A list of the most recent deficiencies for Leahi Hospital. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-14 | 2023-10-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-14 | 2023-10-27 | N |
| Post nurse staffing information every day. | Health | 2023-09-14 | 2023-10-27 | 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 | 2023-09-14 | 2023-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-14 | 2023-10-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-14 | 2023-10-27 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-09-30 | 2022-11-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-09-30 | 2022-11-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-30 | 2022-11-10 | N |
| 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. | Health | 2022-09-30 | 2022-11-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-30 | 2022-11-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-30 | 2022-11-10 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-30 | 2022-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-11-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-30 | 2022-11-10 | 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 | 2022-09-30 | 2022-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-30 | 2022-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-30 | 2022-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-30 | 2022-11-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-09-30 | 2022-11-10 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-30 | 2022-10-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-20 | 2021-11-04 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-09-20 | 2021-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-20 | 2021-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-20 | 2021-11-04 | N |
| Provide activities to meet all resident's needs. | Health | 2021-09-20 | 2021-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-20 | 2021-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-20 | 2021-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-20 | 2021-11-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-09-20 | 2021-11-04 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-09-20 | 2021-11-04 | 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 | 2021-09-20 | 2021-11-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-20 | 2021-11-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-20 | 2021-11-04 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-20 | 2021-11-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-21 | 2021-11-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-21 | 2021-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-21 | 2021-11-04 | N |
