Liliha Healthcare Center

Inspectors wroteBased on interview and document review, the facility did not have a process in place to maintain documentation of grievances. Six out of the six grievances sampled, did not meet the documentation requirements for the grievance decision. In addition the facility did not follow their own policy. As a result of this deficient practice, it is unknown what action had been taken, and if Residents/Representatives were satisfied with the outcome.

Inspectors wroteBased on observation, interviews and record review, the facility failed to have a process in place to ensure resident repositioning to prevent pressure ulcers (damage to the skin with open wound as a result of prolonged pressure). The facility did not have evidence that three of three Residents(R)1, R2 and R6 that were at risk for pressure ulcers, and who required assistance for bed mobility, were repositioned to prevent pressure ulcers. There was not a schedule/regimen for staff to follow and process to document the task. As a result of this deficient practice there is a higher risk residents will develop a pressure ulcer (PU).

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for one Resident (R)3 of a sample size of three reviewed for abuse. This deficient practice potentially compromised the protection and safety of all residents on the unit where R3 resided.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to make timely revisions to two resident's (R)1 and R2's Comprehensive Care Plans (CP) of a sample size of six. As a result of this deficient practice, staff did not have all the information necessary to effectively address the resident's status, condition, and/or needs adequately so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on interviews, medical record and document review, the facility failed to provide the standard of nursing care to one Resident (R)6 of a sample size of three. Specifically, when R6 was diagnosed with COVID infection, the nursing staff failed to consistently monitor all vitals signs, which would include temperature (T), blood pressure (BP), pulse rate (P), respiration rate (R), and pulse oximetry (O2% - measures oxygen in blood). As a result of this deficient practice, there was a higher risk that changes in condition may be missed.

Inspectors wroteBased on staff interview and review of facility assessment, the facility did not fulfill the requirement to designate a registered nurse as the Director of Nursing (DON). As a result of this deficiency, there was risk of negative impact on quality of care and outcomes.

Inspectors wroteBased on staff interview and review Quality Assurance Performance Improvement (QAPI) program, the facility did not fulfill the requirement to have Director of Nursing (DON) participation on the Quality Assessment and Assurance Committee. As a result of this deficiency, there was risk of negative impact on coordination and evaluation activities under the QAPI program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cooked and stored food were properly labeled in accordance with professional standards for food service safety and failed to ensure bottles of sauce were labeled with the manufacturer's expiration date for one of one kitchen observed. Failure to appropriately label cooked and stored food has the potential to affect residents that receive food from the kitchen, and visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness.

Inspectors wroteBased on resident interview and policy review, the facility failed to treat one Residents (R) 10 of eight residents sampled, with respect and dignity. As a result of this deficiency, R10 felt the right to a dignified existence was violated.

Inspectors wroteBased on observation, family interview, staff interview and review of policy, the facility failed to maintain a clean environment as evidenced by noted stains, spots on the cloth napkins. As a result of this deficiency, the facility increased the risk for spread of disease-causing organisms.

Inspectors wroteBased on interviews and record review, the facility failed to provide an environment free from any physical restraint imposed for purposes of convenience, for one of one sampled residents (Resident (R) 5) for restraints. This deficient practice placed R5 at risk for physical harm and has the potential to affect all the residents in the facility. Findings Include: During a Facilty Reported Incident (FRI) investigation, interview was conducted on 01/30/25 with Unit Manager (UM) 2. UM2 stated that Certified Nurse Aide (CNA) 10 approached her on 12/31/24. CNA10 had informed her that while providing personal care, R5 was resisting care by pushing down with her hands. CNA10 decided to wrap R5's hands with the lower portion of her gown so that CNA10 can finish changing her incontinence brief. Interview was conducted on 01/31/25 at 09:35 AM with the Administrator. [...]

Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for one Resident (R)76 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication.

