Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Ching Villas during CMS and state inspections, most recent first.
Improperly Labeled and Expired Food Stored in Walk-In Refrigerator: During a kitchen walkthrough, surveyors observed meatloaf and turkey stored past their discard dates and a tray of Salisbury steak with an open date but no discard date. The DM stated the items should have been thrown out to prevent serving expired food and residents risking foodborne illness.
Missed PT Treatments for Multiple Residents: Multiple residents receiving rehab services did not receive PT at the ordered frequency of five times per week. One resident with a recent fibula fracture and cast, and others recovering from weakness or needing mobility training, reported gaps in therapy, while records showed missed sessions due to cancellation, scheduling conflict, or dialysis. The DOR could not explain several of the missed visits, and the documented PT service logs confirmed the ordered treatment plans were not followed.
Surveyors found that the facility failed to include ordered O2 therapy in a resident’s care plan despite physician orders for continuous O2 via NC with parameters for use and weaning, and the ADON confirmed this omission. In a separate case, a resident with BLE edema and cellulitis was repeatedly observed in bed with exposed legs and no heel protectors in place, even though there were physician orders for bilateral heel protectors and a care plan directive to offload the heels while in bed; nursing staff acknowledged the heel protectors should have been reapplied after PT and a shower.
Two residents were not adequately protected from accidents when one sustained a skin tear during Hoyer lift transfers despite known fragile skin and prior family complaints about staff moving too quickly, and another, identified as high fall risk due to dementia and prior lumbar fractures, was left unsupervised in a hallway in a w/c for a meal after the CNA watching her went to assist another resident, resulting in a fall discovered by a visitor.
Incomplete consent documentation for psychotropic medications was found for two residents with severe cognitive impairment. One resident with Alzheimer's disease, dementia, delirium, restlessness, and agitation had orders for olanzapine and trazodone, and another resident with dementia, Alzheimer's disease, and delirium had an order for quetiapine. In both cases, the consent forms noted verbal consent but did not document the consenting person's name, relationship to the resident, or the date obtained, and there were no progress notes identifying who gave consent.
A resident was observed receiving O2 at 3 L via NC even though the physician order was for continuous O2 at 1-2 LPM with an SpO2 goal of 88-92%. The chart had no documentation supporting the increase, and an RN confirmed there was no order to raise the O2, no progress note explaining the change, and no MD notification.
A resident with an indwelling urinary catheter was observed in bed with the catheter tubing and urine collection bag on the floor. An RN confirmed the bag was on the floor and said it should have been placed in a basin so it would not touch the floor. The resident’s care plan and facility policy both stated the catheter tubing and drainage bag should be kept off the floor.
Medication storage and labeling were deficient in several observations. An LPN left an opened lidocaine patch on a resident’s mattress instead of applying it, an insulin pen for a discharged resident remained in the med refrigerator with a worn, illegible label, and an opened bottle of lactulose in a med cart lacked an open date. An LPN and the IP confirmed the issues during the survey.
The facility did not notify the physician when two residents experienced a change in condition that required oxygen administration. In both cases, nursing staff provided oxygen for shortness of breath and documented the intervention, but failed to inform the provider as required by facility policy and physician orders. The DON confirmed that these incidents met the criteria for a significant change in condition and that provider notification should have occurred.
Three residents experienced deficiencies in medical record documentation, including misfiled nursing notes, inconsistent and incomplete records of oxygen administration, and an inaccurate discharge notice that did not reflect a resident's true condition. Facility leadership confirmed missing assessments and documentation errors, and the facility's own policy for thorough and accurate records was not followed.
A resident admitted for post-stroke rehabilitation had a PIV catheter in place for several days without a physician's order, and staff used a hospital weight as the admission baseline instead of obtaining a new weight on the facility scale. Significant discrepancies in weights were not verified or reported, and required neurological assessments were not documented after the resident was found unresponsive. These failures resulted in a lack of appropriate treatment and care according to orders and resident needs.
A resident was administered Lisinopril despite a documented systolic blood pressure below the ordered threshold, in violation of the physician's order. The facility did not identify or report this medication error to the DON or Administrator as required by policy.
A resident's belongings were collected and bagged by CNAs after hospital transfer, and a family member later discovered a visibly soiled bed pad/brief with urine and feces among the items. Staff interviews and video review confirmed the soiled item was included in the belongings given to the family.
The facility failed to honor the preferences of three residents regarding therapy schedules and outdoor activities, compromising their right to self-determination. A resident preferred morning therapy sessions due to energy levels but was not scheduled accordingly, while another resident was frustrated by the lack of advance notice for therapy times. Additionally, a resident expressed a desire to go outside for fresh air, but the facility did not assist him, leaving him confined to his room. These issues indicate a systemic problem in accommodating resident choices.
