The Ching Villas

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

responses. The APRNs are scheduled on the Tuesday, Thursday schedule. RN1 noted that there are no physicians/APRNs that come on the weekends, so if there are any issues that come up and cannot wait till

the following Monday, they would page the on-call physician. Record review of the facility's communication book on 10/09/25 at 01:30 PM noted that on 09/27/25 (Saturday, time not specified) Resident R2 complained of shortness of breath (SOB). RN 2 assessed Resident R2's lungs and noted them to be clear to auscultation bilaterally and oxygen saturation (SPO2) at 96%. RN2 elevated head of bed and administered oxygen at one liter (L) with positive effect and SPO2 increased to 98%. Physician's response in the MD's response column of the communication book noted ok (time and reviewed date not indicated).Record review of Resident R2's EMR on 10/09/25 at 01:45 PM revealed the nursing progress notes had no documentation of Resident R2's complaints of having shortness of breath on 09/27/25, and no documentation of notification to the on-call physician. There was no previous documentation noted of Resident R2's complaints of having any SOB. A Physician's order was entered on 09/21/25 for Oxygen 1-4 L via nasal cannula for SOB or SPO2<90%, with special instructions to notify MD if 02 is applied or increased.Interview with the DON on 10/09/25 at 02:00 PM confirmed the order to notify MD and said for resident's who required 02 for the first time, a call to the physician should have been made, including at night, when the O2 was needed and administered, as it is considered a change in condition. The facility's Change in a Resident's Condition or Status policy, with a revised date of 05/19/23 was reviewed on 10/09/25. It notes The facility shall notify resident, his or her Attending Physician.of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a .d. significant change in the resident's physical.condition.e. need to alter the resident's medical treatment.2. A significant change.a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Ching Villas

2230 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

approximately 01:00 PM, interviewed Facility Staff (FS) 4 in the conference room. At that time reviewed Resident R1's medical records and FS4 confirmed he/she documented the admission weight of 195.8 lbs. FS4 said he/she had been told by the nurse on duty to take the weight off the hospital records and record as the admission weight. On 10/09/2025 at approximately 01:15 PM, interviewed the DON, who said the facility policy and expectation was to take the admission weight on the facility scale. He also said if there was a significant loss like this, the staff should repeat the weight to ensure accuracy and report the loss to the nursing staff.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Ching Villas

2230 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based 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 Resident R1's SBP was documented as 113 mm Hg, the Lisinopril was administered, when it should have been held. Findings Include: Resident 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). Resident R1's September 2025 Medication Administration Record (MAR) reviewed. On 09/12/25 Resident R1's SBP was documented to be 113, lower than the required parameter for administering the medication. The medication order was not followed, and the resident was administered Lisinopril 2.5 mg. On 10/09/25 at 11:15 AM, conducted an interview and concurrent review of Resident R1's MAR for 09/12/25 with the DON. He confirmed Resident R1's SBP was 113 and the Lisinopril should have been held. Also, the DON confirmed the facility did not identify this medication error prior to this interview and no report was done.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Ching Villas

2230 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

follows 1-step directions independently, had the decision-making ability for routine activities and was independent in cognition. In the PT certification period from 04/21/25-06/01/25, Resident R3's mobility score =2, with LE ROM (lower extremity range of motion) impaired, RLE ROM (right lower extremity range of motion) with severe pain. Resident R3 was noted to only sometimes have the ability to express ideas and wants, sometimes understands the ability to understand others, and for 1-step directions, Resident R3 needed prompts and cues, and cognition was severely impaired. PT discharge recommendations/status was Skilled Nursing Facility (SNF).Initial OT certification period from 09/18/24-10/17/24, noted Resident R3's Self-care function score at 10 (ranges from 0-12, 12 being the highest function) with Resident R3's decision making ability for routines activities to be independent. In the OT certification period notes from 04/21/25-06/01/25, Resident R2's self-care score decreased to 4, with decision making ability for routine activities to be severely impaired. OT discharge recommendations/status was SNF.Interview with the Social Worker (SW) on 10/07/25 at 01:25 PM in her office confirmed that they had been working with Resident R3's family to find long-term care (LTC) placement, but due to various reasons i.e. bed availability and family preference, they had not been successful. SW also agreed that LTC placement would be the best option for Resident R3, as her condition had not improved. Interviewed

