CHATEAU AT SHARMAR ASSISTED LIVING

An administrative relicensure survey was completed on 6/3/26. No deficiencies were cited. A change of ownership occurred on 5/29/26.

A licensure complaint, prompted by #CO41852 and #CO42189 , was completed on 5/7/26. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure that it had trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor, affecting one (#1) of three sample residents reviewed for falls Specifically, on 4/11/26 Resident #1 had an unwitnessed fall. Resident #1 was found on the floor moaning and said she had a pain level of six out of ten. The administrator said if the resident was in pain after a fall they should not be moved and should be assessed. She said staff should assume pain if the resident could not communicate if they are moaning and groaning. However, Staff #5 and Staff#1 helped lift Resident #1 up after they found her. After the fall Resident #1 was unable to communicate and was refusing medications and food. Resident #1 was refusing to get out of bed after the fall. Resident #1 was complaining of pain but could not tell the staff where her pain was. On 4/14/26 Resident #1's family called 911 after visiting her and she was admitted to the hospital with a fractured pelvis. Findings include 1. Record reviewThe Assist to Stand from Floor policy, dated 1/2019, read in part "Residents who have been found on the floor may be assisted to stand or to a chair when it has been determined that the resident is free from injuries ". The policy further noted, "if the resident ' s physical or mental status has declined from baseline, the resident experiences an increase in pain when lifting is attempted, or the resident either can ' t assist in any way or refuses to assist because of pain, injury, or other physical complications the staff will not lift the resident and will call 911". The Lift assist policy,(undated), read in part "Staff will only assist residents to stand who have been found to be free of injuries that will restrict their continued mobility. If the resident is complaining of pain, the staff shall request appropriate medical assistance". After Resident #1s unwitnessed fall on, the fall report dated 4/11/26 read in part that the resident "can ' t say where pain is. Pain level is listed as 6/10, and indicates Resident #1 had occasional moan and groan expressions". Review of fall trainings revealed that Staff #1 took fall training on 4/23/26, Staff #2 took fall training on 4/27/26, Staff #3 took fall training on 8/5/25 and 3/10/26, Staff #4 took fall training on 8/5/25 and 4/15/26, and Staff #5 took fall training on 8/5/25. Progress Notes showed:4/12/26 Post Fall- Laying in bed and not communicating. Unable to attempt to take medications at this time. No signs/symptoms of distress. 4/13/26 Resident in room this morning and afternoon, family visited. The resident ate 50% breakfast, and 25% lunch. Cooperative with care. 4/14/26 The resident's family decided that the resident needed to go to the ER via ambulance. The resident refused care, refused food and fluids, and the staff were unable to sit the resident up as she was complaining of pain, however, could not specify where the pain was. 4/14/26 at 8:30 a.m., the resident had rang the call bell six times in a two and a half hour period but when staff answered, the resident said she did not need anything. 4/14/26 Daughter informed the facility that the resident was being admitted to hospital due to a fractured pelvis. 2. InterviewsOn 5/6/26 at 11:05 a.m. Staff #4 stated that changing and turning the resident in the bed was uncomfortable for her and that she knew this because the resident said "ouch" and that that was unusual for Resident #1 and prior to the fall Resident #1 was getting up to go to the bathroom. Staff #4 said that on 4/14/26 the resident was different than usual and that she was not interested in anything that day (4/14/26) including eating or drinking and that normally she would at least drink water without being prompted. An interview with Staff #5 on 5/7/26 at 10:00 a.m. revealed that when describing the condition of Resident #1 on date of fall, she stated that she entered the bathroom where Resident #1 had fallen and found the resident on the floor moaning, and that she and Staff #2 helped Resident #1 get up. During an interview with Staff #2 on 5/7/26 at 9:40 a.m. she stated,"Normally (Resident #1) would get up with one person assisting, but she wouldn't get up after she fell. Staff #5 and I helped Resident #1 get up". Staff #2 recalled during the interview that Resident #1 said "ow" when sitting on the floor. Staff # 2 said that "the next day the morning crew said that Resident #1 was not getting out of bed. She stopped getting out of bed after the fall". On 5/7/26 at 11:00 a.m. the administrator said that if a resident was in pain they should not be moved and would need to be assessed first. The administrator said that if a resident was non verbal they would be able to express pain by saying a simple phrase such as "ow", moaning, groaning, or making facial expressions, and the administrator agreed that if Resident #1 was making such expressions it would be an indication of pain.

