Cycle 1
Health 2024-04-05 · Fire 2024-04-05
10 health deficiencies
Top issue: Environmental (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Waimea, HI
Kauai Care Center
3-star overall rating with 3-star inspections with 10 recent health deficiencies
9611 Waena Road, Waimea, HI
(808) 338-1681
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
53
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
2011-08-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
27 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,880
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.37
Baseline 37.21% · Performance 45.83% · Measure score 4.37 · Achievement 4.37 · Improvement 0
Adjusted total nurse staffing
4.09
Baseline 4.55 hours · Performance 4.24 hours · Measure score 4.09 · Achievement 4.09 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 6.28% |
| Discharge to community | 71.98% |
50.57%
21.4 pts better
|
Better than the National Rate · Eligible stays 34 · Observed rate 67.65% · Lower 95% interval 52.41% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 36.25% |
42%
5.8 pts worse
|
Numerator 29 · Denominator 80 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
96.3%
0.8 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 91.1% · Q3 97.7% · Q4 100.0% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.7% |
95.4%
16.7 pts worse
|
95.5%
16.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
1.9%
0.1 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
1.4%
1 pts worse
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.7% · Q3 2.3% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.9%
0.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 2.6% · Q4 5.6% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
8.2%
3 pts worse
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 2.6% · Q3 12.8% · Q4 13.5% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.1% |
11.3%
12.8 pts worse
|
16.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 20.6% · Q3 25.0% · Q4 26.5% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.5% |
23.4%
5.9 pts better
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 24.5% · Q3 7.3% · Q4 19.2% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
16.8%
0.6 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 26.3% · Q3 11.1% · Q4 11.8% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.3%
0.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.4%
0.6 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 4.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.7% |
17.8%
9.1 pts better
|
19.8%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 6.8% · Q3 6.5% · Q4 11.9% · 4Q avg 8.7% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
3.6%
2.2 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 1.7% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
82.8%
7.6 pts better
|
81.7%
8.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.0% · Q2 90.0% · Q3 86.4% · Q4 100.0% · 4Q avg 90.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.0%
0.3 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
84.7%
4.7 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-14 · Fire 2023-04-14
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-02-23 · Fire 2022-02-23
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-04-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-04-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-18
D · Potential for more than minimal harm
2022-02-23
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-02-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-02-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-03-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-04-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-05-20
F · Potential for more than minimal harm
2024-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-20
E · Potential for more than minimal harm
2024-04-05
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-20
E · Potential for more than minimal harm
2023-04-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-29
E · Potential for more than minimal harm
2023-04-14
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-05-29
E · Potential for more than minimal harm
2023-04-14
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-05-29
E · Potential for more than minimal harm
2023-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-29
E · Potential for more than minimal harm
2023-04-14
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-05-29
E · Potential for more than minimal harm
2022-02-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-02-23
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-02-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-24
Penalties and ownership
What sits behind the stars
Ownership
Clay, James
5% Or Greater Direct Ownership Interest · Individual
Beddoe, Marvin
Operational/Managerial Control · Individual
Hori-Moises, Brandi
Corporate Director · Individual
Regency Pacific Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Kauai Veterans Memorial Hospital
Waimea, HI
2-star overall rating with 1-star inspections with Special Focus status with $34,300 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Hale Kupuna Heritage Home, LLC
Koloa, HI
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Garden Isle Healthcare And Rehabilitation Center
Lihue, HI
5-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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