SUNRISE AT PINEHURST

A licensure complaint, prompted by #CO42335 was completed on 5/28/26. A deficiency was cited.

Based on observation, record review, and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 62 current residents. Specifically. On 5/28/26, the residence's automated intercom system directed the residents to shelter in place despite directives from the state fire authority, which mandated evacuation due to environmental conditions. A test revealed six of six first-floor alarm pulls were not functioning properly, and two smoke detectors were inoperable. On 5/27/26, the state fire authority placed the residence on a fire watch due to an inoperable fire panel. However, the implemented fire watch was limited to the porch area and the south side of the building and did ot extend to the entire building. Furthermore, there was an observed increase in fire risk attributed to a non-fire-resistant cigarette receptacle adjacent to the building, which contained used cigarette butts. Fire doors were found to be obstructed by doorstops, hindering them from closing properly to stop the spread of fire. Room 212 contained 26 unused portable oxygen tanks that were not secured. Additionally, a power strip located in a closet had been daisy changed to an extension cord. Interviews with staff revealed that fire drills were not being conducted; rather, they were merely discussed. Evacuation drills and instructions had not been discussed with residents. A full evacuation had not occurred until the state fire authority survey on 5/27/26. Staff were unaware that residents were expected to evacuate the building during a fire drill. Several independent residents stated that the announcement indicated they needed to remain in their rooms or wherever they were until staff directed them to evacuate. One resident stated that he "hoped they would come for him." This failure created an immediate jeopardy risk to the safety of safety to 62 current residents who resided in the residence. On 5/28/26 at approximately 3:30 p.m., the department directed the residence to provide written evidence that the risks had been removed. Findings include: 1. Observation On 5/28/26 at approximately 9 a.m., a non fire resistant fire receptacle up against the residence front exterior was observed to be full of cigarette butts. On 5/28/26 at 9:15 a.m., the foyer area of a hallway marked "EXIT" to the room adjacent to the front door was blocked by chairs. On 5/28/26 at 9:29 a.m., a large, unsecured helium tank was observed in a common area on the second floor. On 5/28/26 at 12:49 p.m., the state fire authority and the residence's maintenance coordinator conducted a test of the fire alarm system by pulling the fire alarm. It revealed that six out of six fire alarm pull stations that were tested were not triggering the fire alarm. The state fire authority then used a can of liquid smoke to trigger the fire alarm at approximately 1:00 p.m. During this time, staff were seen telling residents it was a false alarm and to remain where they were and not to worry. The automated intercom system throughout the residence stated to stay where you are and wait for further instructions, and also said not to use the stairwell or elevators. On 5/28/26 at 12:57 p.m., the residence's automated intercom system announcement stated, "Attention please, the fire alarm in this building has been activated. Remain at your present location and stand by for further instructions. Do not enter the exit stairways, do not use the elevator." had been repeated several times. Fire doors intended to close to stop the spread of fire failed to close due to door stoppers or other mechanical issues. On 5/28/26 at approximately 1:30 p.m., DFPC placed the residence on full fire watch. This required the residence to conduct fire watch throughout the entire residence, including the exterior, every 15 minutes, and to document their finding. On 5/28/26 at approximately 3:50 p.m., a closet contained a power supply plugged into the wall, with several other cords coming out of the box to an orange extension cord, then to a white extension cord surge protector power strip with three other electrical devices connected to it. 2. Record reviewa. Fire watch records On 5/28/26 at 9:22 a.m., the residence revealed they had been placed on fire watch by the state fire authority (DFPC) on 5/7/26 at approximately 10:00 a.m. This required the residence to conduct a fire watch every 15 minutes by only walking the front portion of the building and documenting their findings. This was due to the residence not having a fully functional alarm and suppression system. b. Fire drillsOn 5/28/26 at approximately 9:30 a.m., fire drill records revealed no simulated fire drills had been being conducted with staff and the residents. Fire drills were only verbal staff meetings held to go over the plan in case of an emergency. The number of residents involved on the documents provided were marked not applicable. The outcome, along with the response to the risk with the staff and residents during the held drills were also not included in the documentation. 