Based on record review and interview, the residence failed to ensure a resident had the right to be free from neglect, affecting one former resident (#1) who resided in the assisted living environment. Specifically, the residence failed to ensure through and prompt medical care and treatment was provided to Resident #1 post fall. On 4/1/26, Resident #1 fell and was sent out of the residence to the hospital because she had hit her head and sustained a scalp wound. On 4/10/26, Resident #1 fell again, hitting her head and was then taken to the hospital. On 4/11/26, Resident #1 fell in her bathroom and the staff found her moaning. After the fall on 4/11/26, Resident #1 presented with a change in her baseline as evident by requiring two care staff to assist with mobility, transfers, and toileting. Resident #1's status changed from one person minimal or stand by assistance to requiring two person or full dependence on staff. The resident also began refusing to be assisted from her bed to toilet, instead had the staff change her in her bed. After the 4/11/26 fall, the family declined to have the resident sent out to the hospital until 4/14/26 when her increasing discomfort was evident to them and once at the hospital, it was determined that Resident #1 had sustained a fractured pelvis. The resident had a primary diagnosis of Alzheimer's and during the period of 4/11/26 to 4/14/26, the facility failed to assess her increasing pain using non-verbal signs and symptoms as she was unable to adequately express herself verbally at baseline. The residence also failed to notify the provider of her non-verbal indicators of increasing pain such as; refusing to be transferred out of her bed to use the toilet and requiring increased staff assistance with her activities of daily living from her previous baseline. Findings include 1. Record reviewThe Abuse and Neglect policy, (undated), read in part, "Neglect: One element needed; Failure to provide any care or services, resulting in actual harm, staff member intentionally failed to follow standard of practice and/or facility policy with significant potential for harm."Progress notes showed:3/25/26 Check on frequently for toileting, can walk with a walker. 3/25/26 Being taken to the bathroom every 2 hours. Resistive to getting up. Capable of swinging legs off bed, standing, using a walker to the toilet. Doesn't want to eat, only taking a few bites and only eating sweets on the tray. 4/1/26 Resident on bathroom floor, head bleeding, family notified, provider notified, and resident taken to emergency room (ER). 4/10/26 Daughter brought resident back to facility, open wound top of head, no new injuries. Resting in bed. 4/10/26 Post Fall- Resting in bed. Family visit, resident does not remember fall. After Resident #1s unwitnessed fall on, the fall report dated 4/11/26 read in part that the resident "can ' t say where pain is. Pain level is listed as 6/10, and indicates Resident #1 had occasional moan and groan expressions". 4/12/26 Post Fall- Laying in bed and not communicating. Unable to attempt to take medications at this time. No signs/symptoms of distress. 4/13/26 Resident in room this morning and afternoon, family visited. The resident ate 50% breakfast, and 25% lunch. Cooperative with care. 4/14/26 The resident's family decided that the resident needed to go to the ER via ambulance. The resident refused care, refused food and fluids, and the staff were unable to sit the resident up as she was complaining of pain, however, could not specify where the pain was. 4/14/26 at 8:30 a.m., the resident had rang the call bell six times in a two and a half hour period but when staff answered, the resident said she did not need anything. 4/14/26 Daughter informed the facility that the resident was being admitted to hospital due to a fractured pelvis. 2. InterviewsThe director of resident services in an interview on 5/7/26 at 11:00 a.m. said that she did not believe that the resident was in pain because she was not screaming out in pain and that she believed the protocol had been followed. On 5/7/26 at approximately 11:00 a.m. the administrator stated that she believed the resident putting her call lights on multiple times on 4/14/26 was because the resident was lonely and not because she was increasingly uncomfortable. The administrator thought the resident went to physical therapy 4/11/26-4/13/26, but was unable to produce records of those dates. She stated that Resident #1 was not sent to the hospital after the fall on 4/11/26 because Resident #1s husband was contacted and he declined to have her sent out. On 5/12/26, spoke to Resident #1s daughter. She stated that on 4/11/26 her mother declined and it became apparent that she was in pain when she saw her on 4/14/26 because she was moaning, saying "Ow" and not getting up at all. She stated that they asked the residence if there was anything that they could do and they explained that it was their right to call an ambulance, so that is what they did. On 5/6/26 at 11:05 a.m. Staff #4 stated that changing and turning the resident in the bed was uncomfortable for her and that she knew this because the resident said "ouch" and that that was unusual for Resident #1 and prior to the fall Resident #1 was getting up to go to the bathroom. Staff #4 said that on 4/14/26 the resident was different than usual and that she was not interested in anything that day (4/14/26) including eating or drinking and that normally she would at least drink water without being prompted.

A licensure complaint, prompted by #CO39727, was completed on 8/5/25. No deficiencies were cited.

A relicensure survey with complaint #CO38467 was completed on 12/4/24. No deficiencies were cited.