Liliha Healthcare Center

In the surveyor’s words

From the most serious findings on record at Liliha Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Nov 15, 2022

  Based on interviews, record reviews, and review of facility policies and procedures, the facility failed to have adequate knowledge of the facility's COVID-19 policies and procedures in order to effectively implement the facility's COVID-19 plan during an outbreak as evidenced by failing to established a facility-wide infection control plan including written infection control standards, policies, and procedures that are current and based on the facility assessment and national standards, failing to notify state authorities of COVID-19 cases in the facility, failing to provide education to staff on COVID-19, proper use of PPE, and hand hygiene and failing to have an infection surveillance plan in place to monitor and evaluate clusters or outbreaks of illness among staff and residents. […]

• Immediate jeopardy, widespreadF882Nov 15, 2022

  Based on interviews and record reviews, the facility failed to properly prevent and contain COVID-19 as evidenced by failing to clearly identify an individual responsible for the Infection Preventionist (IP) position, failing to ensure that the IP was performing the duties of the position and demonstrated understanding of the facility's COVID-19 policies and procedures. The deficient practice puts all residents at risk of infection diseases, including COVID-19. Four staff and 25 residents tested positive for COVID-19. One Resident (R)10 with a positive COVID-19 test result expired. Findings Include: Cross Reference to F880, Infection Prevention and Control. […]

• Immediate jeopardy, isolatedF610Jul 15, 2021

  Based on interviews, record review (RR) and observation, the facility lacked evidence that the allegation of abuse brought to their attention on 06/02/21 was thoroughly investigated. The Resident (R)1 was not interviewed in her primary language and there was no documentation R1 was monitored for behavioral changes post alleged incident. In addition, there was conflicting information obtained from interviews from R1's family members (FM's) and the Director of Nursing (DON) regarding notification of the alleged incident and a conversation FM2 had with the DON on 06/22/21. The investigation response document provided by the DON included inaccurate information. […]

• Immediate jeopardy, isolatedF689Mar 12, 2021

  Based on observations, interviews, and record review (RR), the facility failed to provide adequate supervision and have a system in place to minimize the potential of elopement. One of three residents (Resident (R)1 sampled eloped on 02/27/21 and was found in an unsafe environment. After the event, the facility failed to ensure the action plan interventions were implemented correctly and consistently and evaluate the effectiveness of the interventions. At the time of survey, the wander guard alarm system was found not to be working properly and the facility did not check the system or utilize the bands according to manufacturer's instructions. In addition, one of the interventions to prevent elopements was to lock the laundry room door that led to the elevator on each unit. […]

• Actual harm, isolatedF689Jun 30, 2023

  Based on record review and interview with staff members, the facility failed to ensure one of four residents (Resident (R) 48) sampled for accidents received adequate supervision to prevent a fall that resulted in a laceration of the head, fracture to neck of right femur, hospitalization , and surgery after R48 displayed atypical behavior and has history of falls. The facility failed to ensure a second resident R15 was identified as a high risk of leaving the facility to obtain cigarettes and alcohol. R15 did not receive the admission agreement, (cross reference (CR) to F572 notice of rights and rules) which included the rules about consumming alcohol in the facility and that it was prohibited without a physicians order. […]