LENNOX GUEST HOME, THE

A life safety code survey, prompted by #CO42327, was completed on 6/10/2026. Six deficiencies were cited. The facility is a three-story (3), Type V (000) wood frame structure with a basement and licensed for fifty-five (55) residents. The facility is not equipped with a fire suppression system. This survey, conducted on June 10, 2026, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities.

Based on observation and staff interviews, it was determined that the facility failed to maintain fire evacuation regulations in accordance with the Life Safety Code 101, 101A. The deficient practice could affect the whole facility, 55 of 55 residents, and an indeterminable number of staff and visitors. 1. The record review, observations, and interviews with the administrator revealed that there were no fire drills; the activations on 5/27/2026 at 5:55 PM and 6:20 PM were not drills. 2. The record review, observations, and interviews with the administrator revealed that staff training is not being conducted every two months. 3. The record review, observations, and interviews with the administrator revealed that the emergency plans are not compliant because they do not include the use of fire protection procedures. 4. The record review, observations, and interviews with the administrator revealed that Five resident rating sheets are missing for residents who have been in the facility for longer than 2 weeks, which is the requirement. 5. The record review, observations, and interviews with the administrator revealed that Fire suppression systems shall be required to be installed due to an impractical rating under Colorado State Health care rules 1507-31 and NFPA 101 Chapter 33.33.7.1 Emergency Plan. 33.7.1.1 The administration of every residential board and care facility shall have, in effect and available to all supervisory personnel, written copies of a plan for protecting all persons in the event of fire, for keeping persons in place, for evacuating persons to areas of refuge, and for evacuating persons from the building when necessary. 33.7.1.2 The emergency plan shall include special staff response, including the fire protection procedures needed to ensure the safety of any resident, and shall be amended or revised whenever any resident with unusual needs is admitted to the home. 33.7.1.3 All employees shall be periodically instructed and kept informed with respect to their duties and responsibilities under the plan, and such instruction shall be reviewed by the staff not less than every 2 months. 33.7.1.4 A copy of the plan shall be readily available at all times within the facility. 33.7.2 Resident Training. 33.7.2.1 All residents participating in the emergency plan shall be trained in the proper actions to be taken in the event of fire. 33.7.2.2 The training required by 32.7.2.1 shall include actions to be taken if the primary escape route is blocked. 33.7.2.3 If the resident is given rehabilitation or habilitation training, training in fire prevention and the actions to be taken in the event of a fire shall be a part of the training program. 33.7.2.4 Residents shall be trained to assist each other in case of fire to the extent that their physical and mental abilities permit them to do so without additional personal risk. 33.7.3 Emergency Egress and Relocation Drills. Emergency egress and relocation drills shall be conducted in accordance with 33.7.3.1 through 33.7.3.6.33.7.3.1 Emergency egress and relocation drills shall be conducted not less than six times per year on a bimonthly basis, with not less than two drills conducted during the night when residents are sleeping, as modified by 33.7.3.5 and 33.7.3.6.33.7.3.2 NFPA 101A 6.8 worksheetsAt least 12 fire drills were conducted during the previous year. (See 6.5.2.5The emergency drills shall be permitted to be announced to the residents in advance. 33.7.3.3 The drills shall involve the actual evacuation of all residents to an assembly point, as specified in the emergency plan, and shall provide residents with experience in egressing through all exits and means of escape required by this Code. 33.7.3.4 Exits and means of escape not used in any drill shall not be credited in meeting the requirements of this Code for board and care facilities. 33.7.3.5 Actual exiting from windows shall not be required to comply with 33.7.3; opening the window and signaling for help shall be an acceptable alternative. 33.7.3.6 If the board and care facility has an evacuation capability classification of impractical, those residents who cannot meaningfully assist in their own evacuation or who have special health problems shall not be required to actively participate in the drill. NFPA 101A6.4.6.1.3 Where any of the conditions in 6.4.6.1.2 exist, the resident should be rated as "response not probable" unless the resident ' s ability to wake up has been demonstrated. The demonstration of the resident ' s ability to wake up in response to the fire alarm should be conducted after the first half hour of sleep and during the first three hours of sleep. In addition, the resident ' s ability to wake up in response to the alarm should be demonstrated on two different nights under normal conditions (e.g., without hearing aid, under usual medications). Also, the resident should be alert enough to follow simple instructions within 1 minute after waking. To avoid waking other residents during the demonstrations of the capability of a particular resident, a device that makes a sound that is similar to, but not louder than, the fire alarm shall be permitted to be used (e.g., an alarm clock or clock radio with a sound similar to the fire alarm). Listed and approved tactile alarms shall be permitted as alternative devices used to demonstrate a hearing-impaired resident ' s response probability. 4.7.6* A written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner. A.?4.7.6 The written record required by this paragraph should include such details as the date, time, participants, location, and results of that drill. Colorado health care 1507-313.3In any facility where the evacuation capability of the facility or resident population is required to be rated, the "Procedure for Determining Evacuation Capability" published by NFPA is to be used by the facility whether the facility is evaluated utilizing the NFPA 101A, Guide on Alternative Approaches to Life Safety (2013), or NFPA Standard 101, Life Safety Code (2012). The Level of Evacuation Difficulty for each facility will be determined by the scores developed in the Worksheet for Rating Residents completed by responsible staff for each resident and the level of staffing maintained at the facility. It is the responsibility of the owner or administrator to ensure that the abilities of the residents are accurately rated in accordance with the published instructions. Each new resident shall be rated utilizing the Worksheet for Rating Residents within two (2) weeks of their admission to the facility. All resident rating scores shall be reviewed at least annually, or when there are significant changes in a resident's physical or cognitive abilities. Failure to rate the evacuation capability in accordance with these provisions upon two inspections will result in a permanent "impractical" rating for the facility. 33.3.3.5.2 Impractical Evacuation Capability. All facilities having impractical evacuation capability shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1). The administrator discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain smoking regulations in accordance with the Life Safety Code 101, Chapter 33. The deficient practice could affect the whole facility, 55 of 55 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the administrator revealed that there was no evidence of smoking indoors. However, evidence of smoking materials was found in non-smoking areas on the first-floor balcony. A.?33.7.4.1 Smoking regulations should include the following:(1)Smoking should be prohibited in any room, compartment, or area where flammable or combustible liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and the following also should apply:(a)Such areas should be posted with signs that read NO SMOKING or the international symbol for no smoking.(b)In residential board and care facilities where smoking is totally prohibited and signs so indicating are placed at all major entrances, secondary signs with language that prohibits smoking are not required.(2)Smoking by residents classified as not responsible with regard to their ability to safely use and dispose of smoking materials should be prohibited.(3)Where a resident, as specified in A.?33.7.4.1(2), is under direct supervision by staff or by a person approved by the administration, smoking might be permitted.(4)Smoking materials should not be provided to residents or maintained by residents without the approval of the administration.(5)Areas where smoking is permitted should be clearly identified.(6)Ashtrays of noncombustible material and safe design should be provided and required to be used in all areas where smoking is permitted.(7)Self-closing cover devices into which ashtrays can be emptied should be made available to all areas where smoking is permitted and should be required to be used. The administrator discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain the fire doors in accordance with the Life Safety Code 101, chapter 33. The deficient practice could affect the whole facility,55 of 55 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the administrator revealed that The fire door to the third floor does not shut. NFPA 10133.3.2.2.2 Doors. Doors in means of egress shall be as follows:(1) Doors complying with 7.2.1 shall be permitted.(2) Doors within individual rooms and suites of rooms shall be permitted to be swinging or sliding.(3) No door in any means of egress, other than those meeting the requirement of 33.3.2.2.2(4) or (5), shall be locked against egress when the building is occupied.(4) Delayed-egress locks in accordance with 7.2.1.6.1 shall be permitted.(5) Access-controlled egress doors in accordance with 7.2.1.6.2 shall be permitted.(6) Revolving doors complying with 7.2.1.10 shall be permitted. 33.7.7 Inspection of Door Openings. Door assemblies for which the door leaf is required to swing in the direction of egress travel shall be inspected and tested not less than annually in accordance with 7.2.1.15.7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 805.2.14.1 Self-closing devices shall be kept in working condition at all times. The administrator discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain the fire extinguishers in accordance with the Life Safety Code 101, NFPA 10. The deficient practice could affect the whole facility,55 of 55 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the administrator revealed that Fire extinguishers are not being signed off monthly. Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire ExtinguishersNFPA 10, 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. The administrator discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain the fire hazardous areas in accordance with the Life Safety Code 101, chapter 33. The deficient practice could affect the whole facility,55 of 55 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the administrator revealed that the Fire suppression system shall be required to be installed due to hazardous areas not meeting 1 hour rating (laundry,workshop areas). 33.3.3.2.2 Hazardous areas, which shall include, but shall not be limited to, the following, shall be separated from other parts of the building by construction having a minimum 1-hour fire resistance rating, with communicating openings protected by approved self-closing fire doors, or such areas shall be equipped with automatic fire-extinguishing systems:(1)Boiler and heater rooms(2)Laundries(3)Repair shops(4)Rooms or spaces used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdictionThe administrator discussed deficient items at the exit conference.

