Deficiency Records for Kulana Malama
Updated as of August 01, 2020
This is not the most recent data for Kulana Malama. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2019-11-08 | 2019-12-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-08 | 2019-12-23 | 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 | 2019-11-08 | 2019-12-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-08 | 2019-12-23 | 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 | 2018-12-03 | 2019-02-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-03 | 2019-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-03 | 2019-02-14 | N |
| Provide or obtain dental services for each resident. | Health | 2018-12-03 | 2019-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-03 | 2019-02-14 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2017-12-29 | 2018-04-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-29 | 2018-04-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-29 | 2018-04-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2017-12-29 | 2018-04-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2017-12-29 | 2018-04-06 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2017-12-29 | 2018-04-06 | N |
| 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 | 2017-12-29 | 2018-04-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2017-12-29 | 2018-04-06 | 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 | 2017-12-29 | 2018-04-06 | 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 | 2017-12-29 | 2018-04-06 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2017-12-29 | 2018-04-06 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2017-12-29 | 2018-04-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2017-12-29 | 2018-04-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-29 | 2018-04-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2017-12-29 | 2018-04-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-29 | 2018-03-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2017-12-29 | 2018-03-07 | 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 | 2017-12-29 | 2018-03-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2017-12-29 | 2018-03-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2017-12-29 | 2018-03-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-29 | 2018-03-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2017-12-29 | 2018-03-07 | 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 | 2017-12-29 | 2018-03-07 | Y |
