Inspection Reports for Highland Chateau Health + Rehabilitation Clinic

The facility failed to revise a resident's care plan after significant changes in condition and therapy orders, and failed to designate a registered nurse as the full-time director of nursing following the former DON's departure. These deficiencies posed minimal harm or potential for actual harm to residents.

The facility had multiple deficiencies including failure to provide timely toileting assistance, incomplete assessments for self-medication administration, inadequate care planning and monitoring of antipsychotic medication, failure to provide scheduled showers and ADL assistance, incomplete wound care implementation, failure to monitor leg measurements and weights, unsafe smoking practices with oxygen use, failure to provide ordered nutritional supplements, improper tube feeding administration, inadequate dialysis care communication, insufficient staffing leading to delayed call light responses, medication errors, improper food handling and sanitation, infection control lapses, delayed dental referrals, diet order noncompliance, and ineffective pest control program.

The complaint investigation was substantiated by observations, interviews with 4 residents who reported seeing mice, and staff reports of mice sightings and droppings. The pest control service acknowledged ongoing issues and stated mice could only be controlled, not eliminated.

The facility failed to implement an effective pest control program to eliminate mice, with multiple residents and staff reporting sightings. Despite weekly pest control visits and documented sightings, mice continued to be present in resident rooms and common areas, posing a potential health risk.

The complaint investigation found that resident R1 experienced severe pain rated 9/10 multiple times without timely administration of pain medication, waited approximately 9 hours for prescribed pain medication, and called 911 due to inadequate pain management. Blood glucose levels were not monitored as ordered. Medication errors with oxycodone dosing were identified, including administration of doses closer than ordered and failure to reorder medications timely.

The facility failed to appropriately monitor and assess pain complaints and blood glucose levels for resident R1, resulting in actual harm. R1 experienced severe pain without timely administration of prescribed pain medication, leading to a hospital visit. Additionally, blood glucose monitoring was delayed despite orders. Medication administration errors related to oxycodone dosing were also identified.

The facility was found deficient in multiple areas including resident dignity and rights, mail delivery, notification of family for change in condition, investigation of missing clothing, MDS accuracy, baseline care planning, comprehensive care planning, personal hygiene care, medication order implementation, respiratory care, staffing adequacy, infection control, food and nutrition services, pest control, and call light response.

The complaint investigation included reports of residents being scolded by staff, missing clothing items not being addressed, non-functioning call lights, and pest control issues with mice sightings and food storage concerns. Some grievances were not properly followed up or documented.

The facility failed to provide a dignified experience for residents, did not investigate missing clothing reports, had non-functioning call lights for a resident, and failed to maintain an effective pest control program resulting in mice sightings and food storage issues.

The facility failed to include bathing preferences and required assistance levels in care plans for 2 of 3 residents (R1, R3). Additionally, the facility failed to complete weekly baths/showers for 2 of 3 residents (R1, R2), resulting in extended periods without bathing. Documentation of bathing was incomplete or missing for these residents.

The complaint investigation found immediate jeopardy due to neglect in care and assistance for dependent residents to get out of bed, with emotional distress and mental anguish reported. The immediate jeopardy was removed after corrective actions, but lower level noncompliance remained.

The facility failed to protect residents from neglect, particularly in assisting dependent residents to get out of bed, resulting in immediate jeopardy for three residents. Care plans lacked specific instructions for mechanical lifts and slings. Residents were not weighed as ordered, did not receive required bathing assistance, and were not supported in activities. The facility also failed to properly assess and manage bed rail use. The Medical Director was not involved in admission decisions or care coordination for bariatric residents.

The complaint investigation found substantiated issues with medication self-administration oversight and staffing shortages leading to delayed call light responses and missed resident baths.

The facility failed to perform assessments and interdisciplinary team reviews for self-administration of medications for one resident, resulting in unsupervised medication use. Additionally, the facility failed to ensure adequate staffing to answer call lights timely and provide scheduled baths for residents requiring assistance.

The visit was complaint-related, focusing on medication self-administration safety, baseline care planning, monitoring of vital signs and wounds, respiratory care orders, and medication administration accuracy. The complaint was substantiated with findings of minimal harm or potential for harm.

