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Deficiency Records for Pu'uwai 'o Makaha
A list of the most recent deficiencies for Pu'uwai 'o Makaha. 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 Pu'uwai 'o Makaha. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-26 | 2024-09-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-26 | 2024-09-04 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-07-26 | 2024-09-04 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-07-26 | 2024-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-26 | 2024-09-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-26 | 2024-09-04 | 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 | 2024-07-26 | 2024-09-04 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-07-26 | 2024-09-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-26 | 2024-09-04 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-24 | 2024-08-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-24 | 2024-08-25 | 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 | 2023-07-28 | 2023-11-08 | 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 | 2023-07-28 | 2023-10-28 | 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 | 2023-07-28 | 2023-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-28 | 2023-10-28 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-07-28 | 2023-10-28 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-07-28 | 2023-10-28 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-07-28 | 2023-10-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-28 | 2023-10-17 | 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 | 2023-07-28 | 2023-10-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-28 | 2023-10-17 | 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 | 2023-07-28 | 2023-10-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-28 | 2023-10-17 | N |
| Post nurse staffing information every day. | Health | 2023-07-28 | 2023-10-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-28 | 2023-10-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-28 | 2023-10-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-07-28 | 2023-10-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-28 | 2023-10-17 | 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 | 2023-08-31 | 2023-09-18 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-31 | 2023-09-18 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-08-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-31 | 2023-08-23 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-02 | 2022-12-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-10 | 2022-09-16 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-08-10 | 2022-09-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-10 | 2022-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-10 | 2022-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-10 | 2022-09-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-10 | 2022-09-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-10 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-10 | 2022-09-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-02 | 2022-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-02 | 2022-08-02 | N |
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