The Estates At Chateau Llc

F-F0812-Food Procurement, Store/Prepare/Serve Sanitary, was cited for the previous three survey cycles (,d+[DATE REDACTED], ,d+[DATE REDACTED], and , d+[DATE REDACTED]), with a last listed date of correction, [DATE REDACTED].

The CMS Statement of Deficiencies Form CMS-2567, dated [DATE REDACTED], identified the last recertification survey was exited on [DATE REDACTED], along with various findings of non-compliance which included

F-F812 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 245222 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245222 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Chateau LLC 2106 Second Avenue South Minneapolis, MN 55404

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 When interviewed on [DATE REDACTED] at 8:31 a.m., the dietary manager (DM) explained they had been in the current role for coming up on one year now and verified they were present for the last onsite recertification survey Level of Harm - Minimal harm or (exited 2022); however, since being new to the role had some oversight and help from a regional person who potential for actual harm was no longer present on campus. DM acknowledged the current survey had identified multiple issues with kitchen safety and serving, and expressed having so many staff turnover was definitely something that is Residents Affected - Many hard to keep everyone in a team and ensure all [people] are doing the same thing. DM stated not labeling and dating food products in the main production kitchen had been an issue more recently again; however,

the unit-based refrigerators were handed off to nursing to address from the last survey. DM verified they attended the routine QA meetings where they had those discussions on the kitchen and refrigerators but no formal audits or ongoing monitoring of them was being done outside of themselves (DM) just trying to manually check the labeling and dating of items as able. DM stated the care center just had a corporate mock survey a month prior and identified many of the same concerns the survey team was now locating; however, only some partial education had been done with the staff on a couple things with more scheduled for later on. DM stated there was no PIP in place for the kitchen, or it's respective identified concerns, adding aloud, Not that I can think of.

On [DATE REDACTED] at 9:11 a.m., the administrator was interviewed and stated the QA team met on a monthly basis.

The administrator explained the current facility' PIPs included various projects on pressure ulcers, long-stay pain management, and falls with all current goals for them being met; and verified they were aware of concerns in the kitchen and expressed the staff needed a lot of coaching in that department with DM needing to more hold staff accountable. The administrator stated the QA team had discussed the kitchen and it's respective issues prior adding it had been on-radar since I've been here which was now several months. The administrator stated the care center recently got a new plating system to help with food temperatures which stemmed from a prior PIP, and expressed a mock survey was conducted a month prior which identified food storage with lack of labeling or dating and the overstuffed fridges [unit] as a concern. However, the administrator stated there was no PIP or documented audits being done of it despite to their knowledge adding, Probably not, honestly. The administrator stated the kitchen, and it's respective concerns, were identified as an issue but not an active PIP at the time.

A request was made for the most recent QAPI meeting' minutes (,d+[DATE REDACTED]). However, these were not provided or received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 245222