GARDENS AT ST ELIZABETH

Tag 0240 - Standards for Hospitals and Health Facilities Ch 2 - General Licensure Standards Part 2. Licensure Process 2.10 Department Oversight 2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities: (A) Individual client records. (B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department. Based on records review andinterviews, the residence failed to provide, upon request, access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities, affecting 92 current residents. (Cross-reference U0540,U0910, U1150, U1604, U2214, U2230, & U3060) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities was provided on survey 4/8/2026 and 4/9/2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents are affected by this deficiency. Access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities was provided on the survey 4/8/2026 and 4/9/2026.3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; Education for Nursing staff will take place for staff to know who to contact, and where information is stored to make future surveys compliant to this regulation. This was completed on 5/7/20264. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director or his/her designee will educate and train staff on identifyingcontacts for survey information and the location of information so it is available and accessible to staff within 2 hours of a request for information from the survey team. The Executive Director or his/her designee will audit the system to ensure two available PCC (point click care) access addresses are set up and available to the Survey team and access is available copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities. The Executive Director or his/her designee will audit 1x per month for three months that the Nursing Leadership Team signatures are correct and up to date indicating by the signatures that those listed have been educated on who to contact and where the information is stored to ensure compliance for the deficiency which will be reported out to the quality assurance performance improvement (QAPI) committee for further review.

Tag 0240 - Standards for Hospitals and Health Facilities Ch 2 - General Licensure Standards Part 2. Licensure Process 2.10 Department Oversight 2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of itsregulatory oversight responsibilities: (A) Individual client records. (B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department. Based on records review andinterviews, the residence failed to provide, upon request, access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities, affecting 92 current residents. (Cross-reference U0540,U0910, U1150, U1604, U2214, U2230, & U3060) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities was provided on survey 4/8/2026 and 4/9/2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents are affected by this deficiency. Access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities was provided on survey 4/8/2026 and 4/9/2026.3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; Education for Nursing staff will take place for staff to know who to contact, and where information is stored to make future surveys compliant to this regulation. This was completed on 5/7/20264. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director or his/her designee will educate and train staff on identifying contacts for survey information and the location of information so it is available and accessible to staff within 2 hours of a request for information from the survey team. The Executive Director or his/her designee will audit the system to ensure two available PCC (point click care) access addresses are set up and available to the Survey team and access is available copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities. The Executive Director or his/her designee will audit 1x per month for three months that the Nursing Leadership Team signatures are correct and up to date indicating by the signatures that those listed have been educated on who to contact and where the information is stored to ensure compliance for the deficiency which will be reported out to the quality assurance performance improvement (QAPI) committee for further review.

Tag 1150 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Resident Care Plan 12.10 Each resident care plan shall: (A) Be developed with input from the resident and the resident's representative; (B) Reflect the most current assessment information; (C) Promote resident choice, mobility, independence and safety; (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs; (E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence's visitation policy as required by Part 9.2, along with care coordination arrangements; and (F) Identify formal, planned, and informal spontaneous engagement opportunities that match the residents personal choices and needs. Based on record review and interviews, the residence failed to ensure each resident's care plan promoted resident choice, mobility, independence and safety; detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs; and identified all external service providers, affecting 92 current residents. (Cross-reference C0240, U0540, U0920, U2214, U2230, U3060, & U3092) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Each resident's care plan in Assisted Living to be reviewed and updated, where necessary, to promote residentchoice, mobility, independence and safety; detailing specific personal service needs and preferences along with the staff tasks necessary to meet those needs. This to be completed within 60 days or less. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents in the assisted living facility were affected by the deficient practice. Each resident's care plan in Assisted Living was reviewed and updated, where necessary, to promote resident choice, mobility, independence and safety; detailing specific personal service needs and preferences along with the staff tasks necessary to meet those needs. This to be completed within 60 days or less. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Nursing Director or their designee will review and update all resident care plans in the assisted Living facility every twelve months or upon change of condition. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Director of Nursing or their designee will audit 5 resident care plans per month for 6 months to ensure 100 percent completion to ensure compliance for thedeficiency, the results will be reported out to the quality assurance performance improvement (QAPI) committee for further review or instruction.

Tag 1604 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Record Keeping 14.31 The ExecutiveDirector and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated andresolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. Based on record review and interviews, the residence failed to record review and interviews the ExecutiveDirector and qualified medication administration person (QMAP) supervisor failed to audit the accuracy and completeness of the medication administration record (MAR), controlledsubstance list (CSL), medication error reports, (MERs), and medication disposal records (MDRs), affecting all 92 current residents. (Cross-reference C0240, U0540, U1600, & U2214) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; All residents were affected by this deficient practice. We did audit the accuracy and completeness of the medication administration record (MAR), controlled substance list (CSL), medication error reports, (MERs), and medication disposal records (MDRs) on 5/9/2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents were affected by this deficient practice. We did an audit on the accuracy and completeness of the medication administration record (MAR), controlled substance list (CSL), medication error reports, (MERs), and medication disposal records (MDRs) on 5/7/2026 reviewing and updating as needed. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Executive Director or their designee will perform the audits of the MAR at the quarterly quality assurance performance improvement (QAPI) meetings as the schedule for ensuring they get completed in a timely manner. The Executive Director will also place on their calendar the quarterly assessment schedule as a second reminder. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director or their designee will monitor and review on a quarterly basis the accuracy and completeness of the medication administration record (MAR), controlled substance list (CSL), medication error reports, (MERs), andmedication disposal records (MDRs) with a QMAP. We will perform this function once every month for three months and then quarterly once we have achieved 100 percent compliance. The results of the audit will get reported out to our QAPI committee for further review and /or instructions.

Tag 2230 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 18 - RESIDENT HEALTH INFORMATION RECORDS - Content 18.8 Resident records shall contain,but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issuethat affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's. Based on record review, and interviews, the residence failed to ensure resident records contained progress notes of any out of the ordinary event or issue that affects a resident's status documented prior to the end of each shift, as well as documentation of ongoing services provided by external service providers, affecting three of 11 sample residents (#4, #7, #18) (Cross-reference C0240, U0540, U1150, U1600, U2214, &U3060) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; For residents 4#, #7 and #18 the Nurse Director or designee have reviewed the current process and have implemented systemic changes to ensure compliance with needed documentation including progress notes before the end of shift related to noted changes of condition or out of ordinary events. Training with current staff on the documentation requirements is in progress to be completed by May 15th, 2026. Notice has been given to outside providers, ie therapy, etc that documentation of services is required to be provided to The Gardens at St. Elizabeth for AL and memory care residents. This was completed on April 15th 2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All resident have the potential to be affected by the deficient practice. Nurse Director will review progress notes daily during scheduled work days for needed followup. Out of ordinary events will be reviewed daily during the scheduled work week by the director of nursing (DON) or designee for followup along with progress notes. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Nursing Director or their designee will review all charting from the previous day during the scheduled work week to ensure all progress notes and change of conditions are documented and followed up on in a timely manner. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Nurse Director or their designee, while transitioning to all electronic charting will review paper charting and compare to progress notes daily during scheduled work days looking for any missed documentation and follow up as needed. Once full transition to electronic charting is completed, DON or designee will review the electronic charting daily during scheduled work days for any further needed follow up or missing documentation. DON or designee will audit all documented events against progress notes to ensure compliance with the needed documentation daily during scheduled work days for 1 month, then weekly for 2 months for reach 100% compliance. DON or designee will audit once monthly for 3 months for needed documentation from outside vendors for AL and Memory Care residents. The results will be reviewed at our QAPI committee meeting for further review or instructions.

