Kalakaua Gardens

In the surveyor’s words

From the most serious findings on record at Kalakaua Gardens, in the surveyor’s own words.

• Actual harm, patternF726Jan 26, 2024

  Based 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. […]

• Actual harm, isolatedF689Jan 17, 2025

  Based 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. Findings include: On 11/17/24 at 08:57 AM, conducted a record review of R22's Electronic Health Record (EHR). Review of progress notes documented on 9/5/24 at 03:28 AM, a Certified Nurse Aide (CNA)65 answered R22's light at 12:45 AM and assisted R22 onto the toilet. CNA65 left R22 unattended, then heard a loud noise and the resident calling for help. CNA65 and Registered Nurse (RN)41 went into the bathroom and found the resident on the floor. […]

• Actual harm, isolatedF689May 27, 2022

  Based on observations, record review, and interviews with staff member, the facility failed to implement the use of a gait belt consistent with the facility's standard of practice and the resident's needs, goals, and care plan to prevent an avoidable fall for 1 out of 2 residents (Resident (R) 11) sampled that resulted in sustaining a fracture to right rib. Findings Include: Review of R11's Event Report regarding an incident 04/26/22, R11 had a witnessed fall and sustained fracture to his right rib. The report documents R11 standing with two therapists at the elevator with his walker and .was attempting to place his face mask on. He fell forward and to the right hitting his right rib cage on the walker frame. The therapists caught him and lowered him to the floor. […]

• Actual harm, isolatedF697Apr 1, 2021

  Based on observations, record review, policy review and interview with staff members, the facility failed to recognize and provide effective pain management to Resident (R)259 and R109. The deficient practice resulted in R259 yelling pain, making grimacing facial expressions, and irritability when repositioned during meals and medication administration. The deficient practice also resulted in R109's pain not managed, monitored or evaluated according to standards of practice. These deficient practices have the potential to affect other residents' pain management in the facility. As a result of this deficiency, residents have the potential for more than minimal harm. Findings Include: Cross Reference to 655 1) R259 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Feb 20, 2026

  Based 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. […]