3. InterviewsOn 5/28/26 at approximately 8:45 a.m., the state fire authority stated that the residence was an older building and that, per guidelines, it should be evacuated in the event of a fire. He stated that the guidance in the announcement to stay in place could pose a danger, as well as smoke detectors that did not work, fire pulls on the first floor that did not work, and fire doors that did not close properly or were propped open by staff. Further, the risk of fire spreading throughout the residence was increased due to excessive oxygen tanks stored in rooms that were not secured in cradles, or the large helium tank on the second floor, which had not been secured, portable space heaters in resident rooms, extension cords that had been hooked together, and a smoking container near the building and that the residence was not conducting fire drills where residents were taken out of the building that was required due to the age and code of the building. He stated that due to fire doors not working properly, the residence would have less time to evacuate, and they failed to meet the required time to evacuate. He stated that the staff had not completed a full evacuation, and staff and residents did not know where to go. On 5/28/26 at 9:39 a.m., Resident #9 stated that during a fire drill, she was told someone would come get her, so she needed to stay in her room. On 5/28/26 at 9:43 a.m., Resident #8, who resided on the second floor and required the use of a wheelchair, stated the intercom system told him to stay in his room until further notice. On 5/28/26 at 9:50 a.m., Resident #10 stated that the residence does not conduct fire drills and that she is not sure what to do in an emergency. Resident #10 resided on the second floor, who required a hoyer lift to get in and out of bed, along with a wheelchair, and was a two person assist. On 5/28/26 at 9:50 AM, Staff #5 stated that she had worked at the residence for one year and had never participated in a fire drill. She stated they talk through fire drills and watch videos. She later added that getting all the residents from the second floor who required a hoyer lift, wheelchair, or walker would be very difficult to get everyone out of the building safely and efficiently. On 5/28/26 at 10:00 a.m., Staff #6 stated she had worked at the residence for over a year and had never been involved in a fire drill. She added she did not know what to do in an emergency situation On 5/28/26 at 1:30 p.m., Staff # 4 stated that she had never been involved in a fire drill. She stated that she did not know what to do in an emergency situation. On 2/28/26 at 2:08 p.m., Resident #6 stated that the announcement said they should stay in their room or wherever they were and wait. On 5/28/26 at 2:15 p.m., Staff #6 stated that she was on fire watch and was employed by the residence. She said that she was instructed to walk the front of the building on the first floor and back to the south facing side of the building to watch for fire and to document the time every 15 minutes. She stated that she did not go into the building to look for signs of a fire. On 5/28/26 at 2:15 p.m., Resident #4 stated that he was in the shower and heard the announcement. He stated that it said to stay in place, so he finished his shower. He stated that staff never came for him, but he would stay there until he had heard from staff. On 5/28/26 at 2:35 p.m., Resident #7 stated that the voice in the announcement said he should stay where he was and that instructions would follow. On 5/28/26 at approximately 3:30 p.m., the maintenance coordinator acknowledged that the fire system was not working, recording a statement for residents to stay where they are and wait for instructions. He acknowledged that residents might be confused by the guidance and stay in their rooms. He stated that if there was a fire, staff were directed to call emergency medical services first, then the administrator. He acknowledged that if a fire occurred at approximately 1 a.m., the staff would have difficulty getting eight two-person assist residents off the second floor before notifying the independent residents. On 5/28/26 at approximately 4:40 p.m., the administrator stated the residence was working to fix the fire system, but acknowledged it was not working. She acknowledged that the cigarette container, space heaters, power cords, fire drills, propane, excessive oxygen tanks not in cradles, and propped doors created potential hazards. She was aware that the residence was in non-compliance with fire standards. She stated that they had not completed a routine evacuation until they were notified of the code, and that an evacuation test was conducted on 5/27/26 with the state fire authority. She stated that she was unaware that staff were only informed in a meeting, and the drills had not been carried out by staff and residents, so residents were aware of what to do. 3. Immediate Jeopardy- Written evidence, Immediate correction The survey established that the findings above placed the 62 current residents at immediate jeopardy risk for potential hazards in the physical environment related to life and fire safety. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations requires residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 5/28/26 at 2:42 p.m., the administrator provided a plan that read in part, Fire announcement corrected An electronic communication was sent to have the annunciator serviced to remove the instructions given to remain in place, and staff training was held for staff and residents. An email communication to resident families, residents, and staff notifying them that the residence was considered an evacuation resident. Pull stations were addressed An urgent request was made to replace smoke alarms that are not functional. Smoking container moved The smoking container was moved from the side of the building to a designated smoking area, and policies will be sent to employees regarding the requirement to keep receptacles 25 feet from the building. Blocked entrance The community removed the chairs that were obstructing the egress point located in the painting room at the front entrance. Team members will receive an in-service on egress doors and their responsibilities of ensuring egress points are accessible and not blocked. Oxygen hazard secured Oxygen tanks removed and secured. The community will call the suppliers to arrange pickup as soon as possible. Community will contact providers for residents with oxygen