HONOLULU, HI - Federal inspectors found significant management and safety deficiencies at Liliha Healthcare Center during a January 2025 inspection, including operating without a Director of Nursing and failing to secure medications properly.
Leadership Vacuum Raises Quality Concerns
The most concerning finding at Liliha Healthcare Center involved the facility's quality assurance program, which has been operating without proper nursing leadership for several months. During interviews conducted on January 27, 2025, the facility administrator confirmed that no Director of Nursing (DON) was currently employed at the 180-bed facility, and that the previous DON had departed "a few months ago."
This absence represents a critical gap in nursing home operations. The Director of Nursing serves as the senior clinical leader responsible for overseeing all nursing care, medication management, infection control, and quality improvement initiatives. Federal regulations require DONs to participate in Quality Assessment and Assurance committees, which meet quarterly to identify problems, develop solutions, and monitor resident care outcomes.
Without this leadership position filled, other staff members have been attempting to cover these essential responsibilities, potentially compromising the systematic approach required for effective quality management. The facility's own assessment documentation acknowledges the need for a full nursing leadership team, including "a DON, ADON, MDS nurses, RN, LPN, CNA, Licensed Treatment Nurse, Treatment Nurse Assistant and Rehab Nurse Aide" to provide competent care.
Medication Security Breach Observed
Inspectors documented a significant medication safety violation when they observed an unlocked medication cart left unattended in a second-floor hallway on January 28, 2025. During this observation at 1:46 PM, two staff members were seen passing the unsecured cart before the responsible Registered Nurse returned and locked it.
This breach represents a serious safety concern in nursing home operations. Medication carts contain controlled substances, prescription drugs, and other pharmaceuticals that could cause harm if accessed by unauthorized individuals. Unsecured medications create risks for drug diversion, accidental ingestion by confused residents, and potential medication errors.
The supervising nurse confirmed that "the medication cart should have been locked and secured when left unattended," acknowledging the policy violation. The facility's own medication storage policy, revised in June 2023, explicitly states that "All drugs and biologicals will be stored in locked compartments."
Proper medication security protocols require nurses to either remain with their medication cart at all times or lock it immediately when stepping away, even briefly. This practice prevents unauthorized access and ensures compliance with federal regulations designed to protect residents and maintain the integrity of the medication distribution system.
Food Safety Protocols Inadequate
Kitchen operations revealed multiple food safety violations that could potentially expose residents to foodborne illness. During a January 28 morning inspection, investigators found improperly labeled food items and products without expiration date information.
A container of cooked white rice was discovered in a refrigerator without any identifying label or preparation date. The dietary coordinator confirmed the rice had been prepared that morning and admitted that proper labeling should have included both the preparation date and required discard date. This labeling system is essential for preventing the service of spoiled food and ensuring proper food rotation.
Additionally, inspectors found bottles of browning and seasoning sauce in dry storage that were missing caps containing expiration dates. Two sealed bottles could not be dated because the caps were absent, prompting the dietary coordinator to remove them from storage during the inspection.
Medical Significance of Violations
These violations carry significant health implications for nursing home residents, who represent one of the most vulnerable populations in healthcare settings. The absence of proper nursing leadership directly impacts clinical oversight and quality improvement processes that are designed to prevent medical errors, infections, and other adverse outcomes.
Medication security breaches can lead to serious consequences including drug interactions, overdoses, or withdrawal symptoms if residents receive incorrect medications. Controlled substances left unsecured also present diversion risks and potential criminal liability for facilities.
Food safety violations pose particular dangers to elderly residents, whose immune systems may be compromised and who often have difficulty recovering from foodborne illnesses. Improperly stored or dated food can harbor bacteria such as Salmonella, E. coli, or Listeria, which can cause severe complications including dehydration, hospitalization, and in extreme cases, death.
Regulatory Standards and Expectations
Federal nursing home regulations establish clear expectations for these operational areas. Quality assurance programs must include designated nursing leadership to ensure clinical expertise guides improvement efforts. The Centers for Medicare & Medicaid Services requires facilities to maintain comprehensive quality assessment committees that meet quarterly and include the Director of Nursing as a core member.
Medication management standards mandate secure storage of all pharmaceuticals in locked compartments, with strict protocols for cart handling during medication passes. These requirements stem from decades of research showing that proper medication security significantly reduces errors and improves resident outcomes.
Food service regulations align with FDA food codes that require clear labeling of prepared foods with preparation dates and discard dates. These standards help prevent foodborne illness outbreaks that can devastate vulnerable nursing home populations.
Additional Issues Identified
The inspection revealed that the facility had been attempting to operate its quality improvement program without the required Director of Nursing participation, potentially compromising the effectiveness of their clinical oversight processes. Staff interviews confirmed that other employees were trying to cover nursing leadership responsibilities, but federal regulations specifically require designated nursing expertise in these roles.
The medication cart violation affected one of four carts observed during the inspection, suggesting that while not systematic, security protocols were not consistently followed by staff. The food safety issues included both immediate concerns with prepared foods and longer-term inventory management problems with condiment storage.
These findings represent systematic issues that extend beyond individual staff errors to encompass facility-wide policies and management oversight. The absence of nursing leadership likely contributed to the inconsistent application of safety protocols observed in both medication handling and food service operations.
The violations collectively demonstrate the interconnected nature of nursing home operations, where management gaps can cascade into multiple areas of resident care and safety. Proper leadership, training, and oversight systems are essential for maintaining the complex regulatory requirements that protect this vulnerable population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liliha Healthcare Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.