A list of the most recent deficiencies for Liliha Healthcare Center. 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 | 2023-06-30 | 2023-07-31 | Y |
Give residents a notice of rights, rules, services and charges. | Health | 2023-06-30 | 2023-07-31 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-30 | 2023-07-31 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-30 | 2023-07-31 | Y |
Establish staff and initial training requirements. | Fire Safety | 2023-02-16 | 2023-05-11 | N |
Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-16 | 2023-05-05 | N |
Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-02-16 | 2023-05-05 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-16 | 2023-05-05 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-14 | 2023-04-14 | N |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-02-14 | 2023-04-14 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-14 | 2023-04-14 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-14 | 2023-04-14 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-14 | 2023-04-14 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-14 | 2023-04-14 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-14 | 2023-04-14 | N |
Provide and implement an infection prevention and control program. | Health | 2023-02-14 | 2023-04-14 | N |
Keep all essential equipment working safely. | Health | 2023-02-14 | 2023-04-14 | N |
Ensure each resident receives an accurate assessment. | Health | 2023-02-14 | 2023-04-14 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-14 | 2023-04-07 | 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 | 2023-02-14 | 2023-04-07 | N |
Respond appropriately to all alleged violations. | Health | 2023-02-14 | 2023-04-07 | 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 | 2023-02-14 | 2023-04-07 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-04-07 | 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 | 2023-02-14 | 2023-04-07 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-14 | 2023-04-07 | 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 | 2023-02-14 | 2023-04-07 | N |
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-02-14 | 2023-04-07 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-14 | 2023-04-07 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-14 | 2023-04-07 | Y |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-02-14 | 2023-04-07 | Y |
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 | 2023-02-14 | 2023-04-07 | Y |
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-02-14 | 2023-04-07 | Y |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-11-15 | 2023-02-10 | 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 | 2022-11-15 | 2023-02-10 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-15 | 2023-02-10 | Y |
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 | 2022-11-15 | 2023-02-10 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-15 | 2023-02-10 | Y |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-11-15 | 2023-02-10 | Y |
Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-15 | 2023-02-10 | 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 | 2022-11-15 | 2022-12-27 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-11-15 | 2022-12-27 | Y |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-15 | 2022-12-27 | Y |
Report COVID19 data to residents and families. | Health | 2022-11-15 | 2022-12-27 | Y |
Perform COVID19 testing on residents and staff. | Health | 2022-11-15 | 2022-12-27 | Y |
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 | 2022-11-15 | 2022-12-27 | Y |
Establish policies and procedures for volunteers. | Fire Safety | 2022-11-15 | 2022-12-27 | Y |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-15 | 2022-12-20 | Y |
Ensure each resident receives an accurate assessment. | Health | 2022-02-10 | 2022-03-25 | 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 | 2022-02-10 | 2022-03-22 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-02-10 | 2022-03-22 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-10 | 2022-03-22 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-03-22 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-10 | 2022-03-22 | N |
Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-22 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-10 | 2022-03-22 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-10 | 2022-03-22 | N |
Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-02-10 | 2022-03-22 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-10 | 2022-03-22 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-10 | 2022-03-22 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-05 | 2022-02-15 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-05 | 2022-02-15 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-15 | 2021-09-14 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-15 | 2021-09-14 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-15 | 2021-09-14 | Y |
Respond appropriately to all alleged violations. | Health | 2021-07-15 | 2021-09-14 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-12 | 2021-04-14 | Y |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
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 | 2021-02-22 | 2021-04-14 | N |
Have exits that are accessible at all times. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-22 | 2021-04-14 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-02-19 | 2021-03-30 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-02-19 | 2021-03-30 | 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 | 2021-02-19 | 2021-03-30 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-02-19 | 2021-03-30 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-02-19 | 2021-03-30 | N |
Respond appropriately to all alleged violations. | Health | 2021-02-19 | 2021-03-30 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-02-19 | 2021-03-30 | 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 | 2021-02-19 | 2021-03-30 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-19 | 2021-03-30 | N |
Provide and implement an infection prevention and control program. | Health | 2021-02-19 | 2021-03-30 | N |