the Administrator on 10/07/25 at 02:50 PM, at which time she disclosed that she generated the Notice of Resident Discharge form to expedite the discharge process for Resident R3, as it has been a year of ongoing discharge planning. Administrator noted that she entered Home because it is what FM2 wanted but felt that

the resident's needs would be better taken care of in a LTC facility, and that it was not safe for Resident R3 to be discharged home. Administrator was also unsure of what to mark for discharge reason but marked The discharge/transfer is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, despite knowing that the Resident R3's health condition had not improved but declined from baseline. She agreed it did not accurately reflect Resident R3's condition. Reviewed the facility's Documentation policy on 10/08/25 at 10:00 AM, which noted, Medical records documentation primarily is a means of communication. and serves as a legal document.Documentation must be timely, accurate, objective, thorough, and complete, and must present the appropriate facts to substantiate the following requirements.1.Clearly reflects the condition of the patient, 2.Clearly reflects the skilled services provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Ching Villas

2230 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 potential for actual harm

Based 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. Resident R1 was transferred to the hospital from the facility on 09/18/25. The resident's belongings were collected from Resident R1's room, bagged, and placed at the nursing station until it was picked up by Resident 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 Resident 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). In a picture (P1), in one of two Clear Bags (CB)1, any reasonable person could identify blue material (bed pad/brief), inside the bag just by looking at it. A second picture (P2) documented the inside of CB1, which contained a visibly soiled item with brown material (feces/urine) at the bottom of the bag. On 10/08/25 at 11:42 AM conducted a concurrent interview and observation of Resident R1's assigned room with Certified Nurse Aide (CNA)45 and CNA3. Both staff confirmed they packed all of the resident's belonging in bags and placed it in the nursing station for the resident's family.On 10/08/25 at 01:40 PM, conducted an interview and review of the picture of the bags with CNA45. Showed CNA45 P1, then inquired if staff recognized the bags as Resident R1's belongings. CNA45 confirmed and recognized all five bags mentioned above as Resident R1's belongings. CNA45 attested to packing the two blues belonging bags but confirmed he/she did not pack any clear bags. On 10/08/25 at 01:43 PM, conducted an interview and

review of the picture of the bags with CNA3. CNA3 reviewed P1 and confirmed all five bags in the pictures were identified as Resident R1's belongings. Inquired with CNA3 about the clear bag (with the bed pads visible at the bottom). CNA3 confirmed bed pads were visible at the bottom and identified Resident R1's boots at the top of CB1.

CNA3 could not recall which bags he/she packed but insisted that he/she would not have knowingly put the resident's belongings in with a soiled bed pad/brief. On 10/08/25 at 02:03 PM, conducted an interview and

review of facility video surveillance with the Administrator and two other surveyors present. The Administrator presented video surveillance of the Unit Clerk (UC) handing off Resident R1's belonging to FM3. In the video, FM3 and UC are seen looking through two of the blue belongings bag and did not look through CB1 identified in P1, which contained the soiled bed pad/brief.Reviewed CB1, P1, and P2 with the Administrator.

Administrator confirmed bed pads/ briefs, and the protection boots are visible through CB1, and that same bag was in the video as part of Resident R1's belongings sent home with FM3. Also, the Administrator confirmed the bed pad/briefs were soiled. After reviewing the video surveillance and pictures, the Administrator confirmed

the bag which contained soiled bed pads/briefs was given to Resident R1's FM3 as part of the resident's belongings.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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