The Ching Villas

Inspectors wroteBased on observation and interview, the facility failed to ensure that food items stored in the walk-in refrigerator were labeled properly and old food discarded. This deficient practice places residents in the facility at risk for foodborne illness. Findings Include:During an initial walkthrough of the kitchen with the Dietary Manager (DM) on 01/13/26 at 09:00 AM, in the walk-in refrigerator, observed meatloaf stored beyond the discard date of 12/24, and turkey beyond the discard date of 01/11. A tray of Salisbury steak was observed with an open date of 11/24 and no discard date. Concurrent interview with the DM noted that these items should have been thrown out to prevent serving expired food and residents risking foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure five out of 10 residents (Resident (R), 112, R182, R177, R179, and R180) sampled for receiving specialized services, received physical therapy (PT) treatments according to their prescribed treatment plan. PT treatments help to assist the residents to restore his/her highest level of physical functioning. This deficient practice affects the resident's ability to meet their therapy goals. Findings Include: Observation and interview with R182 in her room on 01/13/26 at 2:00 PM. R182 said she fell on her front stairs at home and fractured her foot. She said she was getting therapy, but she wasn't supposed to put weight on her foot. Observed R182 lying in her bed, with a blue colored cast on her lower right leg. [...]

Inspectors wroteBased on record reviews and staff interview, the facility failed to ensure the risk and benefits of using psychotropic medications were explained and documented for two of five Residents (R) 162 and R181 or their representatives sampled for unnecessary medications. This deficient practice affect's the residents' ability to understand the risks or benefits of treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop a plan of care to include oxygen (O2) therapy for one of two Resident's (R) 178 sampled for O2 therapy; and failed to implement the care plan for bilateral heel protectors for one of one resident, R173 sampled for having bilateral lower extremity (BLE) edema and cellulitis. This deficient practice puts the residents at risk for not achieving their treatment goals. Findings Include:On 01/13/26 at 10:40 AM, observed R178 with 02 at one liter (L) via nasal cannula (NC). R178 said the 02 is helping him with his breathing but feels he would be ok without it. R178 was admitted on [DATE] with a primary diagnosis of postprocedural complications and disorders of the digestive system and has a history of diaphragmatic hernia. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one of one resident sampled for quality of care received treatment and care in accordance with professional standards of practice and the comprehensive care plan. Findings Include:On 01/14/26 at 09:55 AM, observed Resident (R) 173 in bed with oxygen (O2) on 3L (liter) via nasal cannula (NC). R173 stated her breathing was okay and she had no shortness of breath (SOB), despite having a moist cough. Record review of R173's Electronic Health Record (EHR) on 01/14/26, noted a physician's order for continuous O2 at 1-2 LPM (liters per minute) via NC, Sp02 (oxygen concentration) goal: 88-92%, and to notify Physician (MD) if condition worsens or if requiring additional O2. Review of the progress notes did not indicate the need for O2 to be increased to 3L. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three residents sampled for accidents were free from accidents. Resident (R) 185 had a fall and R58 received a skin tear when transferred with a mechanical device to a wheelchair. The deficient practice placed the residents at risk for injury.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure the indwelling urinary catheter bag was placed in a sanitary position off the floor for one Resident (R) 65 sampled with an indwelling urinary catheter. The deficient practice increased R65's risk of preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter.

Inspectors wroteThe facility failed to securely store a medication patch for one of one resident sampled for medication storage; and 2) discard a medication injectable for a resident who was no longer residing in the facility in one medication room of two medication rooms sampled; and 3) label a medication bottle without an open date in one medication cart of six carts in the sample. The deficient practice increases the risk of a medication diversion.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the physician that two of three residents (R)1, and R2 sampled had a change of condition that required administration of oxygen. The deficient practice of not notifying the physician of a change of condition could affect any resident, and places them at risk for not getting the appropriate treatment that may result in a negative outcome.