The facility failed to maintain the ice and water equipment in a sanitary condition, as observed with a buildup of brown sediment on the dispenser used daily for resident hydration. The Registered Dietician acknowledged the need for regular cleaning, but no maintenance log was kept to verify the cleaning schedule. The Maintenance Associate and Facilities Coordinator agreed that the brown sediment was unusual and should be avoided.
A resident reported feeling disrespected and bullied by a traveling nurse who repeatedly woke her for non-urgent matters and ignored her instructions on wound care. The grievance noted issues with the nurse's bedside manner, but staff education did not address these concerns.
A facility failed to ensure privacy for a resident who was left exposed by a CNA and did not protect the confidentiality of another resident's electronic health record, which was left open and unattended on a laptop. Staff interviews confirmed the expectation to protect residents' privacy and confidentiality.
A resident was transferred to the hospital due to a change in condition, but the facility failed to provide a completed Interact Nursing Home to Hospital Transfer Form. Despite the emergency nature of the situation, the form was not filled out or sent, as confirmed by the Resident Care Manager. The responsible RN did not complete the form, although other documents were sent and a report was given to the hospital ER nurse. Training on the form was part of new hire orientation, but the RN's participation in ongoing training was not verified.
The facility failed to implement comprehensive care plans for two residents, potentially diminishing their quality of life. One resident, admitted for subacute rehab, had no documentation of bleeding at an access site or physician notification. Another resident, admitted post-stroke, had no interventions documented for pain management despite having a care plan addressing acute pain.
A resident admitted for wound care and therapy was not involved in the development of his care plan, despite having no cognitive impairment. The resident was unaware of his care plan and duration of stay, and no documentation of an interdisciplinary team meeting was found. The Social Service Manager admitted the possibility that the meeting did not occur as planned.
The facility failed to provide resident-centered care, resulting in frequent hospitalizations for a resident with complex needs, inadequate scheduling of physical therapy for another resident, and improper insulin management for a third resident. These deficiencies highlight issues in addressing residents' medical and personal preferences, leading to potential risks and avoidable declines.
A facility failed to change an enteral feeding bag within the required 24-hour period for a resident with a history of digestive surgery, risking preventable complications. An LPN initiated tube feeding using a bag labeled with a date indicating it was past the discard time, contrary to facility policy. Upon noticing the error, the LPN stopped the pump and sought a new setup.
A resident with RSV and complex medical conditions was observed with a nasal cannula incorrectly placed and the oxygen meter off, despite a physician's order for oxygen administration. The DON confirmed the incorrect placement, and a nurse's note indicated a room air challenge was unsuccessful, necessitating the re-initiation of oxygen.
A resident with severe cognitive impairment and a history of stroke and diabetes experienced inadequate pain management, affecting her participation in physical therapy and family visits. Despite having a care plan that included Gabapentin, Lidocaine patches, and Tramadol, the resident's pain was not effectively managed, as evidenced by inconsistent medication administration and high pain levels.
A facility failed to provide dialysis care consistent with professional standards for a resident, leading to a deficiency. The resident experienced bleeding from her hemodialysis access site after a session, requiring an ace wrap. However, there was no documentation in the EHR or dialysis communication form about the bleeding or dressing application. The facility's policy requires monitoring and notifying the provider if bleeding persists, but there was no record of such actions being taken.
The facility failed to dispose of expired medications and ensure accurate reconciliation of controlled medications. A nurse administered an expired inhaler medication to a resident, and another medication cart's narcotic count sheet was unsigned for two shifts, indicating a lack of proper documentation and adherence to facility policy.
The facility failed to store and label medications properly, with expired medications found in storage and unsecured medication carts observed. An open vial of Tubersol was also found without proper labeling. Staff acknowledged these oversights.
The facility failed to ensure proper infection control measures, as a CNA did not wear PPE or perform hand hygiene when delivering a lunch tray to a resident on contact precautions, and an RN did not perform hand hygiene between glove changes during a dressing change for a resident with a stage 4 pressure ulcer. The facility's policies require PPE use and hand hygiene, which were not followed in these instances.
A resident with a history of Parkinson's disease, diabetes, and orthostatic hypotension did not receive consistent monitoring of orthostatic blood pressures and pulse as ordered by the physician. Despite the requirement for daily checks, the facility documented these vital signs only 11 times over 34 days, with several instances lacking explanations for missed recordings. The DON confirmed that licensed staff were responsible for these checks, and the physician noted the inconsistency in monitoring, which was crucial for managing the resident's condition.
Improperly Labeled and Expired Food Stored in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure that food items stored in the walk-in refrigerator were properly labeled and that old food was discarded. During an initial walkthrough of the kitchen with the Dietary Manager on 01/13/26 at 09:00 AM, surveyors observed meatloaf stored beyond the discard date of 12/24, turkey stored beyond the discard date of 01/11, and a tray of Salisbury steak with an open date of 11/24 and no discard date. In interview, the Dietary Manager stated these items should have been thrown out to prevent serving expired food and residents risking foodborne illness.
