Inspection Report Summary
The most recent inspection on June 25, 2025, identified deficiencies related to service plans, medication administration, health monitoring, and medication review. Earlier inspections also noted issues with service plan updates, medication delegation and documentation, staff training, and nursing assessments. Common themes across reports included incomplete or delayed service plans, unclear medication orders or administration by unlicensed personnel without proper delegation, and insufficient health monitoring during treatment. Complaint investigations were not listed in the available reports. The pattern of deficiencies has remained consistent over time, with no clear indication of improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 25, 2025
Visit Reason
The inspection was conducted as the annual survey of Kalakaua Gardens assisted living facility to assess compliance with state regulations and licensing requirements.
Findings
Multiple deficiencies were identified related to service plans, medication administration, health monitoring, and medication review. Specific issues included missed antibiotic doses, unclear medication orders, delayed service plan completion, lack of health monitoring during antibiotic treatment, and untimely medication reviews.
Deficiencies (5)
Resident #1 missed one dose of antibiotic Cefdinir during a 7-day course.
Resident #2's order for Calcium Carbonate with Vitamin D and Magnesium lacked specific dose clarification in mg/units.
Resident #3's initial service plan was completed two days after admission, not prior to move-in.
Resident #1 did not receive health monitoring throughout antibiotic treatment for UTI from 6/9/25 to 6/16/25.
Medication reviews for Residents #1 and #2 were not timely completed between October 2024 and March 2025.
Report Facts
Medication course duration: 7
Medication review timeframe: 90
Admission to service plan completion delay: 2
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jun 13, 2024
Visit Reason
The inspection was conducted as the annual survey of the assisted living facility Kalakaua Gardens on June 13 and 14, 2024.
Findings
Multiple deficiencies were identified related to staff training, documentation, service plans, medication administration, and nursing assessments. The facility submitted plans of correction addressing each deficiency with future training, audits, and policy updates.
Deficiencies (9)
Medication Aide collected a urine sample without documented RN delegation and training to collect and properly store urine specimens.
No documentation of first aid certification for Employee #1.
Facility policy on Narcotics Count & Documentation showed multiple missing signatures on shift change.
Resident #1's comprehensive assessment did not address skin problems/needs; resident had open sores and active PRN order for ointment.
Resident #2's service plan did not reflect self-administration of PRN Vagisil cream and blood sugar checks.
Resident #2's service plan did not reflect current diet order regarding food texture and fluid consistency.
Resident #1 had no documented RN delegation or evidence of RN assessment and evaluation following medication administration of PRN Calmoseptine ointment.
Resident #1 had a bedsore on left buttock with no documented evidence that licensed staff was notified or provided appropriate treatment.
Resident #2's medication administration lacked clarification on dosage of Glucosamine-Chondroitin Tablet; documentation incomplete.
Report Facts
Inspection dates: June 13 and 14, 2024
Plan of correction completion dates: Dates range from 6/14/24 to 8/12/24 for various corrective actions
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerwin Higashi | Licensee/Administrator | Signed the plan of correction document |
| Darrin Schadel | Signed on behalf of Kerwin Higashi for plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as the annual survey of the Kalakaua Gardens assisted living facility to assess compliance with state regulations.
Findings
The inspection identified deficiencies related to service plans not being updated timely for residents, medication administration by unlicensed personnel without proper delegation, and lack of documented health monitoring for skin tears. Plans of correction and future plans were submitted for each deficiency.
Deficiencies (4)
Resident #1 and #2 service plans were not updated to reflect current diet orders and were not updated timely (at least annually).
Resident #1 medication order was administered by unlicensed assistive personnel without delegation from a registered nurse and no documented RN assessment or evaluation following medication administration.
No documented evidence that health monitoring was provided for skin tears to determine if wounds resolved on specified dates.
No documented evidence that the facility addressed 'low salt eating plan' and 'watch sodium in diet' with the resident's physician.
Report Facts
Completion date for correction: Jun 27, 2023
Completion date for future plan: Jul 3, 2023
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 7, 2022
Visit Reason
The inspection was conducted as the annual survey of Kalakaua Gardens to assess compliance with state licensing regulations under Chapter 90.
Findings
The report identified deficiencies related to service plans not addressing residents' fall risks, failure to update service plans to reflect current diet orders, lack of documented evidence regarding allergy discussions and medication approvals, missing current physical exams and TB clearances, and failure to generate incident reports for falls. Plans of correction and future plans were submitted to address these issues.
Deficiencies (7)
Service plan did not address resident's falls risk despite multiple falls.
Service plan was not updated to reflect the current diet order.
No documented evidence that allergy to Rotigotine was discussed with physician and medication approved for daily use.
Resident had weight loss but no documented evidence that the facility promptly notified the physician.
Current physical exam unavailable for review.
Current TB clearance unavailable for review for some residents.
No documented evidence an incident report was generated for a resident fall.
Report Facts
Weight loss: 7.6
Dates of falls: Resident #1 experienced falls on 10/16/21, 11/17/21, 1/24/22, 4/2/22, 4/23/22, and 6/6/22; Resident #2 experienced falls on 7/3/21, 7/19/22, 9/28/21, 10/29/21, 11/17/21, 1/14/22, 3/3/22.
Inspection date: Jun 7, 2022
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