A list of the most recent deficiencies for Aloha Nursing and Rehab Centre. 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? |
|---|---|---|---|---|
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-06 | 2023-11-06 | 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 | 2023-10-06 | 2023-11-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-06 | 2023-10-20 | Y |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2023-10-06 | 2023-10-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-24 | 2023-10-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-24 | 2023-10-13 | N |
| 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 | 2023-08-24 | 2023-10-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-24 | 2023-10-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-24 | 2023-10-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-24 | 2023-10-13 | 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 | 2023-08-24 | 2023-10-13 | 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 | 2023-08-24 | 2023-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-24 | 2023-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-24 | 2023-10-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-28 | 2023-09-06 | 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 | 2022-09-02 | 2022-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-02 | 2022-11-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-09 | 2022-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-09 | 2022-11-30 | 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 | 2022-09-09 | 2022-11-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-09-09 | 2022-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-09 | 2022-11-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-09 | 2022-11-30 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-09 | 2022-10-23 | Y |
| 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 | 2022-09-09 | 2022-10-23 | 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 | 2022-09-09 | 2022-10-23 | 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 | 2022-09-09 | 2022-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-09 | 2022-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-02 | 2022-10-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-02 | 2022-10-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-10-16 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-09-02 | 2022-10-16 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-02 | 2022-10-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-08 | 2022-10-03 | 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 | 2022-09-08 | 2022-10-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-09-08 | 2022-10-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-08 | 2022-10-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-09-08 | 2022-10-03 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-25 | 2022-07-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-12 | 2021-12-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-12 | 2021-12-13 | 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 | 2021-10-12 | 2021-12-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-12 | 2021-10-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-12 | 2021-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-12 | 2021-10-15 | N |
| Provide activities to meet all resident's needs. | Health | 2021-08-12 | 2021-10-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-12 | 2021-10-15 | 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 | 2021-08-12 | 2021-10-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-08-12 | 2021-10-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-12 | 2021-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-10-15 | 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 | 2021-08-12 | 2021-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-10-15 | Y |
