HONOLULU, HI - Federal inspectors documented serious safety lapses at Kalakaua Gardens nursing home, including repeated falls by a high-risk resident and multiple food safety violations that could affect all residents and visitors.
Repeated Falls Lead to Head Injury
The most concerning violation involved a resident identified as R22, who experienced two significant falls within three months due to inadequate care planning and supervision failures.
In September 2024, R22 sustained a pelvis fracture during a fall. Despite this serious injury and documented history of multiple falls, facility staff failed to update the resident's care plan with appropriate safety interventions. The comprehensive care plan continued to identify R22 as at risk for falls related to gait and balance problems, but no new preventive measures were implemented.
On November 26, 2024, the consequences of this oversight became apparent. At 8:57 AM, staff escorted R22 to the toilet and helped remove her undergarments, then left her unattended in the bathroom. Staff heard a loud noise and groaning, then discovered R22 sitting on the floor in a puddle of blood coming from her head.
The resident had sustained multiple injuries from the fall: a skin tear to her right knee, multiple bruises on her right arm, and a developing bruise on her right temple and cheekbone. R22 told staff she didn't remember what happened and thought she was just going to sit on the toilet before ending up on the floor.
R22 required emergency hospital treatment and returned with three sutures above her right eye.
Medical Significance of Fall Prevention Failures
Fall prevention protocols in nursing homes typically require comprehensive risk assessments and specific interventions for high-risk residents. When a resident experiences a serious fall resulting in fractures, standard medical practice dictates immediate care plan revisions to prevent recurrence.
The failure to update R22's care plan after the pelvis fracture represents a breakdown in basic safety protocols. Pelvis fractures in elderly residents often indicate significant fall risk factors that require enhanced monitoring and environmental modifications.
Leaving a fall-risk resident unattended in a bathroom violates fundamental safety principles. Bathrooms present multiple hazards for individuals with balance problems, including wet surfaces, hard fixtures, and limited space for safe movement.
During the January 17, 2025 inspection, the Director of Nursing confirmed that R22's care plan was never updated after the September fall and acknowledged that the second fall could have been avoided if the resident had not been left unattended.
Food Safety Violations Threaten All Residents
Inspectors identified multiple food handling and storage violations that could expose residents to foodborne illness risks.
During a January 14 kitchen inspection, surveyors found food boxes stored directly on floors in both dry storage and walk-in freezer areas. Items included spam, apple juice, garbanzo beans, mayonnaise, imitation crab meat, potato rolls, bread, and vegetables. The Dietary Director acknowledged these items should not be on the floor and immediately moved them to appropriate shelving.
Staff were also observed preparing food with expired ingredients. A dietary aide was preparing tuna sandwiches using tuna salad prepared six days earlier on January 8, despite facility guidelines limiting tuna salad storage to four days maximum.
Additional violations included partially covered food containers in refrigeration and staff working without required hair restraints during food preparation activities.
Medical Equipment and Medication Storage Issues
The facility failed to maintain proper quality control for blood glucose testing equipment used to monitor residents' blood sugar levels. Inspectors found expired quality control solutions being used for daily calibration testing, which could compromise the accuracy of glucose readings for diabetic residents.
Temperature monitoring failures in medication refrigeration presented additional safety concerns. Staff did not follow up on an out-of-range temperature recording, potentially compromising the effectiveness of stored medications that require specific temperature control.
Documentation and Record Keeping Failures
Medical record deficiencies included incomplete baseline care plan documentation for a hospice resident. The facility could not demonstrate that required assessments were completed within the mandated 48-hour timeframe following admission, and documentation lacked required signatures and completion dates.
Proper medical record maintenance ensures continuity of care and regulatory compliance. Missing documentation makes it difficult to track care delivery and identify potential safety issues.
Industry Standards and Regulatory Requirements
Federal nursing home regulations require comprehensive fall risk assessments and immediate care plan updates following serious incidents. Facilities must implement specific interventions based on individual resident needs and risk factors.
Food service operations must follow strict safety protocols to prevent foodborne illness, particularly important given residents' potentially compromised immune systems. This includes proper food storage temperatures, appropriate container covering, staff hygiene practices, and adherence to food expiration guidelines.
Medical equipment used for resident care requires regular calibration and quality control testing with non-expired materials to ensure accurate results that inform treatment decisions.
The January 17, 2025 inspection resulted in citations for failure to review and revise care plans (F689), pharmaceutical services violations (F755), medication storage issues (F761), food service safety failures (F812), and medical record deficiencies (F842).
These violations demonstrate systemic issues affecting multiple aspects of resident care and safety at Kalakaua Gardens, requiring immediate corrective action to protect resident welfare and restore regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kalakaua Gardens from 2025-01-17 including all violations, facility responses, and corrective action plans.
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