
The facility did not ensure the wrist blood pressure monitor was used according to the manufacturer's recommendations. The monitor, intended for in-home use only, was used on multiple residents without proper performance checks or adherence to guidelines. The DON was unaware of these guidelines, and the device was used on residents with various medical conditions.
The facility failed to ensure accurate MDS documentation for a resident's discharge. The EHR showed the resident was discharged home, but the MDS inaccurately documented a discharge to an acute hospital. This error was confirmed by the Executive Director.
The facility failed to update a resident's care plan to reflect a new oxygen administration order, despite observations and the resident's confirmation of continuous oxygen use. The care plan remained unchanged from its initial documentation, potentially leading to inappropriate care.
The facility failed to provide care within professional standards for three residents, including not monitoring hemoglobin A1C for a diabetic resident, entering an incorrect oxygen order for a resident without COPD, and not checking blood glucose levels for a diabetic resident who reported dizziness.
The facility failed to maintain accurate controlled drug records, as the Narcotic Count sheet was not signed for two consecutive days, and three residents' medication administrations were not documented on the pharmacy count sheet at the time of removal. The DON confirmed that the procedures were not followed as per the facility's policy.
A resident was prescribed an antibiotic (Levaquin) without adequate documentation of its necessity. The pulmonologist did not order diagnostic tests to confirm an infection, and the facility's staff failed to identify any new infection based on established criteria. The resident's care plan was updated to include antibiotic therapy for pneumonia, but no diagnosis of pneumonia was documented.
The facility failed to ensure a safe environment by not maintaining the lint traps of their industrial dryers. During an inspection, it was found that the lint traps were covered with lint, and the form used to document their cleaning was blank. Staff confirmed that the lint traps should have been cleaned after each use to prevent fire hazards, especially given the facility's dry and hot climate.
Failure to Ensure Safe Discharge Planning and Follow-Up for a Resident Discharged Home Alone
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s transfer/discharge plan met his needs and preferences and that he was adequately prepared and supported for a safe discharge to the community. The resident was an older male admitted after a stroke for medical management and rehabilitation, with a history of encephalopathy, muscle weakness, gait and mobility abnormalities, Type 2 DM on insulin, chronic heel ulcers, and hypertension. While in the facility, he was incontinent of bladder and bowel and wore disposable briefs. Prior to the stroke, he lived alone with community supports including a care coordinator, meals on wheels, transportation, a life alert system, help from a neighbor with groceries, and a friend who cleaned his house. He did not have a power of attorney. During the stay, an interdisciplinary care conference note documented that the resident would be discharged “home with family,” that he lived alone but had community services and a health coordinator, and that he would return home with established services and home health PT/OT/nursing. The discharge planning section inaccurately indicated that he had family and identified a wife as the primary caregiver, and it documented an intervention to evaluate and discuss prognosis, limitations, risks, benefits, and needs for independence. However, the resident did not have a wife or family caregiver, and the private hire caregiver was arranged by the facility. There was no evidence that the facility discussed with the resident the prognosis for independent living with minimal supervision, his limitations, or that he fully understood the risks. There was also no evidence that the provider was aware that the final discharge arrangement would involve only minimal supervision rather than the ordered level of care. The resident’s discharge orders specified a need for 24-hour care and home health services including PT, OT, speech therapy, nursing, and medication management, and therapy documentation indicated he was not safe to be home alone and required increased assistance at home. PT and OT notes recommended 24/7 care or at least a caregiver for 20 hours per week, and the resident’s modified Barthel ADL score reflected moderate dependence. The discharge MDS showed he required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers and mobility, but it documented him as always continent despite nursing documentation of multiple episodes of urinary and bowel incontinence in the week prior to discharge. The social services assistant confirmed the resident had no family or full-time caregiver, knew there would be a lag before community services resumed, and arranged a private hire caregiver for only two hours per day without knowing the caregiver’s qualifications. She acknowledged that the resident needed to be checked on daily and that he required daily insulin injections, which she stated nursing was responsible to ensure