Inspectors wroteBased on review of records and staff interviews, three of ten staff sampled for cardiopulmonary resuscitation (CPR) competency were not properly trained to provide basic life support subject to accepted professional guidelines. This deficient practice could result in the facility not providing the necessary care, placing residents at risk for decline in health status and/or death. Findings Include: A review of Cardiopulmonary Resuscitation (CPR) documentation for three staff was done on [DATE] at 11:15 AM. Documentation for Registered Nurse (RN) 11, Certified Nurse Aide (CNA) 12 and CNA13 reflects training from an online training course that does not provide hands-on practice and in-person skills assessment. Interviewed the Administrator on [DATE] at 11:49 AM, in his office, regarding CPR requirements for the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident sampled (Resident (R) 22) for elopement, received adequate supervision to prevent accidents when he was an elopement risk. As a result of this deficient practice, R22 left the facility without authorization. This put R22 at risk of injury or getting hit by a car at a busy street.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment for one out of four medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. Findings Include: Concurrent observation and interview with Registered Nurse (RN) 10 were conducted on 01/28/25 at 01:46 PM on the second-floor hallway. One of the medication carts was left unlocked and two staff members were observed passing the unlocked cart. A few minutes later RN10 returned to the medication cart and locked it. RN10 then confirmed that the medication cart should have been locked and secured when left unattended. Interview was conducted with Unit Manager (UM) 2 on the second floor. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure a clean working area before initiating wound care for one of one sampled resident (Resident (R) 35) for wounds. This failed practice has the potential to place a resident at risk for the development of infection and has the potential to affect all the residents that require dressing changes. Findings Include: Observation was conducted on 01/29/25 at 10:13 AM in R35's room during wound care rounds. R35 was turned to her side in bed and noted to have bowel movement on her buttocks, extending to the bottom edge of the resident's dressing located over her sacral area. Physician Assistant (PA) 1 proceeded to remove the dressing to the sacral area, and assessed the wound area before the bowel movement of R35 was cleaned, and before a clean brief was placed under the resident. [...]

Inspectors wroteBased on observations, record review, and interview with staff members, the facility did not ensure that the development and implementation of comprehensive person-centered care plans were done for 3 of 25 residents (Residents 33, 60 and 139) in the sample. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations the facility failed to provide a comfortable environment for residents, staff and the public by not maintaining the environment in good repair.

Inspectors wroteBased on resident interviews and policy review, the facility failed to treat two Residents (R) 9 and R139, 68 of eight residents sampled, with respect and dignity.

Inspectors wroteBased on record review and interview, the facility failed to ensure 2 of 6 residents sampled (Residents 33 and 55) were informed of their right to develop an advance health care directive, aided in doing so, and/or was periodically reassessed in his/her decision-making capacity to do such. As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R)33 received the appropriate treatment, equipment, and/or services to increase or prevent further decrease in range of motion (ROM) of her neck/head. As a result of this deficient practice, R33 was hindered from reaching her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with ROM deficits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 residents in the sample (Resident 52) was free from accidents hazards. Resident (R)52 was observed ambulating with slippers oversized for her feet, placing her at increased risk for an avoidable fall. Despite previously being identified as a high risk for falls, the facility failed to recognize R52's oversized footwear as a potential hazard until pointed out by the State Agency (SA). This deficient practice has the potential to affect all ambulating residents at the facility.

Inspectors wroteBased on observation, interview, and record review (RR), the facility failed to ensure nurse competency in pain assessment for 1 of 1 resident (Resident 64) sampled for pain management. As a result of this deficient practice, Resident (R)64 remained on a narcotic with a high risk of addiction and dependence for pain that could potentially have been managed with non-narcotic medication. This deficient practice placed R64 at risk for avoidable addiction and dependence in addition to other adverse effects of taking Fentanyl, and has the potential to affect all the residents at the facility receiving narcotic pain medication.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain from their dental consultant, routine dental services to meet the resident's needs. This deficient practice has the potential to affect all residents currently residing in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect one resident (R)33 from physical harm. R33 was totally dependent on staff for all activities of daily living (ADL's), including repositioning every two hours. R33 suffered an unwitnessed and unexplainable injury due to the manner in which her care was provided. As a result, R33 suffered a dislocated left (L) shoulder and pain, which affected her ability to achieve and maintain her highest level of physical well being. All residents dependent on staff are at risk of this type of unintentional abuse if they are not handled in a safe, secure manner to prevent injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who is unable to carry out acitvities of daily living receives the necessary services to maintain grooming, and personal and oral hygiene for two of four residents (Resident (R)37 and R3) sampled. R37 unable to perform ADLs due to diagnosis of hemoplegia, hemiparesis, progressing Dementia and is dependent on staff for all ADLs needs. Observations on 02/07/23 through 02/10/23 documented R37's ADLs were not completed, appeared increasingly unkept, lips progressed to crack, and body odor was pungent. R3 is dependent on staff for oral hygiene did not receive lip care for dry lips. As a result of severity in the neglect of R37's ADLs, any reasonable person would experience psychosocial harm.

