Inspection Reports for Serenity Care Home Hawaii Kai
1072 Kalapaki St, Honolulu, HI 96825, United States, HI, 96825
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 13, 2025, identified multiple deficiencies related to medication administration, personal care services, resident accounts, and residents' rights. Earlier inspections showed a range of issues including food sanitation, medication labeling, fire drill procedures, staffing education requirements, and medication record accuracy. Inspectors frequently cited medication management and documentation as recurring themes, along with some concerns about resident care and administrative records. No complaint investigations were noted in the available reports, and enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of deficiencies suggests ongoing challenges in compliance, with similar types of issues appearing over time without a clear trend of improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 13, 2025
Visit Reason
The inspection was conducted as the annual survey for Serenity Care Home Hawaii Kai to assess compliance with state licensing regulations.
Findings
Multiple deficiencies were identified related to medication administration, personal care services, resident accounts, and residents' rights and responsibilities. Plans of correction were submitted for each deficiency with future plans to prevent recurrence.
Deficiencies (7)
Resident #1 was administered Aspirin 81mg daily from 12/9/24-12/31/24 without a physician's order.
Resident #1's medication administration record lacked documented evidence of thickener use for liquids as ordered.
No documented evidence that bowel movements were monitored to determine if medication needed after 3 days of no bowel movements for Resident #1.
Schedule of daily activities was unavailable for review for Resident #1.
Financial statement was unavailable for admission on 12/7/24 for Resident #1.
No documented evidence that Resident #1 was informed of their rights and responsibilities upon admission on 12/7/24.
No documented evidence that Resident #1 was informed verbally and in writing of services available and related charges at the time of readmission on 12/7/24.
Report Facts
Inspection Date: Mar 13, 2025
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 12, 2024
Visit Reason
The inspection was conducted as the facility's annual survey to assess compliance with state licensing regulations.
Findings
The inspection identified deficiencies related to food sanitation, medication labeling, and fire drill procedures. Plans of correction were submitted addressing storage of food items, updating medication labels, and scheduling fire drills during various times including darkness.
Deficiencies (3)
Case of Ensure stored on floor in hallway closet
Medication packet label did not reflect updated physician order for Resident #1
Fire drills performed monthly did not include any drills during hours of darkness
Report Facts
Deficiency completion date: Mar 19, 2024
Deficiency completion date: Mar 20, 2024
Deficiency completion date: Mar 19, 2024
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as the annual survey of Serenity Care Home Hawaii Kai to assess compliance with regulatory requirements.
Findings
The facility was found deficient in personnel and staffing requirements, specifically that a substitute care giver completed only seven out of twelve required continuing education hours within the last year.
Deficiencies (1)
Substitute Care Giver (SCG) #1 completed seven out of twelve continuing education hours required within the last year.
Report Facts
Continuing education hours completed: 7
Required continuing education hours: 12
Additional hours completed: 6
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 17, 2022
Visit Reason
The inspection was conducted as the facility's annual survey to assess compliance with state regulations under Chapter 100.1.
Findings
Multiple deficiencies were identified related to nutrition, medication orders and administration, medication record accuracy, and resident record confidentiality, all involving Resident #1. Specific issues included unclear diet orders, incorrect medication dosages, medication given despite hold parameters, inaccurate medication administration records, and suspected tampering of blood pressure records.
Deficiencies (5)
No documented evidence that the diet order 'regular diabetic' from 4/21/2021 was clarified with the physician.
Order for Metoprolol stated 50 mcg instead of 50 mg.
Medication given on 2/27/2022 despite resident's heart rate being 48, below hold parameter of HR <50.
Medication administration record (MAR) incorrectly stated Vitamin B12 dosage as 1000 mg instead of 1000 mcg.
Blood pressure recorded under Amlodipine on 4/26/2021 appears tampered with, originally 107 changed to 117.
Report Facts
Medication dosage: 50
Heart rate: 48
Vitamin B12 dosage: 1000
Blood pressure: 107
Blood pressure: 117
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