Kalakaua Gardens

Inspectors wroteBased on observation, interview, and record review the facility failed to assure the kitchen followed dishwasher manufacturers guidelines for sanitizing their dishware and utensils, failed to label beverages with the opened-on date once they were opened, failed to label prepared vegetables and grated cheese with the prepared-on date and failed to throw away meats by the facility's discard by date. The deficient practice puts all residents who eat their meals at the facility at risk for foodborne illness. On 02/17/26 at 09:20 AM initial tour of the kitchen started with [NAME] (C) 9. Inquired about the facility dishwasher logs which C9 was able to provide. Reviewed the dishwashing/warewashing machine temperature log which states For High Temperature Machine: (Refer to machine data plate for temperature requirements). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that 2 of 2 ice and water machines for the residents were kept in clean and sanitary conditions in accordance with professional standards for food service safety. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents receiving ice or water on the affected resident units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was maintained within professional standards of practice for 4 of 4 Residents (Resident (R) 12, R24, R26, and R45) sampled for Respiratory/Tracheostomy care and suctioning. The facility failed to label and properly store oxygen, nebulizer, and suction equipment. The deficient practice placed the residents at risk of infections and illness.

Inspectors wroteBased on interview and record review the facility failed to inform 1 of 5 residents (Resident (R) 2), of the risk and benefits of taking an antidepressant medication for his insomnia. The deficient practice could affect all residents in the facility who are not informed in advance of starting an antidepressant of the risks and benefits and offered other treatment alternatives or options. On 02/19/26 at 09:12 AM during record review of R2's Electronic Health Record (EHR) found R2 was ordered Trazodone HCL 50 mg one tablet by mouth at bedtime for insomnia. Review of R2's consents and progress notes did not reveal documentation that R2 or his representative was informed in advance of the risks and benefits of this medication or treatment alternatives that he could choose. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide clean personal care equipment and living space for 1 of 13 residents (Resident (R) 26) sampled for a clean environment. The deficient practice placed the resident at risk for discomfort and illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (Resident (R) 3) sampled for unnecessary psychotropic medication was not prescribed as needed (PRN) anti-psychotic medication for greater than 14 days. The deficient practice placed the resident at risk for an adverse event.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident centered activities based on the resident's interests for 1 of 2 residents (Resident (R) 44) sampled for activities. This deficient practice failed to enhance the Resident's sense of well-being of watching news and sporting events on the television.

Inspectors wroteBased on observation, interview, and record review the facility did not correctly transcribe the physician orders for the splints/braces to the Medication/Treatment Administration record (MAR/TAR), did not ensure staff were trained on the application of physician ordered splints/braces, and did not follow-up on therapy recommendations for a palm splint for 1 of 3 residents (Resident (R) 37) sampled for limited range of motion (ROM). This deficient practice hindered R37's ability to maintain the highest practicable well-being and has the potential to affect all residents at the facility who have limited ROM.

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications in 2 of 4 medication carts were stored and locked in accordance with professional standards. Proper storage of medications and locking of the medication cabinet is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications.

Inspectors wroteBased on interview and record review, therapy services failed to follow physician ordered restrictions for 1 of 3 residents (Resident (R) 7) sampled for limited range of motion. This deficient practice had the potential to lead to worsening injury to R7.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement the facility's infection prevention and control measures for Legionnaire's Disease by not monitoring and testing for concentration of hydrogen in a solution (pH) levels in five sinks and showers per floor once a month, not monitoring and testing for presence of Legionella from decorative water fountain in front of facility, and not performing ice machine preventative maintenance once a month. This deficient practice placed everyone at risk for growing and spreading Legionella or other opportunistic waterborne pathogens and other adverse health complications.

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision to prevent a second fall which could have been avoided for one (Resident (R)22) of 14 residents sampled. As a result of this deficient practice, the resident had a second fall which could have been avoided and sustained physical injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow food handling and storage practices in accordance with professional standards for food service safety. Unsafe and/or unsanitary food handling and storage practices have the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness as a result of their compromised health status.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a comprehensive care plan was person-centered to maintain the resident's highest practicable physical well-being and the person-centered care plan was implemented for one resident (Resident (R)348) of 14 residents sampled. As a result of this deficient practice, dependent resident is at risk of more than minimal harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's (R)22 comprehensive care plan was revised with person-centered interventions after a significant change of condition assessment. As a result of this deficient practice, R22 was physically harmed, twice while left unsupervised in the bathroom and on the toilet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the supplies used for Quality Control (QC) testing of the blood glucose meter (device used for testing blood sugar) were not expired or beyond their discard date. This deficient practice has the potential to affect all residents that need glucose testing.

