Chatsworth at Pga National

In the surveyor’s words

From the most serious findings on record at Chatsworth at Pga National, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF690Jan 19, 2024

  Based on observation, interview, record review, and policy review, the facility failed to ensure care and services for the prevention of Urinary Tract Infections (UTIs) or other complications for 3 of 3 sampled residents who had an indwelling urinary catheter. Nursing staff failed to maintain proper positioning and securing of the catheter tubing for Residents #24 and #45, and failed to educate Resident #38 of the risks of refusing to follow-up with a urology consult and discontinue use of the indwelling urinary catheter. The findings included: Review of the policy Urinary Catheters dated 06/2021 documented, Procedure: 1. Catheter Care . c. Use of proper infection control practices regarding hand washing, catheter care, tubing and the collection bag will be followed at all times. h. […]

• No harm, potential for more than minimal, patternF812Aug 5, 2021

  Based on observation and interview, the facility failed to serve food with professional standards in accordance with food service safety, with the potential to affect 39 of 41 residents. The findings included: On 08/02/21 at 9:24 AM, conducted an initial brief tour of the Main kitchen accompanied by the Culinary Director. The following was observed. (1)The oven was dirty with grease. (2)Stove very dirty, with grease and spills. (3) The can opener insert needs to be clean, very greasy and sticky. On 08/04/21 at 12:23 PM, conducted an interview with the Sous Chef to inform him of the findings. On 08/04/21 at 12:23 PM, during an interview with the Sous Chef he was informed of the opened cups of applesauce that were sitting on the nurses' Medication carts not refrigerated. […]

• No harm, potential for more than minimal, isolatedF692Apr 17, 2025

  Based on observations, interviews and record review, the facility failed to maintain acceptable parameters of nutritional status and failed to provide nutritional interventions in a timely manner for 1 of 2 sampled residents reviewed for nutrition (Resident #23). The findings included: Review of the facility's policy titled, Weight Management, dated 06/2021, included the following: Residents will have their weight obtained on admission, re-admission and monthly or at a frequent determined by the interdisciplinary team or provider. Definitions: Significant weight change- As defined in RAI Manual is any unplanned weight change of 5% change over 1 month, 7.5% over 3 months or 10% change over the past 6 months. […]

• No harm, potential for more than minimal, isolatedF561Jan 19, 2024

  Based on record review, observations, and interviews, the facility failed to honor the resident's choice regarding the name that the resident preferred to be called by, as conveyed on the day of admission, and as documented in the resident's records, for 1 of 2 sampled residents (Resident #10), reviewed for choices. The findings included: A review of Resident #10's records revealed that the resident was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, Dementia, unspecified severity with other behavior disorders, and Generalized anxiety disorder. Record review of Resident #10's care plan, dated 01/04/24, related to Engagement and Socialization, documented that the resident had a preferred first name that was different than her legal name. […]

• No harm, potential for more than minimal, isolatedF641Aug 5, 2021

  Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 3 of 19 sampled residents (Resident #48, Resident #28, and Resident #3), related to discharge location (Resident #48) and medication use (Resident #28 and Resident #3). The findings include: 1) Resident #48 was admitted to the facility for short term rehabilitation on 5/21/21. Review of Resident #48's Discharge MDS assessment dated [DATE] showed she discharged to an acute hospital. Review of Resident #48's clinical record showed she was discharged home and was not hospitalized . An interview was conducted with the Assistant Director of Nursing (ADON) on 08/04/21 at 03:23 PM. The ADON confirmed Resident #48 was discharged home and was not hospitalized . […]