Deficiency Records for Highland Chateau Health and Rehabilitation Center
Updated as of April 01, 2024
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? |
---|---|---|---|---|
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 |
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 |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-05 | 2021-09-29 | N |
Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-09-29 | 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 | 2021-08-05 | 2021-09-10 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-05 | 2021-09-10 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-08-05 | 2021-09-10 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-08-05 | 2021-09-10 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-05 | 2021-09-10 | 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 | 2021-08-05 | 2021-09-10 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-09-10 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-05 | 2021-09-10 | 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 | 2021-08-05 | 2021-09-10 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-05 | 2021-09-10 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-09-10 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-05 | 2021-09-10 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-05 | 2021-09-10 | N |
Ensure that residents are free from significant medication errors. | Health | 2021-08-05 | 2021-09-10 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-05 | 2021-09-10 | N |
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 |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Create arrangements with other facilities to receive patients. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Provide emergency officials' contact information. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Establish staff and initial training requirements. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-09 | 2021-08-10 | Y |
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2021-07-09 | 2021-08-10 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-08 | 2021-05-10 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-05-10 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-01 | 2021-05-10 | Y |
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 | 2021-04-01 | 2021-05-10 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-04-01 | 2021-05-10 | Y |