Cycle 1
Health 2025-01-17 · Fire 2025-01-17
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Honolulu, HI
Kalakaua Gardens
3-star overall rating with 3-star inspections with $55,692 in total fines with 8 recent health deficiencies
1723 Kalakaua Avenue, Honolulu, HI
(808) 518-2273
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-06-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.80
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.23
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.74
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
4.62
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.69
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.86
CMS adjusted RN staffing hours
Adjusted total hours
4.91
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
96%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
94%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,627
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.20
Composite VBP score used to determine payment impact.
Payment multiplier
1.0102
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.44
Baseline 17.89% · Performance 18.45% · Measure score 6.44 · Achievement 6.44 · Improvement 0
Healthcare-associated infections
2.65
Baseline 6.14% · Performance 7.04% · Measure score 2.65 · Achievement 2.65 · Improvement 0
Total nurse turnover
6.52
Baseline 49.12% · Performance 37.04% · Measure score 6.52 · Achievement 6.52 · Improvement 4.48
Adjusted total nurse staffing
6.48
Baseline 4.27 hours · Performance 4.92 hours · Measure score 6.48 · Achievement 6.48 · Improvement 3.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 6.43% · Lower 95% interval 6.56% |
| Discharge to community | 69.74% |
50.57%
19.2 pts better
|
Better than the National Rate · Eligible stays 148 · Observed rate 66.89% · Lower 95% interval 62.7% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 78 · Denominator 78 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 78 |
| Discharge self-care score | 16.42% |
53.69%
37.3 pts worse
|
Numerator 11 · Denominator 67 |
| Discharge mobility score | 46.27% |
50.94%
4.7 pts worse
|
Numerator 31 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 3 · Denominator 78 · Adjusted rate 3.36% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 5.97% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 0.57% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 175 |
| Staff flu vaccination coverage | 14.95% |
42%
27.1 pts worse
|
Numerator 32 · Denominator 214 |
| Discharge function score | 19.4% |
56.45%
37.1 pts worse
|
Numerator 13 · Denominator 67 |
| Transfer of health information to provider | 75% |
95.95%
21 pts worse
|
Numerator 27 · Denominator 36 |
| Transfer of health information to patient | 86.21% |
96.28%
10.1 pts worse
|
Numerator 25 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 32.69% |
25.2%
7.5 pts better
|
Numerator 17 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
0.9
0.1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 49.1% |
96.3%
47.2 pts worse
|
93.4%
44.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.3% · Q2 53.3% · Q3 46.7% · Q4 32.1% · 4Q avg 49.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.8% |
95.4%
10.6 pts worse
|
95.5%
10.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
1.9%
4.1 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.7% · Q3 6.7% · Q4 7.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
1.4%
3.5 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.1% · Q3 0.0% · Q4 0.0% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
4.9%
1.8 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.8% · Q3 8.3% · Q4 10.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.4% |
8.2%
3.8 pts better
|
19.6%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.5% · Q3 4.2% · Q4 5.0% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
11.3%
11.3 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.3% |
16.8%
16.5 pts worse
|
14.9%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.4%
0.2 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
17.8%
9.7 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 16.4% · Q3 24.4% · Q4 23.9% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
3.6%
3.9 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.5% · Q3 7.0% · Q4 4.4% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.9% |
82.8%
18.9 pts worse
|
81.7%
17.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.7% · Q2 68.4% · Q3 64.4% · Q4 58.7% · 4Q avg 63.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
10.9%
4.3 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 5.9% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.0%
1.1 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.4% · Q3 2.5% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.5% |
84.7%
11.2 pts worse
|
79.7%
6.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
19.6%
7.2 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 22.1% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-16 · Fire 2023-06-16
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-05-27 · Fire 2022-05-27
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-06-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-16
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-16
K771 · Miscellaneous Deficiencies
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-06-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-18
C · Minimal harm
2023-06-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-18
C · Minimal harm
2023-06-16
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-07-18
F · Potential for more than minimal harm
2022-05-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-05-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-05-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-12
G · Actual harm
2025-01-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-01-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-17
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-03
G · Actual harm
2024-01-26
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-01-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-01-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-01-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-01-26
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-03-11
D · Potential for more than minimal harm
2023-08-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-06-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-06-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-16
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-16
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-07
G · Actual harm
2022-05-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-25
E · Potential for more than minimal harm
2022-05-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-15
Penalties and ownership
What sits behind the stars
$55,692
2025-01-17
Fine
Fine · fine $55,692
Fine
Ownership
1723 Kalakaua LLC
5% Or Greater Direct Ownership Interest · Organization
P E And M LLC
5% Or Greater Indirect Ownership Interest · Organization
Chi Wai Cheung
5% Or Greater Indirect Ownership Interest · Organization
Hua Dai
5% Or Greater Indirect Ownership Interest · Organization
John T S Hung And Siew Yoong Hung Trust
5% Or Greater Indirect Ownership Interest · Organization
American Savings Bank Fsb
5% Or Greater Security Interest · Organization
Hpl Development LLC
Operational/Managerial Control · Organization
Kojima, Colleen
W-2 Managing Employee · Individual
Leong, Louis
General Partnership Interest · Individual
Leong, Louis
Corporate Director · Individual
Leong, Louis
Corporate Officer · Individual
Masuda, Ryuchi
Operational/Managerial Control · Individual
Tony K & Rebecca C Yung 1996 Fam Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Yu, Paul
General Partnership Interest · Individual
Yu, Paul
Corporate Director · Individual
Yu, Paul
Corporate Officer · Individual
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#3
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