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Deficiency Records for Kula Hospital

A list of the most recent deficiencies for Kula Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Kula Hospital. 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 2024-06-06 2024-07-21 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 2024-06-06 2024-07-21 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-06-06 2024-07-21 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-06-06 2024-07-21 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 2024-06-06 2024-07-21 N
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 2024-06-06 2024-07-21 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-06-06 2024-07-21 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-06 2024-07-21 N
Provide and implement an infection prevention and control program. Health 2024-06-06 2024-07-21 N
Keep all essential equipment working safely. Health 2024-06-06 2024-07-21 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2024-06-11 2024-06-18 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-06-05 2023-07-31 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 2023-06-05 2023-07-31 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2023-06-05 2023-07-31 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-06-05 2023-07-31 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-06-05 2023-07-31 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 2023-06-05 2023-07-31 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-06-05 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 2023-06-05 2023-07-31 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-06-05 2023-07-31 Y
Post nurse staffing information every day. Health 2023-06-05 2023-07-31 Y
Provide and implement an infection prevention and control program. Health 2023-06-05 2023-07-31 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-06-05 2023-07-31 Y
Provide family notifications of emergency plan. Fire Safety 2023-06-06 2023-06-15 N
Ensure each resident receives an accurate assessment. Health 2022-06-30 2022-08-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-06-30 2022-08-14 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-06-30 2022-08-14 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-30 2022-08-14 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2022-06-30 2022-08-14 N
Provide and implement an infection prevention and control program. Health 2022-06-30 2022-08-14 N
Perform COVID19 testing on residents and staff. Health 2022-06-30 2022-08-14 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-06-30 2022-08-14 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-07-26 2022-08-04 N

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