Chateau D'ville Rehab and Retirement

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure: 1. A dish towel used for cleaning was contained in sanitation solution when not in use to prevent the risk of cross contamination; 2. The food preparation area was clean and sanitary; 3. Foods were stored in a sanitary manner and in accordance with professional standard of food service safety; 4. A chemical used for cleaning was not stored above items meant for resident consumption; and,5. The drainage pipe of the three-compartment sink was functioning in a sanitary manner.

Inspectors wroteBased on interviews, and record reviews the facility failed to report an allegation of abuse to the State Survey Agency for 1 (Resident #84) of 1 sampled resident investigated for incident and accident documentation and reporting.

Inspectors wroteBased on observations and interviews, the facility failed to: 1. Ensure staff performed hand hygiene while passing ice for 1 (S6Certified Nursing Assistant[CNA]) of 1 (S6CNA) CNAs observed passing ice; and, 2. Ensure hallway linen carts were kept covered for 2 Linen Carts (g, linen cart h) of 3 (linen cart b, linen cart h, linen cart i) linen carts observed.

Inspectors wroteBased on observation, interviews and record review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use for 1 (Treatment Cart A) of 2 (Treatment Cart A, Medication Cart B) medication carts observed for expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Promptly repair the loose toilet fixture (Resident #62); and, 2. Prevent discarded waste and personal protective equipment (PPE) from accumulating in the facility's parking lot. This deficient practice was identified for 1(Resident #62) of 25 (Resident #1, Resident #3, Resident #10, Resident #12, Resident #13, Resident #16, Resident #17, Resident #20, Resident #21, Resident #22, Resident #26, Resident #27, Resident #28, Resident #33, Resident #34, Resident #45, Resident #47, Resident #54, Resident #60, Resident #62, Resident #62, Resident #63, Resident #78, Resident #236, Resident #386) sampled residents observed for environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form from Centers for Medicare and Medicaid Services CMS-10055 were given, explained, and/or signed by residents and/or a resident's responsible party prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 3 (Resident #15, Resident #57, Resident #83) of 3 (Resident #15, Resident #57, Resident #83) sampled residents reviewed for termination of Medicare Part A services.

Inspectors wroteBased on observation and interview, the facility failed to prevent discarded waste and personal protective equipment (PPE) from accumulating around the facility's dumpster for 1 (Dumpster C) of 1 (Dumpster C) dumpsters observed for garbage disposal.

Inspectors wroteBased on observations, interviews, and record review the facility failed to prepare food in a manner to prevent food borne illnesses by failing to discard improperly thawed chicken, preparing the chicken thighs, and placing them in the oven to cook for 76 out of 80 residents who are served/eat food prepared by the facility's kitchen. This deficient practice resulted in an Immediate Jeopardy situation on 02/28/2024 at 8:30 a.m. when an observation revealed multiple chicken thighs were being thawed without the use of running water in the sanitization compartment of the facility's three compartment sink. The Immediate Jeopardy situation continued when an observation on 02/28/2024 at 9:59 a.m. revealed the above mentioned improperly thawed chicken thighs were being baked in the facility's oven to be served to the residents for lunch. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received the appropriate interventions to decrease the risk of falls for 2 (Resident #46 and Resident #79) of the 3 sampled residents (Resident #46, Resident #61, and Resident #79) residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program by: 1.) failed to perform hand hygiene while feeding residents for 4 (Resident #8, Resident #16, Resident #52, and Resident #57) of 6 (Resident #8, Resident #16, Resident #47, Resident #52, Resident #57, and Resident #74) sampled residents observed for dining; 2.) administering crushed medication from an open medication pill crusher pouch that fell on the floor. This practice was observed for 1 (S20Licensed Practical Nurse [LPN]) of 6 (S15LPN, S17LPN, S20LPN, S21LPN, S22LPN, and S23LPN) Licensed Practical Nurses observed during medication administration; 3.) failed to perform proper hand hygiene during urinary catheter care for 1 (Resident #78) of 1 (Resident #78) sampled resident observed for catheter care; [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents were treated with respect and dignity during dining for 2 (Resident #47 and Resident #74) of 6 (Resident #8, Resident #16, Resident #47, Resident #52, Resident #57, and Resident #74) residents observed for dining.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a new diagnosis of Major Depressive Disorder was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #55) of 5 (Resident #3, Resident #15, Resident #40, Resident #55, and Resident #78) sampled residents reviewed for PASARR.

Inspectors wroteBased on observations and interviews, the facility: 1. failed to handle a resident's catheter bag in a manner to prevent urinary tract infections (Resident #78); and 2. failed to ensure staff provided catheter care in a manner to prevent urinary tract infections (Resident #78). This deficient practice was identified for 1 (Resident #78) of 1 sampled residents observed for catheter care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to immediately notify a resident's physician following incidents of resident to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to implement their written policies and procedures for abuse by failing to ensure residents were protected after an allegation of physical abuse for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an alleged violation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to obtain a physician's order prior to transferring a resident to an inpatient psychiatric hospital for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents investigated for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure staff did not transcribe an order that was not obtained from a physician for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse.