Chateau NRSG & Rehab Center

In the surveyor’s words

From the most serious findings on record at Chateau NRSG & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 27, 2026

  Based 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. The findings include:R1's 2/17/26 progress note from 5:30 AM showed R1 .was noted on the floor in front of his wheelchair in an upright sitting position, sustaining a skin tear to the left elbow. When asked what happened, (R1) said that he was reaching for papers on the chair and slid out of the wheelchair. Left elbow cleansed and dressing applied. […]

• Actual harm, isolatedF689Jul 30, 2025

  Based on observation, interview and record review the facility failed to ensure a resident had a leg rest while using a wheelchair, this failure resulted in R24 falling out of her wheelchair face forward sustaining a laceration requiring sutures. The facility also failed to ensure a resident was safely repositioned and transferred in a manner to prevent injury. This applies to 3 of 25 residents (R24, R110, R5) reviewed for safety in the sample of 25.The findings include: 1. R24's electronic face sheet accessed on 7/28/25 shows R47 has diagnoses of progressive supranuclear ophthalmoplegia (Steele-[NAME]) R24's facility assessment dated [DATE] shows R24 has no cognitive impairment with BIMS of 14. […]

• Actual harm, isolatedF689Mar 13, 2025

  Based 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. The findings include: On March 11, 2025, at 10:39 AM, V3 (CNA/Certified Nurse Assistant) said on February 24, 2025, she had gone to R1's room to change R1's incontinence brief. V3 said R1 was a one-assist from staff and could help her with some things. V3 said when she walked into R1's room to the left side of the bed, she observed R1's body was closer to the right side of the bed, versus being centered. […]

• Actual harm, isolatedF689Jan 21, 2025

  Based 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. The findings include: R1's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and R1 has had one fall with no injury and two or more falls with injury since her prior assessment. On 1/21/25 at 11:11 AM, V3, Certified Nursing Assistant (CNA) said that on 1/3/25 he went into R1's room to get her up for the morning. V3 said that he removed her fall mat from the floor and removed her bed bolsters from the bed in order to provide incontinence care. […]

• Actual harm, isolatedF689Jan 5, 2023

  Based on observation, interview, and record review, the facility failed to follow physical therapy's recommendations for safe transfer of the resident. The facility also failed to safely transfer a resident into a wheelchair. This failure resulted in R2 sustaining a leg fracture following a fall, due to an improper transfer. This failure also resulted in R1 sustaining an ankle fracture after telling facility staff to stop when her leg got caught during a transfer into a wheelchair. This applies to 2 of 3 residents (R1 and R2) reviewed for accidents in the sample of 3. The findings include: 1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including: dementia, history of falling, sacrum fracture, and diabetes. […]