Deficiency Records for Highland Chateau Health and Rehabilitation Center
Updated as of August 01, 2024
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Deficiency Records for Highland Chateau Health and Rehabilitation Center
A list of the most recent deficiencies for Highland Chateau Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Highland Chateau Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-06-27 | 2024-07-15 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-06-27 | 2024-07-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-27 | 2024-07-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-27 | 2024-07-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-27 | 2024-07-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-05-15 | 2024-06-17 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-05-15 | 2024-06-17 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-15 | 2024-06-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-15 | 2024-06-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-15 | 2024-06-17 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-15 | 2024-06-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-15 | 2024-06-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-15 | 2024-06-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-15 | 2024-06-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-05-15 | 2024-06-17 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-05-15 | 2024-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-15 | 2024-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-15 | 2024-06-17 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-05-15 | 2024-06-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-05-15 | 2024-06-07 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-08 | 2024-04-23 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-02-02 | 2024-03-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-13 | 2024-03-01 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-02-02 | 2024-02-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-01-25 | 2024-01-24 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-06 | 2023-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-06 | 2023-07-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-07 | 2023-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-06-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-06 | 2023-05-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-06 | 2023-05-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-04-06 | 2023-05-13 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-04-06 | 2023-05-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-06 | 2023-05-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-04-06 | 2023-05-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-06 | 2023-05-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-06 | 2023-05-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-06 | 2023-05-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-06 | 2023-05-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-06 | 2023-05-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-06 | 2023-05-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-06 | 2023-05-12 | N |
| Post nurse staffing information every day. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-06 | 2023-05-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-04-06 | 2023-05-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-04-06 | 2023-05-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-06 | 2023-05-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-06 | 2023-05-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-06 | 2023-05-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-08 | 2023-03-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-03-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-23 | 2023-03-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-03-27 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-23 | 2023-03-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-23 | 2023-03-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-23 | 2023-03-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-23 | 2023-03-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-23 | 2023-03-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-20 | 2023-02-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-20 | 2023-02-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-20 | 2023-02-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-15 | 2022-11-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-15 | 2022-11-30 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-11-15 | 2022-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-23 | 2022-10-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-23 | 2022-10-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-23 | 2022-10-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-23 | 2022-10-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-23 | 2022-10-17 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-09-23 | 2022-10-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-02 | 2022-08-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-02 | 2022-08-22 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-07-05 | 2022-07-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-17 | 2022-04-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-17 | 2022-04-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-17 | 2022-04-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-17 | 2022-04-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-04-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-17 | 2022-04-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-17 | 2022-04-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-17 | 2022-04-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-04-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-17 | 2022-04-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-17 | 2022-04-12 | N |
| Have policies on smoking. | Health | 2022-03-17 | 2022-04-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-17 | 2022-04-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-17 | 2022-04-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-17 | 2022-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-17 | 2022-04-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-17 | 2022-04-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-17 | 2022-04-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-17 | 2022-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-17 | 2022-04-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-04 | 2022-03-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-12 | 2022-02-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-02-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-18 | 2021-12-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-18 | 2021-12-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-03 | 2021-12-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-12-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-03 | 2021-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-05 | 2021-09-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-05 | 2021-09-10 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-05 | 2021-09-10 | Y |
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