Based on observation, interview, and record review, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining life safety code regulations regarding fire evacuation, smoking, fire doors, fire extinguishers, and hazardous areas. The facility failures had the potential to affect all occupants of the building. Findings include:Cross-reference to A0001 for observations, interviews, and record review showing fire evacuation regulations in violation of applicable codes. Cross-reference to A0002 for observations and interviews of smoking activities in violation of applicable codes. Cross-reference to A0003 for observations and interviews of fire doors in violation of applicable codes. Cross-reference to A0004 for observations and interviews of fire extinguishers in violation of applicable codes. Cross-reference to A0005 for observations and interviews of hazardous areas in violation of applicable codes.

A recertification survey was completed on 5/21/26. Deficiencies were cited.

Based on records review and interviews, the facility (residence) failed to allow access to food preparation and storage areas at all times for 23 current members (residents). Findings Include: An environmental tour on 5/19/25 at 8:05 a.m. revealed no independent access to food other than a vending machine that the residence had to pay for. On 5/19/26 at 9:20 a.m., Staff #1 stated the residence had snacks for the residence and put snacks out at 9:30 a.m. On 5/20/26 an environmental tour of the residence revealed no independent access to food from 8:00 a.m. to 6:00 p.m. On 5/20/26 at 3:20 p.m., Resident #7 and #8 stated the staff only puts snacks out at night for the residence to have access to. On 5/21/26 at 11:45 a.m., the licensee stated he was not aware the residence needed to have independent access to food at all times. He stated if food is out for the residents the residents would just take it all.

Based on record review and interview, the facility (residence) failed to shall maintain records documenting the qualifications and training of employees and contractors who provide services to members, for four of four sample staff (#1 - #4), affecting 23 current members (residents). Findings Include: 1. Record Review On 5/19/26 at 8:11 a.m., the complete personnel file, as required for Staff #1-#4 was requested from the administrator designee via electronic mail. On 5/19/26 at approximately 12:08 p.m., an additional request was made for the complete personnel file for the staff. The residence provided staff files for Staff #1, #2, and #4, but they were incomplete, the residence could not provide the personnel record for Staff #3. 2. Interview On 5/19/26 at 3:07 p.m., the licensee stated that the staff files were not on site at the residence and that he had to contact his office to obtain them.

Based on record review and interview, the facility (residence) failed to ensure staff were trained with sufficient scope for employees to carry out duties and responsibilities efficiently, effectively, and competently as no staff member was on-site at all times with current certification in first aid or cardiopulmonary resuscitation (CPR) and obstructed airway techniques certification from a nationally recognized organization, for four of four sample staff (#1 - #4), affecting 23 current members (residents). Findings include: 1. Record Review Personnel files revealed the dates of hire for the following:Staff #1- #4 with an unknown hire date. On 5/19/26 at 8:11 a.m., the residence provided the April and May 2026 schedules, which revealed that all scheduled shifts did not have at least one staff member onsite who had current certification in first aid or CPR from a nationally recognized organization. On 5/19/26 at 9:00 a.m., the residence provided first aid and CPR certifications; however, the certifications for the staff members, #1-#4, were expired as of April 2026. 2. Interview On 5/21/26 at approximately 10:40 a.m., the licensee along with the administrator designee stated they were not aware that staff certifications were expired and a class had not been currently set to recertify the staff.

Based on record review and interview, the facility (residence) failed to conduct fire drills at least quarterly, affecting 23 current members (residents). (Cross-reference C1702)Findings include: The residence's emergency plan failed to include a plan to identify its highest potential risk for its residence and hold routine drills to facilitate staff and resident response to that risk. On 5/19/26 at 8:00 a.m., emergency drill documentation was requested. However, the residence conducted no fire drills. On 5/19/26 at 11:00 a.m., Resident #6 stated that in a fire situation he was unsure what to do. He stated he was told to go to the office or someone would go get him from his room. On 5/19/26 at 2:10 p.m., the administrator designee stated that resident #6 had stated previously he was unsure of what to do in a fire situation. She also stated that the residence had been talking about conducting a fire drill but one had not been conducted since the residence recently reopened late February 2026. In a later interview on 5/21/26 at approximately 10:45 a.m., the administrator designee stated that a fire drill had not been conducted since the building reopened. She acknowledged there was a need for simulated routine emergency drills to track the response to the risk.

Based on interviews and record reviews, the residence failed to provide personal services and protective oversight affecting 23 current residents. (Cross-reference C0900, C1710)Findings include:1. Resident #1 was admitted to the residence on 4/15/26 with a diagnosis of bipolar disorder and failure to thrive.a. Smoking IndoorsOn 5/19/26 at 1:43 p.m., Resident #1 barricaded herself in her room by placing large items and clutter in front of the door, preventing staff access. Staff #2 attempted to force the door open and was able to partially open it; upon doing so, a strong odor of cigarette smoke came from the resident's room into the hallway. On 5/20/26 during the onsite survey, several cigarette butts and whole cigarettes were inside Resident #1 ' s room near the door leading to the front patio. Ashes from cigarettes were also outside Resident #1 ' s room. An incident report dated 5/7/26, read that that staff observed Resident #1 smoking in her room and outside her door despite repeated directions to use only the designated smoking area. Resident #1's room location is near other residents who utilized oxygen creating a significant safety risk. Staff reported Resident #1's room remained cluttered, and she failed to comply with requests to clean it. The resident barricaded her locked door using furniture and personal items, preventing staff access in the event of an emergency. Due to continued noncompliance, staff contacted law enforcement, who responded and spoke with Resident #1 about the importance of adhering to facility rules. The resident was verbally agitated, refused to extinguish her cigarette, and told staff to evict her. The report contained no further follow-up regarding the resident smoking indoors. An incident report dated 5/14/26, read that staff observed Resident #1 ' s feet and ankles remained very red and swollen, with her toes turning purple. Staff encouraged Resident #1 to seek medical care, and she initially agreed to go to the emergency room with staff transport after refusing ambulance services. Upon arrival, Resident #1 became agitated and attempted to leave, but briefly agreed to return after smoking. Hospital staff completed limited testing; however, when additional diagnostic imaging was recommended, Resident #1 refused. Medical staff informed Resident #1 of the risk of infection and possible amputation without further evaluation and treatment. Despite this, Resident #1 declined additional care and requested to return to the residence. The report contained no further follow-up regarding the resident smoking indoors. An undated care plan stated that Resident #1 smoked in her room and required consistent monitoring to ensure her safety and the safety of others. The care plan also identified her room as a hazard and directed staff to conduct regular checks to ensure she had not fallen. The care plan had no mention of the current state of her feet along with no interventions. On 5/19/26 at 1:01 p.m., the administrator designee (AD) stated that Resident #1 smoked in her room and that the local police department was contacted in response to one of the situations that occurred on 5/7/26.5/19/26 at 1:45 p.m., Staff #2 stated that Resident #1 smoked in her room and barricades herself so that staff can not access her room. On 5/19/26 at 2:14 p.m., Staff #3 stated that Resident #1 smoked in her room and reported that it was challenging to access the room due to Resident #1 barricading the entrance. Resident #9 in the unit next door to Resident #1 also used oxygen at night. b. Unaddressed Health ConcernAn incident report dated 5/13/26, read that staff were notified by another individual that the resident was observed returning from the smoking area with visibly red ankles and feet. Upon assessment, staff observed the resident ' s feet and ankles were red, swollen, and her toes had begun to appear purple. Staff advised the resident to seek medical evaluation; however, the resident refused and became verbally agitated, stating she would not go to the hospital and wanted to be left alone. The resident also refused vital sign assessment. The report contained no further follow-up regarding the health concern. On 5/20/26 at 2:08 p.m., the AD took Resident #1 to the community room where Resident #1's feet and ankles were seen to be bright red and swollen and her toes were dark purple in color. On 5/21/26 at 11:00 a.m., the licensee stated he had not observed Residents #1's feet until 5/20/26 and he was extremely concerned about them and wanted her to be evaluated by the emergency department. On 5/20/26 at 3:56 p.m., Resident #1 ' s practitioner stated that on 5/18/26 she informed the administrator designee that Resident #1 needed to be sent out for treatment urgently due to swelling and redness in her feet following her assessment. On 5/20/26 at approximately 3:30 p.m., Resident #1's practitioner stated she needed an ED to be evaluated properly. She added that Resident #1 needed medication to treat her symptoms but would not be able to tolerate the meds due to how thin Resident #1 was, along with her lack of muscle and lack of nutrition. She also stated that Resident #1 needed a higher level of care than what the residence was able to provide.

