CHATEAU DES MONS CARE AND ASSISTED LIVING

A certification complaint, prompted by #CO40622, was completed on 07/17/2025. Zero deficiencies were cited.

A licensure complaint, prompted by #CO40621, was completed on 07/17/2025. Zero deficiencies were cited.

A certification complaint, prompted by #CO36986, was completed on 8/6/24. No deficiencies were cited.

A licensure complaint, prompted by #CO36984, was completed on 8/6/24. No deficiencies were cited.

A revisit survey was completed on 3/6/24 for all previous deficiencies cited on 11/30/23. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 3/6/24 for all previous deficiencies cited on 11/30/23. The facility is in compliance with all deficiencies that were cited.

A relicensure survey with complaint #CO34309. Deficiencies were cited. A change of owenership occured on 11/30/23.

Based on observation, record review and interview, the residence failed to ensure that staff members and volunteers are of good moral and responsible character by requesting prior to staff hire, a name-based criminal history record check conducted by the Colorado Bureau of investigation (CBI) for each prospective staff member, for three of three sample staff (#1-#3) affecting 44 current residents. Findings include:a. Personnel files for Staff #1-#3 were provided and revealed the following:Staff #1 was hired on 10/31/23 and had a name-based criminal history record check completed on 11/28/23Staff #2 was hired on 10/21/21 and had a name-based criminal history record check completed on 10/17/23. Staff #3 was hired on 10/19/22 and had a name-based criminal history record check completed on 10/26/22.c. The staff schedule from 10/27/23 to 11/25/23 read as follows:Staff #1 worked at the residence on 11/9, 11/10, 11/13, 11/14, 11/15, 11/16, 11/17, 11/20, 11/21, 11/22, 11/23, and 11/24/23. Staff #2 worked at the residence on 10/27, 10/28. 10/30, 11/1, 11/2, 11/3, 11/4, 11/6, 11/7, 11/8,11/9, 11/10, 11/11, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/20, 11/21, 11/22, and 11/23/23. Staff #3 worked at the residence on 10/27,10/31, 11/1, 11/2, 11/3, 11/4, 11/7, 11/8, 11/9, 11/10, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/21, 11/22, 11/23,11/24, and 11/25/23. d. Interviews revealed the following:On 11/28/23 at 3:08 p.m., the wellness director stated she was responsible for maintaining the personnel files. She stated she previously had not completed CBI criminal history record checks however, after their last audit, she conducted CBI reports on all staff. On 11/28/23 at 4:27 p.m., the administrator acknowledged criminal record history checks were required to be completed through the CBI for all staff prior to the hire date. He stated there was a misstep in the hiring process and the residence was in the process of fixing the error.

Based on observation, interview and record review, the residence failed to ensure staff files included qualified medication administration person (QMAP) certification documentation for three of three sample staff (#1-#3) affecting 44 current residents. Findings include:1. Observations On 11/28/23 at 7:30 a.m., Staff #1 prepared and administered medications to residents. 2. Record ReviewThe personnel files for Staff #1-#3 were reviewed and revealed Staff #1-#3's files did not contain documentation of QMAP certification. 2. InterviewsOn 11/28/23 at 7:30 a.m., Staff #1 stated she had been a QMAP for several years and stated she had just started at the residence a few weeks prior to the onsite visit. On 11/28/23 at approximately 2:45 p.m., the wellness director stated the personnel files should have contained the QMAP certification documentation for Staff #1-#3 as they were certified. Additionally she stated she was unsure why the staff files did not have the required documentation. On 11/28/23 at 4:27 p.m., the administrator stated he was unaware the QMAP training certifications were not in staff files and readily available.

