Liliha Healthcare Center

F-F727 Registered Nurse, DON.

During staff interview on 01/27/25 at 08:20 AM, Administrator (Admin) said that there was no DON and that

the facility was currently looking for one.

During Quality Assurance Performance Improvement review on 01/31/25 at 01:35 PM, Admin further said that the previous DON left a few months ago and that currently other staff were covering some of the duties and responsibilities of that position.

Review of the QAPI meeting minutes for the past two months did not show a DON present.

Review of Facility Assessment read the following: Purpose, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment is to be used to make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Part 3, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . The following type of staff and other professionals provide

the needed care to our resident population . Nursing Services, we provide 24-hour nursing care. Our nursing staff consists of a DON, ADON, MDS nurses, RN, LPN, CNA, Licensed Treatment Nurse, Treatment Nurse Assistant and Rehab Nurse Aide .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 125041 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125041 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liliha Healthcare Center 1814 Liliha Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 51869 potential for actual harm Based on observation and staff interviews, the facility failed to ensure a clean working area before initiating Residents Affected - Few 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 Resident R35's room during wound care rounds. Resident 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 Resident R35 was cleaned, and before a clean brief was placed under the resident. Certified Nurse Aide (CNA) 11 proceeded to clean

the bowel movement after PA1 was done with the wound assessment.

Interviewed the Infection Preventionist (IP) on 01/29/25 at 12:50 PM at the second-floor nurse's station. IP confirmed that the CNA should clean a resident's incontinence before a wound is looked at.

Interviewed Unit Manager (UM) 2 on 01/30/25 at 08:26 AM near the second-floor nurse's station. UM2 stated that for infection control, incontinence should be cleaned first before starting wound care.

Interviewed CNA11 on 01/31/25 at 07:31 AM at the second-floor resident unit hallway. CNA11 verbalized that the resident needs to be cleaned first before nursing does the wound dressing to prevent infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 125041

F-F868 Quality Assessment and Assurance.

During staff interview on 01/27/25 at 08:20 AM, Administrator (Admin) said that there was no DON and that

the facility was currently looking for one.

During Quality Assurance Performance Improvement review on 01/31/25 at 01:35 PM, Admin further said that the previous DON left a few months ago and that currently other staff were covering some of the duties and responsibilities of that position.

Review of Facility Assessment read the following: Purpose, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment is to be used to make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Part 3, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . The following type of staff and other professionals provide

the needed care to our resident population . Nursing Services, we provide 24-hour nursing care. Our nursing staff consists of a DON, ADON, MDS nurses, RN, LPN, CNA, Licensed Treatment Nurse, Treatment Nurse Assistant and Rehab Nurse Aide .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 125041 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125041 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liliha Healthcare Center 1814 Liliha Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 48351 Residents Affected - Few Based 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. UM2 confirmed that unattended carts should be locked and secured.

A review of the facility policy titled, Medication Storage, with a revised date of 06/01/23 was conducted. The policy documented, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 125041 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125041 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liliha Healthcare Center 1814 Liliha Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43414

Residents Affected - Some Based 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.

Findings include:

On 01/28/25 at 08:05 AM, during interview and observation of the kitchen with Dietary [NAME] (DC) 1, observed a container of cooked white rice, confirmed by DC1, in a small refrigerator without a label identifying the food item or preparation and discard date. DC1 reported the rice was prepared this morning and a label should have been created with today's date and a discard date.

Further observed in the dry food storage room, multiple unopened bottles of Browning and Seasoning Sauce with a yellow cap that included the best-by-date. Two of the bottles did not have a yellow cap to determine

the best-by-date, but were unopened and sealed. DC1 was not sure why the bottles did not have a cap and removed the two bottles from the storage room.

Review of the facility's policy and procedure Food Safety Requirements reviewed/revised 06/2023 documented Follow contract/vendor procedures when food arrives damaged or concerns are noted. Remove

these foods from use .Labeling dating, and monitoring refrigerated food, including, but not limited to leftovers, so it used by its use-by-date, or frozen (where applicable)/discarded .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 125041 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125041 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liliha Healthcare Center 1814 Liliha Street Honolulu, HI 96817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 39754 potential for actual harm Based on staff interview and review Quality Assurance Performance Improvement (QAPI) program, the Residents Affected - Many 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.

Findings include:

Cross-reference to