Based on record review and interview, the facility (residence) failed to complete a comprehensive pre-admission assessment for each member (resident) prior to admission to ensure the residence accepted only those residents whose needs could be fully met by the residence, affecting four of six sample residents (#1, #3, #4 and #6). (Cross-reference C0710)Findings include: On 5/19/26 from 12:05 p.m to 4:40 p.m., the residence failed to provide preadmission assessments for Residents #1, #3, #4, and #6. On 4/20/26 at approximately 10:30 a.m., the residence provided assessments for Residents #1, #3, #4, and #6; however, the assessments were dated:Resident #1 was admitted to the residence on 4/15/26. Her assessment was completed on 4/23/26. Resident #3 was admitted to the residence on 2/24/26. His assessment was completed on 2/25/26. Resident #4 was admitted to the residence on 2/23/26. His assessment was completed on 2/27/26. Resident #6 was admitted to the residence on 2/26/26. His assessment was completed on 2/26/26. All four residents were not completed prior to the residents' admission to the residence. On 5/19/26 at approximately 3:45 p.m., the licensee stated he oversees all assessments prior to admission; however, Residents #1, #3, #4, and #6 were not assessed prior to the residents' admissions.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The service agency was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10.8.7001. B.3.a.iii The Residential Setting does not have institutional features not found in a typical home, such as staff uniforms; entryways containing staff postings or messages; or labels on drawers, cupboards, or bedrooms for staff convenience.

A relicensure survey was completed on 5/21/26. Deficiencies were cited.

Based on record review and interview, the licensee failed to ensure the residence provided accurate and truthful information to the Department during inspections, affecting 23 current residents (Cross-reference U0312, U1110)Findings include:Resident #1 was admitted to the residence on 4/15/26.1. Smoking In RoomAn incident report, dated 5/7/26, read in part that the resident smoked cigarettes in her room. On 5/19/26 at 8:49 a.m Staff #1 and #2 stated that Resident #1 smoked in her bedroom. On 5/19/26 at 1:01 p.m., the administrator designee (AD) stated that Resident #1 smoked in her room on several occasions. However, on 5/20/26 at approximately 12:00 p.m., the AD stated that Resident #1 did not smoke in her room, which was inconsistent with the prior interview and the incident report she created regarding Resident #1 smoked in her room on 5/7/26. On 5/19/26 at 2:14 p.m., Staff #3 stated that the Resident #1 smoked in her room. 2. Urgent Medical NeedsThe residence's plan to address an Immediate Jeopardy citation read in part that Resident #1's practitioner stated to the residence that Resident #1 was not experiencing an urgent medical need during her last visit. On 5/20/26 at 3:56 p.m., Resident #1's practitioner stated that she examined Resident #1 on 5/18/26 and directed the residence to send the resident out for urgent treatment.

Based on a record review and interview, the residence failed to provide, upon request, access to or copies of records and information required by the Department to perform its regulatory oversight responsibilities, affecting 21 current residents. (Cross-reference U0312, U0662, U1010, U1110)Findings include:On 5/19/26 at 8:11 a.m., staff files with orientation, training and resident roster were requested. On 5/19/26 at 11:18 a.m., staff files, including orientation and training documentation, were requested again. . On 5/20/26 during the onsite, the residence provided incomplete staff files for Staff #1, #2, and #4. On 5/20/26 at approximately 12:45 p.m., the residence was asked for a plan to address an Immediate Jeopardy concern that was due at 1:45 p.m. On 5/20/26 at 2:08 p.m. the residence submitted a plan approximately 23 minutes late. Another plan was requested and due by 3:15 p.m. On 5/20/26 from 3:15 p.m. until 4:31 p.m., the plan was requested twice. On 5/20/26 at 4:31 p.m., the residence submitted a plan approximately one hour and 16 minutes late. Another plan was requested and due by 5:15 p.m. On 5/20/26 at 5:55 p.m., the residence submitted the plan approximately 40 minutes late. On 5/19/26 at 3:07 p.m., the licensee stated that the staff files were not on site at the residence and that he had to contact his office to obtain them.

Based on observation, interview, and record review, the licensee failed to ensure the provision of facilities, personnel, and services necessary for the welfare and safety of residents, affecting 23 current residents. (Cross-reference U0662, U0732, U0734, U910, U0918, U1010, U1110, U2632, U2722, C0216, C0240) Findings include:On 5/19/26 at 9:00 a.m., the licensee identified himself as the administrator. He added that the administrator's designee (AD) ran the day-to-day operations of the residence despite identifying himself as the administrator. He stated there was a third administrator present at the residence once per week, and the third administrator was the administrator of record. The licensee stated he was also the licensee of the residence. He added that the residence's physical environment was in working order and safe. In a later interview on 5/21/26 at approximately 11:00 a.m., the licensee stated he was not aware of residents smoking on the balcony, nor was he aware there were a large number of cigarette butts in the gutters. On 5/19/26 at approximately 9:00 a.m., the AD stated the residence required a new water heater and had ongoing plumbing issues. On 5/19/26-5/20/26 during the onsite survey, the residence had a large unknown number of used cigarette butts in a gutter of the balcony of the residence on top of leaves. This area was not a designated smoking area. On 5/19/26-5/21/26, during the onsite survey, the licensee and AD provided documentation and answered questions, but it was unclear who was directing the operations of the residence. On 5/19/26-5/21/26, during the onsite survey, the licensee handled other non-residence related business during the onsite survey. On 5/19/26 during the onsite survey, the residence experienced plumbing issues in multiple residents' rooms, with sinks not draining and toilets not flushing.

Based on record review and interview, the residence failed to have personnel files onsite and readily available for the Department to review, for four of four sample staff (#1-#4), affecting 23 current residents. (Cross-reference U0312, C0240) Findings Include: 1. Record Review On 5/19/26 at 8:11 a.m., the complete personnel file, as required for Staff #1-#4 was requested from the administrator designee via electronic mail. On 5/19/26 at approximately 12:08 p.m., an additional request was made for the complete personnel file for the staff. The residence provided staff files for Staff #1, #2, and #4, but they were incomplete, the residence could not provide the personnel record for Staff #3. 2. Interview On 5/19/26 at 3:07 p.m., the licensee stated that the staff files were not on site at the residence and that he had to contact his office to obtain them.

Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current certification in first aid from a nationally recognized organization, for four of four sample staff (#1 - #4), affecting 23 current residents. (Cross-reference U0312, U0734) Findings include: 1. Record Review Personnel files revealed the dates of hire for the following:Staff #1- #4 with no hire date listed. On 5/19/26 at 8:11 a.m., the residence provided the April and May 2026 schedules, which revealed that no scheduled shifts had at least one staff member on-site with current certification in first aid from a nationally recognized organization. On 5/19/26 at 9:00 a.m., the residence provided first aid certifications; however, the certifications for Staff #1 - #4, were expired as of April 2026. 2. Interview On 5/21/26 at approximately 10:40 a.m., the licensee, along with the administrator designee, stated they were not aware that staff certifications had expired and that a class had not been scheduled to recertify the staff.

Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current cardiopulmonary resuscitation (CPR) and obstructed airway techniques certification from a nationally recognized organization, affecting 23 current residents. (Cross-reference U0312, U0732)Findings include: 1. Record Review Personnel files revealed the dates of hire for the following:Staff #1- #4 date unknown On 5/19/26 at 8:11 a.m., the residence provided the April and May 2026 schedules, which revealed that no scheduled shifts had at least one staff member on-site with current CPR certification from a nationally recognized organization. On 5/19/26 at 9:00 a.m., the residence provided CPR certifications; however, the certifications for staff members #1-#4 had expired as of April 2026. 2. Interview On 5/21/26 at approximately 10:40 a.m., the licensee, along with the administrator designee, stated they were not aware that staff certifications had expired and that a class had not been scheduled to recertify the staff.

Based on record review and interview, the residence failed to ensure a readily available roster of current residents, their room assignments, and emergency contact information, along with a facility diagram showing room locations, affecting 23 current residents. (Cross-reference U0312, U1110, U2722, U2724) Findings include: On 5/19/26 at approximately 8:00 a.m., the roster of current residents, including room assignments and emergency contact information, along with a residence diagram showing room locations, was requested; however, only a list with the resident names and room numbers was provided. On 5/21/26 at 10:45 p.m., the licensee stated that the residence did not have a readily available roster with all required components and that they were unfamiliar with the requirement.