Inspectors wroteBased on observations and interviews, the facility failed ensure to post the most recent survey conducted by State surveyors in a place readily assessable to residents, family members and legal representatives of residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide sufficient dietary staff to safely and effectively carry out the functions of food and nutrition services. As A result of this deficiency, there is the potential for more than minimal harm.

Inspectors wroteBased on observations and interviews, the facility failed to provide nourishing snacks at bedtime, for meals more than 14 hours between a substantial evening meal and breakfast the following day.

Inspectors wrote2) During lunch dining observation on 02/08/23 at 12:43 PM, observed 11 of 15 residents on the second-floor dining room with meal trays underneath residents plates, bowls, and cups while eating and not removed. During the meal pass, observed one Certified Nursing Aide (CNA) remove the trays as he was passing meals to four residents. During dining observation on the second floor on 02/08/23 at 12:44 PM observed nine residents eat lunch with their meal trays not removed. Based on observations and interview with staff member, the facility failed to provide a homelike environment for residents receiving meal service in the first and second floor dining room. The facility failed to remove trays when passing meals to residents. As a result of this deficiency, resident is at risk of a negative psychosocial outcome.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents receive foods in the appropriate form as prescribed by a physician for 2 of 2 residents (Resident (R)28 and R14). As a result of this deficient practice, residents are at risk for more than minimal harm.

Inspectors wroteBased on observations, record review, and interview with staff members the facility failed to ensure three of 21 residents sampled exercised their right to a dignified existence. Resident (R) 60 and R45 were not provided privacy when receiving care requiring them to lift their shirt and a staff member was standing over R21 and R53 while providing assistance during breakfast.

Inspectors wroteBased on record review and interview with staff members, the facility failed to inform three of five residents (Resident (R) 58, R7, and R74) reviewed for unnecessary medications, the risks and benefits of the use of psychotropic drugs and obtain consent. As a result of this deficiency, residents are at risk for more than minimal harm.

Inspectors wroteBased on interviews and document review, the facility failed to report two reportable events of suspected resident (R) abuse events to the State Agency (SA) Adult Protective Services (APS) as mandated by law. On 12/13/23 the facility identified R33 had an unobserved/unexplained dislocation of the left shoulder. On 10/28/22, R10 was allegedly abused by R7. As a result of this deficient practice the SA did not have information to determine if an investigation by their agency was needed, and there is the potential incidents are not thoroughly investigated, putting all residents of potential abuse at risk.

Inspectors wroteBased on interviews and document review, the facility failed to thoroughly investigate the unobserved/unexplained injury of R33, diagnosed as a dislocated shoulder. In addition there was lack of evidence administration was involved as necessary in the investigation. If thorough investigations are not completed and appropriate action taken, it increases the risk of reoccurrence of a similar event to residents who are totally dependant on staff for Activities of Daily Living (ADL's).

Inspectors wroteBased on record review and interviews, the facility failed to notify the family or resident representative of one resident's (R), R39's, transfer to the hospital. The facility failed to provide a written notification to the resident's close contacts about R39's transfer out of the facility for emergent care. This deficient practice does not protect the resident from an inappropriate discharge and has the potential to affect all residents transferred out of the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one residents (R)33 functional ability and required staff support was accurately documented on the MDS (Minimal Data Sheet) dated 12/20/2022. In addition two of four weekly (from 01/14/2023 to 02/02/2023) assessments did not accurately reflect R33's need for two staff support for activities of daily living (ADL's). As a result of this deficiency, R33 may not have received the necessary support to meet her goals. This deficient practice has the potential to affect all residents.