Missed PT Treatments for Multiple Residents
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were provided as ordered for five of 10 residents sampled for therapy services. The deficiency involved physical therapy (PT) treatments that were prescribed at a frequency of five times per week for residents receiving short-term rehabilitation or restorative services, but the documented treatment schedules showed missed or reduced visits for multiple residents. The report states that these missed treatments affected the residents’ ability to meet their therapy goals. Resident R182 was admitted for rehabilitative services after a fall that resulted in a right fibula fracture and surgeries on 12/26 and 12/30. She was observed in bed with a blue cast on her lower right leg and stated she was receiving therapy but was not supposed to bear weight on the foot. Her PT plan called for treatment five times per week, but the service log showed she received only four visits during the first week reviewed, with one missed visit documented as cancelled. The Director of Rehab could not explain why the session was cancelled and noted the therapist was not available for interview. Resident R112 reported that PT had stopped after 01/09/26, and the service log confirmed five consecutive days without PT and only two treatments during the following week, despite an order for five sessions per week. Resident R177 stated he should be receiving PT daily but had only one treatment since evaluation; records showed a missed treatment due to a scheduling conflict, and the DOR could not explain the missed session. Resident R179 said he had only one PT treatment and was waiting for his next session; records showed a missed treatment on his dialysis day, even though the facility had accommodated his dialysis schedule previously. Resident R180 stated she was not ready for discharge and still needed PT to manage stairs at home; records showed she received only four treatments during the week reviewed, with one session cancelled and no explanation provided by the DOR. The report also identifies R112, R182, R177, R179, and R180 as residents whose PT services were not provided according to the prescribed treatment plan.
Failure to Care Plan O2 Therapy and Implement Heel Protector Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed all ordered treatments. For one resident receiving oxygen (O2) therapy, surveyors observed the resident on 1 L O2 via nasal cannula and later without O2, with no signs of respiratory distress. Record review showed a physician’s order for continuous O2 supplementation at 1–4 L/min via nasal cannula for shortness of breath or SpO2 < 90%, with an order to wean O2 as tolerated every shift. However, the resident’s care plan did not include any problems, goals, or interventions related to O2 therapy. The ADON confirmed that O2 therapy was not included in the care plan and acknowledged that the care plan is important as it directs the care provided. The facility’s Oxygen Administration policy stated that the resident’s care plan will identify the interventions of oxygen therapy based on assessment and orders. A second deficiency involved failure to implement the care plan intervention for bilateral heel protectors for a resident with bilateral lower extremity (BLE) edema and cellulitis. The resident was repeatedly observed in bed with BLE edema, redness, and dry, scaly skin, with BLE exposed and no socks or heel protectors applied, despite reporting pain at 8/10 and stating that pain medication and daily cream application provided relief. Record review showed a physician’s order for bilateral heel protectors and a care plan intervention to ensure heels are offloaded by floating heels while in bed. Nursing staff confirmed that heel protectors should have been reapplied after physical therapy and a shower to protect the resident from further skin breakdown. The facility’s Comprehensive Care Plan policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment.
Failure to Prevent Injury During Mechanical Transfer and Unsupervised Hallway Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries during transfers and while residents were out of bed. One resident with dementia, hemiplegia following a stroke, and fragile skin experienced recurrent skin tears associated with transfers using a Hoyer lift. Family members reported that staff needed to be more careful when using the lift because the resident’s skin tears easily and that problems with skin tears occurred during transfers. The resident was observed wearing Geri sleeves on both arms, and a nursing progress note documented a skin tear to the left elbow that occurred after transferring the resident back to bed. Family members had previously filed a grievance stating that a CNA was moving too fast during a transfer from bed to wheelchair, and that the CNA reported she was holding the Hoyer sling to help navigate the resident’s position during the transfer. The resident’s RN stated that CNAs follow an ADL schedule, that the resident receives showers four times per week, and that Geri sleeves are used as a preventive measure. The RN also stated that the resident often screams during Hoyer transfers and characterized this as the resident’s behavior. The DON reported that various considerations had been made for the resident at the family’s request, including an increased shower schedule and discussion about nail trimming, while confirming that the family declined staff trimming the resident’s nails. A second resident, an older female with dementia, debility, pain, and a history of lumbar fractures, was care planned as being at risk for falls, with an approach to observe her frequently and place her in a supervised area when out of bed. Despite this, she was placed in a hallway in a wheelchair for a meal and left unattended when the CNA who had been watching her went to assist another resident in a room. The charge nurse was in the Resident Care Manager’s office when a visitor alerted staff that the resident had fallen; the resident was found on the floor on her left side. The charge nurse later acknowledged that the resident was at high risk for falls due to dementia, should not have been left unsupervised, and that the CNA, a part-time staff member unfamiliar with the residents on that floor, should have called for help before leaving the hallway and losing sight of the resident and others.