Based on record review and interview, the residence failed to identify the highest potential risk and to hold routine drills to facilitate staff and resident responses to that risk, affecting 23 current residents. (Cross-reference U0312, U1110, U2722, U2724) Findings include: The residence's undated emergency plan failed to include measures to identify its highest potential risk and to hold routine drills to facilitate staff and resident responses to that risk. On 5/19/26 at 8:00 a.m., emergency drill documentation was requested. However, the residence conducted no fire drills. On 5/19/26 at 11:00 a.m., Resident #6 stated that in a fire situation he was unsure what to do. He stated he was told to go to the office or someone would go get him from his room. On 5/19/26 at 2:10 p.m., The administrator designee stated that the residence had been talking about conducting a fire drill so the staff and residents knew what the plan was in an emergency, but one had not been conducted since the residence recently reopened late February 2026. The administrator designee added that Resident #6 had stated previously that he was unsure of what to do in a fire situation. In a later interview on 5/21/26 at approximately 10:45 a.m., the administrator designee stated that a fire drill had not been conducted since the building reopened. She acknowledged there was a need for simulated routine emergency drills to track the response to the risk.

Based on record review and interview, the residence failed to complete a comprehensive pre-admission assessment for each resident prior to admission to ensure the residence accepted only those residents whose needs could be fully met by the existing staff and services of the residence, affecting four of six sample residents (#1, #3, #4 and #6). (Cross-reference U0312, U1110, C0240) Findings include: On 5/19/26 from 12:05 p.m to 4:40 p.m., the residence failed to provide preadmission assessments for Residents #1, #3, #4, and #6. On 4/20/26 at approximately 10:30 a.m., the residence provided assessments for Residents #1, #3, #4, and #6; however, the assessments were dated:Resident #1 was admitted to the residence on 4/15/26. Her assessment was completed on 4/23/26. Resident #3 was admitted to the residence on 2/24/26. His assessment was completed on 2/25/26. Resident #4 was admitted to the residence on 2/23/26. His assessment was completed on 2/27/26. Resident #6 was admitted to the residence on 2/26/26. His assessment was completed on 2/26/26. All four residents were not completed prior to the residents' admission to the residence. On 5/19/26 at approximately 3:45 p.m., the licensee stated he oversees all assessments prior to admission; however, Residents #1, #3, #4, and #6 were not assessed prior to the residents' admissions.

Based on interviews and record reviews, the residence failed to provide personal services and protective oversight affecting 23 current residents. (Cross-reference U0312, U0910, U0918, U2230, U2722, U2724, C0216, C0240)Specifically, Resident #1 smoked cigarettes despite known restrictions and risk of fire, which prompted a response from the local fire authority (LFA) for noncompliance on 5/7/26. The residence failed to implement effective measures to mitigate this risk or ensure the safety of Resident #1 and other residents, and she continued to smoke in her room. The resident had used cigarette butts inside her room and cigarette ashes were on the door leading to the front of the building, rather than in the designated smoking area. Additionally, Resident #1 was brought to urgent care on 5/14/26 for severe swelling and redness in her feet, and the practitioner identified her as at risk for infection and possible amputation. Upon her return, staff failed to follow up on her condition or provide appropriate monitoring. Resident #1 ' s practitioner stated that on 5/18/26 she informed the administrator designee (AD) that Resident #1 needed to be sent out for treatment urgently due to the swelling and redness in her feet following assessment; however, the residence did not send Resident #1 for treatment. Further, Resident #1 barricaded herself in her room and refused all care, and the residence failed to take appropriate actions to address these behaviors or ensure her safety and well-being. This failure created an immediate jeopardy risk to resident safety and protective oversight for Resident #1 due to unaddressed health concerns and 23 current residents residing in the residence due to risk of fire . On 5/20/26, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Resident #1 was admitted to the residence on 4/15/26 with a diagnosis of bipolar disorder and failure to thrive.a. Smoking IndoorsOn 5/19/26 at 1:43 p.m., Resident #1 barricaded herself in her room by placing large items and clutter in front of the door, preventing staff access. Staff #2 attempted to force the door open and was able to partially open it; upon doing so, a strong odor of cigarette smoke came from the resident's room into the hallway. On 5/20/26 during the onsite survey, several cigarette butts and whole cigarettes were inside Resident #1 ' s room near the door leading to the front patio. Ashes from cigarettes were also outside Resident #1 ' s room. An incident report dated 5/7/26, read that that staff observed Resident #1 smoking in her room and outside her door despite repeated directions to use only the designated smoking area. Resident #1's room location is near other residents who utilized oxygen creating a significant safety risk. Staff reported Resident #1's room remained cluttered, and she failed to comply with requests to clean it. The resident barricaded her locked door using furniture and personal items, preventing staff access in the event of an emergency. Due to continued noncompliance, staff contacted law enforcement, who responded and spoke with Resident #1 about the importance of adhering to facility rules. The resident was verbally agitated, refused to extinguish her cigarette, and told staff to evict her. The report contained no further follow-up regarding the resident smoking indoors. An incident report dated 5/14/26, read that staff observed Resident #1 ' s feet and ankles remained very red and swollen, with her toes turning purple. Staff encouraged Resident #1 to seek medical care, and she initially agreed to go to the emergency room with staff transport after refusing ambulance services. Upon arrival, Resident #1 became agitated and attempted to leave, but briefly agreed to return after smoking. Hospital staff completed limited testing; however, when additional diagnostic imaging was recommended, Resident #1 refused. Medical staff informed Resident #1 of the riskof infection and possible amputation without further evaluation and treatment. Despite this, Resident #1 declined additional care and requested to return to the residence. The report contained no further follow-up regarding the resident smoking indoors. An undated care plan stated that Resident #1 smoked in her room and required consistent monitoring to ensure her safety and the safety of others. The care plan also identified her room as a hazard and directed staff to conduct regular checks to ensure she had not fallen. The care plan had no mention of the current state of her feet along with no interventions. On 5/19/26 at 1:01 p.m., the administrator designee (AD) stated that Resident #1 smoked in her room and that the local police department was contacted in response to one of the situations that occurred on 5/7/26.5/19/26 at 1:45 p.m., Staff #2 stated that Resident #1 smoked in her room and barricades herself so that staff can not access her room. On 5/19/26 at 2:14 p.m., Staff #3 stated that Resident #1 smoked in her room and reported that it was challenging to access the room due to Resident #1 barricading the entrance. Resident #9 in the unit next door to Resident #1 also used oxygen at night. b. Unaddressed Health ConcernAn incident report dated 5/13/26, read that staff were notified by another individual that the resident was observed returning from the smoking area with visibly red ankles and feet. Upon assessment, staff observed the resident ' s feet and ankles were red, swollen, and her toes had begun to appear purple. Staff advised the resident to seek medical evaluation; however, the resident refused and became verbally agitated, stating she would not go to the hospital and wanted to be left alone. The resident also refused vital sign assessment. The report contained no further follow-up regarding the health concern. On 5/20/26 at 2:08 p.m., the AD took Resident #1 to the community room where Resident #1's feet and ankles were seen to be bright red and swollen and her toes were dark purple in color. On 5/21/26 at 11:00 a.m., the licensee stated he had not observed Residents #1's feet until 5/20/26 and he was extremely concerned about them and wanted her to be evaluated by the emergency department. On 5/20/26 at 3:56 p.m., Resident #1 ' s practitioner stated that on 5/18/26 she informed the administrator designee that Resident #1 needed to be sent out for treatment urgently due to swelling and redness in her feet following her assessment. On 5/20/26 at approximately 3:30 p.m., Resident #1's practitioner stated she needed an ED to be evaluated properly. She added that Resident #1 needed medication to treat her symptoms but would not be able to tolerate the meds due to how thin Resident #1 was, along with her lack of muscle and lack of nutrition. She also stated that Resident #1 needed a higher level of care than what the residence was able to provide. 4. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The survey established that the findings above placed one current resident at immediate jeopardy risk for the residence not providing protective oversight. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.10 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/20/26 at 2:08 p.m., the licensee submitted written evidence that read in pertinent part: "We have reached out to the resident's long term case worker to request an urgent care conference for Rights Modification to have all smoking materials removed from her room and person. If she refused Right Modification then the residence will issue immediate safe discharge. We will place resident on 15 mins checks effective immediately and if that does not help or fail then we will provide a one-on-one sitter with resident to ensure safety and compliance with all house rules. If the resident does not comply we will issue a 30 day notice. Residence has reached out to the resident's medical provider, who said the resident is not in acute distress but gave us permission to call 911 for the resident to seek immediate medical care. However, the written evidence did not demonstrate that the risk had been adequately mitigated, as it lacked an acceptable monitoring of the resident, did not address how the resident ' s care would be provided if she continued to refuse to follow house rules, and did not describe coordination of care. The plan also failed to include timelines for staff training, methods for documenting and implementing each required element, and did not include dates and times the residence would begin implementation. The plan provided no evidence that the resident's practitioner stated that the issue was not acute, and the statement contradicted a later interview with the practitioner. Additionally, it did not address protections to ensure resident safety during a potential 30-day discharge process. The licensee was directed to submit additional written evidence. On 5/20/26 at 4:31 p.m., the licensee submitted written evidence that read in pertinent part: "The licensee of (residence) and administrator designee (AD) have reached out to the resident's long term caseworker by phone on 05/20/2026 at 3pm, to request an urgent care conference for Rights Modification to have all smoking materials removed from her room. (residence's address and Resident #1's room number) . The case manager has agreed to write the Modification and connect with the licensee and administrator designee on 5/21/2026 by 4pm. The AD will then give the Rights modification to the resident to review and sign to put it in place by 5/21/2026, 5pm. (The residence) has reached out to the residents' medical provider and advised (the residence) to call 911 for the resident to seek immediate medical care. The resident refused treatment from emergency medical services (EMS) called on 5/20/2026 around 3pm. The AD will call (community mental health emergency response team) to have the resident evaluated on 5/20/2026, 4:20pm. The AD will place Resident #1 on 15 mins checks from (residence) staff, effective immediately. If that does not help or fails then the AD will provide a one-on-one sitter from the (residence) staff or (home care agency) staff for the resident to ensure safety and compliance with all house rules. If the resident refuses the Rights Modification changes then the (residence) will issue immediate safe discharge by 5/21/2026 6pm. Please see attached staff training plan for all (residence) staff. The AD will provide training to all staff assigned or on shift with the resident before the start of shift, all staff will be educated within the next 24hours, 5/21/2026. 4p.m."However, the written evidence did not demonstrate that the risk had been adequately mitigated, as it lacked the coordination of a safe discharge if required and how the residence monitored other residents found smoking in their rooms. The licensee was directed to submit additional written evidence. On 5/20/26 at 5:55 p.m., the licensee/operator submitted written evidence that read in pertinent part: "The (resident's) caseworker agreed to complete the modification and follow up with the licensee and AD on 05/21/2026 by 4:00 p.m. The AD planned to present the Rights Modification to the resident for review and signature to implement it by 05/21/2026 at 5:00 p.m. The caseworker advised the facility to call 911 for immediate medical evaluation. The resident refused treatment from EMS on 05/20/2026 at approximately 3:00 p.m. The caseworker planned to return on 05/22/2026 to assess the resident. The AD initiated coordination with (community mental health emergency response team) on 05/20/2026 at 4:20 p.m. A smoking monitoring plan was initiated on 05/20/2026, which included increased monitoring of smoking behaviors, staff notification procedures, and progressive corrective actions for noncompliance, including verbal warnings, written warnings, behavioral contracts, and Rights Modifications in coordination with case management. The plan further stated that continued noncompliance could result in an involuntary 30-day safe discharge in accordance with facility policy. The facility also indicated that transportation and referrals would be provided as part of discharge planning."On 5/20/26 at 6:30 p.m., the plan of correction was accepted.

