Highland Chateau Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the walk-in cooler remained functional and in good repair which had the potential to affect all 44 residents who received perishable food from the kitchen. In addition, the facility failed to maintain safe working air temperatures in the kitchen which had the potential to affect 2 of 2 shifts daily/ 6 of 6 staff members working per day. Findings Include: On 6/10/26 at 4:30 p.m., cook-A was observed reading the temperature inside the walk-in cooler in the main kitchen. The thermometer read at 50 F. Cook-A stated the walk-in cooler was currently broken down and had periodically broken down, particularly during the last few weeks which has caused the temperatures to be too high. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain comfortable temperatures for 4 of 10 residents reviewed (R2, R4, R5 and R6), which had to potential to affect all 44 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure preferences for clothing and getting out of bed were honored and implemented for 1 of 1 resident (R46) reviewed for choices.

Inspectors wroteBased on interview and document review, the facility failed to provide notification of discharge to family/representative for 1 of 2 residents (R57) reviewed for discharge. In addition, the facility failed to promptly notify the provider of low blood pressure and medication errors occurring for 1 of 1 resident (R1) reviewed for physician notification of change.

Inspectors wroteBased on observation, interview and document review the facility failed to monitor for resident specific target behaviors related to antipsychotic medications use for 1 of 4 residents (R3) reviewed for antipsychotic medications.

Inspectors wroteBased on interview and document review, the facility failed to sufficiently prepare for discharge 1 of 2 residents (R57) reviewed for discharge. R57 was sent home without sufficient home care services, which led to emergency services assisting her twice and resulting in transfer to the emergency department and hospital readmission.

Inspectors wroteBased on interview and document review the facility failed to ensure appropriate discharge documentation was in the medical record for 1 of 2 residents (R57) reviewed for discharge. R57's medical record was missing a recapitulation of stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication (both prescribed and over the counter medications).

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive care plan including pain interventions, had been developed for 1 of 5 residents (R48) reviewed for medications.

Inspectors wroteBased on interview, and document review, the facility failed to provide the opportunity to attend and participate in a care conference for 1 of 1 residents (R2) reviewed for care conferences.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., shaving) were completed for 1 of 1 resident (R3) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 2 resident (R46) reviewed for activities.

Inspectors wroteBased on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complications for 1 of 1 resident (R4) reviewed for dialysis care. In addition, the facility failed to ensure adequate weight monitoring was implemented for 1 of 1 resident (R4) reviewed for dialysis.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure provider orders for weekly weights were implemented and maintained for 1 of 5 residents (R33) reviewed for unnecessary medication. In addition, the facility failed to ensure non-pharmacological interventions were attempted and recorded before administration of as-needed (PRN) pain medication to reduce the risk of potential complications for 2 of 3 residents (R2, R27) reviewed for pain management.

Inspectors wroteBased on interview and document review, the facility failed to ensure antihypertensive (blood pressure) medication were administered or held per physician orders for 1 of 1 resident (R1) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure provider's orders for urinalysis were completed for 1 of 2 residents (R57) reviewed for discharge.

Inspectors wroteBased on interview and document review, the facility failed to ensure identified dental concerns (i.e., broken missing teeth, need for appointment) were acted upon and, if needed, referred to the appropriate resource in a timely manner for 1 of 1 resident (R2) reviewed who voiced dental complaints during the survey.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure identified preferences for menu selection were honored for 1 of 3 residents (R27) reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and implement individualized interventions to ensure safe independent community access for 1 of 3 residents (R1) who had expressive aphasia and cognitive impairment and went on community outings independently placing R1 at risk for inability to effectively communicate needs or obtain assistance while unsupervised in the community.

Inspectors wroteThe facility failed to ensure appropriate interventions to prevent elopement for 1 of 3 residents (R1) who was assessed to be an elopement risk. This resulted in an Immediate Jeopardy (IJ) when R1 was able to leave the facility, get on a city bus where she was found three hours and 15 minutes later at the Mall of America (5.8 miles away). The immediate jeopardy began on 2/10/26 at approximately 2:30 p.m. when R1 was able to leave the facility after demonstrating exit seeking behaviors without appropriate individualized interventions to prevent elopement. The immediate jeopardy was identified on 2/13/26, and the administrator and director of nursing were notified of the immediate jeopardy at 2/13/26 at 4:10 p.m. The immediate jeopardy was removed on 2/10/26, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the contents of a 30-day discharge notice included the correct information for 2 of 2 residents (R2, R7) reviewed for admission/discharge.

