A list of the most recent deficiencies for Hale Makua Health Services. 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 | 2023-11-08 | 2023-12-20 | 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 | 2023-11-08 | 2023-12-20 | 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 | 2023-11-08 | 2023-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-08 | 2023-12-20 | 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 | 2023-11-08 | 2023-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-12-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-08 | 2023-12-20 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-11-08 | 2023-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2023-12-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-12 | 2023-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-12 | 2023-07-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-12 | 2023-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-12 | 2023-07-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-12 | 2023-07-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-12 | 2023-07-31 | 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 | 2023-05-12 | 2023-07-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-12 | 2023-07-31 | 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 | 2023-05-12 | 2023-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-07-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-16 | 2023-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-06-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-14 | 2022-12-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-14 | 2022-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-14 | 2022-12-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-20 | 2022-08-23 | 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 | 2022-05-20 | 2022-08-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-20 | 2022-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-20 | 2022-08-23 | 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 | 2022-05-20 | 2022-07-18 | 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 | 2022-05-20 | 2022-07-18 | 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 | 2022-05-20 | 2022-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-20 | 2022-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-20 | 2022-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-20 | 2022-07-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-20 | 2022-07-18 | Y |
