Manila Healthcare Center

Based on record review, observation, interview, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for one (Resident #17) of two residents reviewed for EBP and failed to ensure hand hygiene was consistently implemented during incontinence care for one (Resident #46) of one resident reviewed for incontinence care.The findings include:Resident #17A review of Resident #17's Physician's Orders, dated 03/16/2026, revealed all medications were to be administered by way of (via) a Percutaneous Endoscopic Gastrostomy (PEG) tube, with a start date of 04/10/2024. The resident had an active order for EBP related to indwelling devices, with a start date of 06/24/2024. A review of Resident #17's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2025, revealed a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident was severely impaired and never/rarely made decisions. Resident #17's MDS also revealed the resident had a feeding tube while a resident.A review of Resident #17's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure that one (Resident #95) of one resident reviewed for self-determination, had the opportunity to exercise autonomy in choosing when to have medication administered. The findings include: Review of an admission Record revealed Resident #95 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease with (acute) exacerbation, congestive heart failure, pneumonia, vitamin deficiency, dizziness, and gastroesophageal reflux disease (GERD). Review of Resident #95's admission Minimum Data Set (MDS) revealed that the MDS was in progress. Review of the CMT Medication Administration Record (MAR) dated 03/16/2026 revealed that Resident #95 refused the following medications: an antibiotic, a high blood pressure medication, an allergy medication, vitamin, an iron supplement, an anticholinergic, a probiotic, a blood thinner, an antacid, an oral steroid, an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on record review, interview and facility policy review, the facility failed to ensure a Comprehensive Care Plan was consistently implemented for one (Resident #17) of four residents reviewed. The findings include: Review of an admission Record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses which included epilepsy, restless leg syndrome and hemiplegia and hemiparesis (decreased sensation or mobility on one side of the body) affecting the right dominant side. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 12/18/2025, revealed Resident #17 had a Staff Assessment for Mental Status score of 03, which indicated Resident #17 had severe cognitive impairment, never/rarely made decisions, and was dependent on staff for rolling left and right. Review of March 2026 Physician's Orders revealed Resident #17 was receiving comfort measures only. Review of a Care Plan with a revised date of 02/01/2020, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure nails were trimmed for one (Resident #4) of three residents reviewed for Activities of Daily Living (ADL) care. The findings include: Review of a facility policy on nail care titled Fingernails/Toenails, Care of revealed the propose of nail care is the clean the nail bed, keep nails trimmed, and prevent infections. The policy revealed that nail care included daily cleaning and regular trimming. The policy revealed that the condition of a resident's nails and nail bed should be documented in the resident's medical record. The policy revealed that proper nail care helps to prevent skin problems around the nail bed. The policy revealed nails should be trimmed and smooth to prevent the resident from accidentally scratching and injuring his skin and the nurse supervisor should be contacted if there is evidence of ingrown nails, or if the nails are too hard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to add oxygen to the Physician Orders for one (Resident #40) of two residents reviewed for oxygen orders. The findings include: Review of Resident #40's admission Record indicated that the facility admitted Resident #40 on 12/11/2025 with diagnoses which included pneumonia, shortness of breath, obstructive sleep apnea, and acute bronchitis. Review of a discharge return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/28/2026 revealed Resident #40 had modified independence for daily decision according to a Staff Assessment of Mental Status (SAMS). Review of Residents #40's Physician Orders did not indicate that Resident #40 had an order for oxygen administration. Review of a form titled Standing Orders dated 02/08/2021, signed by the Nurse Practitioner (NP), indicated to administer oxygen at 2-4 liters per minute as needed for shortness of breath and/or a pulse oximetry less than 90%. Review of Resident #40's Care Plan did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled:Number of residents cited:Based on interview and record review the facility failed to ensure one (Resident #14) of one resident reviewed for pain management, received their pain medication when requested. The findings include: Review of an admission Record revealed the facility admitted Resident #14 on 10/18/2024 with diagnoses which included age-related osteoporosis with current pathological fracture. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 1/20/2026, revealed Resident #14 had a Brief Interview of Mental Status score of 15 which indicated Resident #14 was cognitively intact. Review of Resident #14's Order Summary Report with a start date of 10/18/2024, revealed a Physician's Order for an opioid pain medication, to be given every eight hours as needed (PRN) for pain. Review of Resident #14's Care Plan, revised on 10/26/2024, revealed the resident had acute pain related to fracture of the back, and osteoporosis. The Care Plan interventions included to anticipate the resident's need for pain relief and respond immediately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observation, record review and interviews, the facility failed to ensure the Medical Director (MD) or Nurse Practitioner (NP) were contacted for orders when two medications were unavailable for one resident (Resident #98) during medication pass. Specifically, this surveyor observed 2 of 37 opportunities for medication not administered in accordance with the physician orders by way of omission, resulting in a medication error rate of 5.41%. The