The Estates at Chateau LLC

Inspectors wroteBased on interview and document review the facility failed to ensure contracted hospice agency staff reported allegations of sexual abuse immediately to the administrator for 1 of 1 residents (R1) reviewed for allegations of abuse.

Inspectors wroteBased on observation, interview, and document review the facility failed to prevent an unintentional fire related to 1 of 1 resident (R1) who set fire to oxygen when she was smoking in her room. R1 remained in possession of a lighter and cigarettes after the fire, placing all 63 residents at likelihood of serious harm or death. The Immediate Jeopardy began on 1/29/26 when the facility failed to ensure R1's smoking materials were secured per the care plan, resulting in R1 lighting a cigarette in her room, with oxygen in use, and igniting an unintended fire. The facility did not implement appropriate supervision, monitoring, and interventions to prevent recurrence, and R1 continued to possess a lighter and cigarettes without staff knowledge resulting in the likelihood of serious harm or death for R1 and other residents at the facility. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure monitoring and timely removal of facility food stored in refrigerators was completed to reduce the risk of foodborne illness. In addition, the facility failed to ensure the refrigerator and cooler temperatures were properly monitored and maintained to reduce the risk of foodborne illness. This had the potential to affect all 64 residents who consumed meals from the main kitchen.

Inspectors wroteBased on interview and document review, the facility failed to ensure an adequate discharge planning process was maintained to ensure resident preference for discharge was met for 1 of 2 residents (R46) reviewed for discharge planning.

Inspectors wroteBased on interview and document review, the facility failed to provide a written bed hold notice for 2 of 2 residents (R3, R70) reviewed for hospitalization. Findings Include: R3 R3's significant change Minimum Data Set (MDS) assessment, dated 9/8/25, indicated R3 had intact cognition with no hallucinations or delusions and no behaviors. On 9/15/25 at 5:18 p.m., R3 was observed sitting outside. R3 declined to talk with surveyor. R3's admission record, dated 9/18/25, did not identify R3 as having a health care power of attorney (POA). R3's census log, printed 9/18/25, indicated R3 was on hospital leave the following dates:-7/5/25 with return on 7/8/25-7/22/25 with return on 8/1/25-8/8/25 with return on 8/15/25-8/19/25 with return on 8/26/25 R3's progress notes, dated 7/4/25 to 8/27/25 were reviewed and indicated the following: -7/5/25 at 5:51 p.m.: [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., showers, hair care, shaving) were completed for 2 of 5 residents (R7, R1) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively monitor and assess for edema (swelling caused by fluid retention) so intervention effectiveness could be determined, and new interventions could be developed if needed, and ensure recommended edema management interventions were followed as appropriate for 1 of 1 residents (R29) assessed for edema management.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident who had several documented incidents of smoking in the facility was free from potential smoking accidents for 1 of 3 residents (R4) reviewed for smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one resident (R2), reviewed for catheter use, had documented clinical decision-making regarding the use of an indwelling urinary catheter including the reason for insertion, justification for continued use, and evidence of periodic reassessment. In addition, the facility failed to attempt and document a trial removal of the catheter, despite the resident experiencing repeated urinary tract infections associated with catheter use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow developed nutritional interventions to ensure nutritional status was maintained or improved for 3 of 4 residents (R22, R60, R66) reviewed for nutrition. In addition, the facility failed to ensure an order for fluid restriction was followed for 1 of 1 resident (R8) reviewed for fluid restrictions.

Inspectors wroteBased on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complication (i.e., missed orders, insufficient preparation for treatment) for 2 of 2 resident (R5, R24) reviewed for dialysis care. Furthermore, the facility failed to provide snacks/meals as ordered for 1 of 1 resident on dialysis days.

Inspectors wroteBased on observation, interview and document review the facility failed to compressively assess a resident with several mental health diagnoses including post-traumatic stress disorder to ensure, if needed, accurate interventions were in place to prevent traumatization. The facility further failed to ensure collaboration with a resident's outside psychiatric provider for 1 of 2 residents (R8) reviewed for trauma informed care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) narcotic medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 2 of 6 residents (R1, R46) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to provide rehabilitative services as ordered for 1 of 1 residents (R7) reviewed for therapy services.

