A list of the most recent deficiencies for Kulana Malama. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-23 | 2023-07-14 | 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 | 2023-06-23 | 2023-07-14 | 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 | 2023-06-23 | 2023-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-23 | 2023-07-14 | 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 | 2023-06-23 | 2023-07-14 | N |
| Keep all essential equipment working safely. | Health | 2023-06-23 | 2023-07-14 | 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 | 2022-07-15 | 2022-08-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-15 | 2022-08-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-15 | 2022-08-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-15 | 2022-08-26 | 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 | 2022-07-15 | 2022-08-26 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-03-30 | 2022-06-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-30 | 2022-06-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-30 | 2022-06-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-30 | 2022-06-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-30 | 2022-06-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-30 | 2022-06-13 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-03-30 | 2022-06-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-18 | 2021-05-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-18 | 2021-05-18 | N |