Based on the interview and record review, the residence failed to ensure staff documented in progress notes all out-of-the-ordinary events or issues that affect the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address the resident's changing needs, affecting 23 current residents. Findings included: On 5/19/26 at approximately 8:00 a.m., resident progress notes were requested; however, the residence was not able to provide them. On 5/19/26, at approximately 11:00 a.m., Staff #2 stated the residence used a staff communication binder but not daily notes on the residents. Staff #2 stated she was unable to locate the communication binder.

Based on observation and interview, the residence failed to ensure a sufficient supply of hot water during peak usage demand to meet the needs of the residents, affecting three of three sample residents (#7, #8, #20) who resided on the south side of the residence. (Cross-reference U0312) Findings include: 1. References According to hot water technology for burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing. https://hohwatertechnology.com/blog/3-water-safety-challenges-skilled-nursing-facilities/2. Observation On 5/19/26 at 9:30 a.m., water temperatures throughout the residence were measured after running the water for 2 minutes. The second-floor shower read 101 degrees Fahrenheit (F). The sink read 91 degrees (F). The sink on the first floor read 68 degrees (F). On 5/20/26 at 1:30 p.m., the following temperatures read: The first-floor shower read 99.5 degrees F and 77.2 degrees F.The second-floor shower read 86.4 degrees F and 98.8 degrees F. The third-floor shower read 95.5 degrees F and 116.3 degrees F. 3. Interviews On 5/19/26 at 9:00 a.m., the administrator designee stated the residence had been having hot water issues and was in need of a new hot water heater or one of them to be repaired. She added that residents have been telling the staff that the showers have been cold for weeks. On 5/19/26 at approximately 9:45 a.m., the licensee stated the residence did not have any issues with anything and that everything had been functioning normally. On 5/19/26 at 10:38 a.m., Resident #6 stated the hot water had not been working for a few weeks. Resident #7 stated there were no hot showers, and it had been cold. On 5/19/26 at 12:30 p.m., Resident #8 stated he had to go up to the second floor to find a warm shower, as the one on the first floor by his unit was too cold. On 5/21/26 at approximately 11:30 a.m., the licensee stated he was aware of the need for a new hot water heater. He stated the pilot light kept needing to be relit and that it had not been working very well. He added the water feltwarm to the touch, but stated he did not take the temperature of the water.

Based on observations, record review, and interviews, the residence failed to ensure the outdoor smoking area was monitored when residents were present, affecting 23 current residents. (Cross-reference U0312, U1110, U2724) Findings Include:Observations of the designated smoking area (DSA) on 5/19/26 at approximately 8:15 a.m., again at 10:00 a.m., and again at 2:00 p.m., revealed as follows:Multiple different residents were observed smoking. No staff were present at either time. On 5/19/26 at approximately 8:30 a.m., Staff #1 stated they had never been told they needed to monitor residents when residents were present in the DSA. They stated they had never done so. On 5/20/26 at approximately 4:00 p.m., Staff #2 stated they use cameras to monitor the residents in common areas; however, there was no camera in the DSA.On 5/21/26 at approximately 11:00 a.m., the administrator designee, along with the licensee, confirmed that no official process was in place to monitor the DSA. They stated they were unaware of the state regulation and confirmed that the residence did not monitor the DSA.

Based on observation and interview, the residence failed to ensure it had a fire-resistant waste disposal container in the designated smoking area, affecting 23 current residents. (Cross-reference U0312, U1110, U2722)Findings include: On 5/19/26, during an environmental tour at 8:05 a.m., the residence grounds revealed a cigarette wastebasket in the designated smoking area that was not fire-resistant, three residents were observed smoking in the area. The grounds were also covered with cigarette butts around the area. On 5/19/26 at approximately 2:10 p.m., the administrator designee stated she was not aware that the wastebasket in the designated outdoor smoking area was not fire-resistant and acknowledged the need for one.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.22.24 Toilet paper in a dispenser, liquid soap, and paper towels or hand drying devices shall be available at all times in each common bathroom.

A complaint revisit was completed on 2/3/26 for all previous deficiencies cited on 5/13/25. The residence is in compliance with all regulations surveyed.

A complaint revisit was completed on 2/3/26 for all previous deficiencies cited on 5/13/25. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.

On-site revisit of to the 5/09/2025 survey was completed on 01/29/2026. The facility was in compliance with the regulation surveyed.

A life safety code survey, prompted by #CO39958, was completed on 5/09/2025. Five deficiencies were cited. The facility is a one (3) story, Type V (000) wood frame structure with a basement and licensed for fifty-five (55) residents. The facility is not equipped with a fire suppression system. This survey, conducted on May 9, 2025, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities.

Based on observation and interviews, it was determined that the facility failed to implement a smoking policy in accordance with the Life Safety Code 101. The deficient practice affected all smoke compartments, 51 of 51 residents, and indeterminable number of staff and visitors. During an interview and observation with the facility owner, evidence of smoking was discovered in the building's basement, in rooms 350 and 302, on the sun patio, and on the second-floor deck. The owner acknowledged the evidence smoking was present the basement; room 302 and 350; the sun patio; and on the second floor deck. 33.7.4 Smoking. 33.7.4.1* Smoking regulations shall be adopted by the administration of board and care occupancies. 33.7.4.2 Where smoking is permitted, noncombustible safety-type ashtrays or receptacles shall be provided in convenient locations. COLORADO CLEAN INDOOR AIR ACTARTICLE 14, TITLE 25, C.R.S(7) "Entryway" means the outside of the front or main doorway leading into a building orfacility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includesthe area of public or private property within a specified radius outside of the doorway. Thespecified radius may be determined by the local authority pursuant to section 25-14-207 (2)(a),but must be at least twenty-five feet unless section 25-14-207 (2)(a)(II)(B) or (2)(a)(II)(C)applies. If the local authority has not acted, the specified radius is twenty-five feet. The deficient items were discussed with the building owner during the exit conference.