Inspectors wroteBased on interview, observation, and record review the facility failed to protect 1 of 3 residents (R1) from staff to resident verbal abuse.

Inspectors wroteBased on interview, observation and record review the facility failed to report an allegation of staff to resident abuse to the State Agency (SA) and administrator for 1 of 3 resident (R1) who had a verbal altercation with a staff member, requiring another staff to intervene and no report was made.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for residents by allowing former resident FR4, who had been discharged , to repeatedly gain unauthorized entry through an unsecured door without staff awareness, resulting in unwanted interactions for residents (R)5 and R7.

Inspectors wroteBased on observation, interview, and document review, the facility failed to protect two residents (R1 and R2) from abuse when R3 had a verbal and physical altercation with R1, which escalated to a physical incident with R2 later that day. R1's face sheet dated 5/31/25, identified diagnoses of multiple fractures of pelvis, alcohol abuse, and open wound on left lower leg. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive issues. R1 had verbal behavior issues directed at others, was independent with all self-cares, and used a wheelchair for mobility. R1's care plan identified that she would remain free from abuse or neglect. [...]

Inspectors wroteBased on interview and document review, the facility failed to report allegations of stolen money immediately (within 24 hours) to the State Agency (SA) for 1 of 3 residents (R2) reviewed for abuse. In addition, the facility did not report the missing money to law enforcement.

Inspectors wroteBased on interview and document review, the facility failed to have a process in place for prior authorization (PA) of medications to ensure resident medications were re-ordered and refilled in a timely manner for 1 of 3 residents (R1) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow policy of removing alcohol from residents' room and analyze underlying causes of resident increased aggression for 1 of 1 resident (R3) reviewed for behavioral health when R3 had continued alcohol intoxication with increased behaviors.

Inspectors wroteBased on observation, interview and record review, the facility failed to produce a care plan that was consistent for one of four residents (R4) reviewed for care plans. R4's care plan stated two staff members were to provide cares for R4 while further down in the care plan it stated one staff was to assist R4 with bathing, dressing, and personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use aseptic technique when providing pericare for one of four residents (R2) observed for pericare, provide timely incontinent cares for two out of four (R1, R4) residents, and provide weekly showers for one of four (R1) residents reviewed for activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed staff were trained on wound vacuum-assisted closure (VAC) for five of sixteen licensed staff. R1 was admitted to the facility with a wound vac.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure monitoring and timely removal of facility food stored in refrigerators and freezers was completed. In addition, the facility failed to ensure facility food was stored in a manner to reduce the risk of physical cross-contamination and potential foodborne illness. In addition, the facility failed to ensure all food items were properly covered when served to residents to reduce and/or prevent the risk of foodborne illness. These facility failures had the potential to affect all 65 residents who consumed food from the facility kitchen. In addition, the facility failed to ensure the third-floor unit refrigerator temperatures were properly monitored and maintained to reduce the risk of foodborne illness. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance and Assessment (QAA) program identified and implemented ongoing, effective actions or monitoring to promote proper food storage (i.e., labeling, dating) and handling in 1 of 1 main production kitchen and various unit-based refrigerators despite known quality issues in this area and similar, repeated non-compliance with Federal regulations being identified for multiple years in a row during the recertification survey process. This had potential to affect all 65 residents, staff and visitors who consumed food at the care center.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 3 of 3 residents (R16, R35, R44) reviewed for dining. This had the the potential to affect 24 residents identified to reside on the unit where the meal was served.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide and maintain personal dignity for 1 of 1 residents (R16) reviewed for dignity with personal care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure necessary maintenance services were performed to provide a home-like environment for 1 of 1 residents (R41) with a broken overhead light.

Inspectors wroteBased on interview and document review, the facility failed to ensure care-planned interventions for substance use were implemented and documented to provide continuity of care for 2 of 2 residents (R44, R1); and failed to individualize the care plan to include target behaviors for psychotropic medication use for 1 of 5 (R48) residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review, the facility failed to accurately and comprehensively assess for smoking practices for 1 of 1 residents (R35) reviewed for smoking.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and, if needed, develop or implement interventions with newly developed back pain for 1 of 2 residents (R11) reviewed for pain management.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complication for 1 of 6 residents (R34) observed to receive medication during the survey.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure adequate blood sugar monitoring was completed and documented to reduce the risk for potential unnecessary administration or associated complications related to insulin (medication used to lower blood sugar levels) use for 1 of 5 residents (R8) reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to have a qualifying diagnosis for routine use of an antipsychotic medication and failed to complete an abnormal involuntary movement scale (AIMS) for 1 of 1 resident (R48) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the accuracy of the posted nurse staffing information with the potential to affect all 65 residents residing in the facility and/or visitors who may wish to view the information.