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis following the exit of the former DON. This practice had the potential to affect all 54 residents who resided at the facility.

Inspectors wroteBased on interview and record review the facility failed to revise R1's care plan after a change occurred for 1 of 3 residents reviewed for care plan development and implementation. R1's care plan was not revised to include increased needs in cares for home exercise program dated 9/11/25 by physical therapy (PT), for R1's comprehensive assessment dated [DATE] for maximum assistance in some of her ADL's, and to restart therapy on 11/18/25.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure smoking safety interventions were identified, implemented, and monitored for 1 of 1 resident (R29) reviewed who used oxygen and smoked. The facility also failed to provide adequate supervision to ensure oxygen was not taken into the designated smoking area, which resulted in an immediate jeopardy (IJ) when R29, who had oxygen present and was observed smoking and in close proximity to others who were smoking and present in the smoking patio, which posed a serious safety risk of fire or explosion and endangering R29 and others. The IJ began on 9/15/25 at 6:46 p.m., when R29 was observed on the outdoor smoking patio with a portal oxygen tank and in close proximity to other residents smoking. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure metal pans were clean and dry before storing. In addition, the facility failed to monitor dish machine temperatures to ensure dishes were properly cleaned and sanitized. Further, the facility failed to ensure food temperatures were documented at the time of meal service. In addition, the facility failed to follow manufacturer's instructions for cleaning and sanitizing 2 of 2 ice machines used for resident consumption. This had the potential to affect all 42 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys in regards to quality of care, accuracy of assessments, activities of daily living (ADL) care provided, accidents, nutrition, tube feeding, sufficient nursing staff, food procurement, infection prevention and control and pest control, and were also identified during this survey. Additionally, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas, identified thorough and appropriate data collection, analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 42 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure glucometer was cleaned per manufactures guideline for 1 of 1 resident (R9) observed for blood glucose testing, ensure enhanced barrier precautions (EBP) were followed for 2 of 2 residents (R26 and R41) observed for enhanced barrier precautions, ensure 1 of 1 resident (R26) had a clean water cup in place. In addition, the facility failed to ensure resident lift equipment was cleaned per manufactures guidelines, and a comprehensive Legionella prevention plan was in place. This had the potential to affect all residents who reside in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement an effective pest control program to eliminate mice in the building. In addition, concerns related to pest control in the facility were voiced by 4 of 4 residents (R3, R36, R10, R14). This failure had the potential to affect all 42 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents were assessed for safe self-medication administration for 4 of 4 residents (R14, R37, R13, R1) who had medications at the bedside.

Inspectors wroteBased on observation, interview, and record review the facility failed to have sufficient staff available to provide nursing and related services to meet the residents' needs in a manner that promotes each resident's right to physical, mental, and psychosocial well-being for 10 of 10 residents reviewed for sufficient staffing (R4, R53, R11, R18, R5, R3, R29, R37, R43, R23).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 4 residents (R23) reviewed for dignified care, was provided toileting assistance in a timely manner.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a homelike environment for 1 of 1 resident (R2) who had feeding tube formula hooked up to the feeding tube pump in R2's room after the feeding tube was removed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately for 2 of 2 residents (R14, R37) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure the care plan included management and monitoring of an antipsychotic medication for 1 of 2 residents (R2) reviewed for antipsychotic use.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure care plans were revised and updated with current health status for 3 of 4 residents (R4, R27, R13) reviewed for care planning.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure activities of daily living (ADL) assistance was provided for 1 of 1 resident (R27) reviewed for ADLs who required supervision and cueing during meals.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide ADL (activities of daily living) care to 1 of 1 resident (R14) reviewed for ADLs and who was dependent upon staff for bathing.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure wound care orders were implemented for 2 of 2 residents (R13, R26) who had venous ulcers (skin openings caused by weak blood circulation), failed to ensure provider-ordered leg measurements were completed and documented for 1 of 1 resident (R29) reviewed for edema management, and failed to obtain a weight upon admission and follow orders for 1 of 3 residents (R46) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a palm brace was used for 1 of 1 resident (R27) reviewed for range of motion.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a nutritional supplement was ordered and implemented per the dietician recommendation for 1 of 1 resident (R3) reviewed for food.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow physician orders to provide appropriate gastrostomy/jejunostomy (GJ Tube) tube feeding (TF) solution and to use appropriate tube to administer medication for 1 of 1 resident (R41) reviewed for tube feeding administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure continuous positive airway pressure (CPAP) therapy was used in accordance with physician orders to meet the individual needs for 1 of 3 residents (R6) reviewed for respiratory care and services.