needs and obtain ordersfor electric concentrators. Space Heaters removedRemoved from rooms. Staff training on how to report and address a space heater and letters to families. However, the plan failed to mention the timing of the fire walks, how the residents would ensure the oxygen taken out of resident rooms would remain available so as not to run out, and how they would communicate with families after confirmation of classification from the state fire authority to defend in place or is full evacuation is requiredOn 5/28/26 at 3:45 p.m., the administrator provided a plan that included the following: a. The community has initiated a full building fire walk. The walks will occur every 15 minutes and will include an exterior and total interior walk. The walks will continue to be recorded and signed off on the fire walk log.b. Community sent a communication on 5/28/2026. Community held evacuation drill with staff and residents on 5/27/2026 with support from FD and DFPC. Community has evacuation and fire safety training being conducted with Denver FD on 5/28/2026. Community will send an email to all residents, family members, and responsible parties detailing that the community will be considered an evacuation residence pending the completed review from DFPC. This letter will be sent out no later than 5/28/2026.c. The community has gathered the unsecured tanks, and they are being picked up by the supplier on the morning of 5/29/2026. Cages will be requested prior to pick up of tanks.i. Team members will receive in-service on proper oxygen storage no later than 5/29/2026. Training will include the storage methods that are allowed for residents' oxygen and ensuring tanks are in their proper ii. Community will contact providers for residents with oxygen needs and obtain orders for electric concentrators to assist in removing liquid oxygen containers. The additional evidence that was received by the residence was approved and the immediate jeopardy was removed on 5/28/26 at 3:55 p.m.

A life safety code survey, prompted by #CO42316, was completed on 5/28/2026. Four deficiencies were cited. The facility is a three (3) story, Type II (222) (I B) structure and licensed for one hundred and eight (108) residents. The facility has a National Fire Protection Association (NFPA) 13 automatic fire suppression system. This survey, conducted on May 28, 2026, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities.

Based on observation and staff interviews, it was determined that the facility failed to maintain the Fire evacuation in accordance with the Life Safety Code 101, 101A, chapter 33.7, SOM,and NFPA 99. The deficient practice could affect all smoke zones,108 of 108 residents, and an indeterminable number of staff and visitors. 1. During the inspection, observations and interviews with the maintenance director revealed that staff routed residents from the stairwell back into the building to the front lobby, rather than following the egress path. 2. During the inspection, observations and interviews with the maintenance director revealed that a fire drill conducted took 15 minutes to evacuate (impractical rating). 3. During the record review, observations and interviews with the maintenance director revealed that there were no resident rating sheets. 4. During the record review, observations and interviews with the maintenance director revealed that only one staff training on evacuation was found. 5. During the record review, observations and interviews with the maintenance director revealed that the facility is set to be 'defend in place,' but the alarms and fire suppression systems are not properly zoned. 15.7.4.3 Defend in Place. For new and existing facilities, where the response to a fire is to defend in place within a safe place in the building, occupant notification shall be in accordance with the facility fire plan. 15.8.1.2* Defend in Place. For new and existing facilities, where the response to a fire is to defend in place within a safe place in the building and not to automatically evacuate the building, sprinkler system zones shall coincide with smoke compartment boundaries or shall be in accordance with the facility fire plan. 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 33.7.3 Emergency Egress and Relocation Drills. Emergency egress and relocation drills shall be conducted in accordance with 33.7.3.1 through 33.7.3.6.33.7.3.1 Emergency egress and relocation drills shall be conducted not less than six times per year on a bimonthly basis, with not less than two drills conducted during the night when residents are sleeping, as modified by 33.7.3.5 and 33.7.3.6.33.7.3.2 The emergency drills shall be permitted to be announced to the residents in advance. 33.7.3.3 The drills shall involve the actual evacuation of all residents to an assembly point, as specified in the emergency plan, and shall provide residents with experience in egressing through all exits and means of escape required by this Code. 33.7.3.4 Exits and means of escape not used in any drill shall not be credited in meeting the requirements of this Code for board and care facilities. 33.7.3.5 Actual exiting from windows shall not be required to comply with 33.7.3; opening the window and signaling for help shall be an acceptable alternative. 