could be safely managed, but the facility could not provide evidence that the resident was competent to self-inject insulin or that a capable caregiver was identified and trained. Additional documentation and interviews showed that the care coordinator had informed the social services assistant that the resident had no support at home and that community services such as meals on wheels would not resume immediately, and that home health evaluation and possible services would not start until several days after discharge. The social services assistant did not document her discharge planning communications with the care coordinator in the medical record at the time and later produced a retrospective typed note. The friend who cleaned the resident’s home reported that upon discharge he struggled to get out of a chair, walked slowly, had frequent accidents on the floor, and could not figure out how to set his insulin pen correctly. The PT and OT confirmed that the resident had memory issues, was not at his pre-stroke baseline, could not change his own brief, and still needed assistance and cues for toileting and hygiene. The DON stated that nursing was responsible to ensure the resident could self-inject insulin or that a trained caregiver was identified, and confirmed the facility lacked evidence of such competence or caregiver training. The deficiency also included a failure to ensure appropriate follow-up for an ordered diagnostic test prior to discharge. Nursing documentation showed the resident had persistent diarrhea and stomach upset, and a stool culture and O&P were ordered along with a probiotic. The laboratory later reported that the stool sample was received in a sterile container instead of stool media, was no longer stable for testing, and that the resident was no longer at the facility so recollection was not needed. There was no documentation that the provider, primary medical doctor, or resident was notified that the stool culture was not completed. The DON confirmed that the stool culture and sensitivity had not been done and that the provider should have been notified to ensure follow-up after discharge.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to meet the regulatory requirement for having a designated full-time Director of Nursing (DON) who works 40 or more hours a week. The individual identified as the DON was also designated as the Infection Preventionist (IP), responsible for the Infection Prevention and Control Program (IPCP). Due to these dual roles, the DON was unable to allocate the required 40 hours per week to oversee the nursing department, potentially impacting the quality of care and resident outcomes. The facility is licensed for 52 beds and requires a DON and an IP as per their facility assessment. However, the DON confirmed that she spends approximately 50% of her time on infection control duties, which affects her ability to fulfill her responsibilities as the DON fully. During the survey, it was observed that the DON had to cover breaks and assist with tasks and resident care due to the facility having only one licensed staff on each unit. For instance, the DON was observed assisting with the waste of a narcotic pill and covering the unit floor for a licensed staff member who was at lunch. The Administrator confirmed that the DON has full responsibility for the IPCP and that corporate resource staff do not assist with daily duties or tasks related to infection prevention. The job descriptions for both the DON and the IP outline extensive responsibilities, making it challenging for one individual to manage both roles effectively. The survey also revealed that the facility's infection prevention training documents included corporate staff who are not currently working as registered nurses at the facility. The DON admitted that corporate resource staff occasionally contact her but do not share the infection prevention duties. This lack of delineation of duties and the dual role of the DON as both the director of nursing and the infection preventionist led to the deficiency, as the DON could not dedicate the required time to oversee the nursing department adequately.
Failure to Establish Water Management Program
Penalty
Summary
The facility failed to establish a water management program as part of its infection prevention and control program, which is necessary to prevent the transmission of diseases associated with water-borne pathogens. During an interview and document review, it was found that the facility did not have a documented water management program based on nationally accepted standards. This program should include an assessment to identify where Legionella and other water-borne pathogens could grow and spread, as well as measures to prevent their growth and how to monitor for these pathogens. On the specified date, a concurrent interview and record review were conducted with a maintenance staff member. The maintenance staff confirmed that the facility had not completed an assessment of the building's water system and did not have a plan for monitoring the water system for the presence of Legionella and other opportunistic water-borne pathogens. The maintenance staff member was unaware that such an assessment and monitoring plan were required, indicating a significant gap in the facility's infection prevention and control program.