Inspectors wroteBased on observations, staff interview and review of policy, the facility failed to follow up on an out-of-range temperature recording for one medication refrigerator out of one sampled. As a result of this deficiency, there was risk of decreasing the effectiveness for the stored medications.

Inspectors wroteBased on record review and interviews, the facility failed to maintain a complete and accurate medical records for one of the residents (Resident (R)4) in the sample. This deficient practice has the potential to affect all the residents admitted to the facility.

Inspectors wroteBased on interviews and record review, the facility nursing staff failed to demonstrate the competency (knowledge and skill set) to meet the needs of one Resident (R)1 of a sample size of three. The Nursing Staff: 1) did not identify a change in R1's level of consciousness, 2) did not report the trend Rl's high blood pressure (BP) medication was held due to low blood pressure. 3) administered medication twice when it should have been held because BP was outside parameters, and 4) did not administer oxygen timely or notify the physician (MD)1 when R1's oxygen level (PO2) remained below. Due to these deficiencies, R1's changing condition was not recognized and reported to the MD, which did not allow for timely interventions, and she suffered harm. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide information to one Resident's (R)1 representative about the right to formulate an advanced health care directive (AHCD). The facility staff documented advanced directive information was provided to R1, and she agreed to the status of full code (resuscitation). R1 was not competent to make that decision or understand the information, and her representative was not involved. In addition, the physician wrote a conflicting order of do not resuscitate (DNR) on admission. As a result of this deficiency there was the potential the resident/representatives wishes were not taken into consideration during her treatment.

Inspectors wroteBased on interviews, and record review (RR), the facility failed to include one resident's (R)1 representative in the development of the comprehensive care plan. In addition, R1's physician (MD)1 does not attend the care planning IDT (interdisciplinary team) meetings. As a result of this deficiency, there was the potential the facility was not aware of R1's goals and desired outcomes, which could have a negative impact on her quality of life, as well as the quality of care and services received.

Inspectors wroteBased on record review (RR) and interviews, the facility did not ensure one residents (R)1 care plan was revised timely to include changes in therapy and new diagnoses. This deficient practice failed to ensure the continuity of care, and communication between facility staff and resident/ family members regarding care that is being provided to the resident.

Inspectors wroteBased on interviews and record review (RR), the facility failed to provide evidence that one Resident (R)1 received the required physician (MD) face-to-face initial comprehensive visit within 30 days of admission. As a result of this deficient practice, the resident's needs may not be met so she could meet her highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all new admissions.

Inspectors wroteBased on observations and staff interviews, the facility failed to follow safe food storage requirements. This deficient practice has the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for food-borne illnesses. Findings Include: On 06/13/23 at 08:31 AM, initial tour and observation of the kitchen area was conducted with the Food Service Manager (FSM). While checking the contents of the refrigerator by the food preparation area, noted an unlabeled black container on the top shelf. FSM immediately removed the container and said, that's not supposed to be there. The container was identified as a water bottle that belonged to one of the kitchen staff. At 08:45 AM, entered the walk-in refrigerator and freezer with FSM. Noted two plastic bags of meat placed in a metal container without a cover. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled appropriately including clearly identified discard dates. Proper labeling of medications is necessary to promote safe administration practices, and to decrease the risk of medication errors. This deficient practice has the potential to affect all residents in the facility taking medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to facilitate resident self-determination through support of resident choice for two residents (R), R48 and R217, out of five residents at the resident council meeting. The facility did not disclose the rehabilitation treatment times to R48 and R217 rendering them unable to plan for visits, activities, and appointments for their day and to worry about their therapy treatment time .

Inspectors wroteBased on record review and interview, the facility failed to provide written notice of transfer or discharge for two of the four residents (R) sampled (R24 and R48) for discharge, who were transferred to an acute care hospital for a higher level of care. The facility failed to provide notice to the residents or the residents' representative(s) and to the Office of the State Long-Term Care Ombudsman (LTCO).

Inspectors wroteBased on observations, interviews, and record reviews (RR), the facility failed to ensure staff had the knowledge to provide care, coordinate, and respond to the individualized needs for one resident (R)35 out of two residents sampled for hospice care. This lack of knowledge and coordination was evident as facility staff were unsure of the delineation of hospice responsibilities, hospice visit schedule, and other hospice services necessary for care of the resident's terminal illness and related conditions. This deficient practice created a potential for physical and psychosocial harm.

Inspectors wroteBased on interviews and record reviews (RR), the facility failed to ensure safe and secure storage/disposal of Fentanyl, a pain medication that is a narcotic and controlled medication, to minimize loss or diversion. This deficient practice has the potential for the medication to be obtained and used illegally.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure proper hand hygiene procedures were followed by all staff members. This deficient practice increases the risk for the development and transmission of communicable diseases and infections.