Tag 3060 - Based on records review and interviews, the residence failed to ensure each resident in the secure environment (SE) had care plans that described the resident's wandering patterns and known behavioral expressions, along with individualized approaches to beimplemented by staff to protect the resident and others from whom they have contact, identify the type and level of staff oversight, monitoring, and accompaniment, and documentation affecting three of five sample residents who resided in the secured environment (#4, #7, #8).(Cross-reference C0940, U0540, U0920, U1150, U2214, U2230, & U3092) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; The Director of Nursing or designee audited all memory care care plans and updated the care plans including wandering patterns, behavioral expressions and individualized approaches to be implemented by staff to protect the resident. This to be completed by May 15th 2026.2. How you will identify other residents having the potential to be affected by then same deficient practice and what corrective action will be taken; All residents in the memory care unit may be affected by this deficient practice. The Director of Nursing or designee audited all memory care care plans and updated the care plans including wandering patterns, behavioral expressions and individualized approaches to be implemented by staff to protect the resident. This to be completed by May 15th 2026.3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Nursing Director or their designee will review and update all residents in the memory care every six months on all residents in memory care. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Nursing Director or their designee will audit five residents care plans per month for 6 months to achieve 100 percent completion to ensure compliance for thedeficiency, the results will be reported out to the quality assurance performance improvement (QAPI) committee for further review or instruction.

Tag 0240 - Standards for Hospitals and Health Facilities Ch 2 - General Licensure Standards Part 2. Licensure Process 2.10 Department Oversight 2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of itsregulatory oversight responsibilities: (A) Individual client records. (B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department. Based on records review andinterviews, the residence failed to provide, upon request, access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities, affecting 92 current residents. (Cross-reference U0540,U0910, U1150, U1604, U2214, U2230, & U3060) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities was provided on survey 4/8/2026 and 4/9/2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents are affected by this deficiency. Access to copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities was provided on survey on 4/8/2026 and 4/9/2026.3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; Education for Nursing staff will take place for staff to know who to contact, and where information is stored to make future surveys compliant to this regulation. This was completed on 5/7/20264. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director or his/her designee will educate and train staff on identifying contacts for survey information and the location of information so it is available and accessible to staff within 2 hours of a request for information from the survey team. The Executive Director or his/her designee will audit the system to ensure two available PCC (point click care) access addresses are set up and available to the Survey team and access is available copies of individual client records, reports, and other information required by the Department for the performance of its regulatory oversight responsibilities. The Executive Director or his/her designee will audit 1x per month for three months that the Nursing Leadership Team signatures are correct and up to date indicating by the signatures that those listed have been educated on who to contact and where the information is stored to ensure compliance for the deficiency which will be reported out to the quality assurance performance improvement (QAPI) committee for further review.

Tag 0540 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES (ALR) PART 6 - EXECUTIVE DIRECTOR - Duties 6.8 The Executive Director, or individual appointed as an interim Executive Director, shall be responsible for the overall day-to-day operation of theassisted living residence, including, but not limited to: (A) Managing the day-to-day delivery of services to ensure residents receive the care that is described in the resident agreement, the comprehensive resident assessment, and the resident care plan; (B) Organizing and directingthe assisted living residence's ongoing functions including physical maintenance; (C) Ensuring that resident care services conform to the requirements set forth in Part 12 of this chapter; (D) Employing, training, and supervising qualified personnel; (E) Providing continuing education for all personnel; (F) Establishing and maintaining a written organizational chart to ensure there are well-defined lines of responsibility and adequate supervision of all personnel; (G) Reviewing the marketing materials and information published by an assisted living residence to ensureconsistency with the services actually provided by the ALR; (H) Managing the business and financial aspects of the assisted living residence which includes working with the licensee to ensure there is an adequate budget to provide necessary resident services; (I) Completing, maintaining, and submitting all reports and records required by the Department; (J) Complying with all applicable federal, state, and local laws concerning licensure and certification; (K) Ensuring the assisted living residence's compliance with the involuntary discharge requirements, and these rules. Based on observations, record review, and interviews, the residence failed to have a qualified Executive Director or individual appointed asan interim Executive Director responsible for the overall day-to-day operations, affecting 92 current residents. (Cross-reference C0240, U0910, U0920, U1150, U1600, U1604, U2214,U2230, U3060, & U3092) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; An interim Executive Director was hired and started on April 9th , 2026. A permanent replacement will be hired soon. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have been affected by this deficient practice. An interim Executive Director was hired and started on April 9th , 2026. A permanent replacement will be hired soon. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; If and when an Executive Director leaves employment at the gardens at St. Elizabeth an interim or permanent hire will be scheduled to follow and take possession as the Executive Director of record the first day after the current Executive Director’s last day of employment. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director (ED) or his/her designee will work with the corporate vice president to ensure there is coverage for operations by a qualified individual to assume the role of Executive Director for the facility. The Executive Director or his/her designee will audit monthly x 3 months to ensure that both the current ED and designee are aware of the need for at least one of these designated leaders to be available physically to The Gardens at St. Elizabeth in Denver to ensure compliance for the deficiency which will be reported out to the quality assurance performance improvement (QAPI) committee for further review.

Tag 0910 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 10 - EMERGENCY PREPAREDNESS - Emergency Policies and Procedures 10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. Based on record review and interviews, the residence failed to have a readily available roster of current residents, their room assignments, and emergency contact information, affecting 92 current residents. (Cross-reference C0240, U0540 & U0920) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Access to copies of roster of current residents, their room assignments, and emergency contact information roster ofcurrent residents required by the Department for the performance of its regulatory oversight responsibilities was provided during the survey on 4/8/2026 and 4/9/2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents are affected by this deficiency. Access to copies roster of current residents, their room assignments, and emergency contact information for current residents required by the Department for the performance of its regulatory oversight responsibilities was provided during the survey on 4/8/2026 and 4/9/2026.3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; Education for Nursing staff for staff to know who to contact, and where information is stored to make future surveys compliant to this regulation. This was completed 5/7/26.4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director or his/her designee will educate and train staff on identifying contacts for survey information and the location of information so it is available and accessible to staff within 2 hours of a request for information from the survey team. The Executive Director or his/her designee, will audit the process to ensure access to the roster of current residents, their room assignments, and emergency contact information for current residents required by the Department for the performance of its regulatory oversight responsibility. The Executive Director or his/her designee will audit 1x per month for three months that the Nursing Leadership Team signatures are correct and up to date indicating by the signatures that those listed have been educated on where and how to access the Resident Listing Report to ensure compliance for the deficiency which will be reported out to the quality assurance performance improvement (QAPI) committee for further review.

Tag 0920 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 10 - EMERGENCY PREPAREDNESS - Emergency Policies and Procedures 10.6 Each assisted living residence's emergency policies shall address, at a minimum, all of the following items: (A)Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations; (B) A schematic plan of the building or portions thereof placedvisibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; (C) When to evacuate the premises and the procedure for doing so; (D) A pre-determined means of communicating with residents, families, staff and other providers; (E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; (F) Storage and preservation ofmedications; (G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; (H) Protection and transfer of health information as needed to meet the care needs of residents; and (I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. Based on observations, interviews, and record review, the residence failed to ensure the assignment of specific tasks and responsibilities to the staff members on each shift, including the use of a triage system to assess the needs of the most vulnerable residents first, particularly having no plan for evacuation of residents who require two-person assistance for evacuation from the second and third floors, affecting all 92 current residents. (Cross-reference U0540, U0910, U1150, U3060)Specifically, no staff members could state the procedure for using a triage system to assess the needs of the most vulnerable residents first during an evacuation; nor could residence staff speak on how to evacuate two residents in wheelchairs on the second and third floors who required two-person assistance for evacuation in the event of an emergency when the elevators were inoperable. Further, there were no egress devices available on the second or third floors. This failure created an immediate jeopardy risk of serious injury or death to all 92 residentsresiding in the residence. On 4/7/26, the department directed the residence to provide written evidence that the risk had been removed. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Modified current policies as necessary to ensure appropriate procedures are in place to prevent harm. Educated allstaff on 4/8/2026 on evacuation procedures including return demonstration where appropriate. Video education for all staff in the proper use of Med Sleds. Purchase of 6 additional sleds and installation hardware for the building was purchased 4/30/2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents are affected by the deficient practice. Modified current policies as necessary to ensure appropriate procedures are in place to prevent harm. Educated all staff on 4/8/2026 on evacuation procedures including return demonstration where appropriate. Video education for all staff in the proper use of Med Sleds. Purchase of 6 additional sleds andinstallation hardware for the building was purchased 4/30/2026.3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does notrecur; Educated all staff on 4/8/2026 on evacuation procedures including return demonstration where appropriate. Video education for all staff in the proper use of Med Sleds. These educations will be incorporated into the orientation process in the future. Purchase of 6 additional Med sledsand installation hardware for the building was purchased 4/30/2026.4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director or his designee will ensure the installation of Med sleds is completed within 60 days. The Executive Director or his/her designee, will audit the orientation process to ensure evacuation education and Med Sled education is completed 1x per month for 3 months to ensure 100 percent completion to ensure compliance for the deficiency which the results will be reported out the to quality assurance performance improvement (QAPI) committee for further review or instruction.