Based on observation, interview and record review the residence failed to ensure that only medication that was ordered by a practitioner was prepared and administered to residents affecting one of three sample residents (#4). Findings include:1. Record ReviewResident #4 was admitted to the residence with diagnoses including schizoaffective disorder, bipolar disorder. The record for Resident #4 revealed the resident had three medications administered in which there was no evidence of a written practitioner's order as follows:b. The November 2023 medication administration record (MAR) read olanzapine 20 mg 1.5 tablets was administered once daily at bedtime from 11/21-11/27/23 in which there was no evidence of a written practitioner ' s order.c. The November 2023 MAR read apixaban 5 mg was administered twice daily from 11/21 p.m. -11/28/23 a.m., in which there was no evidence of a written practitioner's order. The November 2023 MAR read trihexyphenidyl HCL 3 mg tablet was administered three times daily from 11/21 p.m.-11/28/23 a.m., in which there was no evidence of a written practitioner's order. 2. ObservationDuring a medication audit on 11/20/23 at approximately 4:00 p.m., it was revealed trihexyphenidyl and olanzapine was in stock. 3. InterviewsOn 11/28/23 at 12:41 p.m., the wellness director stated she was not aware the orders the residence had used were not signed by a practitioner. On 11/28/23 at 4:27 p.m., the administrator stated he was unaware the residence was administering medications to resident #4 in which there was no signed practitioner's order.

Based on observation, interview and record review the residence failed to contact the authorized practitioner for clarification of any orders in which were unclear and obtain new orders in writing affecting one of three sample residents (#3). Findings include:1. The residence's undated resident agreement read in part: The residence agreed to provide medication administration services to residents. 2. Resident #3 was admitted to the residence on 9/28/22. A written practitioner's order, dated 10/30/23, directed the residence to administer prednisolone acetate ophthalmic suspension four times daily starting 10/19/23 for seven days; then three times daily for seven days (10/27-11/2/23); then two times daily for seven days (11/3-11/9/23) and then once daily for seven days (11/10-11/16/23). However, the medication administration record for November 2023 read prednisolone acetate was administered four times daily from 11/3-11/9/23; three times daily from 11/10-11/17/23; two times daily from 11/19-11/25/23 and once daily from 11/27 and 11/28/23. During a medication cart audit on 11/28/23 at approximately 4:30 p.m., prednisolone acetate revealed it was filled on 9/27/23 and 10/19/23. On 11/28/23 at 12:41 p.m., the wellness director stated there was an appointment set up with an external service provider; however, there was some miscommunication between the practitioner and the residence which resulted in some back and forth conversations which led to the surgery being delayed. The wellness director stated the residence did not have any other orders that what was provided for Resident #3. She stated the residence had struggled with the external service provider to provide orders each time the appointment had to be rescheduled and the external service provider did not provide them. On 11/28/23 at 4:27 p.m., the administrator stated he was aware the residence was required to clarify any orders incomplete or unclear. He stated he was not aware of the need for clarification of orders for Resident #3; however, he confirmed the orders for the eye drops should have been clarified.

Based on observation, interview and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration affecting two of three sample residents (#3, #4) and one former resident (#16). Findings include:1. The residence's undated resident agreement read in part: The residence agreed to provide medication administration services to residents. 2. Resident #4 was admitted to the residence with diagnoses including schizoaffective disorder, bipolar disorder. A written practitioner's order, dated 9/26/23, directed the residence to administer Lithium 300 mg twice daily. However, November 2023, Medication administration record (MAR) read Lithium 900 mg was administered from 11/21-11/27/23. A written practitioner's order, dated 9/26/23, directed the residence to administer levothyroxine 100 mcg once daily. However, November 2023 MAR read levothyroxine 75 mcg was administered from 11/1-11/6 and 11/22-11/28/23.3. Resident #3 was admitted to the residence on 9/28/22. A written practitioner's order, dated 9/28/22, directed the residence to administer calcium with vitamin D 600-400 units once daily. However, the November 2023 MAR read calcium with vitamin D 600-400 units two tablets were administered daily from 11/1-11/28/23. On 11/28/23 at 12:41 p.m., the wellness director stated she was not aware that the change order for Resident #3's mediation from one tablet to two tablets was not signed by the practitioner. On 11/18/23 at 4:23 p.m., the administrator stated he was not aware the residence was not in compliance with practitioner's orders for Residents #3 and #4. 4. Former Resident #16 was admitted to the residence on 3/31/18. A written practitioners order, dated 3/1/23, directed the residence to administer metoprolol tartrate tablet 12.5 mg by mouth twice daily. However, the January through March 2023 MARs read, the medication was not administered at 7:00 p.m., on 1/17, 1/20, 2/12, 2/13, 3/3, 3/10 and 3/17/23. A written practitioners order, dated 6/30/22, directed the residence to administer mirtazapine tablet 7.5 mg once daily at bedtime. However, the January through March 2023 MARs read, the medication was not administered on 1/17, 1/20, 2/12, 2/13, 3/3, 3/10 and 3/15/23. A written practitioners order, dated 3/1/22, directed the residence to administer acetaminophen 500 mg three times daily. However, the January through March 2023 MAR read, it was not administered at 7:00 p.m., on 1/17, 1/20, 2/12, 2/13, 3/3, 3/10 and 3/15/23. A written practitioners order, dated 03/01/22, directed the residence to administer Senna Tablet 8.6 mg once daily. However, the February through March 2023 MARs read, the medication was not given on 2/25 through 2/28 and 3/1 through 3/7/23. A written practitioners order, dated 3/7/23, directed the residence to administer fiber oral powder one tsp by mouth once daily. However, the March 2023 MAR read, the medication was not given on 3/7 through 3/16/23 due to reason not given. A written practitioners order, dated 11/15/22, directed the residence to administer Refresh Tears Solution instill two drops in both eyes twice daily. However, the March 2023 MAR read, the solution was not given at 4:00 p.m., on 3/10/23.

