A list of the most recent deficiencies for Avalon Care Center - Honolulu, LLC. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2023-03-20 | 2023-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-17 | 2023-05-01 | 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 | 2023-03-17 | 2023-05-01 | N |
| 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 | 2023-03-17 | 2023-05-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-17 | 2023-05-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-17 | 2023-05-01 | N |
| 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 | 2023-03-17 | 2023-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-17 | 2023-05-01 | 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 | 2023-03-17 | 2023-05-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-17 | 2023-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-17 | 2023-05-01 | 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 | 2023-03-17 | 2023-05-01 | N |
| Post nurse staffing information every day. | Health | 2023-03-17 | 2023-05-01 | 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 | 2023-03-17 | 2023-05-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-17 | 2023-05-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-17 | 2023-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-17 | 2023-05-01 | N |
| Keep all essential equipment working safely. | Health | 2023-03-17 | 2023-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-20 | 2023-05-01 | 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 | 2023-03-20 | 2023-03-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-20 | 2022-11-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-22 | 2022-08-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-22 | 2022-08-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-22 | 2022-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-22 | 2022-08-22 | 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 | 2022-07-22 | 2022-08-22 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-01 | 2022-05-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-01 | 2022-05-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-01 | 2022-05-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-01 | 2022-05-02 | 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 | 2022-04-01 | 2022-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-01 | 2022-05-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-03-31 | 2022-05-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-31 | 2022-05-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-03-31 | 2022-05-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-31 | 2022-05-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-31 | 2022-05-02 | 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 | 2021-10-28 | 2021-12-03 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-10-28 | 2021-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-28 | 2021-12-03 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-10-28 | 2021-12-03 | 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 | 2021-10-28 | 2021-12-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-15 | 2021-10-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-15 | 2021-10-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-15 | 2021-10-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-02-02 | 2021-06-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-02-02 | 2021-06-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-02-02 | 2021-06-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-02 | 2021-06-10 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-02-02 | 2021-06-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-02-08 | 2021-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-08 | 2021-04-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-02-08 | 2021-04-29 | 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 | 2021-02-08 | 2021-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-08 | 2021-04-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-02-08 | 2021-04-29 | N |