Based on observation, interview, and record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 Section 9.6 and NFPA 72. The deficient practice affected all smoke compartments, 51 of 51 residents, and an indeterminable number of staff and visitors. The facility was observed with the building owner. The following concerns were identified:1. The fire alarm panel revealed seven problems with the system. 2. The fire alarm was not programmed correctly and the supervisory alarms did not direct one to the correct location. 3. The fire panel has never been inspected. 4. The fire alarm strobes and heat detectors hanging from the ceiling on the second and third floors were not functioning and multiple fire alarm strobes were missing throughout the facility. The building owner acknowledged the above observations related to the fire panel problems, programming malfunction, lack of fire panel inspection, and non-compliance with the heat detectors and strobes. Record review of the state life safety plan review database revealed the building's fire alarm panel had not been submitted for plans review prior to replacement. The fire alarm panel was not approved. 33.3.3.4.2 Initiation. The required fire alarm system shall be initiated by each of the following means:(1)Manual means in accordance with 9.6.2, unless there are other effective means (such as a complete automatic sprinkler or detection system) for notification of fire as required(2)Manual fire alarm box located at a convenient central control point under continuous supervision of responsible employees(3)Automatic sprinkler system, other than that not required by another section of this Code(4)Required detection system, other than sleeping room smoke alarms9.6.9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 7210.18.1 Approval and Acceptance. 10.18.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. 10.18.1.2* At the authority having jurisdiction ' s request, complete information regarding the system or system alterations, including specifications, type of system or service, shop drawings, input/output matrix, battery calculations, and notification appliance circuit voltage drop calculations, shall be submitted for approval. 10.18.1.3 Before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer ' s published instructions and the appropriate NFPA requirements. 10.18.1.4* The record of completion form, Figure 10.18.2.1.1, shall be permitted to be a part of the written statement required in 10.18.1.3. When more than one contractor has been responsible for the installation, each contractor shall complete the portions of the form for which that contractor had responsibility. 10.18.1.5 The record of completion form, Figure 10.18.2.1.1, shall be permitted to be a part of the documents that support the requirements of 10.18.2.4. The deficient items were discussed with the facility owner during the exit conference.

Based on observation and interview, it was determined that the facility failed to arrange and maintain fire doors in accordance with Life Safety Code 101. The deficient practice affected all smoke compartments, 51 of 51 residents, and an indeterminable number of staff and visitors. Observation with the building owner revealed the following:1. The front entrance was locked against egress by a deadbolt. 2. The back door was locked against egress by a deadbolt. 3. The west sun porch was locked against egress by a deadbolt. The building owner acknowledge the three doors were locked against egress with a deadbolt. 33.3.2.2.2 Doors. Doors in means of egress shall be as follows:(1)Doors complying with 7.2.1 shall be permitted.(2)Doors within individual rooms and suites of rooms shall be permitted to be swinging or sliding.(3)No door in any means of egress, other than those meeting the requirement of 33.3.2.2.2(4) or (5), shall be locked against egress when the building is occupied.(4)Delayed-egress locks in accordance with 7.2.1.6.1 shall be permitted.(5)Access-controlled egress doors in accordance with 7.2.1.6.2 shall be permitted.(6)Revolving doors complying with 7.2.1.10 shall be permitted. The deficient items were discussed with the facility owner during the exit conference.

Based on observation and interviews with the facility owner, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 54. The deficient practice affected all smoke compartments, residents, staff and visitors to the facility. A staff member reported smelling a gas odor in the mechanical room. During an interview and observation with the facility owner acknowledge there was gas odor. The owner called a plumber to the facility. Upon inspection of the facility gas piping, the plumber reported the whole gas piping system had leaks at all joints. NFPA 548.1.1.3 Where repairs or additions are made following the pressure test, the affected piping shall be tested. Minor repairs and additions are not required to be pressure tested, provided that the work is inspected and connections are tested with a leak-detecting fluid or approved leak-detecting methods. The facility owner discussed the deficient items during the exit conference.

Based on observation, interview, and record review, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining the life safety code for fire alarm, means of egress, gas code, and smoking policy. The facility failures had the potential to affect all occupant of the building. Findings include:Cross-reference to A0001 for observations and interviews of smoking activities in violation of applicable codes. Cross-reference to A0002 for observation, interview, and record review of the fire alarm panel's malfunction. Cross-reference to A0003 for observations and interviews of failures to meet means of egress requirements. Cross-reference to A0004 for observation and interviews of the facility failure to comply with gas code requirements. The deficient items were discussed with administrator and maintenance director at the exit conference.

A certification complaint, prompted by #CO39034, #CO39950 and #CO39952, was completed on 5/13/25. Deficiencies were cited.

Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 54 current residents. (Cross-reference B808, B1702)Specifically, the residence did not maintain the Colorado Clean Indoor Air Act and residents were not smoking 25 feet from the residence. The residents were also smoking marijuana throughout the residence's property. The residence also had two enclosed smoking areas attached to the building where residents regularly smoked. Multiple residents were found smoking cigarettes and marijuana inside their bedrooms. Additionally, the residence had a gas leak. This failure created an immediate jeopardy risk of harm to all 54 current residents residing in the residence. Findings include:ObservationsOn 5/8/25 at approximately 10:45 a.m., during an environmental tour multiple residents were smoking cigarettes and marijuana in designated non-smoking areas of the residence. These areas included an upper balcony accessible only through specific residents' bedrooms, a wraparound balcony, resident rooms and throughout the residence. On 5/8/25 at approximately 11:15 a.m., during an environmental tour it was observed that the residence had two designated enclosed smoking areas that were attached to the inside of the building, in which residents smoked cigarettes throughout the day. On 5/8/25 at 12:07 p.m., an unidentified resident was smoking marijuana in his room and set the fire alarm off. The resident had cigarette butts and half used joints throughout his room. On 5/8/25 at approximately 12:30 p.m., three unidentified residents were smoking cigarettes on the front porch adjacent to the front door while it was propped open. On 5/8/25 at 4 p.m., an unidentified resident walked down the main set of stairs in the residence smoking a cigarette. On 5/9/25 at approximately 9:00 a.m., during an environmental tour it was observed that multiple residents were smoking cigarettes less than 25 feet from the front door of the residence, they also were throwing their cigarette butts directly on the ground. On 5/9/25 at approximately 10:30 a.m., an unidentified resident was sitting next to the front door, smoking a cigarette beside another unidentified resident who was on oxygen. On 5/9/25 approximately 11:30 a.m., during an environmental tour a strong odor of marijuana was smelled throughout the second and third floors of the residence. On 5/9/25 approximately 1:30 a.m., during an environmental tour two unidentified residents were sitting on the sidewalk outside the residence, smoking a joint of marijuana. On 5/9/25 at 3:51 p.m., during an environmental tour, a strong odor of marijuana was smelled on the second floor but intensified on the third floor. On 5/9/25 at 7:20 p.m., during an environmental tour a candle was burning in a bedroom after the residents had been evacuated. InterviewsOn 5/8/25 at approximately 11:00 a.m., the state fire authorities stated that he had seen cigarette butts inside and outside of the residence including in the basement. On 5/8/25 at approximately 11:10 a.m., Staff #3 stated that staff do not monitor the residents while they are smoking. On 5/8/25 at approximately 11:15 a.m., the state fire authorities stated that the designated smoking area that is located on the west side of the residence did not meet code for a designated smoking area. On 5/9/25 at approximately 10:30 a.m., the administrator acknowledged that he was aware that the residents were not smoking 25 feet from the entrance from the building. He further mentioned that he had been aware that residents were smoking in their rooms. On 5/9/25 at 3:51 p.m., the health and wellness director stated that Resident #6 had been smoking marijuana in his bedroom and that is why there was such a strong odor in the hallways. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed the 54 residents at immediate jeopardy for not maintaining the Colorado Clean Indoor Air Act which increased the likelihood of serious adverse outcomes or criminal charges. With the building having multiple gas leaks, residents smoking cigarettes and marijuana throughout the residence, this puts the residents at a significant risk. The residents were directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/8/25 at 8:46 p.m., the administrator submitted written evidence that read in pertinent part: The residence would be doing 30 minute smoking checks throughout the residence. The smoking checks will be documented and signed for every shift. The residence would also have a third party company who would be doing 15 minute fire checks throughout the residence.