Inspectors wroteBased on medical record review, document review and interviews, the facility failed to ensure the medical records of three Resident's (R)1, R2 and R3 were complete and accurate. 1) R1 and R2's records did not include complete, accurate documentation of oxygen administration. 2) R1's records included a nursing progress note of an assessment on a different resident and in error, entered into the wrong record. 3) R3's discharge notice included inaccurate information regarding her current condition.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the nursing staff provided the standard of quality care to one of three Residents (R)1 sampled. 1.) R1 had a peripheral intravenous access (PIV) in his right arm for three days, with no order. 2) Staff used R1's hospital weight as his baseline weight upon admission, and 3) Licensed Staff (LS)4 did not document a neurological assessment and monitoring as required, to ensure there was no change of condition. The deficient practice placed R1 at an increased risk of infection at the catheter site; an increased the risk of his nutritional needs not being met; and an increased risk of acquiring an unidentified medical condition that may result in a negative outcome.

Inspectors wroteBased on an interview and record review, the facility failed to identify and report a medication error to the Administrator or Director of Nursing (DON) for review and appropriate action as required by facility policy. Resident (R) 1 was ordered Lisinopril (to treat high blood pressure) 2.5 mg (milligrams) orally and hold the medication if the resident's Systolic Blood Pressure (SBP) was less than 120 millimeters (mm) of mercury (Hg). Although R1's SBP was documented as 113 mm Hg, the Lisinopril was administered, when it should have been held. Findings Include: R1's Electronic Medical Record (EMR) reviewed on 10/09/25. The physician orders documented an order for Lisinopril 2.5 mg, to be given once an evening, hold for systolic blood pressure (SBP) less than 120 (started on 09/03/25, ended 09/16/25). R1's September 2025 Medication Administration Record (MAR) reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure safe handling and disposal of a soiled bed pad/brief for one Resident (R)1. R1 was transferred to the hospital from the facility on 09/18/25. The resident's belongings were collected from R1's room, bagged, and placed at the nursing station until it was picked up by R1's Family Member (FM)3 on 09/22/25. FM3 discovered a soiled bed pad/brief in a bag marked as the resident's belongings. Findings Include: On 09/25/25 at 07:50 PM, the State Agency (SA) received a complaint via email that a soiled (with urine and feces) bed pad/ brief was found in a bag given to them as part of the resident's belongings. The bag was labeled with R1's name and room number. Pictures of all the resident's belongings bags (five bags; one gift bag with a balloon, two blue personal belongings bags, and two clear bags). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, support, and honor the preferences of 3 of 11 Residents (R) sampled for Choices. Specifically, the facility failed to honor R60's and R79's preference to be informed of a time range that rehabilitation therapy services would occur and failed to honor R21's preference to be assisted outside periodically for fresh air. As a result of this deficient practice, these residents did not have their needs met and were placed at risk of not attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: 1) R60 is a [AGE] year-old female admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the ice and water equipment for the residents were kept in clean and sanitary conditions in accordance with professional standards for food service safety. Residents risk serious complications from foodborne illness as a result of their compromised health status. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents receiving ice or water on the affected floor.

Inspectors wroteBased on interview and record review, the facility failed to protect and promote patient's rights for 1 of 26 residents sampled (Resident (R)60) by ensuring that she was treated with respect and dignity. This deficient practice has the potential to affect all residents in the facility. Findings Include: R60 is a [AGE] year-old female admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of her Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 10/30/24 noted R60 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 12/10/24 at 04:17 PM, an interview was done with R60 at her bedside. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide privacy for one resident (Resident (R)274) and failed to protect the confidentiality of another resident's (R113) electronic health record. These failed practices have the potential to negatively impact the psychosocial well-being of the affected residents. Findings Include: 1) On 12/12/24 at 02:30 PM, while exiting the 3rd floor recreation room, made observations into room [ROOM NUMBER] at the end of the hall. Observed Certified Nurse Aide (CNA)3 assisting Resident (R)274 from the bathroom, located just inside the room entrance, back to her bed located next to the window. R274 was wearing a top that ended above her hips and an adult incontinence brief. [...]

Inspectors wroteBased on record review and interview the facility failed to provide Resident (R)107's completed Interact Nursing Home to Hospital Transfer Form to the hospital R107 was sent to when his condition changed and he became unstable, requiring a transfer and admission to an acute hospital. Findings Include: Record Review (RR) was done of R107's Electronic Health Record (EHR). On 11/17/24 Registered Nurse (RN) 25 documented R107 was sent to the emergency room (ER) because R107 complained of shortness of breath and could not breath and his Oxygen (O2) saturations were in the 70's. R107 was sent to the ER by 911 ambulance. Progress note dated 11/17/24 stated R107 was admitted to the hospital for diagnosis of AFib (Atrial fibrillation (AFib) is an irregular and often very rapid heart rhythm.). On 12/12/24 at 10:59 AM met with and interviewed Resident Care Manager (RCM) 5. [...]