Based on observation and interview, the residence failed to ensure medications were stored in a locked cabinet, cart or storage area when unattended by qualified medication administration persons or other licensed staff, affecting ten current residents. (#4, #6, #7 and #9-#15)Findings include:1. Residence PolicyThe residence medication administration agreement, dated 7/2023, read in part; all medication storage areas and carts were locked when not attended by a qualified staff member. 2. ObservationsOn 11/28/23 at approximately 7:40 a.m., Staff #1 prepared medication for Resident #6. She called the resident from the top floor of the residence over to the lower floor where the resident room was located. After the resident consumed their medications, Staff #1 took the resident into the room to administer lotion, she did not lock the medication cart before she walked away. On 11/28/23 at 8:19 a.m., Resident #7 walked by the unlocked med cart on the lower level of the residence. On 11/28/23 from 8:19 a.m. to 8:24 a.m., the medication cart was unlocked and unattended when Staff #1 came back to the medication cart to prepare medications for Resident #3. The medication cart contained medications for Residents #4, #7 and #9-#15. 3. InterviewsOn 11/28/23 at 4:27 p.m., the administrator stated the medication cart should have been locked when unattended by a QMAP and did not know it was left unlocked on the day of survey.

A recertification survey with complaint #CO34310 was completed on 11/30/23. A deficiency was cited.