Based on observations, record review, and interview the facility (residence) failed to have a documented contingency plan for providing services if the residence staff was unavailable due to an emergency circumstance, affecting 54 current members (residents). (Cross-reference B164, B1702) Specifically, the residence did not establish clear evacuation procedures. There is no predetermined system for communication with residents, families, staff and external providers, which could lead to confusion and delays in critical situations. Furthermore, the residence did not have signed written documents with other facilities or community agencies in case the residents needed to be relocated. This failure created an immediate jeopardy risk due to a lack of emergency preparedness procedures for all 54 current residents residing in the residence. On 5/9/25, the department directed the residence to provide written evidence that the risk had been removed. Finding include:ObservationsOn 5/8/25 at approximately 2:15 p.m., Resident #1 was observed running up and down the street, visibly agitated and crying. On 5/8/25 at approximately 2:30 p.m., the local police department and fire department showed up and talked with Resident #1 on the corner of the street adjacent to the residence. On 5/8/25 at approximately 5:00 p.m., during the onsite visit, the residence staff were visibly upset and tearful. Subsequently, the residents became agitated, and expressed fear. On 5/9/25 at approximately 9:30 a.m., during the onsite visit, the administrator did not delegate his staff to leave the office space to engage with residents to help with deescalation and personal engagement with the residents who were fearful of being evacuated. On 5/9/25 at approximately 6:30 p.m., Resident #7 had left the residence and went to a local shelter. Record ReviewOn 5/8/25 at approximately 12:15 p.m., the emergency preparedness book was requested. However, the book did not have clear evacuation procedures, predetermined system for communication with residents, families, staff and external providers and the residence did not have signed written documents with other facilities or community agencies in case the residents needed to be relocated. InterviewsOn 5/8/25 at approximately 11:15 a.m., the state fire authorities stated that the building was not safe due to multiple gas leaks and the building needs to be evacuated. On 5/8/25 at approximately 1:00 p.m., the owner stated that he had arrangements with a couple facilities including a hotel in the case of an emergency evacuation. On 5/8/25 at approximately 4:30 a.m., Resident #1 stated that he was scared that the residence was going to explode because of the gas leaks and that is why he was calling emergency services and running up and down the street. He further mentioned that he smelled the gas. On 5/9/25 at 1:30 p.m., the administrator stated that the residence did not have placement secured for all of their residents. The placement that the residence had nearby fell through along with the hotel. The residence did not have any further contracted residences that could relocate the residents without the department's help. The administrator acknowledged that the emergency plan was not effective and lacked critical components of communication, staff assignments and transportation. On 5/9/25 at approximately 6:30 p.m., the administrator stated that he was not aware that Resident #7 had left the residence and went to a shelter. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 54 current residents at immediate jeopardy risk for the residence's failure to have emergency preparedness procedures in place. Additionally, the residence did not have a clear evacuation procedure. There was not a predetermined system for communication with residents, families, staff and external providers. Furthermore, the residence did not have signed written documents withother facilities to relocate residents in case of an evacuation. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/8/25 at 8:46 p.m., the administrator submitted written evidence that read in pertinent part: protocols will be put in place. Fire drills will happen every month including staff meetings to go over procedures. Every new staff member will be walked through the procedures and will be present at the next scheduled fire drill. If an evacuation occurs, residents will be relocated to Havana Tower in which we have a contract with. If they can not accommodate all the residents we will provide hotel rooms for the rest of the displaced residents. On 5/9/25 evacuation for all residents was initiated until the emergency situation with the gas leaks has been resolved and inspection allows for the safe return of the residents.

Based on observation, record review, and interview, the facility (residence) failed to monitor its members to assure health, safety and well-being, affecting 54 current members (residents). (Cross-reference B164, B808)Specifically, on 5/8/25 the residence's fire panel read there was trouble with the system, affecting the smoke detectors throughout the entire residence. Therefore, the smoke detectors were ineffective and would not have sent an accurate signal to the fire panel and its monitoring system to set off the residence's alarm in the event of smoke or fire. The residence also had a significant gas leak issue where gas odor could be smelt throughout the residence. On 5/8/25, the department directed the residence to provide written evidence that the risk had been removed. Additionally, a representative from the local fire authority (LFA) stated that the residence had never had their fire panel tested or inspected hence it had no approval from the LFA. Lastly, the residence's elevator had currently been non operational to the residents with physical impairments. This failure created an immediate jeopardy risk due to a lack of emergency preparedness procedures for all 54 current residents residing in the residence. On 5/9/25, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Protective Oversight and Safe EnvironmentOn 5/8/25 at approximately 1:00 a.m., an environmental tour was conducted. The tour found that the fire panel was located on the south entrance of the residence, and the screen read: "Trouble". The fire panel was found to be non permitted or ever tested and was not fully functional. The fire alarm would sound when detecting smoke but would signal the wrong room of where the smoke was originating from. Hence the panel had a faulty system. The smoke detectors in the basement were not connected to the ceiling but dangling from the connection wires. The basement also had a significant amount of gas build up with a defining smell. The LFA had then placed the residence on fire watch every 15 minutes until the system could be resolved. On 5/8/25 at approximately 2:00 p.m., the LFA along with the local fire department (LFD) had the utility company out to the residence to turn off the gas to the building until the system could be tested and or fixed. The residence had a plumbing company out to test the gas system to determine the amount of gas leaks within the building. The plumbing company determined there were roughly 15 gas leaks within the piping system, from the street of the residence into their boiler room, within the boiler system. The plumbing company stated the gas would need to remain shut down until the system could be fixed. This led to the residence having no heat or running hot water or a way to cook for its residents. On 5/8/25 at approximately 2:15 p.m., while the system was being tested Resident #1 had been very agitated and ran down the street of the residence yelling and stating he was calling emergency services. When emergency services arrived Resident #1 stated he had been scared due to the smell of gas. The residence and the staff had been unaware Resident #1 had been agitated over the situation. On 5/8/25 at approximately 2:30 p.m., the LFA stated per the LFD the residence's elevator had been having operational issues for the past two years and that it would need to be replaced in order to function properly. The LFA stated the residences elevator was currently not working and residents with physical impairments were forced to take the stairs to reach the upper levels of the residence. The LFA also stated the residence's current elevator would not function properly during an emergency situation and the fire door needing to be held open would block the egress path. On 5/8/25 at approximately 2:30 p.m., the LFA stated that the residence's emergency rating scores for its residents were rated impractical, meaning the amount of assistance needed for residents to evacuate the building safely in the event of an emergency. Hence the need for a fire suppression system needing to be installed within the residence. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 54 current residents at immediate jeopardy risk for smoke inhalation and burn injury in the event of a fire for not having a fully functioning fire alarm system. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/8/25 at 7:40 p.m., the owner and operator submitted written evidence that read in part that the residence would continue to conduct fire watch every 15 minutes and that a third party company would be out to the residence to take over that fire watch to ensure the safety of its residents. The residence would also supply extra blankets to the residents as the building would be without heat for the night due to the gas being shut off. The evidence also included a written contract with another residence in case residents needed to be evacuated. If there were not enough rooms the residence would place residents in a local hotel where staff would continue care and administer medications to the residents. It also stated that if residents were to leave the residence or have left the residents to go with family, that list of residents would be provided. On 5/9/25 evacuation for all residents was initiated until the emergency situation with the gas leaks has been resolved and inspection allows for the safe return of the residents.

A licensure complaint, prompted by by #CO39033, #CO39951 and #CO39953, was completed on 5/13/25. Deficiencies were cited.

Based on observations, record review, and interview the residence failed to ensure that the residence's emergency policies included the circumstances and procedures to evacuate the premises, assignment of specific staff duties on each shift using triage to identify the most vulnerable residents, or agreements with other residences in the event of relocation of residents, affecting 54 current residents. (Cross-reference T1110, T2720)Specifically, the residence did not establish clear evacuation procedures. There is no predetermined system for communication with residents, families, staff and external providers, which could lead to confusion and delays in critical situations. Furthermore, the residence did not have signed written documents with other facilities or community agencies in case the residents needed to be relocated. This failure created an immediate jeopardy risk due to a lack of emergency preparedness procedures for all 54 current residents residing in the residence. On 5/9/25, the department directed the residence to provide written evidence that the risk had been removed. Finding include:ObservationsOn 5/8/25 at approximately 2:15 p.m., Resident #1 was observed running up and down the street, visibly agitated and crying. On 5/8/25 at approximately 2:30 p.m., the local police department and fire department showed up and talked with Resident #1 on the corner of the street adjacent to the residence. On 5/8/25 at approximately 5:00 p.m., during the onsite visit, the residence staff were visibly upset and tearful. Subsequently, the residents became agitated, and expressed fear. On 5/9/25 at approximately 9:30 a.m., during the onsite visit, the administrator did not delegate his staff to leave the office space to engage with residents to help with deescalation and personal engagement with the residents who were fearful of being evacuated. On 5/9/25 at approximately 6:30 p.m., Resident #7 had left the residence and went to a local shelter. Record ReviewOn 5/8/25 at approximately 12:15 p.m., the emergency preparedness book was requested. However, the book did not have clear evacuation procedures, predetermined system for communication with residents, families, staff and external providers and the residence did not have signed written documents with other facilities or community agencies in case the residents needed to be relocated. InterviewsOn 5/8/25 at approximately 11:15 a.m., the state fire authorities stated that the building was not safe due to multiple gas leaks and the building needs to be evacuated. On 5/8/25 at approximately 1:00 p.m., the owner stated that he had arrangements with a couple facilities including a hotel in the case of an emergency evacuation. On 5/8/25 at approximately 4:30 a.m., Resident #1 stated that he was scared that the residence was going to explode because of the gas leaks and that is why he was calling emergency services and running up and down the street. He further mentioned that he smelled the gas. On 5/9/25 at 1:30 p.m., the administrator stated that the residence did not have placement secured for all of their residents. The placement that the residence had nearby fell through along with the hotel. The residence did not have any further contracted residences that could relocate the residents without the department's help. The administrator acknowledged that the emergency plan was not effective and lacked critical components of communication, staff assignments and transportation. On 5/9/25 at approximately 6:30 p.m., the administrator stated that he was not aware that Resident #7 had left the residence and went to a shelter. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 54 current residents at immediate jeopardy risk for the residence's failure to have emergency preparedness procedures in place. Additionally, the residence did not have a clear evacuation procedure. There was not a predetermined system forcommunication with residents, families, staff and external providers. Furthermore, the residence did not have signed written documents with other facilities to relocate residents in case of an evacuation. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/8/25 at 8:46 p.m., the administrator submitted written evidence that read in pertinent part: protocols will be put in place. Fire drills will happen every month including staff meetings to go over procedures. Every new staff member will be walked through the procedures and will be present at the next scheduled fire drill. If an evacuation occurs, residents will be relocated to Havana Tower in which we have a contract with. If they can not accommodate all the residents we will provide hotel rooms for the rest of the displaced residents. On 5/9/25 evacuation for all residents was initiated until the emergency situation with the gas leaks has been resolved and inspection allows for the safe return of the residents.