Inspectors wroteBased on record review, the facility failed to implement a comprehensive person-centered care plan to meet the medical, physical, and psychosocial needs for two of two Residents (R) 36 and R228 in the sample. The deficient practice has the potential to diminish both resident's quality of life. Findings Include: Cross reference to F698. Physical medicine and rehabilitation note 12/09/24 17:14 reviewed. R36 is a [AGE] year-old female admitted to the facility on [DATE] for subacute rehab services for decline in Activities of Daily Living (ADL's) and functional mobility after hospitalization. Care plan dated 11/15/24 reviewed. Approach: Check bruit and thrill. Assess site for bleeding. If bleeding, call the physician. Review of the medical record revealed there was no documentation of bleeding to the access site, or that it was reported to the physician (cross reference to F697). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the involvement of one resident (Resident (R)79) in the development of his comprehensive care plan (CP). As a result of this deficient practice, staff did not have all the information necessary to assist R79 in meeting his highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: R79 is a [AGE] year-old male admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of his Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 10/29/24 noted R79 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 12/11/24 at 09:21 AM, an interview was done with R79 at his bedside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide resident centered care and services in accordance with the goals to meet the physical, mental, and psychosocial needs for three residents of 26 in the sample, Resident (R) 55, R228 and R34. Specifically the facility failed to meet R55's complex physical needs that resulted in frequent hospitalizations. Failed to schedule R228's Physical Therapy (PT) per her preference to coincide with her higher energy level in the morning and better pain management with as needed pain medication before PT. Failed to clarify and correct ambiguous insulin orders for R34 and failed to ensure standards of good clinical practice were followed with regards to documenting a hypoglycemic (low blood sugar) episode. As a result of this deficient practice, the facility placed R34 at risk for avoidable declines and injuries. [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to provide treatment and services to prevent complications of enteral feeding for one resident (Resident (R)10) in the sample. The facility did not ensure the formula bag was changed every 24 hours when enteral feeding was initiated using a bag past the stated discard date and time. This deficient practice has the potential to put residents on enteral feeding at risk for preventable complications. Findings Include: Record review of R10's Electronic Health Record (EHR) revealed the resident is an [AGE] year-old admitted to the facility for surgical aftercare following surgery on the digestive system. Diagnoses included but not limited to diverticulosis (condition in which pockets develop on the inside of the colon) and nontraumatic perforation of intestine. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to correctly dispense oxygen for one resident with a respiratory infection of two residents in the sample. The deficient practice may increase the resident's risk of illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively manage the pain for one resident of 26 in the sample based on professional standards of practice. The deficient practice diminished the resident's quality of life due to decreasing the ability to successfully participate in Physical Therapy (PT) and family visit. Findings Include: Cross reference to F656 & F684. Observation and interview with Resident (R) 228 in the rehabilitation gym with her Family Member (FM) on 12/11/24 at 10:45 am, who said R228 is having a bad day and is in a lot of pain. R228 was speaking sharply in her native language with her face in a scowl. Surveyor asked the FM if R228 was medicated prior to coming to Physical Therapy (PT). He said no, but the nurse is going to bring the medicine now. The nurse came and gave R228 one Tramadol 25 milligram (mg) tab for the pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services for the provision of dialysis consistent with professional standards of practice for one of one resident in the sample. The deficient practice may increase the risk for an adverse outcome. Findings Include: Cross reference to F656. Observation and interview in Resident (R) 36 room on 12/10/24 at 2:20 PM. She stated that her hemodialysis access site is in her left arm, and sometimes after her dialysis session, the site continues to bleed. When that happens, she has to keep a dressing with pressure to the site. Observation and interview in R36 room on 12/12/24 at 8:30 AM with the Registered Nurse (RN) 35. R36 had an ace wrap to her left upper arm, she stated that she had bleeding to her arterio-venous fistula (AVF) after her dialysis last night. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications of discharged residents, and medications that were past their discard date are disposed of and not administered to the residents. The facility also failed to implement a thorough process to assure accurate reconciliation and accounting of all controlled medications, for 1 of 12 medication carts, in order to promptly identify loss or potential diversion. Findings Include: 1) On 12/12/24 at 08:51 AM, inspection of one of the medication carts on the fifth floor was conducted with Registered Nurse (RN)8. An open box Wixela Inhub (inhaler medication for asthma) was found in one of the drawers. The box had a label where the open and discard dates were written. Discard date stated 12/09/24. Asked RN8 if a dose of the Wixela Inhub was administered to the resident recently. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with professional standards. Proper storage and labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures. Specifically, the facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to a resident on transmission-based precautions (TBP) and perform hand hygiene after exiting the room and between glove changes. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.