Incomplete Consent Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the risks and benefits of psychotropic medications were explained and documented for two residents with severe cognitive impairment. One resident, admitted for short-term rehabilitation with diagnoses including Alzheimer's disease, delirium, restlessness and agitation, and dementia, had a BIMS score of 3 and orders for olanzapine 5 mg and trazodone 50 mg daily. The consent form dated 01/02/26 showed verbal consent for both medications, but it did not document the name of the consenting individual, the relationship to the resident, or the date consent was obtained, and there was no supporting progress note documentation. Another resident, also admitted for short-term rehabilitation with a history of dementia, Alzheimer's disease, and delirium, had a BIMS score of 3 and an order for quetiapine 50 mg at bedtime. The consent form dated 01/07/26 indicated verbal consent for the antipsychotic medication, but it did not document the name or relationship of the person giving consent or the date it was obtained, and no progress notes identified who the facility obtained consent from. During interview, the Resident Care Manager stated that family members or authorized representatives would be asked to sign when residents could not consent due to cognitive impairment, and acknowledged that the consents for both residents were documented as verbal without identifying who gave the consent.
Oxygen Administered Above Ordered Level Without Documentation or Physician Notification
Penalty
Summary
The facility failed to ensure that one resident received oxygen treatment and care in accordance with the physician’s order and the comprehensive care plan. On 01/14/26 at 09:55 AM, the resident was observed in bed with oxygen at 3 L via nasal cannula. The resident stated her breathing was okay and denied shortness of breath, although she had a moist cough. The resident’s electronic health record showed a physician’s order for continuous oxygen at 1-2 LPM via nasal cannula with an SpO2 goal of 88-92%, and to notify the physician if the condition worsened or if additional oxygen was required. Review of the progress notes did not show any documentation supporting an increase in oxygen to 3 L. During interview, RN1 confirmed the oxygen was set at 3 L, verified that the current order remained 1-2 L, and stated there were no orders to increase the oxygen level. RN1 also stated that evening shift RN2 had endorsed the resident on 3 L, but there was no documentation that the resident needed the increase and no physician notification had been made. Facility policies reviewed stated that oxygen is to be administered consistent with professional standards and the care plan, that the physician is to be notified of changes in condition including significant changes in oxygen concentration, and that documentation must be accurate and timely.
Urinary catheter drainage bag left on the floor
Penalty
Summary
The facility failed to ensure the indwelling urinary catheter bag for one resident was kept in a sanitary position off the floor. On 01/13/26 at 12:26 PM, R65 was observed lying in bed with eyes closed on an air mattress, with the bed in the lowest position. The urinary catheter line was connected to a urine collection bag on the left side of the bed, and both the catheter line and urine collection bag were on the floor. RN9 was in the hallway by the medication cart and, when asked to check the bag, confirmed that it was on the floor and stated it was supposed to be placed in a basin as a barrier so it would not touch the floor. R65’s EHR identified him as a [AGE]-year-old resident admitted for short-term rehabilitation services with diagnoses including sepsis, hemiplegia, hemiparesis, and UTI. The care plan dated 12/07/25 included an intervention for the indwelling urinary catheter stating not to allow tubing or any part of the drainage system to touch the floor. The facility policy titled Indwelling Urinary Catheter Care, revised 10/05/25, stated that catheter tubing and the drainage bag should be kept off the floor.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in three separate observations. During an observation in a resident’s room, an opened and labeled lidocaine patch was found placed on the resident’s mattress at the foot of the bed while the resident was lying in bed awake. When asked about pain, the resident said they were not having pain at that moment but had pain earlier. The LPN stated that she had gone into the room to apply the patch, was called out for something else, and forgot to return to apply it. In the fifth-floor medication room, surveyors found an insulin pen in the medication refrigerator with a worn label and the resident’s name no longer legible. The IP reviewed the EHR and confirmed the resident had been discharged, and the insulin pen should have been discarded. In a separate medication cart, surveyors observed an opened one-quart bottle of lactulose that was about two-thirds full but did not have an open date written on it. The LPN acknowledged the missing open date and stated that the date should have been written on the bottle.
