Kauai Care Center

Inspectors wroteBased on interviews, document and record review, the facility failed to provide and document sufficient preparation to ensure that one Resident (R)1 of a sample size of three had the resources and support to meet his needs when discharged to the community. R1 had a Provider order for 24 hour supervision, but was discharged with a Private Hire (PH) two hours a day. There was lack of evidence that R1 was informed of the need for more supervision, or that the risks of refusing ordered services were discussed and understood. The post-discharge plan did not address resident limitations in ability to care for himself, which increased the risk of complications, and readmission to the hospital. This deficient practice could affect all Resident's being discharged to the community. Findings Include:1) On 10/15/25, the Office of Health Care Assurance received a concern that R1: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the rights of one Resident (R) 198 of one resident sampled by ensuring the resident was treated with respect and dignity. R198 was receiving therapy from a staff member who spoke to her in a manner that R198 felt was disrespectful and demeaning, leaving R198 very upset. Findings Include:Facility Reported Incident (FRI) reviewed on 07/09/25 at 12:17 PM, intake #11576 for an incident that occurred on 03/12/25 at 02:41 PM involving a Physical Therapist (PT) 5 and R198. R198 reported to the facility staff that she was made to feel uncomfortable by PT5 regarding the way she spoke to her. R198 stated I was going to the toilet, and she came into my room and opened the curtain and stated, you are going to do therapy today, R198 told the PT5 that she was given a water pill and now must go to the bathroom more often. [...]

Inspectors wroteBased on interviews, observation, and document review, the facility failed to meet regulatory requirement for having a designated Full-time (working 40 or more hours a week) director of nursing. The individual identified by the facility as the DON was also designated as the infection preventionist, and responsible for the Infection Prevention and Control Program (IPCP). As a result of the designated DON not being able to allocate 40 hours or more a week to oversee the nursing department, there is the potential the quality of care provided, and resident outcomes may be impacted and could affect all residents living at the facility.

Inspectors wroteBased on an interview and document review, the facility failed to establish a water management program as part of an infection prevention and control program to prevent the transmission of disease associated with water-borne pathogen. The facility was unable to demonstrate its measures to minimize the risk of Legionella and other water borne opportunistic pathogens in building water systems in a documented water management program. This program must be based on nationally accepted standards and include an assessment to identify where Legionella and other water borne pathogens could grow and spread and measures to prevent the growth of opportunistic water borne pathogens and how to monitor for pathogens. As a result of this deficiency, resident are potentially at risk for infections related to water-borne pathogens.

Inspectors wroteBased on observations, interviews and document review, the facility did not ensure the wrist blood pressure (BP) patient care monitor was used according to manufacturer's recommendations. Specifically, the monitor is recommended for in-home use only. To ensure accuracy, it should be used according to manufacturer's guidelines. This has the potential to affect any resident that had their BP taken with the wrist monitor.

Inspectors wroteBased on record review (RR), staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure that information populated in the Minimum Data Set (MDS) was accurate for one of two residents sampled (Resident (R)51). R51's electronic health record (EHR) documented the resident was discharged home. Review of R51's discharge MDS documented the resident was discharged to an acute hospital. Failure to complete the MDS assessment accurately could potentially lead to missed opportunities for generating appropriate care plans and possibly not providing needed services, which could result in harm to the resident.

Inspectors wroteBased on observation, interviews, and RR, the facility failed to revise the care plan for one of 14 residents sampled (R12). R12's care plan (CP) was not revised to include an updated oxygen administration order. R12's care plan did not include a new order to maintain R12's oxygen saturation be maintained between 88%-92%. Failure to revise care plans to reflect new orders could potentially lead to resident's not receiving appropriate nursing and medical care which has the potential to harm resident(s).

Inspectors wroteBased on observations, interviews, and RR, the facility failed to provide the needed care within the professional standards of practice that met the needs for three of 14 residents sampled (R8, R12, and R17). As a result of this deficient practice, all residents at the facility are at risk of the potential for harm due to not achieving their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews, and RR, the facility failed to ensure drug records are in order and an account of all controlled drugs is maintained and periodically reconciled. As a result of this deficient practice, there is the potential for diversion of controlled medication(s).

Inspectors wroteBased on interviews, observation, and RR, the facility failed to ensure a resident (R)12 is free from an unnecessary drug (antibiotic). R12 was prescribed an antibiotic (Levaquin) by a consultant at the time of an off-site office visit. Neither the prescribing consultant or facility provider documented adequate indications for the antibiotics use. As a result of this deficient practice, the antibiotic may be unnecessary and increase R12's resistance to antibiotics and put her at risk for adverse reactions to the medication.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a safe environment for residents, staff, and the public. Observation of the facility's industrial dryers used by the facility documented the lint traps were not cleaned and the facility's formed used to document staff cleaned the lint traps was blank, indicating staff did not clean it. Interviews with staff confirmed the environment was unsafe for residents, staff, and the public due to the fire hazard of the amount of lint contained in both industrial dryers. Also, the facility is physically located in a dry and hot climate which would make it easier for the fire to spread and affect the residents, staff, and public resulting in

Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for two residents (R)13 and R26 out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication.

Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to provide written notice of bed-hold policy for two residents (R)13 and R26 out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication of the facility's bed-hold policy.

Inspectors wroteBased on interviews and record review, the facility failed to provide assistance in obtaining routine dental care for 2 out of 6 sampled residents (R) R16 and R20.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment which would help prevent the development and transmission of communicable disease and infections.

Inspectors wroteBased on record review and staff interview, the facility failed to inform all residents, their representatives, and families of those residing in the facility by 5:00 PM the next calendar day of a confirmed case of COVID-19 as required by regulation.

Inspectors wroteBased on observation, interview and record review, the facility failed to report the results of an investigation of alleged abuse (invasion of privacy) for two of two sampled residents (R)20 and R21.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide non-pharmacological methods to help alleviate depression for one resident (R)11. This hinders R11's ability of attaining his highest practicable physical, mental, and psychological well-being.

Inspectors wroteBased on observation, interviews and record review, the facility failed to update and revise the care plan to include interventions and treatment for a suspected hairline fracture of the left 5th proximal phalanx. The facility failed to update and revise the care plan for one of one sampled resident (R)20.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to appropriately provide the necessary behavioral health care and services for one resident (R), R11, to attain his highest practicable physical, mental, and psychological well-being. The facility failed to recognize R11's depressive symptoms and provide non-pharmacological interventions to help alleviate R11's depression.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure foods stored in the freezer were labeled, dated when opened, and sealed closed. They also failed to allow dishes to air dry before being stored. These failures had the potential to affect all 41 residents in the facility who ate food from the kitchen with foodborne illness.

Inspectors wroteBased on interviews, records review, and facility policies review, the facility failed to ensure the appropriate CPR (cardiopulmonary resuscitation) status was consistently recorded throughout the clinical records for one (Resident (R)37) of two residents reviewed for advanced directives. The facility's deficient practice had potential for staff to provide or withhold Cardiopulmonary Resuscitation CPR inconsistent with R37's wishes and directives in an emergent situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADL) for one (Resident (R) 191) of two residents reviewed for ADL care. Specifically, the facility failed to provide bathing for R191. This failure has the potential to affect the resident's comfort and increase the risk for infections.