A list of the most recent deficiencies for Hale Malamalama. 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-15 | 2023-12-06 | 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 | 2023-09-15 | 2023-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-15 | 2023-12-06 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-09-15 | 2023-10-31 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-15 | 2023-10-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-15 | 2023-10-31 | 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 | 2023-09-15 | 2023-10-31 | 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 | 2023-09-15 | 2023-10-31 | 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 | 2023-09-15 | 2023-10-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-15 | 2023-10-31 | 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 | 2023-09-15 | 2023-10-31 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-15 | 2023-10-31 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-15 | 2023-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-15 | 2023-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-15 | 2023-10-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-15 | 2023-10-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-15 | 2023-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-15 | 2023-10-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-15 | 2023-10-31 | N |
| 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 | 2023-09-15 | 2023-10-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-15 | 2023-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-15 | 2023-10-31 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-15 | 2023-10-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-09-15 | 2023-10-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-15 | 2023-10-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-20 | 2023-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-20 | 2023-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-14 | 2022-11-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-14 | 2022-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-06 | 2022-11-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-14 | 2022-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-14 | 2022-11-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-06 | 2022-10-28 | 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 | 2022-10-06 | 2022-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-06 | 2022-10-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-06 | 2022-10-28 | 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 | 2022-10-06 | 2022-10-28 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-10-06 | 2022-10-28 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2022-10-06 | 2022-10-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-06 | 2022-10-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-04 | 2021-08-05 | 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 | 2021-06-04 | 2021-08-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-04 | 2021-08-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-04 | 2021-08-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-04 | 2021-08-05 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-04 | 2021-08-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-04 | 2021-08-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-04 | 2021-08-05 | 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 | 2021-06-04 | 2021-08-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-04 | 2021-08-05 | 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 | 2021-06-04 | 2021-08-05 | 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 | 2021-06-04 | 2021-08-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-06-04 | 2021-08-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-04 | 2021-08-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-06-04 | 2021-08-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-06-04 | 2021-08-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-04 | 2021-08-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-06-04 | 2021-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-04 | 2021-08-05 | N |
| Keep all essential equipment working safely. | Health | 2021-06-04 | 2021-08-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-04 | 2021-08-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-04 | 2021-08-05 | N |