Tag 1150 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Resident Care Plan 12.10 Each resident care plan shall: (A) Be developed with input from the resident and the resident's representative; (B) Reflect the mostcurrent assessment information; (C) Promote resident choice, mobility, independence and safety; (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs; (E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence's visitation policy as required by Part 9.2, along with care coordination arrangements; and (F) Identify formal, planned, and informal spontaneous engagement opportunities that match the residents personal choices and needs. Based on record review and interviews, the residence failed to ensure each resident's care plan promoted resident choice, mobility, independence and safety; detailed specific personal serviceneeds and preferences along with the staff tasks necessary to meet those needs; and identified all external service providers, affecting 92 current residents. (Cross-reference C0240, U0540, U0920, U2214, U2230, U3060, & U3092) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Each resident's care plan in Assisted Living to be reviewed and updated, where necessary, to promote resident choice, mobility, independence and safety; detailing specific personal service needs andpreferences along with the staff tasks necessary to meet those needs. This to be completed within 60 days or less. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents in the assisted living facility were affected by the deficient practice. Each resident's care plan in Assisted Living was reviewed and updated, where necessary, to promote resident choice, mobility, independence and safety; detailing specific personal service needs andpreferences along with the staff tasks necessary to meet those needs. This to be completed within 60 days or less. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Nursing Director or their designee will review and update all resident care plans in the assisted Living facility every twelve months or upon change of condition. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Director of Nursing or their designee will audit 5 resident care plans per month for 6 months to ensure 100 percent completion to ensure compliance for thedeficiency, the results will be reported out to the quality assurance performance improvement (QAPI) committee for further review or instruction.

Tag 1600 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Record Keeping 14.29 All prescribedand PRN (as needed)medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, anyknown allergies, and the name and telephone number of the resident's authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time ofadministration, any special considerations related to administration, and the signature or initial of the person administering the medication. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing therecord for medication administration, along with each of their signatures and, if used, their initials. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event iscompleted for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses tomedications. Based on records review and interviews, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration event (MAE) in the medication administration record (MAR), affecting four ofeight residents' whose MARs were reviewed (#4, #7, #8, and #18). (Cross-reference C0240, U0540, U1604, & U2214) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; For residents 4, 7, 8, and 18 we contacted family and their Physicians to inform them of the missed medication and followed and doctor’s instruction on 5/7/2026. We educated all qualified medication administration personnel (QMAP) on accurately documenting each medication administration events (MAE) in the medicationadministration record (MAR). This was completed between April 17th and April 23rd 2026 with new hires being added and trained with onboarding. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have the potential to be affected by the deficient practice. We educated all qualified medication administration personnel (QMAP) on accurately documenting each medication administration events (MAE) in the medication administration record (MAR). This was completed between 4/17/26 and 4/23/26 with new hires being added and trained with onboarding. We adopted a new process to verify, at shift change, allmedications were distributed, with an audit function by the Director of Nursing or their designee to ensure compliance. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The systematic change is we will have the QMAPs verify the medication pass during shift change to ensure all medications were given and documented appropriately. The Director of nursing will monitor this process and audit reports twice a week to ensure this process is hardwired into operations. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Nurse Director or their designee will educate/train all QMAPs on this new verification process. The Nurse Director or their designee will audit the process twice a week for 3 months to ensure 100 percent compliance with medication pass and documentation deficiency. The results will be reported out to our quality assurance performance improvement (QAPI) committee for further review or instructions.

Tag 1604 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Record Keeping 14.31 The ExecutiveDirector and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated andresolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. Based on record review and interviews, the residence failed to record review and interviews the ExecutiveDirector and qualified medication administration person (QMAP) supervisor failed to audit the accuracy and completeness of the medication administration record (MAR), controlled substance list (CSL), medication error reports, (MERs), and medication disposal records (MDRs), affecting all 92 current residents. (Cross-reference C0240, U0540, U1600, & U2214) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; All residents were affected by this deficient practice. We did audit the accuracy and completeness of the medication administration record (MAR), controlled substance list (CSL), medication error reports, (MERs), and medication disposal records (MDRs) on 5/9/2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents were affected by this deficient practice. We did an audit on the accuracy and completeness of the medication administration record (MAR), controlled substance list (CSL), medication error reports, (MERs), and medication disposal records (MDRs) on 5/7/2026 reviewing and updating as needed. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Executive Director or their designee will perform the audits of the MAR at the quarterly QAPI meetings as the schedule for ensuring they get completed in a timely manner. The Executive Director will also place on their calendar the quarterly assessment schedule as a second reminder. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Executive Director or their designee will monitor and review on a quarterly basis the accuracy and completeness of the medication administration record (MAR), controlled substance list (CSL), medication error reports, (MERs), andmedication disposal records (MDRs)with a QMAP. We will perform this function once every month for three months and then quarterly once we have achieved 100 percent compliance. The results of the audit will get reported out to our quality assurance performance improvement (QAPI) committee for further review and /or instructions.

Tag 2214 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES (ALR) PART 18 - RESIDENT HEALTH INFORMATION RECORDS - General 18.3 Each assisted living residenceshall implement a policy and procedure for an effective information management system that is either paper-based or electronic. If the ALR maintains both paper-based and electronic records, there shall be a method for integration of those records that allows effective continuity of care. Processes shall include effective management for capturing reporting, processing, storing and retrieving care/service data and information. Based on observations, records review, andinterviews, the residence failed to implement a policy and procedure for an effective information management system (IMS) for capturing, reporting, processing, storing, and retrieving care andservices data and information, affecting 92 current residents. (Cross-reference C0240, U0540, U0910, U1150, U1600, U1604, U2230, & U3060) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; All residents were affected by this deficient practice. We currently are opening the POC (point of care) module in PCC (point click care) to allow staff to document and review information in the resident electronic charts. We will continue to use paper charts in a binder on the floor until everyone is trained on the computer systems. There are currently 47 Nursing employees with the exception of thedirector of nursing (DON). The qualified medication administration persons (QMAPs) have access to POC along with access to PCC. 31/47 of the employees are QMAPs, there are 5 nurses out of 47 employees who have access to both PCC and POC and 12 care partners. The care partners are the ones who require training and access on POC. We are currently in the process of training and obtaining their access, many have been trained already, few are left to be trained and half of the care partners have access. The other half are pending their POC access. This training and transition to POC electronic documentation to be completed by June 1, 2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents were affected by this deficient practice. We currently are opening the POC module in PCC to allow staff to document and review information in the resident electronic charts. We willcontinue to use paper charts in a binder on the floor until everyone is trained on the computer systems. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; Once floor staff members are trained on electronic records we will always have current access to all the information the floor staff will need to perform their duties. As a back up, we will have the updated paper copies in a binder on the floor in case of power outages monthly for staffreference. All new care staff will get trained during orientation on the POC system in PCC and where to find the Binders. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Nurse Director or their designee will audit access for POC for all floor staff 1x a month for three months to ensure 100 compliance for the deficiency. The results will beshared at the QAPI committee meeting for further input or instruction.