Inspectors wrote3) R38 is a [AGE] year-old resident admitted on [DATE]. Diagnoses that include traumatic subdural hemorrhage (bleeding in the area between the brain and the skull) and dementia with agitation. Observation on 02/07/23 at 09:10 AM, R38 was awake lying on specialty mattress, face appeared oily and started yelling in Korean and waving his arms when we knocked on door to ask permission to enter room. According to another surveyor that understands Korean, R38 was using curse words. On 02/08/23 at 12:48 PM, this surveyor knocked on door to ask permission to enter room, no response from R38. As soon as he saw us approach his bed, he started yelling in Korean so we exited the room. Interview with Certified Nurse Aide (CNA) 6 and Nurse (N) 11 on 02/09/23 at 12:52 PM. CNA6 said R38 yells a lot when the staff care for him, he sometimes refuses care. [...]

Inspectors wroteBased on record review and interviews the facility failed to revise two Resident (R)33 and R58's care plans (CP) in a timely manner. Specifically the facility failed to ensure Resident (R) 58's comprehensive CP plan was person-centered and does not include safe approaches for smoking, expressing the facility's current designated smoking area is unsafe and prefers to smoke at a non-designated smoking area. R33's CP was not revised in a timely manner after it was determined she needed more staff assist for activities of daily living (ADL's).

Inspectors wroteBased on observation, record review, and interviews the facility failed to identify and assess hazards and risks for Resident (R) 58's smoking enviroment, designated by the facility and non-designated by the facility, and implement interventions to reduce hazards and risks. This deficient practice effects R58's individual safety, as well as the safety of others in the facility.

Inspectors wroteBased on observation and record review, the facility failed to adhere to professional standards of practice and infection prevention and control measures for one resident with an indwelling urinary catheter. This deficient practice has the potential to affect all residents that have an indwelling urinary catheter putting them at risk to develop complications including urinary tract infections. Finding Includes: On 02/07/23 at 09:10 AM, observed Resident (R)53 lying in bed with indwelling urinary catheter tubing and collection bag touching the floor. Then at 12:35 PM when the resident was being brought to the dining area via wheelchair, observed the urinary catheter tubing being dragged on the floor during transport. On 02/08/23 at 11:29 AM, observed R53 lying in bed and no longer has the indwelling urinary catheter. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to identify and verify a significant weight loss/gain and ensure a resident maintained acceptable parameters of body weight for 1 of 4 residents (Resident (R)64) sampled. R64 had a significant weight loss of 19.30% from 10/27/22 to 11/10/22 and a significant weight gain of 20.62% from 11/10/22 to 01/29/23 that was not verified and/or addressed. As a result of this deficiency, residents are at risk for the potential of negative outcomes due to unidentified changes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an account (route and time) of a controlled medication for one resident (Resident (R)23) sampled. As a result of this deficiency, the resident is at risk for more than minimal harm and provides an opportunity for diversion of a controlled medication.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medication error rates are not 5 percent (%) or greater. The survey team observed a total of 28 medications, the total number of errors were 2, and the medication error rate was 7.14%. As a result of this deficient practice, there is potential for more than minimal harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs are stored in locked compartments and intravenous (IV) fluid was discarded when IV therapy was discontinued. A treatment cart with topical medications was not kept locked or under the direct observation of authorized staffing in an area where residents could access it. No medications were taken by the resident but the potential for more than minimal harm exist.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure Resident (R) 58's menu was followed to meet her choices and preferences.

Inspectors wrote3) On 02/09/23 at 08:15 AM, observed RN71 using a wrist blood pressure cuff on R33. RN71 did not disinfect the wrist blood pressure cuff before or after use. Inquired with RN71 how the wrist blood pressure cuffs should be disinfected due to the porous material that is in direct contact with the resident's skin and if it should have been disinfected before and/or after use. RN71 stated the wrist blood pressure cuff should have been cleaned before it was used on R33 but was not and purple wipes are used to clean the reusable equipment and had not thought about the band of the cuff is fabric and the purple wipes may not be an appropriate way to disinfect it. Conducted an interview with the facility's IP and shared my observation of staff not disinfecting the reusable wrist blood pressure cuff. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a safe, clean equipment for a resident (Resident(R14) sampled. R14 is dependent on supplemental oxygen and the filter of the oxygen concentrator machine had a layer of dust on it. As a result of this deficient practice, the resident is at risk for more than minimal harm.