Based on observation, record review, and interview, the residence failed to either directly or indirectly provide protective oversight, personal services and a physically safe and sanitary environment, affecting 54 current residents. (Cross-reference T920, T2720)Specifically, on 5/8/25 the residence's fire panel read there was trouble with the system, affecting the smoke detectors throughout the entire residence. Therefore, the smoke detectors were ineffective and would not have sent an accurate signal to the fire panel and its monitoring system to set off the residence's alarm in the event of smoke or fire. The residence also had a significant gas leak issue where gas odor could be smelt throughout the residence. On 5/8/25, the department directed the residence to provide written evidence that the risk had been removed. Additionally, a representative from the local fire authority (LFA) stated that the residence had never had their fire panel tested or inspected hence it had no approval from the LFA. Lastly, the residence's elevator had currently been non operational to the residents with physical impairments. This failure created an immediate jeopardy risk due to a lack of emergency preparedness procedures for all 54 current residents residing in the residence. On 5/9/25, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Protective Oversight and Safe EnvironmentOn 5/8/25 at approximately 1:00 a.m., an environmental tour was conducted. The tour found that the fire panel was located on the south entrance of the residence, and the screen read: "Trouble". The fire panel was found to be non permitted or ever tested and was not fully functional. The fire alarm would sound when detecting smoke but would signal the wrong room of where the smoke was originating from. Hence the panel had a faulty system. The smoke detectors in the basement were not connected to the ceiling but dangling from the connection wires. The basement also had a significant amount of gas build up with a defining smell. The LFA had then placed the residence on fire watch every 15 minutes until the system could be resolved. On 5/8/25 at approximately 2:00 p.m., the LFA along with the local fire department (LFD) had the utility company out to the residence to turn off the gas to the building until the system could be tested and or fixed. The residence had a plumbing company out to test the gas system to determine the amount of gas leaks within the building. The plumbing company determined there were roughly 15 gas leaks within the piping system, from the street of the residence into their boiler room, within the boiler system. The plumbing company stated the gas would need to remain shut down until the system could be fixed. This led to the residence having no heat or running hot water or a way to cook for its residents. On 5/8/25 at approximately 2:15 p.m., while the system was being tested Resident #1 had been very agitated and ran down the street of the residence yelling and stating he was calling emergency services. When emergency services arrived Resident #1 stated he had been scared due to the smell of gas. The residence and the staff had been unaware Resident #1 had been agitated over the situation. On 5/8/25 at approximately 2:30 p.m., the LFA stated per the LFD the residence's elevator had been having operational issues for the past two years and that it would need to be replaced in order to function properly. The LFA stated the residences elevator was currently not working and residents with physical impairments were forced to take the stairs to reach the upper levels of the residence. The LFA also stated the residence's current elevator would not function properly during an emergency situation and the fire door needing to be held open would block the egress path. On 5/8/25 at approximately 2:30 p.m., the LFA stated that the residence's emergency rating scores for its residents were rated impractical, meaning the amount of assistance needed for residents to evacuate the building safely in the event of an emergency. Hence the need for a fire suppression system needing to be installed within the residence. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 54 current residents at immediate jeopardy risk for smoke inhalation and burn injury in the event of a fire for not having a fully functioning fire alarm system. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/8/25 at 7:40 p.m., the owner and operator submitted written evidence that read in part that the residence would continue to conduct fire watch every 15 minutes and that a third party company would be out to the residence to take over that fire watch to ensure the safety of its residents. The residence would also supply extra blankets to the residents as the building would be without heat for the night due to the gas being shut off. The evidence also included a written contract with another residence in case residents needed to be evacuated. If there were not enough rooms the residence would place residents in a local hotel where staff would continue care and administer medications to the residents. It also stated that if residents were to leave the residence or have left the residents to go with family, that list of residents would be provided. On 5/9/25 evacuation for all residents was initiated until the emergency situation with the gas leaks has been resolved and inspection allows for the safe return of the residents.

Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 54 current residents. (Cross-reference T920, T1110)Specifically, the residence did not maintain the Colorado Clean Indoor Air Act and residents were not smoking 25 feet from the residence. The residents were also smoking marijuana throughout the residence's property. The residence also had two enclosed smoking areas attached to the building where residents regularly smoked. Multiple residents were found smoking cigarettes and marijuana inside their bedrooms. Additionally, the residence had a gas leak. This failure created an immediate jeopardy risk of harm to all 54 current residents residing in the residence. Findings include:ObservationsOn 5/8/25 at approximately 10:45 a.m., during an environmental tour multiple residents were smoking cigarettes and marijuana in designated non-smoking areas of the residence. These areas included an upper balcony accessible only through specific residents' bedrooms, a wraparound balcony, resident rooms and throughout the residence. On 5/8/25 at approximately 11:15 a.m., during an environmental tour it was observed that the residence had two designated enclosed smoking areas that were attached to the inside of the building, in which residents smoked cigarettes throughout the day. On 5/8/25 at 12:07 p.m., an unidentified resident was smoking marijuana in his room and set the fire alarm off. The resident had cigarette butts and half used joints throughout his room. On 5/8/25 at approximately 12:30 p.m., three unidentified residents were smoking cigarettes on the front porch adjacent to the front door while it was propped open. On 5/8/25 at 4 p.m., an unidentified resident walked down the main set of stairs in the residence smoking a cigarette. On 5/9/25 at approximately 9:00 a.m., during an environmental tour it was observed that multiple residents were smoking cigarettes less than 25 feet from the front door of the residence, they also were throwing their cigarette butts directly on the ground. On 5/9/25 at approximately 10:30 a.m., an unidentified resident was sitting next to the front door, smoking a cigarette beside another unidentified resident who was on oxygen. On 5/9/25 approximately 11:30 a.m., during an environmental tour a strong odor of marijuana was smelled throughout the second and third floors of the residence. On 5/9/25 approximately 1:30 a.m., during an environmental tour two unidentified residents were sitting on the sidewalk outside the residence, smoking a joint of marijuana. On 5/9/25 at 3:51 p.m., during an environmental tour, a strong odor of marijuana was smelled on the second floor but intensified on the third floor. On 5/9/25 at 7:20 p.m., during an environmental tour a candle was burning in a bedroom after the residents had been evacuated. InterviewsOn 5/8/25 at approximately 11:00 a.m., the state fire authorities stated that he had seen cigarette butts inside and outside of the residence including in the basement. On 5/8/25 at approximately 11:10 a.m., Staff #3 stated that staff do not monitor the residents while they are smoking. On 5/8/25 at approximately 11:15 a.m., the state fire authorities stated that the designated smoking area that is located on the west side of the residence did not meet code for a designated smoking area. On 5/9/25 at approximately 10:30 a.m., the administrator acknowledged that he was aware that the residents were not smoking 25 feet from the entrance from the building. He further mentioned that he had been aware that residents were smoking in their rooms. On 5/9/25 at 3:51 p.m., the health and wellness director stated that Resident #6 had been smoking marijuana in his bedroom and that is why there was such a strong odor in the hallways. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed the 54 residents at immediate jeopardy for not maintaining the Colorado Clean Indoor Air Act which increased the likelihood of serious adverse outcomes or criminal charges. With the building having multiple gas leaks, residents smoking cigarettes and marijuana throughout the residence, this puts the residents at a significant risk. The residents were directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/8/25 at 8:46 p.m., the administrator submitted written evidence that read in pertinent part: The residence would be doing 30 minute smoking checks throughout the residence. The smoking checks will be documented and signed for every shift. The residence would also have a third party company who would be doing 15 minute fire checks throughout the residence.

A revisit survey was completed on 9/05/24 for all previous deficiencies cited on 7/01/24. 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