Tag 2230 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 18 - RESIDENT HEALTH INFORMATION RECORDS - Content 18.8 Resident records shall contain,but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's. Based on record review, and interviews, the residence failed to ensure resident records contained progress notes of any out of the ordinary event or issue that affects a resident's status documented prior to the end of each shift, as well as documentation of ongoing services provided by external service providers, affecting three of 11 sample residents (#4, #7, #18) (Cross-reference C0240, U0540, U1150, U1600, U2214, & U3060) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; For residents 4#, #7 and #18 the Nurse Director or designee have reviewed the current process and haveimplemented systemic changes to ensure compliance with needed documentation including progress notes before the end of shift related to noted changes of condition or out of ordinary events. Training with current staff on the documentation requirements is in progress to be completed by May 15th, 2026. Notice has been given to outside providers, ie therapy, etc that documentation of services is required to be provided to The Gardens at St. Elizabeth for AL and memory care residents. This was completed on April 15th 2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All resident have the potential to be affected by the deficient practice. Nurse Director will review progress notes daily during scheduled work days for needed followup. Out of ordinary events will be reviewed daily during the scheduled work week by the director of nursing (DON) or designee for followup along with progress notes. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Nursing Director or their designee will review all charting from the previous day during the scheduled work week to ensure all progress notes and change of conditions are documented and followed up on in a timely manner. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Nurse Director or their designee, while transitioning to all electronic charting will review paper charting and compare to progress notes daily during scheduled work days looking for any missed documentation and follow up as needed. Once full transition to electronic charting is completed, DON or designee will review the electronic charting daily during scheduled work days for any further needed follow up or missing documentation. DON or designee will audit all documented events against progress notes to ensure compliance with the needed documentation daily during scheduled work days for 1 month, then weekly for 2 months for reach 100% compliance. DON or designee will audit once monthly for 3 months for needed documentation from outside vendors for assisted living (AL) and Memory Care residents. The results will be reviewed at the QAPI committee for further review and instructions.

Tag 2814 - 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 23 - ENVIRONMENTAL PEST CONTROL 23.3 Screens or other pest control measures shall beprovided on all exterior openings except, where prohibited by fire regulations. Assisted living residence doors, door screens, and window screens shall fit with sufficient tightness at their perimeters to exclude pests. Based on observations and interview, the residence failed toprovide screens or other pest control measures that fit with sufficient tightness to exclude pests on all exterior openings, affecting 92 current residents. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; Damaged window screens were either removed or refitted, or new ones will replace the current exterior window screens which are deficient.) The interior and exterior were searched to see if there were pests inside the premises but this resulted in no action as their were no pests in the building to remove. This was all completed by 4/9/2026) 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have the potential to be affected by this deficient practice. The Director of Maintenance or his designee will examine all window screens to ensure the deficient practice is corrected. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; and, Damaged screens were removed or refitted and new ones will be placed on the exterior windows screens which are deficient. This was completed by (04/09/2026). The Director of Maintenance or his designee will examine all window to ensure the deficient practice is corrected. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Maintenance Director will Audit/Monitor the exterior and interior of the building including all window coverings 2x a month for three months to ensure exterior window screens meet 100 percent completion for the deficiency. The results will be reported out to the quality assurance performance improvement (QAPI) committee for further review or instruction. or instruction.

Tag 3060 - Based on records review and interviews, the residence failed to ensure each resident in the secure environment (SE) had care plans that described the resident's wandering patterns and known behavioral expressions, along with individualized approaches to beimplemented by staff to protect the resident and others from whom they have contact, identify the type and level of staff oversight, monitoring, and accompaniment, and documentation affecting three of five sample residents who resided in the secured environment (#4, #7, #8).(Cross-reference C0940, U0540, U0920, U1150, U2214, U2230, & U3092) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; The Director of Nursing or designee audited all memory care care plans and updated the care plans including wandering patterns, behavioral expressions and individualized approaches to beimplemented by staff to protect the resident. This to be completed by May 15th 2026.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents in the memory care unit may be affected by this deficient practice. The Director of Nursing or designee audited all memory care care plans and updated the care plans including wandering patterns, behavioral expressions and individualized approaches to beimplemented by staff to protect the resident. This to be completed by May 15th 2026.3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; The Nursing Director or their designee will review and update all residents in the memory care every six months on all residents in memory care. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Nursing Director or their designee will audit five residents care plans per month for 6 months to achieve 100 percent completion to ensure compliance for thedeficiency, the results will be reported out to the quality assurance performance improvement (QAPI) committee for further review or instruction.