Failure to Notify Physician of Change in Condition Requiring Oxygen Administration
Penalty
Summary
The facility failed to notify the physician of a change in condition for two residents who required administration of oxygen. In the first case, a male resident with a history of stroke, dysphagia, and mild cognitive impairment experienced shortness of breath with oxygen saturation dropping to 87-89%. Nursing staff administered oxygen as ordered, but there was no documentation that the provider was notified of this change in condition, nor was there documentation of how long the resident required oxygen. The Director of Nursing confirmed that this met the criteria for a condition change and that the provider should have been notified. In the second case, another resident complained of shortness of breath and was administered oxygen, resulting in improved oxygen saturation. The event was recorded in the facility's communication book, but not in the resident's electronic medical record, and there was no documentation of notification to the on-call physician, despite a physician's order requiring notification if oxygen was applied or increased. The facility's policy requires notification of the attending physician for significant changes in a resident's condition or when medical treatment is altered. These failures were confirmed through interviews and record reviews.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation of oxygen administration, misfiled nursing notes, and inaccurate discharge information. For one resident, the electronic medical record contained a nursing progress note that was intended for a different resident, and this error was not identified prior to the survey. Additionally, the documentation of oxygen administration for two residents was inconsistent and incomplete across multiple record-keeping systems, including nursing notes, vitals reports, and respiratory administration records. There were missing assessments, discrepancies in the timing and documentation of oxygen use, and a lack of clarity regarding when oxygen was administered or discontinued. Interviews with facility leadership confirmed that the records did not provide sufficient information to determine the accurate use of PRN oxygen and that required assessments were missing. For another resident, a complaint of shortness of breath and subsequent oxygen administration was documented in a unit communication book but was not entered into the resident's official nursing progress notes. The nursing notes for that day did not reflect the resident's complaint or the intervention provided, and the DON confirmed that this documentation should have been included in the progress notes. This omission resulted in an incomplete medical record for the resident. A third resident received a Notice of Discharge that inaccurately stated her health had improved sufficiently to no longer require facility services, despite therapy and assessment records indicating a decline in her condition and ongoing need for skilled nursing care. Interviews with the social worker and administrator revealed that the discharge notice did not accurately reflect the resident's true condition, and the administrator acknowledged marking the form incorrectly. The facility's own documentation policy requires that records be timely, accurate, objective, thorough, and complete, but these standards were not met in the cases reviewed.
Failure to Provide Appropriate Care and Documentation for Post-Stroke Resident
Penalty
Summary
Nursing staff failed to provide the standard of quality care to a male resident admitted for rehabilitation following a stroke. The resident, who had dysphagia, expressive aphasia, mild cognitive impairment, and was dependent on staff for all activities of daily living, had a peripheral intravenous (PIV) catheter in place for three days without a physician's order. Documentation showed that the PIV was eventually pulled out by the resident, resulting in bleeding, but there was no evidence of an order for the PIV at any time during his stay. Additionally, staff used the resident's hospital weight as his baseline admission weight instead of obtaining a weight on the facility's scale, as required by facility policy. Subsequent weights showed significant discrepancies, with no repeat weights performed to confirm accuracy and no documentation that nursing staff or the provider were notified of the large weight loss. Furthermore, licensed staff did not document a neurological assessment or monitoring as required after the resident was found unresponsive to verbal stimuli and unable to be awakened. There was no evidence of reassessment or documentation of the resident's neurological status during the shift, despite the facility's stroke program and staff education on the importance of neurological monitoring. These actions and omissions resulted in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Identify and Report Medication Error
Penalty
Summary
The facility failed to identify and report a medication error as required by its policy. A resident with an order for Lisinopril 2.5 mg, to be administered orally in the evening and held if the systolic blood pressure (SBP) was less than 120 mm Hg, received the medication despite having an SBP of 113 mm Hg documented on the Medication Administration Record. The medication order was not followed, and the error was not detected or reported to the Administrator or Director of Nursing (DON) for review and appropriate action. During an interview and concurrent review of the resident's records with the DON, it was confirmed that the medication should have been held and that the facility had not previously identified or reported the error.
Soiled Bed Pad/Brief Included in Resident's Discharge Belongings
Penalty
Summary
The facility failed to ensure the safe handling and disposal of a soiled bed pad/brief for one resident. After the resident was transferred to the hospital, staff collected and bagged the resident's belongings, which were then placed at the nursing station for pickup by a family member. Upon receiving the belongings, the family member discovered a soiled bed pad/brief, visibly contaminated with urine and feces, inside a clear bag labeled with the resident's name and room number. Photographic evidence confirmed the presence of the soiled item among the resident's personal effects. Interviews with the certified nurse aides involved in packing the belongings revealed that while they recognized the bags as the resident's, neither could recall specifically packing the clear bag containing the soiled item. One aide confirmed packing the blue bags but not the clear ones, while the other could not recall which bags they packed but denied knowingly including soiled items. Video surveillance confirmed that the clear bag with the soiled bed pad/brief was handed off to the family member as part of the resident's belongings. The administrator and surveyors reviewed the evidence and confirmed the deficiency.
Failure to Honor Resident Preferences in Therapy Scheduling and Outdoor Activities
Penalty
Summary
The facility failed to honor the preferences of three residents regarding their therapy schedules and outdoor activities, which compromised their right to self-determination. Resident 60, a female admitted for wound care and therapy, expressed a preference for morning therapy sessions due to her energy levels. Despite notifying the therapy team of her preference, no schedule was created, and she was often approached for therapy in the afternoon without prior notice. This lack of scheduling was confirmed by the Director of Rehabilitation, who acknowledged the oversight. Similarly, Resident 79, a male admitted for similar reasons, expressed frustration over not being informed of therapy times in advance, which was corroborated by a Resident Care Manager who noted frequent complaints about this issue. Additionally, Resident 21, a male admitted for wound care and therapy, expressed a desire to go outside for fresh air, a preference documented in his care plan. However, he reported that the facility had not assisted him in going outside, leaving him confined to his room. These failures to accommodate resident preferences were observed through interviews and record reviews, indicating a systemic issue in the facility's approach to honoring resident choices, potentially affecting all residents.