Inspectors wroteBased on interviews, document and record review, the facility failed to ensure one Resident (R)1 of a sample size of three received the monitoring in accordance with the nursing professional standards of practice, the resident's individualize care plan or the physician's (MD)1 orders. Specifically, the nursing staff did not complete orthostatic blood pressures (BP) and pulse (P) as ordered. As a result of this deficiency, R1's vital signs were not monitored as needed, which resulted in lack of timely data and made R1 at higher risk of not reaching his highest physical practical wellbeing.

Inspectors wroteBased on interviews and record review, the facility failed to treat resident (R)337 with dignity. R337 had an interaction with a nursing staff during which the staff told the resident she had Dementia due to not recalling information correctly, R337 does not have Dementia. As a result of this deficient practice, the resident is at potential risk of psychosocial harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an assessment accurately reflected the residents' status at the time of the assessment for one of twenty-four residents (Resident (R)82) sampled. This deficient practice places all the facility residents at risk for assessment inaccuracy.

Inspectors wroteBased on observations, interviews, record review, the facility failed to ensure the resident and the resident representative participated in the development of the comprehensive care plan or documented explanation must be included in the resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for one of four residents (Resident (R)236) sampled.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident was free of accident hazards as is possible. Resident (R)84 sustained second-degree burn on her right thigh after hot tea spilled on her lap. As a result of this deficient practice, the resident sustained physical harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure medication reconciliation on admission was accurate and met the needs of one Resident (R)236 sampled. R236 has insulin- dependent, type 2 diabetes mellitus and received a sliding scale of short-acting and scheduled long-acting insulin at home and in the acute hospital, prior to admission to the facility. On admission, a nurse reconciled R236's medications with a Non-Physician Practitioner (NPP)1 and omitted the insulin. There was no documentation by NNP1, physician, or nursing for a plan of care regarding R236's insulin. Insulin was only ordered after the resident's representative (Family Member (FM)1) questioned staff. As a result of this deficient practice, all newly admitted residents are at risk for potential harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident was free of any significant medication errors. Resident (R)29's routine insulin was not administered in accordance with the prescriber's order.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment and failed to appropriately label eye drops. Observed Resident (R)340's eye drops in the medication cart which was not labeled with an open and discard by date once it was opened. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications. The deficient practice could affect all residents who receive medications at the facility.

Inspectors wroteBased on resident (R)338 and staff interview the facility failed ensure the resident's right to dietary choices for one Resident (R)338 sampled. The deficient practice could affect all the residents who provide the input in ordering their meals.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure infection control practices were implemented to help prevent the development and transmission of communicable disease and infections. Observed Physician (P)1 not wearing Personal Protective Equipment (PPEs) in direct contact with Resident (R)234, who was on contact precaution for Clostridioides Difficile (C. diff which is a highly contagious bacteria that causes diarrhea and inflammation of the colon (colitis) and is spread through contact with any contaminated surface, device, or material). Observed Certified Nurse Aide (CNA)99 did not disinfect his/her hands with soap and water after disposing trash (contained fecal matter) from R234's room of trash which contained fecal matter. As a result of this deficient practice, residents are at the potential risk of harm of exposure to a communicable disease.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident's medical record includes documentation that indicates, at minimum, the resident or resident representative was provided education regarding the benefits and potential side effects of the influenza/pneumococcal immunization and documentation that the resident either received or did not receive the influenza/pneumococcal immunization due to medical contradiction or refusal for one of five residents (Resident (R)25) sampled. As a result of this deficient practice, all residents are potential risk of exposure and/or an increase potential for harm.

Inspectors wroteBased on observations, staff interview, review of policy and vendor procedure, the facility failed to properly dispose of seven filled medication disposal containers (Rx Destroyer) as evidenced by the containers being stored in an unsecured Trash Room. As a result of this deficiency, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards.