Chateau Nrsg & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess a resident for post-fall complications, including failing to identify worsening acute pain and failing to obtain timely diagnostics. This failure resulted in a resident receiving delayed care for his left hip fracture. This applies to 1 of 3 residents (R1) reviewed for quality of care in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a timely hip X-ray was obtained for a resident after a fall. This applies to 1 of 3 residents (R1) reviewed for diagnostic services in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a resident from falling off the bed during care resulting in R1 sustaining a femur fracture. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure fall interventions were in place for a resident who is at high risk for falls for 1 of 4 residents (R1) reviewed for safety in the sample of 6. This failure resulted in R1 falling out of bed and sustaining a laceration to her forehead requiring stitches.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse prevention policy by not protecting a resident from verbal abuse from staff. This applies to 1 of 3 residents (R1) reviewed for verbal Abuse in a sample of 3.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse prevention policy by not reporting a verbal abuse allegation to state agency. This applies to 1 of 3 residents (R1) reviewed for abuse reporting in a sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a personal mail with a gift check was given to the resident whom it was addressed to, and not deposited to the transferring account intended for payment of the resident's room and board. This applies to 1 of 3 residents (R1) reviewed for personal funds in the sample of 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in a sanitary manner. This has the potential to affect all 116 residents that receive food prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 4 of 5 residents (R20, R85, R100 and R108) reviewed for ADLs (activities of daily living) in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the dietary staff followed the approved recipe for chef salad. This applies to 8 of 8 (R25, R26, R27, R6, R84, R91, R101, R113) residents reviewed for dining in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care. This applies to 5 of 25 (R20, R62, R64, R80, R85) residents reviewed for infection control in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the indwelling urinary catheter was not positioned above the resident's bladder and failed to clean the catheter tube during incontinence care. This applies to 2 of 4 (R64 and R80) residents reviewed for peri-care and catheter care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check the placement of the gastrostomy tube (g-tube) prior to administration of medication. This applies to 1 of 2 residents (R80) reviewed for gastrostomy tube in the sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize, evaluate and manage a resident's pain during care. This applies to 1 of 1 resident (R24) reviewed for pain management in the sample of 25.

Inspectors wroteBased on interview and record review the facility failed to provide residents residing in the facility both orally and in writing of their resident rights. This applies to 7 of 10 residents (R1, R17, R25, R34, R53, R75, R101) reviewed for resident rights in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care for 2 of 5 residents (R1 and R2) reviewed for activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed keep call lights accessible to dependent residents. This applies to 7 of 7 residents (R23, R28, R38, R41, R83, R91, and R103) reviewed for accommodation of needs in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinent care, facial hair grooming, and nail trimming/grooming to dependent residents. This applies to 5 of 7 residents (R6, R36, R41, R58, and R103) reviewed for activities of daily living (ADL) in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise residents with aspiration precautions during meals, failed to implement fall interventions, failed to secure oxygen tanks in resident rooms, failed to safely position a resident during incontinence care, and failed to safely transfer residents. This applies to 12 of 12 residents (R2, R8, R14, R24, R33, R43, R50, R55, R70, R80, R91, and R99) reviewed for accidents and supervision in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered routes or per the schedule). There were 29 opportunities with 7 errors resulting in a 24.1% error rate. This applies to 4 of 4 residents (R51, R24, R43, R16) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: label and date resident food, remove expired food items, complete temperature logs, and keep thermometers inside resident personal refrigerators. This applies to 11 of 11 residents (R29, R34, R35, R41, R43, R50, R51, R52, R80, R110, R112) reviewed for personal room refrigerators.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents with eating their meals in a dignified manner. This applies to 2 of 2 residents (R50 and R66) reviewed for dignity in a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Physician Order Sheet concurred with a resident's most recent POLST (Practitioner Order for Life-Sustaining Treatment) form. This applies to 1 of 6 residents (R74) reviewed for advanced directives in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that hand soap is always available for hand washing. In addition, the facility also failed to follow standard infection control practices related to hand hygiene and gloving during provisions of wound care. This applies to 6 residents (R1, R3, R4, R5, R6, R7) reviewed for infection control in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and comfortable environment. This applies to 2 of 5 residents (R1, R8) reviewed for clean and comfortable environment in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify areas of pressure before becoming unstageable and failed to change the dressings as ordered by the Physician. This applies to three of eight residents (R49, R38, R81) in the sample of 24 reviewed for pressure. This failure resulted in two residents (R49) and (R38) developing unstageable pressure injuries.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to ensure there was sufficient staffing available to meet the needs and safety of the residents in the facility. This failure has the potential to affect all 110 residents residing in the facility.

Inspectors wroteBased on the observation, interview, and record review the facility failed to ensure freezer temperatures were maintained below zero degrees Fahrenheit and failed to ensure expired food and water were discarded. This has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) into a COVID positive residents (R99) room per Centers for Disease Control (CDC) guidelines and failed to perform hand hygiene to prevent the spread of COVID-19. These failures have a potential to affect all residents in the building.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life for 1 of 1 (R21) residents reviewed for resident rights in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's privacy during wound care for 1 of 1 resident (R36) reviewed for privacy in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet resident incontinent needs for one of one resident (R23) reviewed for activities of daily living in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform dressing changes per physician's orders for one of one resident (R205) reviewed for non-pressure wounds in the sample of 24.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to ensure the resident received respiratory care and services that is in accordance with professional standards of practice for 1 of 1 (R21) resident reviewed for oxygen therapy in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 21 opportunities with 4 errors resulting in a 19.04 % error rate. This applies to 1 of 5 residents (R55) observed in the medication pass.