Unsanitary Ice and Water Equipment
Penalty
Summary
The facility failed to maintain the ice and water equipment in a clean and sanitary condition, as observed during an inspection of the resident nourishment room on the 4th floor. A buildup of hardened brown sediment was found around the bottom edge of the plastic chute dispensing water and ice. This equipment is used daily to provide hydration to residents, and the unsanitary condition poses a risk of pathogen exposure. The Registered Dietician present during the inspection acknowledged that the dispenser should be cleaned regularly but could not identify the brown buildup or confirm its acceptability. Interviews with the Maintenance Associate and Facilities Coordinator revealed that the ice and water dispenser is cleaned weekly, with the last cleaning reportedly occurring three days prior to the inspection. However, no maintenance log was kept to verify this cleaning schedule. Both the Maintenance Associate and Facilities Coordinator agreed that while calcium deposits are typically white, the brown sediment observed was unusual and should be avoided. The lack of proper documentation and the presence of brown sediment indicate a failure in maintaining the equipment according to professional standards for food service safety.
Resident Rights and Dignity Deficiency
Penalty
Summary
The facility failed to protect and promote the rights of a resident, identified as R60, by not ensuring she was treated with respect and dignity. R60, a female resident admitted for wound care, antibiotic, and rehabilitative therapy, was found to have no cognitive impairment based on her Minimum Data Set Admission Assessment. During an interview, R60 reported an incident involving a traveling nurse, RN2, who repeatedly woke her for non-urgent matters and did not listen to her instructions regarding her dressing change. R60 felt bullied and disrespected by RN2's behavior. The issue was brought to the attention of the Resident Care Manager, RCM4, who acknowledged the complaint and completed a grievance form. The grievance noted R60's dissatisfaction with RN2's wound care approach and bedside manner. However, the staff education provided in response to the complaint did not address the issues of bedside manner, resident approach, or cultural competency, which were central to R60's concerns.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to ensure privacy for Resident 274, as observed on December 12, 2024. A Certified Nurse Aide (CNA) was seen assisting the resident from the bathroom to her bed without providing adequate coverage, leaving the resident exposed in a top that ended above her hips and an adult incontinence brief. Despite noticing the presence of a State Agency observer, the CNA did not take measures to protect the resident's privacy, such as offering a towel or gown, or closing a door or privacy curtain. Interviews with another CNA and the Resident Care Manager confirmed that staff are expected to protect residents' privacy by providing cover-ups or using privacy curtains. Additionally, the facility failed to protect the confidentiality of Resident 113's electronic health record. On December 12, 2024, a medication cart on the 5th floor was found unattended with a laptop displaying the resident's health information. The Registered Nurse responsible for the cart acknowledged that the laptop should not have been left open and unattended, thereby compromising the confidentiality of the resident's medical records.
Failure to Complete Transfer Form for Hospitalized Resident
Penalty
Summary
The facility failed to provide a completed Interact Nursing Home to Hospital Transfer Form for a resident, identified as R107, who was transferred to the hospital due to a change in condition. R107 experienced shortness of breath and low oxygen saturation levels, prompting an emergency transfer to the hospital. Despite the emergency nature of the situation, the facility's protocol required the completion and transmission of the transfer form, which was not done. The Resident Care Manager confirmed that the form was not filled out and acknowledged that it should have been sent with the resident to the hospital. Interviews with the staff revealed that the Registered Nurse responsible for the transfer, RN25, did not complete the form, although she sent other documents and gave a report to the hospital ER nurse. The nurse educator and resident care manager indicated that training on the form is part of new hire orientation and ongoing huddles, but RN25's name was not found on the huddle rosters. The facility's documents stated that in emergency situations, the form could be faxed later, but this was not done. The failure to complete and send the transfer form was identified as a deficiency in the facility's process for transferring residents to the hospital.