Improper Use of Wrist Blood Pressure Monitor
Penalty
Summary
The facility did not ensure the wrist blood pressure (BP) patient care monitor was used according to the manufacturer's recommendations. Specifically, the monitor, which is intended for in-home use only, was being used on multiple residents in the facility. Observations revealed that the wrist BP monitor was kept on the medication cart and used to check residents' BP prior to administering hypertension medications. The Resident Care Manager (RCM) and a Certified Nursing Assistant (CNA) were observed using the monitor on different residents, and it was noted that the device was wiped down between uses. However, the Director of Nursing (DON) was unaware of the manufacturer's guidelines and had not purchased new units since being hired. The user guide for the wrist BP monitor indicated that it should be used for adult in-home use only and required performance checks every two years, which were not being conducted by the facility. The wrist BP monitor, Model MDS4003, manufactured by Medline Industries, had specific guidelines that were not being followed. The user guide highlighted that the device was not suitable for use on patients with certain medical conditions, such as those with implanted electronic devices or undergoing intravascular therapy. Additionally, there was no process in place to verify the calibration of the monitor as recommended by the manufacturer. This deficiency has the potential to affect any resident who had their BP taken with the wrist monitor, as the accuracy and suitability of the device for their medical conditions were not ensured.
Inaccurate MDS Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that the information populated in the Minimum Data Set (MDS) was accurate for one resident. The resident's electronic health record (EHR) documented that the resident was discharged home, but the discharge MDS inaccurately documented that the resident was discharged to an acute hospital. This discrepancy was confirmed during a staff interview with the Executive Director, who acknowledged the error. The inaccurate documentation in the MDS could potentially lead to missed opportunities for generating appropriate care plans and possibly not providing needed services to the resident.
Failure to Revise Care Plan for Updated Oxygen Administration Order
Penalty
Summary
The facility failed to revise the care plan for one of the 14 residents sampled, specifically for a resident with severe persistent asthma, muscle weakness, acute and chronic respiratory failure, hypertension, pulmonary hypertension, anxiety disorder, seizure disorder, and gastrointestinal hemorrhage. The resident's care plan, initially documented on 09/02/2023, included an order for oxygen administration via nasal prongs/mask at 2-4 liters per minute continuously with a humidifier. However, this care plan was not updated to reflect a new order issued on 03/12/2024 by the Director of Nursing, which specified oxygen administration at 2-3 liters per minute via cannula to maintain oxygen saturation between 88%-92% for COPD management. Observations on 04/01/2024 and 04/04/2024 confirmed that the resident was receiving 3 liters of oxygen via nasal cannula, both in her room and in the activity/dining area. During an interview on 04/04/2024, the resident confirmed her continuous use of oxygen. Despite these observations and the updated order in the Electronic Health Record (EHR), the care plan was not revised to include the new oxygen administration order, potentially leading to inappropriate nursing and medical care for the resident.
Failure to Provide Care Within Professional Standards
Penalty
Summary
The facility failed to provide the needed care within professional standards of practice for three residents, leading to potential harm. Resident 17, a bedbound female with multiple comorbidities including Type 2 diabetes, did not have her hemoglobin A1C monitored as ordered. Despite a provider's verbal order for an A1C test, the staff failed to follow through, resulting in no A1C test being conducted since January 2023. This oversight was confirmed by the Director of Nursing (DON) during a review of the resident's electronic health record (EHR). Resident 12, a female with severe persistent asthma and other chronic conditions, had an incorrect oxygen administration order entered into her medical record. The order specified an oxygen saturation range appropriate for COPD, a condition she did not have. The nursing staff failed to identify this error and did not notify the provider for clarification. The DON admitted to entering the order incorrectly, which led to the resident receiving inappropriate care. Resident 8, who has hypertension, Type 2 diabetes, and other conditions, reported feeling dizzy but did not have her blood glucose level checked as required. The staff failed to document blood glucose values and insulin administration on multiple occasions. The DON confirmed that the staff did not follow the physician's orders to monitor blood glucose levels immediately before administering insulin, which could have prevented the resident from experiencing a hypo/hyperglycemic episode.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to ensure drug records were in order and an account of all controlled drugs was maintained and periodically reconciled. During an observation and interview, it was found that the Narcotic Count sheet was not signed or initialed on two consecutive days for the 0700-1900 shift. The RCM confirmed that the sheet should have been signed by both the off-going and on-coming nurses immediately after verifying the count of controlled medications. The DON also confirmed that the procedure was not followed, and the responsible staff were called in to sign the sheet retroactively. The facility's policy requires a physical inventory of controlled medications to be conducted by two licensed clinicians at each shift change and documented on an audit record, which was not adhered to in this instance. Additionally, during a reconciliation of narcotic medications, it was found that three residents had been administered controlled medications, which were documented on the electronic medication administration record (EMAR) but not on the individual pharmacy count sheet at the time of removal from the medication cart. The RCM admitted to not signing the pharmacy count sheet for these residents when the medications were removed. The DON stated that staff are supposed to sign the pharmacy's count sheet after the resident takes the medication, which contradicts the facility's policy that requires immediate documentation upon removal of the dose from controlled storage.