Inspectors wroteBased on interviews and document review the facility failed to ensure residents right to be free from abuse, provide adequate supervision, and develop a comprehensive care plan including interventions for two of two residents (R1, R2) reviewed for abuse. R1 and R2 had a history of resident-to-resident altercations while intoxicated and physically assaulted each other while under the influence of alcohol and intoxication. Findings Include: R1's care plan indicated on 1/24/24, R1 was involved in an altercation with another resident while intoxicated on 1/24/24. R1's care plan indicated R1 actively uses alcohol while living at the facility. R1's care plan instructed staff need to monitor R1 while intoxicated. R1's Minimum Data Set for facility entry dated 5/9/24 indicated R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nutrient and/or calorie substantive snacks were offered and readily available to reduce the risk of resident-associated complication (i.e., low blood glucose, hunger) after the dinner hour (i.e., bedtime) on 1 of 3 units reviewed. This had potential to affect 21 of 21 residents identified to reside on the third floor, and numerous residents identified who had voiced concern about a lack of bedtime snacks at the Resident Council meeting. In addition, the facility failed to ensure 1 of 1 resident (R12) reviewed for dialysis was provided meals prior to treatment (i.e., outside of traditional hours) to prevent a greater than 14 hour lapse in time between dinner and breakfast times.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food stored in the kitchen freezers and refrigerators were labeled and dated to ensure expired food was not served. In addition, the facility also failed to ensure 1 of 1 commercial can opener was kept in a clean and sanitary manner. These findings had potential to affect all 58 residents, staff, and visitors who consumed food from the facility kitchen. In addition, the facility failed to ensure the food stored in the floor kitchenettes refrigerators was properly stored. These findings had the potential to affect the residents who consumed food from these refrigerators.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R1, R41) who utilized an indwelling catheter.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure self-administration of medications was assessed for safety and care planned accordingly to reduce the risk of adverse events for 2 of 2 residents (R21, R23) reviewed for self adminstration of medications.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure provider orders were followed and physical therapy (PT) services were offered for 1 of 1 residents (R15) who had surgery related to a fractured ankle treated with a boot brace.

Inspectors wroteBased on observation, interview and record review the facility failed to comprehensively assess and implement appropriate and updated interventions for 1 of 1 resident (R21) with multiple falls with injury related to alcohol use. The facility further failed to implement behavioral health specialist's (Licensed Social Worker) recommendations regarding managing continued substance abuse which may have reduced the risk of falls for 1 of 1 resident (R21) who sustained a laceration to his forehead requiring emergency room intervention.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure humidifier and oxygen tubing was changed in a timely manner for 3 of 3 residents (R2, R12, and R36) reviewed for respiratory care.

Inspectors wroteBased on interview, observation and document review the facility failed to assess and monitor for complications per standard of practice before and after dialysis for 1 of 1 resident (R12) reviewed for dialysis care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure alternate interventions were assessed and/or attempted prior to side rail installation for 1 of 1 resident (R19) reviewed who had a bariatric bed with bilateral, metallic one-half (1/2) side rails installed.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow behavioral health specialist's (Licensed Social Worker) recommendations regarding managing continued substance abuse for 1 of 1 resident (R21) reviewed for behavioral health services. In addition, the facility failed to update the primary physician and the facility medical director regarding the behavioral health recommendations of attempting to limit alcohol consumption and attempting to manage cravings by attempting medications to manage the substance abuse for 1 of 1 resident (R21).

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate side effect monitoring was completed, in accordance with the care plan and standard of care, for consumed antipsychotic medication for 1 of 5 residents (R14) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper infection control practices were implemented during wound care for R1 reviewed for wound care.

Inspectors wroteDuring observation, interview, and document review the facility failed to ensure resident medical records were stored in a manner to safeguard confidential personal information for residents who had discharged from the facility and for residents who received narcotic medications.