Deficient Care Plans for Two Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, which potentially diminishes their quality of life. The first resident, a female admitted for subacute rehab services following a decline in ADLs and functional mobility, had a care plan that included monitoring for bleeding at an access site. However, there was no documentation of bleeding or that it was reported to a physician, indicating a lapse in care. The second resident, a female admitted for rehab services after a stroke, had a care plan addressing acute pain related to the stroke and left-sided weakness. Despite this, there were no interventions documented for managing the resident's pain, highlighting a deficiency in addressing her medical needs.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to involve a resident, identified as R79, in the development of his comprehensive care plan. R79, a male admitted for wound care, antibiotic, and rehabilitative therapy, was found to have no cognitive impairment with a BIMS score of 15. Despite this, R79 reported not being invited to or participating in any care planning meetings, leaving him uncertain about his current plan of care and the duration of his stay. A review of his electronic health record revealed no documentation of an interdisciplinary team (IDT) discussion since his admission. Further investigation revealed that the Resident Care Manager (RCM4) acknowledged that IDT meetings are typically held on admission and quarterly, with documentation expected in a progress note by Social Services. However, no such documentation was found, and the Social Service Manager (SSM) confirmed that the IDT discussion should have been documented. The SSM could not explain the absence of the progress note and admitted the possibility that the IDT meeting did not occur as planned. This lack of documentation and potential failure to hold the meeting resulted in the deficiency.
Deficiencies in Resident-Centered Care and Insulin Management
Penalty
Summary
The facility failed to provide resident-centered care and services in accordance with the goals to meet the physical, mental, and psychosocial needs of three residents. For one resident, the facility did not adequately address her complex physical needs, resulting in frequent hospitalizations. This resident, who was admitted with conditions such as diabetic ketoacidosis, acute hypoxic respiratory failure, and end-stage renal disease, experienced multiple transfers to acute care due to issues like hypoglycemia and infections. The facility's management of her insulin and dietary needs was insufficient, leading to severe hypoglycemic episodes and subsequent hospitalizations. Another resident's preferences for physical therapy scheduling were not honored, impacting her ability to manage pain effectively. The resident preferred morning sessions when her energy levels were higher, and pain management could be optimized with as-needed medication. However, the facility failed to schedule her therapy sessions accordingly, leading to difficulties in administering pain medication in a timely manner before therapy. Additionally, the facility did not clarify and correct ambiguous insulin orders for a third resident, which resulted in a hypoglycemic episode. The resident's insulin orders were incorrectly documented, and a hypoglycemic event was not properly recorded, lacking critical details such as the time of occurrence and interventions applied. This oversight placed the resident at risk for avoidable declines and injuries, highlighting a deficiency in the facility's documentation and medication management practices.
Failure to Change Enteral Feeding Bag Within 24 Hours
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident. The resident, an elderly individual admitted for surgical aftercare following digestive system surgery, had a medical history including diverticulosis and nontraumatic perforation of the intestine. The resident was prescribed enteral feeding four times a day. During an observation, an LPN initiated tube feeding for the resident and checked the feeding tube placement and residual presence. However, the feeding bag used was labeled with a date indicating it was past the 24-hour discard time, contrary to the facility's policy that requires changing the feeding bag and tubing every 24 hours. Upon realizing the oversight, the LPN stopped the pump and left to obtain a new setup. This deficiency in practice had the potential to put residents on enteral feeding at risk for preventable complications.
Oxygen Dispensation Error for Resident with RSV
Penalty
Summary
The facility failed to correctly dispense oxygen for a resident diagnosed with Respiratory Syncytial Virus (RSV) and placed in isolation on droplet/contact precautions. The resident, a male with complex medical conditions including Diabetes Mellitus and pneumonia, was observed wearing a nasal cannula with the oxygen monitor in the off position. The family member present confirmed the resident had tested positive for RSV and was started on antibiotics. The Resident Care Manager confirmed the physician's order for oxygen was 1-4 Liters per minute as needed, but the oxygen was not being administered correctly. Further observations revealed the nasal cannula was incorrectly placed on the side of the resident's face, and the oxygen meter remained off. The Director of Nursing confirmed the incorrect placement and noted that if the resident did not need oxygen, it should be removed and stored properly after a respiratory assessment. The physician's orders specified oxygen administration for shortness of breath or oxygen saturation less than 92%, with instructions to notify the medical doctor if oxygen was applied or increased. A nurse's progress note indicated a room air challenge was unsuccessful, with the resident presenting at 87% oxygen saturation, leading to the re-initiation of oxygen at 1 LPM.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to effectively manage the pain of a resident, identified as R228, which negatively impacted her quality of life and ability to participate in physical therapy and family visits. On multiple occasions, the resident experienced significant pain, as observed by her family member and noted by the surveyor. During an observation in the rehabilitation gym, the resident was in visible discomfort and had not received pain medication prior to her physical therapy session. The nurse administered Tramadol only after the session had begun, and the resident's pain was severe enough to cause a breakdown, leading her son to defer the therapy session. The resident's medication administration record indicated inconsistent administration of pain medication, with Tramadol documented as given on only two occasions in December, despite the resident frequently experiencing pain rated as high as 10 on a numeric scale. The resident's care plan included orders for Gabapentin, Lidocaine patches, and Tramadol for severe pain, but there was a lack of timely administration of these medications. The resident, who is severely cognitively impaired and primarily Cantonese-speaking, has a primary diagnosis of stroke and diabetes mellitus, further complicating her pain management needs.