Inspectors wroteBased on observation, interview and document review, and staff interview, the facility failed to ensure provider-ordered pain medications were administered for 1 of 3 residents (R29) reviewed for pain management.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure ongoing assessment of resident's condition and monitoring for complications before and after dialysis treatments and failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 resident (R4) reviewed for dialysis services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a medication error rate of less than 5 percent (%). 3 medication errors occurred out of 35 opportunities resulting in an error rate of 8.57% for 2 of 5 residents (R41, R19) observed during medication administration.

Inspectors wroteBased on interview and document review, the facility failed to ensure antibiotics were administered as prescribed for 1 of 1 resident (R13) reviewed for infection, thus leading to a significant medication error.

Inspectors wroteBased on interview, observation and document review, the facility failed to timely refer 1 of 2 residents (R27) to dental services reviewed for dental services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a diet as ordered for 1 of 1 resident (R27) reviewed for correct diet textures.

Inspectors wroteBased on interview and document review, the facility failed to ensure their antibiotic stewardship program was implemented for 1 of 1 resident (R13) who was taking an antibiotic.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R6 and R35) were offered, educated on risks and benefits and administered or refused the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on interview and document review, the facility failed to appropriately monitor and comprehensively assess complaints of pain for 1 of 3 residents (R1) reviewed for pain management. Additionally, the facility failed to assess or monitor blood glucose levels and for 1 of 1 resident (R1) reviewed with blood glucose monitoring. R1 complained of pain rated as 9/10 (pain that is extremely severe or excruciating) four assessments in a row, was not administered pain medication as ordered, and R1 waited approximately 9 hours for prescribed pain medication. This resulted in harm when R1 called 911 for himself, and returned to the hospital for pain management, assessment, and monitoring.

Inspectors wroteBased on interview and document review, the facility failed to ensure oxycodone hydrochloride (HCL, a narcotic pain medication used to treat moderate to severe pain) was administered per physician orders for 1 of 3 residents (R1) reviewed for pain management.

Inspectors wroteFacility Resident Call System policy dated 3/5/25, indicated calls for assistance were answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. Call light response times were reviewed as part of the QAPI program. Based on observation, interview, and document review, the facility failed to provide sufficient staffing and/or oversight of non-licensed nursing staff to ensure 7 of 7 residents (R16, R37, R12, R38, R8, R4, R21) received care and assistance as needed and in a timely manner. These deficient practices had the potential to affect all 47 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure employed and agency nursing assistants (NA's) received appropriate orientation, training and supervision. In addition, the facility failed to ensure 2 of 5 nursing assistants (NA-A and NA-C) received and demonstrated required competency skills for resident cares. Further, NA-C had not completed all in-service trainings upon hire. This had potential to affect all 47 residents who resided in the facility.

Inspectors wroteBased on interview and document review the facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service, which had the potential to affect 44 of 44 residents who received food from the kitchen.

Inspectors wroteDuring an interview on 4/24/25 at 1:44 p.m., the director of nursing (DON) was informed of the dead mouse finding and stated the facility had not had a mouse sighting in over 90 days or longer but would put a plan in place. Facility Pest Control policy dated 9/6/23, indicated on-going measures are taken to prevent, contain and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice and rats. General measures to decrease pests include elimination of cracks and crevices, proper lighting and ventilation, use of screen on windows and doors, and the use of self-closing doors. All food stored in the dietary area is kept in a designated area in securely covered containers, is off the floor and away from walls. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure kitchen food items were labeled and dated, scoops were not stored in the dry bins, opened foods were properly wrapped or stored, outside food containers were cleaned. In addition the facility failed to ensure resident meals brought from outside were labeled and dated in the 1 of 1 kitchenettes. This had the potential to affect all residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide a dignified experience for 2 of 2 residents (R30 and R1) who did not have clothing to wear and were spoken to in an undignified manner by staff.

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification to a family member for change of condition and hospitalization for 1 of 1 resident (R22) reviewed for change in condition.

Inspectors wroteBased on observation, interview, and document review the facility failed to investigate a report of missing clothing for 1 of 1 resident (R30) who reported missing clothing items to nursing staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 1 of 2 residents (R16) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to offer/provide a summary of the baseline care plan to the resident and/or resident's representative for 1 of 1 resident (R36) reviewed for baseline care plan.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed and maintained for 2 of 2 residents reviewed, (R7) who was assessed for facility acquired pressure ulcers and (R4) for respiratory cares.

