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Deficiency Records for Liliha Healthcare Center

A list of the most recent deficiencies for Liliha Healthcare Center. 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 Liliha Healthcare Center. 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?
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-01-29 2024-04-30 N
Have properly located and lighted "Exit" signs. Fire Safety 2024-01-29 2024-04-10 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-01-26 2024-03-01 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 2024-01-26 2024-03-01 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-26 2024-03-01 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 2024-01-26 2024-03-01 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-26 2024-03-01 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 2024-01-26 2024-03-01 N
Provide routine and 24-hour emergency dental care for each resident. Health 2024-01-26 2024-03-01 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-01-26 2024-03-01 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-06-30 2023-07-31 Y
Give residents a notice of rights, rules, services and charges. Health 2023-06-30 2023-07-31 Y
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-06-30 2023-07-31 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-30 2023-07-31 Y
Establish staff and initial training requirements. Fire Safety 2023-02-16 2023-05-11 N
Establish an Emergency Preparedness Program (EP). Fire Safety 2023-02-16 2023-05-05 N
Have elevators that firefighters can control in the event of a fire. Fire Safety 2023-02-16 2023-05-05 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-02-16 2023-05-05 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-02-14 2023-04-14 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2023-02-14 2023-04-14 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-02-14 2023-04-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-02-14 2023-04-14 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-02-14 2023-04-14 N
Provide enough food/fluids to maintain a resident's health. Health 2023-02-14 2023-04-14 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-02-14 2023-04-14 N
Provide and implement an infection prevention and control program. Health 2023-02-14 2023-04-14 N
Keep all essential equipment working safely. Health 2023-02-14 2023-04-14 N
Ensure each resident receives an accurate assessment. Health 2023-02-14 2023-04-14 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2023-02-14 2023-04-07 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 2023-02-14 2023-04-07 N
Respond appropriately to all alleged violations. Health 2023-02-14 2023-04-07 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 2023-02-14 2023-04-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-02-14 2023-04-07 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 2023-02-14 2023-04-07 N
Ensure medication error rates are not 5 percent or greater. Health 2023-02-14 2023-04-07 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 2023-02-14 2023-04-07 N
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2023-02-14 2023-04-07 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-02-14 2023-04-07 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-02-14 2023-04-07 Y
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2023-02-14 2023-04-07 Y
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2023-02-14 2023-04-07 Y
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Health 2023-02-14 2023-04-07 Y
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 2022-11-15 2023-02-10 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 2022-11-15 2023-02-10 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-11-15 2023-02-10 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 2022-11-15 2023-02-10 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-11-15 2023-02-10 Y
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 2022-11-15 2023-02-10 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2022-11-15 2023-02-10 Y
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 2022-11-15 2022-12-27 Y
Provide and implement an infection prevention and control program. Health 2022-11-15 2022-12-27 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-11-15 2022-12-27 Y
Report COVID19 data to residents and families. Health 2022-11-15 2022-12-27 Y
Perform COVID19 testing on residents and staff. Health 2022-11-15 2022-12-27 Y
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 2022-11-15 2022-12-27 Y
Establish policies and procedures for volunteers. Fire Safety 2022-11-15 2022-12-27 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2022-11-15 2022-12-20 Y
Ensure each resident receives an accurate assessment. Health 2022-02-10 2022-03-25 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 2022-02-10 2022-03-22 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2022-02-10 2022-03-22 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-02-10 2022-03-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-02-10 2022-03-22 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2022-02-10 2022-03-22 N
Provide and implement an infection prevention and control program. Health 2022-02-10 2022-03-22 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-02-10 2022-03-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-02-10 2022-03-22 N
Have elevators that firefighters can control in the event of a fire. Fire Safety 2022-02-10 2022-03-22 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-02-10 2022-03-22 N
Have proper medical gas storage and administration areas. Fire Safety 2022-02-10 2022-03-22 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-01-05 2022-02-15 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-01-05 2022-02-15 Y

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