Failure to Document and Report Post-Dialysis Bleeding
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident, leading to a deficiency. The resident, who has a hemodialysis access site in her left arm, reported that the site sometimes continues to bleed after dialysis sessions, requiring her to apply pressure with a dressing. On one occasion, the resident had an ace wrap on her left upper arm due to bleeding from her arterio-venous fistula (AVF) after dialysis. Despite this, there was no documentation in the Electronic Health Record (EHR) or the dialysis communication form regarding the bleeding or the application of a dressing. The facility's policy for hemodialysis care requires monitoring of the access site for bleeding and notifying the provider if bleeding lasts longer than 30 minutes or is severe. However, there was no documentation that the bleeding was reported to the Medical Doctor (MD), and the nurse's notes did not mention any active bleeding or the application of a dressing. The Director of Nursing (DON) and Resident Care Manager (RCM) confirmed the lack of documentation in the EHR, indicating a failure to adhere to the facility's policy and procedure for hemodialysis care.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper disposal of medications for discharged residents and those past their discard date, as well as to implement a thorough process for accurate reconciliation and accounting of controlled medications. During an inspection of a medication cart on the fifth floor, a Registered Nurse (RN8) was found to have administered a dose of Wixela Inhub, an inhaler medication for asthma, to a resident despite the medication being past its discard date of 12/09/24. The nurse acknowledged the oversight and indicated she would discard the expired medication and obtain a new one. Additionally, an inspection of another medication cart on the third floor revealed that the Narcotic Count Sign In Sheet had not been signed by the off-going and oncoming nurses for two shifts. This lack of documentation was confirmed by another Registered Nurse (RN6), who stated that both nurses should initial the log to confirm that the narcotic count was conducted and correct. The facility's policy requires a physical inventory of all controlled substances at each shift change, which was not adhered to in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to professional standards, which is necessary to promote safe administration practices and decrease the risk of medication errors. During an inspection of the medication storage room on the 4th floor, a bottle of magnesium citrate and a bottle of Colace liquid were found with expiration dates that had already passed. The Resident Care Manager (RCM) acknowledged that these expired medications were missed during weekly checks and should have been discarded. Additionally, there were instances of unsecured medication carts. An unlocked medication cart was observed outside a room with no staff present, and the responsible nurse admitted to not locking it before leaving. Another unlocked cart was found on the 5th floor, and the nurse responsible for it acknowledged the oversight. Furthermore, an open vial of Tubersol in the 5th floor medication storage room was found without an open date or discard date, and the RCM confirmed it needed to be discarded due to the lack of labeling.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as observed in two separate incidents. In the first incident, a Certified Nurse Aide (CNA) delivered a lunch tray to a resident on contact precautions without wearing the required personal protective equipment (PPE), such as gloves and a gown, and did not perform hand hygiene after exiting the room. The CNA admitted to not seeing the precautionary signage due to being unfamiliar with the floor. The facility's policy on contact precautions clearly states that gloves and gowns should be worn when entering a room and hand hygiene should be performed immediately after removing gloves. In the second incident, a Registered Nurse (RN) failed to perform hand hygiene between glove changes while conducting a dressing change on a resident with a stage 4 pressure ulcer. The resident, who is totally dependent on staff for care, developed the ulcer at the facility, and it is being managed by an outside wound specialist and facility nurses. The Resident Care Manager confirmed that staff are expected to wash their hands or use hand sanitizer between glove changes, and this practice is reinforced during training and huddles.
Failure to Monitor Orthostatic Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that a resident received the necessary monitoring in accordance with nursing professional standards, the individualized care plan, and physician orders. The resident, who was admitted following surgery for a fractured left hip and had a medical history including advanced Parkinson's disease, diabetes, anemia, hypertension, and orthostatic hypotension, was supposed to have orthostatic blood pressures and pulse monitored daily. However, the nursing staff did not consistently complete these vital sign checks as ordered. The first set of orthostatic vitals was recorded a week after the order was written, and out of 34 days, orthostatic vitals were documented only 11 times. There were also instances where the pulse was not recorded, and several days where the vital signs were not taken without documented reasons. Interviews with the Director of Nursing and a Registered Nurse revealed that the facility's practice was for licensed staff to take orthostatic vitals, not Certified Nurse Assistants. The Director of Nursing confirmed that if vital signs were not done, there should be a documented reason. The physician who ordered the orthostatic vitals noted in a progress note that the nursing staff had not been consistently performing the checks, which was important for confirming hypotension and monitoring after medication adjustments. The lack of consistent monitoring resulted in insufficient data to manage the resident's condition effectively.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 164 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Care Center Of Honolulu | 0.4 mi | ★★★★★ | 16 | 0 |
| 15 Craigside | 0.4 mi | ★★★★★ | 0 | 0 |
| Maluhia | 0.6 mi | ★★★★★ | 0 | 0 |
| Liliha Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Kuakini Geriatric Care, Inc | 0.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.