The resident, identified as R1 in inspection records, had been able to walk throughout the facility upon admission but became bedridden and noncompliant with getting out of bed. Staff documented her as independent with daily living activities, yet she now needs assistance with basic transfers.
On November 18, 2025, a medical provider ordered therapy services to resume. The facility never initiated those services.
Licensed practical nurse LPN-A, who serves as the facility's assessment coordinator, completed the resident's evaluation on November 1 but failed to update the care plan accordingly. She told inspectors she was new to the job and had only recently begun updating care plans when assessments changed.
The assistant director of nursing, LPN-B, worked at Highland Chateau for three months and said she wasn't aware the resident previously walked around the facility. She described the resident as noncompliant, refusing to get out of bed despite education attempts.
LPN-B admitted she didn't document those education efforts or reach out to therapy, the nurse practitioner, pain clinic, or psychiatric services about the resident's declining condition. She said documentation was something "all the nurses at the facility were currently working on."
A certified nursing assistant who worked with the resident said he rarely transferred her because she refused to get out of bed most days. He wasn't certain what care staff provided, noting her care plan indicated she remained independent with daily activities.
The facility's own policy requires care plan updates when resident conditions change and assessments are completed. The administrator confirmed her expectation that care plans should be updated simultaneously with comprehensive assessments.
The resident's current medical provider had not yet met her and was unaware of the missed therapy orders.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Chateau Health and Rehabilitation Center from 2025-12-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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