Based on observation, interview and record review the facility (residence) failed to develop and implement a rights modification affecting six of six sample participants (residents) (#4-#9). Findings include:1. Residence PolicyThe residence's undated Resident Rights policy read in part: Residents had the right to choices and decisions. 2. Observations:On 11/28/23 at approximately 7:05 a.m., a small group of residents were located outside in the secure outdoor courtyard, smoking. 3. Record ReviewA list of resident who smoked, provided by the wellness director read Residents #4-#6 smoked at the residence. a. Resident #4The record for Resident #4 contained a Smoking Evaluation, dated 7/5/23, which read in part: Resident #4 had cognitive loss, smoked morning, afternoon, evening and night. The assessment further read the resident did not keep smoking materials in his room for safety and was not able to smoke independently due to safety skills. However, the smoking assessment contained no evidence of unsafe smoking behavior. The record further read Resident #4 had a rights modification, dated 7/13/23, for placement in a secure environment; however, the record contained no evidence of a rights modification regarding Resident #4's right to make decisions and choices regarding their own schedules and activities. b. Resident #5The record for Resident #5 contained a Smoking Evaluation, dated 10/9/23 which read in part: Resident #5 had cognitive loss smoked morning, afternoon, evening and night. The assessment further read the resident did not keep smoking materials in his room for safety and was not able to smoke independently due to safety skills. However, the smoking assessment contained no evidence of unsafe smoking behavior. c. Resident #6The record for Resident #6 contained a Smoking Evaluation, dated 7/27/23 which read in part: Resident #6 had cognitive loss smoked morning, afternoon, evening and night. The assessment further read the resident did not keep smoking materials in his room for safety and was not able to smoke independently due to safety skills.d. Resident #7The record for Resident #7 contained a Smoking Evaluation, dated 1/18/23 which read in part: Resident #7 had cognitive loss smoked morning, afternoon and evenings. The assessment further read the resident did not keep smoking materials in his room for safety and was not able to smoke independently due to safety skills.e. Resident #8The record for Resident #8 contained a Smoking Evaluation, dated 10/24/23 which read in part: Resident #8 had cognitive loss smoked morning, afternoon, evening and night. The assessment further read the resident did not keep smoking materials in his room for safety and was not able to smoke independently due to safety skills. However, the smoking assessment contained no evidence of unsafe smoking behavior. f. Resident #9 The record for Resident #9 contained a Smoking Evaluation, dated 8/18/23 which read in part: Resident #9 had cognitive loss smoked morning, afternoon and evenings. The assessment further read the resident did not keep smoking materials in his room for safety and was not able to smoke independently due to safety skills. However, the smoking assessment contained no evidence of unsafe smoking behavior. 4. InterviewsOn 11/28/23 at 11:45 a.m., Resident #4 stated he was able to smoke at certain times, 7:00 a.m, 11:00 a.m., 4:00 p.m., and 7:00 p.m. He also stated a caregiver would go outside with the residents who smoke. On 11/28/23 at 3:23 p.m., Resident #6 stated she would like to smoke two cigarettes during smoke breaks but only certain staff let her do that. On 11/28/23 at 3:23 p.m., Resident #7 stated he would like to smoke more often. He also stated that the staff hold his cigarettes and bring them outside for them. On 11/28/23 at 3:40 p.m., the wellness director stated the residence kept resident cigarettes and lighters until it was time (7:00 a.m., 11:00 a.m., 4:00 p.m. and 7:00 p.m.) for the residents whosmoked. Also, she stated that the residence had not done rights modification on the residents who smoked and was not aware of the requirement as they were in a secure enviroment. On 11/28/23 at 3:59 p.m., Resident #4 alerted the department and stated "were going out to smoke". On 11/28/23 at 4:27 p.m., the administrator stated there should be a rights modification for every resident that did not keep their cigarettes and had a schedule; however, he acknowledged there were no rights modifications in resident files for smoking at certain time or holding smoking materials.