Tag 3092 - Based on observations, records review, and interviews, the residence failed to consider the day-to-day resident needs and activities, including the intensity of staff assistance, on an individual resident basis to determine the appropriate level of staffing, affecting 28 currentresidents who resided in the secure environment (SE). (Cross-reference U0540, U0920, U2230, & U3060) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice, on both a temporary and permanent basis, including the date the correction will be accomplished; We have increased staffing levels in the Memory Care units with consideration of acuity based needs to ensure effective staffing levels. This was completed on this date 5/7/26.2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have the ability to be affected by this deficient practice. We have increased staffing levels in the memory care units with consideration of acuity based needs to ensure effective staffing levels. This was completed 5/7/263. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; We have increased staffing levels in the memory care units with consideration of acuity based needs to ensure effective staffing levels. This was completed 5/7/264. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and the title, or position, of the person responsible for implementing/monitoring the corrective action. The Director of Nursing or their designee will audit staffing levels in the Memory care units 1x a week for 3 months, to achieve100 percent completion for this deficiency. The results will be reported out to the quality assurance performance improvement (QAPI) committee for further review or instruction.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Performing and documenting effective fire drills for each shift. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents but going forward will fire drill on one shift per month and rotate so that night shift gets done twice in the next rolling 12 months and that the other shifts divide the rest. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: Fire drills and documentation thereofHow often monitoring will occur: MonthlyHow monitoring will be documented: Sign-off sheets for the staff will be attained for each of the below fire drills per this schedule:2025June 29 4:00 AM (night shift)July 26 11:00 PM (night shift)August 22 3:00 PMSeptember 3 7:00 AMOctober 1 5:00 PMNovember 5 9:00 AMDecember 6 7:00 PM2026January 7 11:00 AMFebruary 7 9:00 PMMarch 4 1:00 PMApril 1 3:00 PMMay 6 9:00 AMJune 3 5:00 PMMonitoring will continue until June 3, 2026. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by July 18th when schedule of fire drills was created and agreed to by Maintenance Director.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Performing and documenting effective fire drills for each shift. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents but going forward will fire drill on one shift per month and rotate so that night shift gets done twice in the next rolling 12 months and that the other shifts divide the rest. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: Fire drills and documentation thereofHow often monitoring will occur: MonthlyHow monitoring will be documented: Sign-off sheets for the staff will be attained for each of the below fire drills per this schedule:2025June 29 4:00 AM (night shift)July 26 11:00 PM (night shift)August 22 3:00 PMSeptember 3 7:00 AMOctober 1 5:00 PMNovember 5 9:00 AMDecember 6 7:00 PM2026January 7 11:00 AMFebruary 7 9:00 PMMarch 4 1:00 PMApril 1 3:00 PMMay 6 9:00 AMJune 3 5:00 PMMonitoring will continue until June 3, 2026. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by July 18th when schedule of fire drills was created and agreed to by Maintenance Director.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for the relevant residents despite this deficiency. State surveyors misunderstood that some resident records are only kept in the corporate office. The issue was not local accessibility as records have been accessible locally electronically, but that the corporate office was not letting these incident reports be released. Their stance has since changed and they will allow us to access these records to give copies to surveyors. B. The facility will cooperate with future state surveys now that corporate understands that incident reports are part of the resident records. Facility's pertinent staff that have access to these records are the DON, ADON and RN Manager. The current employees in these roles had already had training to access such records if requested pre-survey. On August 25, 2025 administrator designated the above-mentioned roles to help during a survey event and they all know how to make such records available (without delay) if requested by a future state surveyor. C. The following measures were put into place to ensure that the deficient practice does not occur again: administrator has changed his position on providing incident reports if state auditors ask for them as part of their survey. This record is in this portal so if another administrator takes over at any point, they understand how to be compliant. He has designated the above-mentioned roles to help during a survey event and they all know how to make such records available (without delay) if requested by a future state surveyor. D. The plan to ensure correction is achieved and sustained is: Administrator has explained to his leadership what he learned regarding this issue. Each monthly QMP this will be reviewed so those designated to help in this regard remember our new position on this issue. This will be reviewed each QMP meeting monthly for three months to ensure all resident records can be copied and given to surveyors upon request without delay. E. Corrective action was completed by August 26, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire watch procedures began immediately on 3/21/25 to be every 15 minutes by someone who had that sole responsibility 24/7 until the fire panel was fixed to where Colorado's DFPC said it was no longer necessary. Immediate negotiation occurred with Johnson Controls (JCI) to be able to fix this fire panel system to code. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above as relates to keeping all residents safe. Residents were trained on proper fire protocols by April, 11, 2025. Revised evacuation maps were put on inside of each resident door and in proper places in hallways on April 11, 2025. Fire protocol was posted on inside of each resident's door on April 11, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Fire Watch and the fix of the fire panel system. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until Fire panel system is up to code. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until fire panel system is up to code. E. Corrective action is completed.in that the vendor is working to complete asap so community can be out of fire watch.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for the relevant residents despite this deficiency. State surveyors misunderstood that some resident records are only kept in the corporate office. The issue was not local accessibility as records have been accessible locally electronically, but that the corporate office was not letting these incident reports be released. Their stance has since changed and they will allow us to access these records to give copies to surveyors. B. The facility will cooperate with future state surveys now that corporate understands that incident reports are part of the resident records. Facility's pertinent staff that have access to these records are the DON, ADON and RN Manager. The current employees in these roles had already had training to access such records if requested pre-survey. On August 25, 2025 administrator designated the above-mentioned roles to help during a survey event and they all know how to make such records available (without delay) if requested by a future state surveyor. C. The following measures were put into place to ensure that the deficient practice does not occur again: administrator has changed his position on providing incident reports if state auditors ask for them as part of their survey. This record is in this portal so if another administrator takes over at any point, they understand how to be compliant. He has designated the above-mentioned roles to help during a survey event and they all know how to make such records available (without delay) if requested by a future state surveyor. D. The plan to ensure correction is achieved and sustained is: Administrator has explained to his leadership what he learned regarding this issue. Each monthly QMP this will be reviewed so those designated to help in this regard remember our new position on this issue. This will be reviewed each QMP meeting monthly for three months to ensure all resident records can be copied and given to surveyors upon request without delay. E. Corrective action was completed by August 25, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action to help the specific resident be safe is not at issue because the deficiency is related to the lack of reporting potential abuse of an at-risk person to law enforcement within 24 hours of learning about the incident on 6/15/25 and this survey was much after that time. However, law enforcement was called on the same day of this deficiency being cited and the Denver police visited the community that night of 6/26/25 under case # 25-331-314B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. All residents are at-risk persons and need to be protected by proper compliance here. No other residents had relevant incidents to be reported. C. The following measures were put into place to ensure that the deficient practice does not occur again:In-servicing of DON that any potential abuse, even if between husband and wife, needs to be reported to police within 24 hours of learning about it. How and what is being reviewed: Executive Director to ask DON if any potential abuse has occurredHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until September 27, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive DirectorE. Corrective action was completed by July 27, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. Corrective action was done to change the Residence Emergency Procedures to provide detailed contingency plans for the continuation of care for residents directly following the beginning of an emergency for 72 hours, including long-term power failure. The policy now includes procedures to follow to care for residents on long term oxygen and/or food/water and other care for residents within a 72 hour period following the onset of an emergencyCorrective action was completed by August 25, 2025 when this POC was submitted and when in-servicing of staff occurred via sign-off of their understanding of said policy to educate them on the change of the policy.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency:Fire watch procedures began immediately on 3/21/25 to be every 15 minutes by someone who had that sole responsibility 24/7 until the fire panel was fixed to where Colorado's DFPC said it was no longer necessary. Immediate negotiation occurred with Johnson Controls (JCI) to be able to fix this fire panel system to code. CO DFPC knows that the fire panel has not been fixed yet as we await approval of a permit so CO DFPC can come out to facility to have satisfactory survey findings. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above as relates to keeping all residents safe. Residents were trained on proper fire protocols by April, 11, 2025. Revised evacuation maps were put on inside of each resident door and in proper places in hallways on April 11, 2025. Fire protocol was posted on inside of each resident's door on April 11, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Administrator will monitor in the following ways:How and what is being reviewed: Fire Watch and the fix of the fire panel system. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until Fire panel system is up to code. Once fire panel is fixed aka "up to code" it will be monitored weekly for three months by maintenance director to ensure fire panel works properly moving forward. He will report to the monthly QMP meeting to document his findings. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until fire panel system is up to code and remains in working order for three months thereafter. E. Corrective action is in process in that the vendor is working to complete asap so community can be out of fire watch and then the rest of the above POC can continue after fire panel and system fixed. As of September, 22, 2025, the permit is still in queue for CO DFPC to approve so that the fire panel can be completed and so that CO DFPC can revisit the residence and provide a satisfactory survey finding.

(Cross-reference POCD to tags T1412 and T2230)This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. Corrective action was accomplished by in-servicing clinical staff to be compliant with policy that states "The staff will assist residents who have fallen or are otherwise unable to independently get up off the floor ...The staff will document the action taken and ongoing efforts to prevent a reoccurrence of the situation in the future."The following measures were put into place to ensure that the deficient practice does not occur again: Director of Nursing will monitor in the following ways:How and what is being reviewed: Falls and if documentation shows actions taken and ongoing efforts to prevent a reoccurrence of the situation in the future. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until September 27 unless compliance has not occurredThe plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until fire panel system is up to code. Corrective action to be completed by July 27, 2025

(Cross-reference POCD to tags T1412 and T2230)This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. Corrective action was accomplished by in-servicing clinical staff to be compliant with policy that states "The staff will assist residents who have fallen or are otherwise unable to independently get up off the floor ...The staff will document the action taken and ongoing efforts to prevent a reoccurrence of the situation in the future."The following measures were put into place to ensure that the deficient practice does not occur again:Director of Nursing will monitor in the following ways:How and what is being reviewed: Falls and if documentation shows actions taken and ongoing efforts to prevent a reoccurrence of the situation in the future. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until September 27 unless compliance has not occurredThe plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until fire panel system is up to code.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action to help the specific resident be safe is not at issue because the deficiency is related to the lack of thorough investigation of the abuse allegation related to the incident on 6/15/25. However, the incident was investigated thoroughly upon receiving the deficiency and documentation occurs in our electronic records systems and in the state portal system where reportable are documented. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. All residents are at-risk persons and need to be protected by proper compliance here. No other residents had relevant incidents to be investigated. C. The following measures were put into place to ensure that the deficient practice does not occur again: In-servicing of DON that any potential abuse, even if between husband and wife, needs to be reported to police within 24 hours of learning about it. DON confirmed staff understanding that incident/event gets documented in progress note and also into incident portal that is now considered part of the resident record. How and what is being reviewed: Executive Director to ask DON if any potential abuse has occurredHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until November 25, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by August 25, 2025 when this POC was submitted.

