Chateau St. James Rehab and Retirement

In the surveyor’s words

From the most serious findings on record at Chateau St. James Rehab and Retirement, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 21, 2022

  Based on observation, interview, and record review the facility failed to ensure a resident with a known history of choking and severe cognitive impairment was supervised during meals. This deficient practice was identified for 1 (Resident #91) of 2 (Resident #91 and Resident #43) sampled residents identified as having dysphagia, requiring assistance from staff with eating, and that were investigated for accident hazards in a total sample of 26. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] when Resident #91, a resident with severe cognitive impairment and an identified risk for choking and had a habit of grabbing food and placing things into his mouth, was provided a sandwich wrapped in plastic by a Certified Nursing Assistant (CNA) and left unsupervised. […]

• Immediate jeopardy, isolatedF835Dec 21, 2022

  Based on interview and record review the Administrator failed to: 1.) Take steps to ensure a resident with a known history of choking and severe cognitive impairment was supervised during meals (Resident #91); and 2.) Ensure a system was put in place to identify other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards. to identify other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards (Resident #91). […]

• Actual harm, isolatedF689Apr 5, 2023

  Based on interview and record review the facility failed to ensure a resident was free from accident after S4Certified Nursing Assistant (CNA) failed to ensure a client's safety while turning a resident in order to provide personal care per facility policy for 1 (Resident #1) of 5 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accident. This deficient practice resulted in an actual harm on 02/08/2023 when S4CNA disregarded Resident #1's request to stop turning him in bed due to safety concerns and failed to position a resident properly in the bed prior to turning a resident. This caused Resident #1 to roll out of bed onto the floor where Resident #1 sustained a fractured tooth. […]

• No harm, potential for more than minimal, patternF584Dec 10, 2025

  Based on observations, interviews, and record reviews, the facility failed to:1. Ensure weighted sandbag (weighted base to prevent something from tipping over) located on a resident's intravenous pole (pole to hold fluids or equipment), and enteral feeding pump (equipment used to deliver liquid nutrition) was maintained in a sanitary manner (Resident #12); and,2. Ensure a resident's wheelchair was maintained in a sanitary manner (Resident #43). This deficient practice was identified for 2 (Resident #12, Resident #43) of 61 sampled resident rooms observed for environmental requirements. […]

• No harm, potential for more than minimal, patternF698Dec 10, 2025

  Based on interviews and record reviews, the facility failed to ensure staff had ongoing communication and collaboration with the resident's dialysis provider regarding the resident's dialysis care and services for 1 (Resident #7) of 1 sampled resident investigated for dialysis requirements. Findings:Review of the facility's End-Stage Renal Disease, Care of a Resident, undated, policy revealed, in part, that agreements between the facility and the end stage renal disease facility should include all aspects of how the resident's care would be managed, including how information would be exchanged between the facility and dialysis center facility's. […]