A list of the most recent deficiencies for Kalakaua Gardens. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-29 | 2023-09-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-22 | 2023-07-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-06-22 | 2023-07-18 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-06-22 | 2023-07-18 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-06-22 | 2023-07-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-22 | 2023-07-18 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2023-06-22 | 2023-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-22 | 2023-07-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-16 | 2023-07-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-16 | 2023-07-07 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-16 | 2023-07-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-16 | 2023-07-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-16 | 2023-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-16 | 2023-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-16 | 2023-07-07 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-02 | 2023-03-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-02 | 2023-03-19 | Y |
| 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. | Health | 2023-02-02 | 2023-03-19 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-02 | 2023-03-19 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-02-02 | 2023-03-19 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-27 | 2022-07-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-27 | 2022-07-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-27 | 2022-07-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-27 | 2022-07-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-27 | 2022-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-27 | 2022-07-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-27 | 2022-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-27 | 2022-07-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-27 | 2022-07-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-27 | 2022-05-27 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Have proper openings in smoke barrier doors. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-04-01 | 2021-05-20 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-04-01 | 2021-05-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-04-01 | 2021-05-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-04-01 | 2021-05-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-01 | 2021-05-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-01 | 2021-05-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-01 | 2021-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-05-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-01 | 2021-05-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-01 | 2021-05-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-04-01 | 2021-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-01 | 2021-05-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-04-01 | 2021-05-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-04-01 | 2021-05-20 | N |