33.7.3.6 If the board and care facility has an evacuation capability classification of impractical, those residents who cannot meaningfully assist in their own evacuation or who have special health problems shall not be required to actively participate in the drill. SOM 25.13 In addition to the training requirements in Part 7.9, staff assigned to a secure environment shall receive training and education on assisted living residence policies and procedures specific to the secure environment resident care, services, and protections. Such training shall include, at a minimum, the following: (A) Information on the secure environment that identifies and describes the areas where residents have free passage, where passage may be restricted, and where passage is prohibited; (B) Information regarding the current mobility status of all residents so that staff are prepared to successfully evacuate all residents in the event of an emergency; NFPA 101 201233.7.1 Emergency Plan. 33.7.1.1 The administration of every residential board and care facility shall have, in effect and available to all supervisory personnel, written copies of a plan for protecting all persons in the event of fire, for keeping persons in place, for evacuating persons to areas of refuge, and for evacuating persons from the building when necessary. 33.7.1.2 The emergency plan shall include special staff response, including the fire protection procedures needed to ensure the safety of any resident, and shall be amended or revised whenever any resident with unusual needs is admitted to the home. 33.7.1.3 All employees shall be periodically instructed and kept informed with respect to their duties and responsibilities under the plan, and such instruction shall be reviewed by the staff not less than every 2 months. 33.7.1.4 A copy of the plan shall be readily available at all times within the facility. 33.7.2 Resident Training. 33.7.2.1 All residents participating in the emergency plan shall be trained in the proper actions to be taken in the event of fire. 33.7.2.2 The training required by 32.7.2.1 shall include actions to be taken if the primary escape route is blocked. 33.7.2.3 If the resident is given rehabilitation or habilitation training, training in fire prevention and the actions to be taken in the event of a fire shall be a part of the training program. 33.7.2.4 Residents shall be trained to assist each other in case of fire to the extent that their physical and mental abilities permit them to do so without additional personal risk. A.?3.3.75 Evacuation Capability. The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. It is intended that the evacuation capability be determined by the procedure acceptable to the authority having jurisdiction. It is also intended that the timing of drills, the rating of residents, and similar actions related to determining the evacuation capability be performed by persons approved by or acceptable to the authority having jurisdiction. The evacuation capability can be determined by the use of the definitions in 3.3.75, the application of NFPA 101A, Guide on Alternative Approaches to Life Safety, Chapter 6, or a program of drills (timed). Where drills are used in determining evacuation capability, it is suggested that the facility conduct and record fire drills six times per year on a bimonthly basis, with a minimum of two drills conducted during the night when residents are sleeping, and that the facility conduct the drills in consultation with the authority having jurisdiction. Records should indicate the time taken to reach a point of safety, date and time of day, location of simulated fire origin, escape paths used, and comments relating to residents who resisted or failed to participate in the drills. Translation of drill times to evacuation capability is determined as follows:(1)3 minutes or less - prompt(2)Over 3 minutes, but not in excess of 13 minutes- slow(3)More than 13 minutes - impracticalEvacuation capability, in all cases, is based on the time of day or night when evacuation of the facility would be most difficult, such as when residents are sleeping or fewer staff are present. Evacuation capability determination is considered slow if the following conditions are met:(1)All residents are able to travel to centralized dining facilities without continuous staff assistance.(2)There is continuous staffing whenever there are residents in the facility. The administrator discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 Section 9.6 and NFPA 72. The deficient practice could affect all smoke zones,108 of 108 residents, and an indeterminable number of staff and visitors. 1. During the inspection, observations and interviews with the maintenance director revealed that all smoke/fire doors on the first floor did not drop with the fire alarm, and one fire door on the second floor south side does not close when the fire alarm is activated. 2. During the inspection, observations and interviews with the maintenance director revealed that the fire alarm devices on the second floor were not properly mounted. 3. During the inspection, observations and interviews with the maintenance director revealed that a smoke detector was missing in the dining room. 4. During the inspection, observations and interviews with the maintenance director revealed that the fire alarm panel's trouble card 3 is malfunctioning, according to the maintenance director. 5. During the inspection, observations and interviews with the maintenance director revealed that the fire alarm message is incorrect; it instructs residents to stay in their rooms and avoid using the stairwells, which contradicts the requirement for a full building evacuation. 6. During the inspection, observations and interviews with the maintenance director revealed fire alarm impairments, and the whole facility was consequently put on fire watch with DFPC at 1 p.m. on 5/28/26. 7. During the inspection, observations and interviews with the maintenance director revealed that all pull stations on the first floor do not initiate the fire alarm system. 14.4.1.2.2 Changes to all control units connected or controlled by the system executive software shall require a 10 percent functional test of the system, including a test of at least one device on each input and output circuit to verify critical system functions such as notification appliances, control functions, and off-premises reporting. