A list of the most recent deficiencies for Hale Makua - Kahului. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-19 | 2023-12-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-19 | 2023-12-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-19 | 2023-12-08 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-10-19 | 2023-12-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-19 | 2023-12-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-19 | 2023-12-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-10-19 | 2023-12-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-19 | 2023-12-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-19 | 2023-12-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-19 | 2023-12-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-19 | 2023-12-08 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-19 | 2023-12-08 | 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 | 2023-10-19 | 2023-12-08 | 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 | 2023-10-19 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-19 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-12-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-19 | 2023-12-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-19 | 2023-12-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-19 | 2023-12-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-19 | 2023-12-08 | 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 | 2023-10-19 | 2023-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-19 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-19 | 2023-12-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-19 | 2023-12-08 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-13 | 2023-05-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-13 | 2023-05-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-13 | 2023-05-19 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-04-13 | 2023-05-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-22 | 2023-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-22 | 2023-03-23 | Y |
| 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 | 2023-02-08 | 2023-03-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-09 | 2023-01-23 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-12-09 | 2023-01-23 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-12-09 | 2023-01-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-22 | 2022-10-21 | Y |
| 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 | 2022-09-22 | 2022-10-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-22 | 2022-10-21 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-22 | 2022-10-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-22 | 2022-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-22 | 2022-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-22 | 2022-09-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-22 | 2022-09-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-22 | 2022-09-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-07-22 | 2022-09-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-22 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-22 | 2022-09-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-22 | 2022-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-22 | 2022-09-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-22 | 2022-06-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-26 | 2022-02-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-26 | 2022-02-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-26 | 2022-02-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-26 | 2022-02-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-26 | 2022-02-13 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-26 | 2022-02-13 | Y |
| 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 | 2021-03-25 | 2021-05-07 | 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 | 2021-03-25 | 2021-05-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-25 | 2021-05-07 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-25 | 2021-05-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-03-25 | 2021-05-07 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-26 | 2020-01-21 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-11-26 | 2020-01-21 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-26 | 2020-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-26 | 2020-01-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-26 | 2020-01-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-26 | 2020-01-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-26 | 2020-01-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-26 | 2020-01-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-26 | 2020-01-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-26 | 2020-01-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-26 | 2020-01-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-26 | 2020-01-21 | 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 | 2019-11-26 | 2020-01-21 | N |