Inspectors wroteR31's face sheet received on 4/24/25, included diagnoses of left below the knee amputation, diabetes, protein calorie malnutrition, and depression. R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 was cognitively intact, had clear speech, could understand and be understood. R31 was able to transfer from bed to wheelchair independently and self-propel wheelchair throughout the facility. R31's care plan with revised date of 1/7/25, indicated R31's preferences would be considered when providing care. During an interview on 4/22/25 at 9:42 a.m., R31 stated she did not recall having had a care conference. A care conference was explained to her, and she still did not recall having had one. During an interview on 4/23/25 at 12:19 p.m., social services (SS)-A stated care conferences were conducted quarterly, as needed, or at family or resident request. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R22) reviewed for activities of daily living (ADLs) who was dependent on staff for his care.

Inspectors wroteBased on observation, interview and document review, the facility failed to properly transcribe and implement physician orders for a resident requiring edema and surgical incision monitoring for 1 of 1 resident (R36) reviewed for edema and skin conditions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement interventions to prevent the development of new pressure ulcers for 1 of 3 residents (R7) who were reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility was unaware of and failed to comprehensively assess a resident for safe vaping practices for 1 of 1 resident (R37) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to have a comprehensive incontinence care plan and provide timely assistance with toileting for 1 of 1 resident (R21) reviewed for bladder incontinence.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R46) reviewed for nutrition and weight loss had received ice cream to increase calorie intake and weight per provider order.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure staff provided cares according to standard of practice for gastrostomy tube care for 1 of 1 resident (R22) reviewed for tube feeding.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure non-invasive ventilator (uses positive pressure to increase lung volume and decrease work of breathing, and allows for support of breathing without breathing tube) was used in accordance with physician orders to meet the individual needs for 1 of 1 resident (R4) reviewed for respiratory care and services. In addition, the facility failed to have an oxygen administration order for R4 who was on continuous oxygen.

Inspectors wroteBased on observation and interview, the facility failed to maintain safe storage of medications when over the counter stock medications were left unlocked and unattended in an office.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure identified preferences for menu selection were honored for 1 of 1 resident (R16) reviewed for choices.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide water, consistent with the resident needs and preferences, and sufficient to maintain hydration for 1 of 1 resident (R31) reviewed for hydration. In addition, 2 of 2 resident (R18 and R33) voiced concern of not receiving clean water mugs.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (R22) reviewed for EBP. In addition, facility failed to ensure proper use of gloves while providing personal cares for 1 of 1 resident (22) observed for personal cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident call lights were functioning for 1 of 1 resident (R31) reviewed for call lights.

Inspectors wroteBased on interview and document review, the facility failed to ensure mail was delivered to residents on Saturdays for 4 of 4 residents (R16, R47, R32, R42) who attended the resident council meeting, who verbally confirmed mail was not delivered on Saturdays. This had the potential to affect all 47 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to complete annual performance reviews for 2 of 5 nursing assistants (NA-A, NA-B) whose employee files were reviewed. This had the potential to affect all 47 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to include residents bathing preferences and bathing in the care plan for 2 of the 3 residents (R1, R3).

Inspectors wroteBased on observation, interview, and record review the facility failed to complete at a minimum, weekly baths/showers for residents for 2 of 3 residents (R1, R2) which resulted in the residents not being bathed for an extended time period.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the residents' rights to be free from neglect when the facility did not provide care, comfort, and safety. This resulted in immediate jeopardy (IJ) for 3 of 4 residents (R1, R2, R3) who experience mental anguish, and emotional distress when care and services were not provided to assist these dependent residents to get out of bed. In addition, the facility failed to provide care and services for R5 who was dependent on staff to get out of bed. The immediate jeopardy began on 2/28/25, when the facility failed to provide care, comfort, and safety. This resulted in mental anguish, and emotional distress when care and services were not provided to R1, R2, and R3 to get out of bed. These residents were dependent on staff for bed mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to update their facility assessment when they no longer provided restorative nursing (continuous specialized approach in nursing care to maintain and improve physical and emotional wellbeing of individuals who have experienced a decline in function abilities) at the facility. Two of two residents (R1 and R2) had the potential to benefit from restorative nursing. This failure had the potential to affect all 56 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the Medical Director (MD) assisted in the implementation and guidance of resident care policies, coordination, and admission of three bariatric residents (body weight greater than 100 poiunds (lbs.) of ideal body weight) residents (R1, R2 and R3). The facility was unable to safely manage these residents due to lack of guidance upon admission and provided cares received at the facility. This had the potential to affect all 56 residets who resided at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to try alternative devices before using bedrails on resident's beds for 5 of 5 residents (R1, R2, R3, R6, & R7) when the facility failed to accurately assess the resident for risk of entrapment by assessing residents' medical diagnoses, height and weight, cognition, communication, mobility, and risk of falling. In addition, the facility failed to provide ongoing assessments to assure the bedrail was used to meet the resident's needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan. The care plans for 3 of 3 residents (R1, R2, and R3) failed to indicate specifically which mechanical lift and sling was to be used during transfers. In addition R3 had conflicting information on his care plan of how he was to transfer out of his bed.