(Cross-reference T1194 and T2230)This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action to help the specific resident(s) be safe is not at issue because the deficiency is related to the lack of investigation and identification of former injuries of unknown originB. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. All residents are at-risk persons and need to be protected by proper compliance here. No other residents had relevant incidents to be investigated. C. The following measures were put into place to ensure that the deficient practice does not occur again:In-servicing of clinical team to notify DON of injuries of unknown origin so she can investigate and identify the resident injury. Clinical team to put identification of these kind of injuries into incident reporting system which alerts DON for review. DON to put findings into resident's progress notes in our electronic records system. How and what is being reviewed: Incident Reports being reviewed by DON as well as a weekly sample of progress notes to ensure incidents are identified if investigation is required. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until November 25, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive DirectorE. Corrective action was completed by August 25, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Clinical team was in-serviced that meds need to be given per physician orders and that they need to make sure meds are availableB. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as aboveC. The following measures were put into place to ensure that the deficient practice does not occur again: Director of Nursing will monitor in the following ways:How and what is being reviewed: MARs that meds being given per physician order and are availableHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until September 27, 2025 unless compliance is not assured. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until fire panel system is up to code. E. Corrective action is completed in that the in-servicing is completed

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This deficiency did not affect anyone specifically. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Quarterly audit will occur going forward by the ED and the QMAP supervisor to audit the accuracy and completeness of the MARs, controlled substance list, medication error reports, and medication disposal records. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: that the above audits are done quarterlyHow often monitoring will occur: QuarterlyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until the first few quarterly audits have been completed for 2025..D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until .E. Corrective action is completed in that the plan is in place to perform and document such audits and review them in the monthly QMP meeting.

(Cross-reference T1110 and T1412)This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: The relevant falls were not current as to the survey but this deficiency is more about getting a systematic approach to ensure all documentation, not just falls, is captured to properly address resident needs. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: all residents will benefit from an in-service of all clinical staff that they agree that (before their shift is over) to inform a QMAP or nurse if a resident fell so they can pass that information along so a progress note gets written regarding such incident, and that this includes any out-of-the-ordinary event or issue that affected a resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs. This documentation chain of communication applies to more than falls, but also to any information on resident status or wellbeing as well as to documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs. QMAPs and nurses are able to write such progress notes. They are expected to write them upon any change of condition for a resident. Nurses to review them in sample sizes weekly. C. The following measures were put into place to ensure that the deficient practice does not occur again: Director of Nursing will monitor in the following ways:How and what is being reviewed: Incident Reports and progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs. How often monitoring will occur: Weekly in samplesHow monitoring will be documented: Checklist, notes and comments kept in a POC binder. Monitoring will continue until November 25 unless compliance has not been shown, then indefinitely. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until November 25 unless compliance has not been shown, then indefinitely. E. Corrective action is completed in that in-servicing is completed.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: large tree branch, roofing materials, tall weeds, and a disassembled swing were immediately removed from the grounds on 6/26/25. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: all residents will benefit from the following monitoring and the in-servicing done with the Director of Maintenance. The following measures were put into place to ensure that the deficient practice does not occur again: Director of Maintenance will monitor in the following ways:How and what is being reviewed: grounds that has accumulated any rubbish or garbage. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until September 27 unless compliance has not been shown, then indefinitely. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until September 27 unless compliance has not been shown, then indefinitely. Corrective action is completed in that in-servicing is completed.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Tree limb and 25-foot ladder were removed on 6/26/25. Drop off next to walking path was filled with mulch by 7/27/25. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: all residents will benefit from the following monitoring and the in-servicing done with the Director of Maintenance that he will maintain grounds weekly to protect residents from slopes, holes, and other hazards. The following measures were put into place to ensure that the deficient practice does not occur again: Director of Maintenance will maintain grounds weekly to protect residents from slopes, holes, and other hazards. How and what is being reviewed: grounds to protect residents from slopes, holes, and other hazards. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until September 27 unless compliance has not been shown, then indefinitely. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QMP meeting by IDT team led by Executive Director until September 27 unless compliance has not been shown, then indefinitely. Corrective action is completed in that in-servicing is completed.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: inquiry is being made to corporate team on reasoning behind not giving state surveyors incident reportsB. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: After gaining an understanding from the corporate team on their stance to not provide incident reports to the surveyors, Executive Director will communicate to the state. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: incident report sharing with state surveyorsHow often monitoring will occur: weekly until get a response from corporate teamHow monitoring will be documented: Checklist, notes and comments kept in a POC binder. Monitoring will continue until June 30, 2025D. The plan to ensure correction is achieved and sustained is: monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 18, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. There is no plan for correcting the specific deficiency as the internal investigation cannot be recreated at this point. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Going forward, the DON or whomever conducts the investigation, will give a copy of their internal investigation to Executive Director. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director in-serviced DON on April 18, 2025 on this expected practice and will monitor in the following ways:How and what is being reviewed: internal investigations when something is reportableHow often monitoring will occur: as each reportable occurrence presents itselfHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on April 18, 2025 when this POC was submitted.

(Cross Reference S0430, S910, S918, S920, S1110, S1146)This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Vice President of Operations in-serviced Executive Director aka Administrator on his comprehensive role and responsibilities including everything related to maintenance, fire prevention, fire panel operation, care plans staying current, proper investigation and documentation of reported occurrences, compliance with local and state fire ordinances, and the creation and implementation of an effective evacuation plan. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Executive Director to review his day-to-day responsibilities already mentioned. C. The following measures were put into place to ensure that the deficient practice does not occur again: Vice President of Operations to discuss these responsibilities monthly with Executive Director to make sure they are being handled responsibly. How and what is being reviewed: Executive Director's management of day-to-day operationsHow often monitoring will occur: MonthlyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitely. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive Director. E. Corrective action was completed by April 18, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Resident roster with names and room numbers, and diagram showing room locations is now available at front desk. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Anytime there is a change in room assignments, thr roster will be changed accordingly by the Marketing Director and given to the front deskC. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Availability and currency of resident roster to include room numbers and names along with diagram of roomsHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 18, 2025 when this POC was submitted.

(Cross-reference S0540)The plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiency, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The below is the POC submitted and accepted on 3/21/25 before the state exited their IJ survey. It has been adjusted only to show further progress on the POC.Identify: Highest potential risk for harm to resident is fire and that routine drills where not be held or documented. Immediate Plan for Correction: Effective immediately, fire drills will be scheduled monthly but conducted randomly. All drills will be documented with staff participation sign-offs. Fire drill in-services were conducted with staff on 3.20.25 while department was in the building. Participation sign-off available. Additional drills completed 3.21.25 at 6:00 AM for 3rd Shift and 3.21.25 at 7:00 AM for 1st Shift. All drills have been documented with sign-off sheets. Continued in-services continued at start of each shift until all relevant staff had been educated. Sign-off documentation available. Fire drill policy communicated electronically to All Staff channel in Serenity platform on 3.21.25 at 8:30 AM. Next Steps/ Education/ Monitoring: Executive Director to audit monthly drills to assure we stay in compliance by communicating compliance reports to department quarterly. Fire drill in-service on fire safety and drill details was given at All Staff Meeting on April 3, 2025. Documentation available. Hiller to do a fire protocol presentation on April 25, 2025. Revised evacuation maps and FIRE protocol put in relevant hallways and behind each resident door to serve as a reminder.

(Cross Reference S0540, S1110)The plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiency, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The below is the POC submitted and accepted on 3/21/25 before the state exited their IJ survey. It has been adjusted only to show further progress on the POC.Identify: Emergency Operation Plan was identified as needing to be updated with current information including critical information outlined in Chapter 7 10.6 of the Colorado Assisted Living Residences regulations as outlined by the department in citation text. Immediate Plan for Correction: Emergency Operations Plan was reviewed and updated to include plans for evacuation, communication and access to emergency power, storage for preservations of medication, assignments of tasks and responsibilities during triage, and protection and transfer of health information to meet the care needs of residents. Next Steps/ Monitoring: Department approved updated Emergency Operations Plan on March 21, 2025; EOP red binders were updated and put throughout the community, but specifically, in the treatment room in the relevant East building close to all the relevant residents. Leadership met immediately to review and discuss, then in-serviced on the roles each has on April 2nd-April 4th. Sign-off documentation is available. Emergency Operations Plan was also discussed at the next All Staff Meeting scheduled on April 3, 2025. Sign-off documentation is available. Further training was done for all-staff between 3/20/25-4/2/25 revisiting what RACE means specifically. Sign-off documentation is available. Rating Resident Worksheets were done and filed for each relevant resident to understand evacuation better. Training was done by April 11 and documented for each resident on the specifics of RACE and an evacuation plan.