The facility failed to properly assess and determine safety for medication self-administration, develop baseline care plans within 48 hours for residents, adequately monitor vital signs and wounds, obtain proper orders for oxygen therapy, and accurately obtain blood pressure readings prior to administering blood pressure medication, resulting in potential harm to residents.

The facility was found deficient in multiple areas including medication self-administration assessment, access to survey results, investigation of abuse allegations, accuracy of resident assessments, baseline care planning, care conferences, discharge planning, communication interventions for hearing-impaired residents, wound care, assistive device safety, nutritional supplementation, dialysis care coordination, medication management, medication storage, infection prevention and control, vaccination administration, and provision of snacks.

The facility failed to ensure proper monitoring of blood pressure for one resident with hypertension despite multiple physician orders for blood pressure checks and medication administration. The facility policy did not address as-needed medication administration, and the assistant director of nursing confirmed the lack of monitoring.

The facility failed to ensure adequate pest control as surveyors observed three mice in various locations during the survey. Multiple residents and staff reported ongoing issues with mice, and pest control treatments were deemed ineffective. The facility lacked a pest control policy and procedure.

The complaint investigation focused on R5's behavioral health needs related to alcohol abuse and substance use disorder. The facility was found to have failed in providing adequate care planning, monitoring, and staff training to manage R5's condition. The resident was found consuming alcohol in the facility, with multiple incidents of intoxication and falls. Staff were unaware of policies and protocols to manage alcohol use and withdrawal. The facility lacked individualized behavioral health interventions and psychosocial support.

The facility failed to develop a comprehensive, person-centered care plan for R5 addressing substance use disorder, behavioral health needs, and psychosocial wellbeing. Staff lacked training and competencies to manage alcohol dependency and withdrawal, and there were multiple incidents of R5 consuming alcohol in the facility without proper monitoring or intervention. The facility policy on alcohol administration was not properly followed, and staff were unaware of protocols such as CIWA for withdrawal assessment.

The complaint investigation found that on 1/23/24, R1, who was NPO due to severe dysphagia, was mistakenly given a regular meal tray. Staff interviews revealed lack of communication and failure to check meal tickets. The incident led to R1 choking, requiring Heimlich maneuver, CPR, and ultimately death. The facility acknowledged the error and implemented corrective actions promptly.

The facility failed to follow dietary orders for a resident who was NPO, leading to immediate jeopardy when the resident received an incorrect meal and subsequently died from choking. The facility implemented immediate corrective actions including staff re-education, revised plating processes, and audits to ensure compliance.

The complaint investigation found a physical altercation between residents R1 and R2 on 5/28/23. R2 denied the altercation during a follow-up interview. Staff interviews confirmed the incident and described interventions taken, including 30-minute checks to prevent contact. The director of nursing acknowledged care plan gaps and staff education efforts.

The facility failed to ensure residents were free from abuse when R1 physically assaulted R2 in the elevator. The investigation found that care plans did not include directions to keep R1 and R2 apart, and staff were unable to prevent the altercation despite interventions. The facility policy on resident-to-resident altercations was reviewed, and staff education was noted.

The investigation was complaint-related, focusing on bathing, grooming, skin assessments, and wound care. The complaint was substantiated as deficiencies were found in care provision and documentation.

The facility failed to ensure proper bathing and grooming for one resident, failed to complete weekly skin assessments for two residents, and failed to assess and provide appropriate wound care for one resident. Documentation and physician notification were also lacking.

The investigation was complaint-driven, triggered by concerns about resident R2's dignity, care, environment, falls, nutrition, and pain management. The resident and family reported neglect and inadequate care, including untreated pain, frequent falls, poor hygiene, and unsafe living conditions.

The facility failed to provide adequate care and a safe, clean environment for resident R2, including failure to maintain dignity, develop person-centered care plans, manage activities of daily living, prevent falls, assess and monitor nutrition and weight loss, manage pain appropriately, and maintain a clean and safe living environment. Multiple deficiencies were documented related to neglect, inadequate care planning, and environmental hazards.