findings include: Review of Resident #98's Medical Diagnosis revealed the facility admitted Resident #98 with diagnoses which included dementia, fibromyalgia (widespread chronic pain and fatigue) and polyneuropathy (widespread damage to peripheral nerves causing numbness, burning pain and weakness starting in the hands and feet). Review of an admission Minimum Data Set with an Assessment Reference Date of 12/10/2025, revealed Resident #98 had a Brief Interview for Mental Status score of 5, which indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure that the environment was clean and sanitary to provide a homelike environment on the secured unit. This failed practice had the potential to affect all 20 residents who resided in the secure unit. The findings are: A review of the facility policy Housekeeping Cleaning Guidelines indicated: a. Corridors and Public Areas: (including dining rooms, day rooms, lobby, activity areas, therapy areas etc.) Dust mopping, (including corners and edges) daily, damp/wet mop daily, scrubbing of resilient tile as scheduled. b. Corridors and Public Areas: (including dining rooms, day rooms, lobby, activity areas, therapy areas etc.) 3. Check/dust horizontal areas daily, 4. check/dust/clean vertical services daily, 16. Public area deep clean (light fixtures, vents, cubicle curtains/tracks, air/heat units, fire alarms, extinguishers, call lights/devices, baseboards, room corners, edges, ceiling corners etc.) monthly. c. Patient Room Cleaning: 3.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and interviews, the facility failed to ensure infection control measures, including the storage of resident equipment, were implemented during residents smoking for 1 (Resident #1) of 1 sampled resident observed for prevention of potential infection and/or the spread of infections. The findings include: Review of a facility policy titled, Cleaning and Disinfection of Resident-Care items and Equipment dated September 2022, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. A review of an admission Record indicated the facility admitted Resident #1 with diagnoses that included cerebral palsy and Parkinson's disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 (08-12 indicates moderately impaired). Review of Resident #1's Care Plan initiated: 06/15/2015, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure maintenance was in place to maintain and prevent broken and exposed wall plug outlets, broken trim on walls, holes in sheet rock, wall nail holes, and leaky toilet rims in resident rooms to maintain a safe, clean, and homelike environment in Hall 1 of eleven (11) Resident rooms. The findings are: On 01/02/2023, at 12:20 PM, environmental rounds were made in the facility rooms, the following were observed: a. Standing in the entrance of room eight (8), wall trim behind the headboard on the left, is located on the floor. In addition, the 4-plug wall outlet is separated from the sheetrock, exposing 1/2 inch across the top of the wall plate. A 2-plug wall outlet on the right side of the wall, is separated from the sheetrock exposing 1/2 inch across the top of the wall plate. b. Standing in the entrance of room ten (10), behind the entrance door, is a hole in the sheetrock approximately (12 x 12 cm [centimeters]). In addition, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure medications were given within a timely manner to avoid adverse effects on resident's condition and ensure that medications were administrated without unnecessary interruptions, for 2 (Resident #7 and #44) sampled residents. This failed practice had the potential to affect 51 residents who were dependent on the nurses for medication administration. The findings are: 1. Resident #7 [R#7] had diagnosis Hemiplegia ( weakness or paralysis on one side of the body) and Hemiparesis ( weakness of one side of the body) following unspecified Cerebrovascular Disease affecting Left Non-Dominant side. a. On 01/02/24 at 12:11 p. m., R #7 stated, My night medications [meds] are always late, I get them around 11 p. m. I have filed a grievance because on 12/19/23 I didn't get them until 2:00 a.m. I don't think they are short-staffed; I think the nurses just don't do their jobs. b. Review of the grievance filed by R#7 on 12/19/23 documented .Nature of Grievance: didn't get her night times meds until 2 am . Resolution:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: Young, [NAME] Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with a maintenance program in place to prevent broken, exposed wall plug outlets, broken wall trim, holes in sheet rock, wall nail holes and leaky toilets in resident's rooms to maintain a safe, clean, and homelike environment. These failed practices had the potential to affect 51 residents who reside in the facility. The findings are: 1. A Recertification survey was conducted on 01/05/2024 at the facility. During this survey, the team identified concerns with food services, food storage, and hand hygiene when preparing and serving food in a sanitary manner and concerns with infection control. A. The Plan of Correction with a completion date of 10/22/2022 documented: This Plan of Correction is to be considered as an allegation of Compliance. Step #1: Corrective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure staff did not leave medications unattended on a secured unit. The findings are: During observation on 10/4/23 at 11:16 AM, a resident was sitting in the day room at a table with two other residents on the secured unit. The resident had a cup of water and a medication cup with four pills on a table in front of her. There was a total of four residents in the day room. During interview on 10/4/23 at 11:27 AM, Licensed Practical Nurse (LPN) #1 came into the day room. The Surveyor asked LPN #1 should a cup of medications be on a table unsupervised with residents in the day room? LPN #1 said she gave the resident her morning medications and she does not how the medications got on the table. During interview on 10/4/23 at 11:32 AM, the Director of Nursing (DON) confirmed a cup of medications should not have been left on a table in a secured unit unsupervised. Review on 10/4/23 at 3:18 PM of facility policy titled Administering Medications showed, medications shall be administered in a safe and timely manner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.