(Cross-reference S0540)The plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiency, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The below is the POC submitted and accepted on 3/21/25 before the state exited their IJ survey. It has been adjusted only to show further progress on the POC.Acknowledge: Fire panel is not operational and poses risk to residents and staff should there be a fire and unsafe materials in basement of Assisted Living East storage area. Immediate Plan for Correction: Fire watch started on Tuesday, Mar. 18th at 3:30 PM with 30 minute logged checks by 3rd party company, learned on Thursday, Mar. 20th that department mistakenly said 30 minutes, but corrected us to 15 minute logged checks. Started 15 minutes logged checks on Thursday, Mar. 20th at 7 PM. Unsafe materials in basement of Assisted living East storage area were immediately moved outside of building. Next Steps/ Education/ Monitoring: Contacted fire panel vendor, Johnson Controls, and they have committed to completing the fire panel system installation by May 31, 2025 to the satisfaction of DFPC. Executive Director has requested to set-up weekly status calls for replacement and installation of new fire panel system. Fire watch will continue with 15 minute logged checks until both new panel is installed/operational and department has given approval to cease fire watch to assure resident and staff safety. Executive Director will keep notes on status which will be available to the department on a weekly basis. Staff will monitor storage areas for unsafe materials monthly for the next six months to assure continued compliance. Executive Director will maintain monthly sign-off records.

IDR finalized on 5/22/25 and deficiency substantiated so POC below. The plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiency, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. Identify: Reassessment was needed and review of care plan should have been done and documented following a significant change to Resident #2's baseline status. Immediate Plan for Correction: Resident #2 no longer lives at this community as her cognitive level is beyond our level of care. Nurses were all educated that a reassessment and review of care plan should occur immediately and documented appropriately after a significant change happens to a resident's baseline status, e.g., elopement when there has been no history of elopement. Next Steps/ Education/ Monitoring: Executive Director to audit incidents weekly at Care Rounds weekly meeting through August of 2025 (only if consistent compliance has been found) to make sure that none are a change of condition that is different from the resident's baseline status, and if so, that proper reassessment and care plan review were completed timely and documented accordingly. Follow up as well at our monthly QAPI meeting through August 2025 to make sure consistent compliance has been found at the weekly checks, otherwise to continue weekly and monthly monitoring until consistent compliance has been found for three months.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. 1. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: resident evacuation rating sheets were completed for each resident in existing buildings rated impractical. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Resident rating sheets will be completed at admission going forward and upon any assessment. C. The following measures were put into place to ensure that the deficient practice does not occur again: Director of nursing to monitor in the following ways:How often monitoring will occur: Weekly at Care Rounds weekly meetingHow monitoring will be documented: Checklist, comments and notes to be kept current in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted2. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Emergency plans were made current. Leadership team signed off on understanding their roles in disaster crisis and that they know the multiple places that they are located being each floor of the West building in the admin area, in the Treatment room in the East building, at the front desk, and in each office of the leader who has a role in disaster crisis. Staff taught at 4/3 all-staff meeting where EOP binders are and will be reminded of such every two months at all-staff meetings. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents. C. The following were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: that the emergency plans are in proper places readily available for staffHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. 3. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency:Staff training was done immediately on Fire protocols starting on 3/21/25. Follow up staff training was done at the all-staff meeting on 4/3/25. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Staff training on fire protocols to be done at least every two months at all-staff meetings; Relias on-line course training on fire protocols to be done annually. Special demonstration practical training for all staff to be done with Hiller Fire on April 25, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: staff training regarding fire protocols to be done at least every two monthsHow often monitoring will occur: MonthlyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. 4. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Performing and documenting effective fire drills for each shift. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents but going forward will fire drill on one shift per month and rotate so that each shift gets drilled each quarter. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: Fire drills and documentation thereofHow often monitoring will occur: MonthlyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. 1. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire watch procedures began immediately on 3/21/25 to be every 15 minutes by someone who had that sole responsibility 24/7 until the fire panel was fixed to where Colorado's DFPC said it was no longer necessary. Immediate negotiation occurred with Johnson Controls (JCI) to be able to fix this fire panel. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above as relates to keeping all residents safe. Residents were trained on proper fire protocols by April, 11, 2025. Revised evacuation maps were put on inside of each resident door and in proper places in hallways on April 11, 2025. Fire protocol was posted on inside of each resident's door on April 11, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Fire Watch and the fix of the fire panelHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025, if necessary, but expectations are that the fire panel will be fixed by 5/31/25 to where the residents are safe and fire watch can discontinue. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. 2. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Maintenance Director demonstrated to Executive Director on March 26, 2025 that he knew how to sound the alarm for fire drills and that he knew what keys operate the pull stations. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all of the residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: that the Maintenance Director knows how to sound the alarm for fire drills and that knows what keys operate the pull stations. How often monitoring will occur: MonthlyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on March 26, 20253. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire watch procedures began immediately on 3/21/25 to be every 15 minutes by someone who had that sole responsibility 24/7 until the fire panel was fixed to where Colorado's DFPC said it was no longer necessary. Immediate negotiation occurred with Johnson Controls (JCI) to be able to fix this fire panel. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above as relates to keeping all residents safe. Residents were trained on proper fire protocols by April, 11, 2025. Revised evacuation maps were put on inside of each resident door and in proper places in hallways on April 11, 2025. Fire protocol was posted on inside of each resident's door on April 11, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Fire Watch and the fix of the fire panelHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025, if necessary, but expectations are that the fire panel will be fixed by 5/31/25 to where the residents are safe and fire watch can discontinue. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. 4. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire watch procedures began immediately on 3/21/25 to be every 15 minutes by someone who had that sole responsibility 24/7 until the fire panel was fixed to where Colorado's DFPC said it was no longer necessary. Immediate negotiation occurred with Johnson Controls (JCI) to be able to fix this fire panel. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above as relates to keeping all residents safe. Residents were trained on proper fire protocols by April, 11, 2025. Revised evacuation maps were put on inside of each resident door and in proper places in hallways on April 11, 2025. Fire protocol was posted on inside of each resident's door on April 11, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Fire Watch and the fix of the fire panelHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025, if necessary, but expectations are that the fire panel will be fixed by 5/31/25 to where the residents are safe and fire watch can discontinue. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. 5. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire watch procedures began immediately on 3/21/25 to be every 15 minutes by someone who had that sole responsibility 24/7 until the fire panel was fixed to where Colorado's DFPC said it was no longer necessary. Immediate negotiation occurred with Johnson Controls (JCI) to be able to fix this fire panel system including the fire suppression systems in residential room closets and bathrooms. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POCfor this deficiency: Same as above as relates to keeping all residents safe. Residents were trained on proper fire protocols by April, 11, 2025. Revised evacuation maps were put on inside of each resident door and in proper places in hallways on April 11, 2025. Fire protocol was posted on inside of each resident's door on April 11, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Fire Watch and the fix of the fire panel systemHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025, if necessary, but expectations are that the fire panel system will be fixed by 5/31/25 to where the residents are safe and fire watch can discontinue. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. 1. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: We asked our current Fire control vendor if they had done annual fire door inspections and they had no documentation of that. DH Pace Compliance Services has said they have the proper expertise to do this and will perform this before April 20, 30 days from the exit of the survey. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Annual fire door inspections will protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: making certain that annual fire door inspections are performedHow often monitoring will occur: Weekly until done for this yearHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until completedD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive Director. Annual checks will be put into the TELS system so Maintenance Director is alerted to stay in complianceE. Corrective action to be completed by April 20, 2025, 30 days after the survey exit. 2. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Door stops for fire doors outside of rooms 248 and 149 were removed March 21, 2025. Signs have been placed on all fire doors where the magnets are not reliable. Staff was trained on no wedging open of fire doors at April 3, 2025 all-staff meeting. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed:Fire Doors not being propped open by wedges or stops. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until fire panel system has been fixed, including magnet reliability. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on March 21, 2025.3. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire door closer outside of room 261 was reattached on March 21, 2025. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Resident in room 263 was moved to room 260 on April 5, 2025 so that resident would not have to open the closed fire door outside of room 261 to get to things. This eliminates the temptation to prop it open by resident or staff. Signs are on that fire door to keep it closed until Fire panel gets fixed and magnet is installed at that fire door. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: that fire door closer stays on the fire door outside of room 261How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until fire panel is fixed and magnet is installed at that fire door to keep it open safelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by March 21, 2025 when this POC was submitted. 4. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: PLan review was submitted and paid for on April 9 to be able to remove the delayed egress bars in the former memory care ward in the basement. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: The two residents in the basement in rooms 25 and 27, while safe, are being moved to rooms not in the basement as soon as practicable in an abundance of caution. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Plan review submission to remove delayed egress bars in basementHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until plan review allows removal of egress bars there. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on April 9, 2025.5. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: DH Pace Compliance Services has said they have the proper expertise to do this and will perform this before April 20, 30 days from the exit of the survey. They will help us determine if it is wiser to incorporate a delayed egress or access control feature for the gate, at which time a plan review will be submitted. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above as this will protect all of the residents in their potential egress. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor the Maintenance Director in the following ways: to make sure that the vendor comes the week of April 14 like they committed to and gets direction on the wisest control feature for the gate, so that Executive Director can immediately submit for plan review accordingly. How and what is being reviewed: vendor feedback and agreement to affix proper gate control feature so plan review can be submittedHow often monitoring will occur: Weekly until doneHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue weekly until completedD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive Director. E. Corrective action to be completed by April 20, 2025, 30 days after the survey exit. 6. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Kitchen fire doors were unblocked on March 21, 2025. Signs were placed on those fire doors to not block them. Staff was trained on no blocking open of fire doors at April 3, 2025 all-staff meeting. DH Pace Compliance Services has said they have the proper expertise to either fill the holes to be fire safe according to code after removing the deadbolts or replace the doors. They will assess this before April 20, 30 days from the exit of the survey, and fix or replace fire doors as soon as practicable. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways: to make sure that the vendor comes the week of April 14 like they committed to, and that the kitchen fire doors stay unblockedHow and what is being reviewed: kitchen fire doors staying unblocked and vendor feedback on fire door fixes or replacementHow often monitoring: weeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until fire doors and fire panel system has been fixed,D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on March 21, 2025.7. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Latch on the fire door outside of room 38 was adjusted on March 21, 2025 so it latched effectively. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: same as above to protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: latch on the fire door outside of room 38 working effectivelyHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitely. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on March 21, 2025.8. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire door outside the salon was unblocked on March 21, 2025. Staff was trained on no wedging open of fire doors at April 3,2025 all-staff meeting. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed:Fire Doors not being blocked or propped open by wedges or stops. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until fire panel system has been fixed, including magnet installation where necessary and reliability. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on March 21, 2025.9. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Cardboard door stops were removed from fire and smoke doors on March 21, 2025. Signs have been placed on all fire doors where the magnets are not reliable. Staff was trained on no wedging open of fire doors at April 3,2025 all-staff meeting. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed:Fire Doors not being propped open by wedges or stops. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until fire panel system has been fixed, including magnet reliability. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed on March 21, 2025.10. A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: DH Pace Compliance Services has said they have the proper expertise to either fill the holes on the old memory care fire doors to be fire safe according to code after removing the deadbolts or replace the doors. They will assess this before April 20, 30 days from the exit of the survey, and fix or replace fire doors as soon as practicable. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways: to make sure that the vendor comes the week of April 14 like they committed toHow and what is being reviewed: vendor feedback on fire door fixes after removal of deadbolts or replacementHow often monitoring: weeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until fire doors have been made fire safe after deadbolt removal or fire door replacedD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action to be completed by April 20, 30 days after survey exit.