Based on interview and record review the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations, affecting three of four sample participants (residents) (#3, #4) and one former resident (#16). Findings Include:1. Chapter VII regulations governing assisted living residence, require in part 14.21, that the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. Residence policy The residence's Medication Administration Policy, dated June 2023, read in part; a medication record would be maintained on residents for whom the staff monitors or administers medications, this includes, physician order for the medication. The residence's undated resident agreement read in part: The residence agreed to provide medication administration services to residents.b. Resident #4 was admitted to the residence with diagnoses including schizoaffective disorder, bipolar disorder. A written practitioner's order, dated 9/26/23, directed the residence to administer Lithium 300 mg twice daily. However, November 2023, Medication administration record (MAR) read Lithium 900 mg was administered from 11/21-11/27/23. A written practitioner's order, dated 9/26/23, directed the residence to administer levothyroxine 100 mcg once daily. However, November 2023 MAR read levothyroxine 75 mcg was administered from 11/1-11/6 and 11/22-11/28/23.c. Resident #3 was admitted to the residence on 9/28/22. A written practitioner's order, dated 9/28/22, directed the residence to administer calcium with vitamin D 600-400 units once daily. However, the November 2023 MAR read calcium with vitamin D 600-400 units two tablets were administered daily from 11/1-11/28/23. On 11/28/23 at 12:41 p.m., the wellness director stated she was not aware that the change order for Resident #3's mediation from one tablet to two tablets was not signed by the practitioner. On 11/18/23 at 4:23 p.m., the administrator stated he was not aware the residence was not in compliance with practitioner's orders for Residents #3 and #4.d. Former Resident #16 was admitted to the residence on 3/31/18. A written practitioners order, dated 3/1/23, directed the residence to administer metoprolol tartrate tablet 12.5 mg by mouth twice daily. However, the January through March 2023 MARs read, the medication was not administered at 7:00 p.m., on 1/17, 1/20, 2/12, 2/13, 3/3, 3/10 and 3/17/23. A written practitioners order, dated 6/30/22, directed the residence to administer mirtazapine tablet 7.5 mg once daily at bedtime. However, the January through March 2023 MARs read, the medication was not administered on 1/17, 1/20, 2/12, 2/13, 3/3, 3/10 and 3/15/23. A written practitioners order, dated 3/1/22, directed the residence to administer acetaminophen 500 mg three times daily. However, the January through March 2023 MAR read, it was not administered at 7:00 p.m., on 1/17, 1/20, 2/12, 2/13, 3/3, 3/10 and 3/15/23. A written practitioners order, dated 03/01/22, directed the residence to administer Senna Tablet 8.6 mg once daily. However, the February through March 2023 MARs read, the medication was not given on 2/25 through 2/28 and 3/1 through 3/7/23. A written practitioners order, dated 3/7/23, directed the residence to administer fiber oral powder one tsp by mouth once daily. However, the March 2023 MAR read, the medication was not given on 3/7 through 3/16/23 due to reason not given. A written practitioners order, dated 11/15/22, directed the residence to administer Refresh Tears Solution instill two drops in both eyes twice daily. However, the March 2023 MAR read, the solution was not given at 4:00 p.m., on 3/10/23. 2. Chapter VII regulations governing assisted living residences, require in part 14.11, that only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.a. Residence Policy The residence's undated resident agreement read in part: The residence agreed to provide medication administration services to residents.b. Resident #3 was admitted to the residence on 9/28/22. A written practitioner's order, dated 10/30/23, directed the residence to administer prednisolone acetate ophthalmic suspension four times daily starting 10/19/23 for seven days; then three times daily for seven days (10/27-11/2/23); then two times daily for seven days (11/3-11/9/23) and then once daily for seven days (11/10-11/16/23). However, the medication administration record for November 2023 read prednisolone acetate was administered four times daily from 11/3-11/9/23; three times daily from 11/10-11/17/23; two times daily from 11/19-11/25/23 and once daily from 11/27 and 11/28/23. During a medication cart audit on 11/28/23 at approximately 4:30 p.m., prednisolone acetate revealed it was filled on 9/27/23 and 10/19/23. On 11/28/23 at 12:41 p.m., the wellness director stated there was an appointment set up with an external service provider; however, there was some miscommunication between the practitioner and the residence which resulted in some back and forth conversations which led to the surgery being delayed. The wellness director stated the residence did not have any other orders that what was provided for Resident #3. She stated the residence had struggled with the external service provider to provide orders each time the appointment had to be rescheduled and the external service provider did not provide them. On 11/28/23 at 4:27 p.m., the administrator stated he was aware the residence was required to clarify any orders incomplete or unclear. He stated he was not aware of the need for clarification of orders for Resident #3; however, he confirmed the orders for the eye drops should have been clarified. 3. Chapter VII regulations governing assisted living residences, require in part that all medications shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff.a. Residence PolicyThe residence medication administration agreement, dated 7/2023, read in part; all medication storage areas and carts were locked when not attended by a qualified staff member. b. ObservationsOn 11/28/23 at approximately 7:40 a.m., Staff #1 prepared medication for Resident #6. She called the resident from the top floor of the residence over to the lower floor where the resident room was located. After the resident consumed their medications, Staff #1 took the resident into the room to administer lotion, she did not lock the medication cart before she walked away. On 11/28/23 at 8:19 a.m., Resident #7 walked by the unlocked med cart on the lower level of the residence. On 11/28/23 from 8:19 a.m. to 8:24 a.m., the medication cart was unlocked and unattended when Staff #1 came back to the medication cart to prepare medications for Resident #3. The medication cart contained medications for Residents #4, #7 and #9-#15. c. InterviewsOn 11/28/23 at 4:27 p.m., the administrator stated the medication cart should have been locked when unattended by a QMAP and did not know it was left unlocked on the day of survey.