Failure to Ensure Resident is Free from Unnecessary Antibiotic
Penalty
Summary
The facility failed to ensure that a resident (R12) was free from an unnecessary drug, specifically an antibiotic (Levaquin). R12, a female with multiple health issues including severe persistent asthma, muscle weakness, and chronic respiratory failure, was prescribed Levaquin by a pulmonologist during an off-site visit. However, neither the prescribing consultant nor the facility provider documented adequate indications for the antibiotic's use. The pulmonologist did not order a diagnostic chest x-ray or a culture and sensitivity test prior to starting the antibiotic. The facility's Infection Preventionist (IP) confirmed that R12 had not been identified as having a potential new infection based on the McGeer criteria, and there was no documentation of pneumonia or other infection that would justify the antibiotic prescription. Additionally, the facility's exception charting method revealed no deviations from R12's baseline condition that would indicate the need for an antibiotic. The IP later admitted that a verbal order for a sputum culture and sensitivity test was given but not recorded or completed by the nursing staff. Observations of R12 showed her using oxygen continuously and being in a stable condition without signs of increased respiratory distress or infection. The facility's care plan for R12 was revised to include antibiotic therapy related to pneumonia, but there was no documented diagnosis of pneumonia. The last chest x-ray taken for R12 showed increased reticular opacities in both lungs, but this was not recent enough to justify the antibiotic prescription. The IP was attempting to reach the pulmonologist to clarify the indications for the antibiotic, but no further information was provided in the report.
Failure to Maintain Clean Lint Traps in Industrial Dryers
Penalty
Summary
The facility failed to ensure a safe environment for residents, staff, and the public by not maintaining the lint traps of their industrial dryers. During an inspection of the laundry room, it was observed that the lint traps of two out of three industrial dryers were not cleaned. The lint traps were found to be covered with lint approximately half an inch to one inch thick. The Housekeeping/Laundry Supervisor (HLS) and laundry staff confirmed that the lint traps should have been cleaned after each use to prevent fire hazards, especially given the facility's location in a dry and hot climate. However, the form used to document the cleaning of the lint traps was blank, indicating that the staff did not perform the required cleaning on the observed days. Interviews with the laundry staff revealed that the lint traps were supposed to be cleaned after each use, but this was not done. One staff member, who worked in the laundry room the previous day, confirmed that the lint traps should be cleaned to prevent fire hazards. Another staff member, who was working during the inspection, initially claimed that the lint traps were being cleaned after each use but was later informed by the HLS that they were not. The review of the lint trap cleaning form corroborated that the responsible staff did not sign or initial the form on the days in question, confirming the deficiency in maintaining a safe environment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waimea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kauai Veterans Memorial Hospital | 0.2 mi | ★★★★★ | 8 | 0 |
| Hale Kupuna Heritage Home, Llc | 11.7 mi | ★★★★★ | 13 | 0 |
| Garden Isle Healthcare And Rehabilitation Center | 19.3 mi | ★★★★★ | 0 | 0 |
| Samuel Mahelona Memorial Hospital | 24.7 mi | ★★★★★ | 8 | 0 |
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