This plan of correction was executed solely because provisions of state and federal law require it. The preparation of the following plan of correction, for the deficiencies, does not constitute and should not be interpreted as an admission nor an agreement, by the facility, of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. A0001Resident Evacuation RatingA. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: resident evacuation rating sheets were completed for each resident in existing buildings rated impractical. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Resident rating sheets will be completed at admission going forward and upon any assessment. C. The following measures were put into place to ensure that the deficient practice does not occur again: Director of nursing to monitor in the following ways:How often monitoring will occur: Weekly at Care Rounds weekly meetingHow monitoring will be documented: Checklist, comments and notes to be kept current in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submittedEmergency PlansA. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Emergency plans were made current. Leadership team signed off on understanding their roles in disaster crisis and that they know the multiple places that they are located being each floor of the West building in the admin area, in the Treatment room in the East building, at the front desk, and in each office of the leader who has a role in disaster crisis. Staff taught at 4/3 all-staff meeting where EOP binders are and will be reminded of such every two months at all-staff meetings. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents. C. The following were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: that the emergency plans are in proper places readily available for staffHow often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. Staff training at required intervalsA. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency:Staff training was done immediately on Fire protocols starting on 3/21/25. Follow up staff training was done at the all-staff meeting on 4/3/25. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Staff training on fireprotocols to be done at least every two months at all-staff meetings; Relias on-line course training on fire protocols to be done annually. Special demonstration practical training for all staff to be done with Hiller Fire on April 25, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: staff training regarding fire protocols to be done at least every two monthsHow often monitoring will occur: MonthlyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. Fire DrillsA. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Performing and documenting effective fire drills for each shift. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above to protect all residents but going forward will fire drill on one shift per month and rotate so that each shift gets drilled each quarter. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: Fire drills and documentation thereofHow often monitoring will occur: MonthlyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025 if compliance has been consistent throughout, otherwise it will continue indefinitelyD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. A0002Maintaining fire alarm and fire suppression systemsA. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: Fire watch procedures began immediately on 3/21/25 to be every 15 minutes by someone who had that sole responsibility 24/7 until the fire panel was fixed to where Colorado's DFPC said it was no longer necessary. Immediate negotiation occurred with Johnson Controls (JCI) to be able to fix this fire panel system to code. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Same as above as relates to keeping all residents safe. Residents were trained on proper fire protocols by April, 11, 2025. Revised evacuation maps were put on inside of each resident door and in proper places in hallways on April 11, 2025. Fire protocol was posted on inside of each resident's door on April 11, 2025. C. The following measures were put into place to ensure that the deficient practice does not occur again: Executive Director will monitor in the following ways:How and what is being reviewed: Fire Watch and the fix of the fire panel system. How often monitoring will occur: WeeklyHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until June 30, 2025, if necessary, but expectations are that the fire panel will be fixed by 5/31/25 to where the residents are safe and fire watch can discontinue. D. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive DirectorE. Corrective action was completed by April 11, 2025 when this POC was submitted. A0003A. Corrective action was accomplished for those residents found to have been affected by the deficient practice in the following way. This is the plan for correcting the specific deficiency: We asked our current Fire control vendor if they had done annual fire door inspections and they had no documentation of that. DH Pace Compliance Services has said they have the proper expertise to test and maintain fire doors and will perform this before April 20, 30 days from the exit of the survey. B. The facility will identify other residents having the potential to be affected by the same deficient practice in the following way. This will be the procedure for implementing the relevant POC for this deficiency: Annual fire door inspections will protect all residents. C. The following measures were put into place to ensure that the deficient practice does not occur again: Maintenance Director will monitor in the following ways:How and what is being reviewed: making certain that annual fire door inspections are performed and that fire doors are maintainedHow often monitoring will occur: Weekly until done for this yearHow monitoring will be documented: Checklist, notes and comments kept in a POC binderMonitoring will continue until completedD. The plan to ensure correction is achieved and sustained is: Monitoring will be evaluated monthly in QAPI meeting by IDT team led by Executive Director. Annual checks will be put into the TELS system so Maintenance Director is alerted to stay in complianceE. Corrective action to be completed by April 20, 2025, 30 days after the survey exit.