Inspectors wroteBased on interview, and record review the facility failed to carry out activities for 1 of 3 (R3) dependent residents reviewed for assistance with activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to support the facility-sponsored and individual activities for residents preference to support their physical, mental and psychosocial well-being for 3 of 3 residents (R1, R2, & R3) who were dependent on staff for activities.

Inspectors wroteBased on interview and record review the facility failed to weigh residents per their standing order guidelines for 2 of 3 residents (R1 and R2) reviewed for weekly weights.

Inspectors wroteBased on observation, interview, and document review, the facility failed to perform an assessment for self-administration of medications (SAM), and failed to perform Interdisciplinary Team (IDT) review for SAM for 1 of 3 residents (R5) reviewed for accurate medication administration, who kept an antiseizure medication locked in her bedside table and self-administered the medication twice daily without staff oversight.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure adequate staffing to answer call lights timely for 3 of 3 residents (R2, R3, R4) reviewed for call lights. In addition, the facility failed to provide adequate staffing to ensure scheduled baths were provided to residents who required assistance from staff for activities of daily living (ADLs).

Inspectors wroteBased on interview and document review, the facility failed assess and determine safety for 1 of 1 resident (R3) reviewed for self-administration of medication.

Inspectors wroteBased on interview and document review, the facility failed to develop a baseline care plan for 2 of 3 residents (R1, R3) reviewed for wounds, pain, and respiratory concerns.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess and monitor 2 of 3 residents (R1, R3) reviewed for monitoring.

Inspectors wroteBased on interview and document review, the facility failed to properly assess and obtain orders for 1 of 1 residents (R1) receiving oxygen therapy.

Inspectors wroteBased on observation, interview and document review, the facility failed to accurately obtain blood pressure reading prior to administering blood pressure medication per provider orders for 1 of 1 resident (R3) reviewed for medication administration in accordance with physician instructions.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring of hypertension for one of one resident (R1) reviewed for quality of care. R1 had a history of hypertension and an order for Hydralazine as needed for a systolic blood pressure 140 or greater but the facility failed to monitor R1's blood pressure.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate pest control when surveyor observed three mice in the building during survey. This had the ability to affect all sixty-seven residents in the building.

Inspectors wroteBased on interview and document review the facility failed to develop a comprehensive care plan with appropriate services, treatments, and prevention interventions and reevaluation of intervention effectiveness for substance use disorders for 1 of 1 resident (R5) reviewed for behavioral health needs. R5's care plan lacked person-centered planning identifying mental health stressors, an interdisciplinary approach to care, and meaningful activities to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. In addition, R5 had falls related to alcohol use while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were trained to appropriately to respond to a residents need of an active substance use disorder and to address a history of trauma for 1 of 1 resident (R5) reviewed for behavioral health needs. The facility assessment identified the ability to serve residents with mental health disorders and staff did not have appropriate competencies and skills sets to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on interview and document review, the facility failed to follow dietary orders for a resident who was NPO (nothing by mouth) for 1 of 3 residents (R1) reviewed for diet modifications. This resulted in an immediate jeopardy (IJ) when R1 received a regular textured meal on 1/23/24, which caused R1 to choke, lose consciousness, require the Heimlich maneuver, cardiopulmonary resuscitation (CPR), and resulted in death. The facility immediately implemented corrective action so the deficient practice was issued at past non-compliance. The IJ began on 1/23/24, when R1 received a regular textured meal, which caused R1 to choke, lose consciousness, require the Heimlich maneuver, CPR, and died as a result of choking. The administrator was notified of the past non-compliance IJ on 1/25/24, at 1:29 p.m. [...]