Kauai Care Center

In the surveyor’s words

From the most serious findings on record at Kauai Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880May 20, 2022

  Based on observation, interview, and record review, in response to a COVID-19 outbreak (one positive direct-care staff member) identified on 05/16/22, the facility failed to ensure appropriate protective and preventive measures for COVID-19 were executed, as evidenced by the facility failing to follow and implement their infection prevention and control policies and procedures, including the transmission-based precautions and testing procedures of their COVID-19 Plan to control and prevent the spread of COVID-19. […]

• Immediate jeopardy, isolatedF689May 20, 2022

  Based on observations, record reviews, interviews with staff and family representative, and review of the facility's policy and procedure, following an incident of sexual abuse (04/30/22), the facility failed to consistently implement interventions to reduce unsafe wandering behavior. The facility also failed to monitor interventions for efficacy. This deficient practice placed female residents of the facility at risk for sexual abuse and placed the Resident (R)21 at risk for altercation with other residents. On 05/19/22 at 10:54 AM, Immediate Jeopardy was called. The facility leadership was informed and the State Agency (SA) requested immediate action to prevent repeat of this failure. The facility provided a removal plan on 05/19/22. The SA accepted the removal plan. […]

• Actual harm, isolatedF600May 20, 2022

  Based on review of an event report submitted by the facility, record reviews, interviews with staff members, residents, and family members, and review of the facility's policy and procedures, the facility failed to ensure a resident was free from sexual abuse. Findings include: Cross Reference to F689. Resident (R)21 has a history of wandering into other residents' rooms. The facility failed to monitor interventions for efficacy and consistently implement interventions to prevent the resident from wandering into other residents' rooms. On 05/02/22 at 01:23 PM the facility sent an Event Report to the State Agency (SA) via facsimile regarding resident-to-resident abuse. […]

• Actual harm, isolatedF684May 27, 2021

  Based on observations, interviews and record reviews, the facility failed to provide care to one Resident(R)1 within professional standards of nursing practice between 05/08/21 to 05/21/21. R1 did not receive routine treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff failed to assess and report R1's severe bilateral lower extremity [CONDITION(S)] that resulted from the application of an occlusive wrap to R1's bilateral extremities (calf). The deficient practice caused increased pain and suffering for the resident and did not provide care that was at the highest practicable physical and emotional wellness. […]

• No harm, potential for more than minimal, widespreadF727Apr 5, 2024

  Based 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. Findings include: The facility is licensed for 52 beds, Review of the facility assessment included: B.2. […]