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 17.2 Purpose. Automatic and manual initiating devices shall contribute to life safety, fire protection, and property conservation by providing a reliable means to signal other equipment arranged to monitor the initiating devices and to initiate a response to those signals. 9.6.2.10.1.4 System smoke detectors in accordance with NFPA 72, National Fire Alarm and Signaling Code, and arranged to function in the same manner as single-station or multiple-station smoke alarms shall be permitted in lieu of smoke alarms. 9.6.5.1 Fire safety functions shall be installed in accordance with the requirements of NFPA 72, National Fire Alarm and Signaling Code. 9.6.5.2 Where required by another section of this Code, the following functions shall be actuated:(1)Release of hold-open devices for doors or other opening protectives(2)Stairwell or elevator shaft pressurization(3)Smoke management or smoke control systems(4)Unlocking of doors(5)Elevator recall and shutdown(6)HVAC shutdown9.6.3.9 Automatically transmitted or live voice evacuation or relocation instructions shall be permitted to be used to notify occupants and shall comply with either 9.6.3.9.1 or 9.6.3.9.2.9.6.3.9.1 Automatically transmitted or live voice evacuation or relocation instructions shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code. 9.6.2.6* For fire alarm systems using automatic fire detection or waterflow detection devices to initiate the fire alarm system in accordance with Chapters 11 through 43, not less than one manual fire alarm box shall be provided to initiate a fire alarm signal. The manual fire alarm box shall be located where required by the authority having jurisdiction. 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. The administrator discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain the Fire suppression system in accordance with the Life Safety Code 101 section 9.6, NFPA 25, and NFPA 13. The deficient practice could affect all smoke zones,108 of 108 residents, and an indeterminable number of staff and visitors. 1. During the record review, observations and interviews with the maintenance director revealed that the dry system has been out of commission since 12/2/25. 2. During the inspection, observations and interviews with the maintenance director revealed that 27 dry barrel heads were replaced on the dry system without a permit from DFPC or Denver Fire. 3. During the inspection, observations and interviews with the maintenance director revealed fire alarm impairments, and the facility was consequently put on fire watch with DFPC at 10 a.m. on 5/27/26. NFPA 25 (2011) 4.1.9.1 Where an impairment to a water-based fire protection system occurs, the procedures outlined in Chapter 15 of this standard shall be followed, including the attachment of a tag to the impaired system. 4.1.9.2 Where a water-based fire protection system is returned to service following an impairment, the system shall be verified to be working properly by means of an appropriate inspection or test. 4.2 Corrective Action. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. 24.2.1.5 Where addition or modification is made to an existing system affecting more than 20 sprinklers, the new portion shall be isolated and tested at not less than 200 psi (13.8 bar) for 2 hours. 1.5 Equivalency. Nothing in this standard is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety over those prescribed by this standard. 1.5.1 Technical documentation shall be submitted to the authority having jurisdiction to demonstrate equivalency. 1.5.2 The system, method, or device shall be approved for the intended purpose by the authority having jurisdiction. 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.7.6 Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:(1) The extent and expected duration of the impairment have been determined.(2) The areas or buildings involved have been inspected and the increased risks determined.(3) Recommendations have been submitted to management or the property owner or designated representative.(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:(a) Evacuation of the building or portion of the building affected by the system out of service(b) *An approved fire watch(c)*Establishment of a temporary water supply(d)* Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire(5) The fire department has been notified.(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.(7) The supervisors in the areas to be affected have been notified.(8) A tag impairment system has been implemented. (See Section 15.3.)(9) All necessary tools and materials have been assembled on the impairment site. 33.3.1.2.1.1* Facilities where the authority having jurisdiction has determined equivalent safety is provided in accordance with Section 1.4 shall not be required to comply with the requirements of Section 33.3, as indicated for the appropriate evacuation capability. A.?33.3.1.2.1.1 In determining equivalency for existing buildings, conversions, modernizations, renovations, or unusual design concepts, the authority having jurisdiction might permit evaluations based on the residential board and care occupancies fire safety evaluation system (FSES) of NFPA 101A, Guide on Alternative Approaches to Life Safety. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. The administrator discussed deficient items at the exit conference.

Based on observation, interview, and record review, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining the life safety code for Fire evacuation, Fire alarm, and Fire suppression. The facility failures had the potential to affect all occupants of the building. Findings include:A cross-reference to A0001 for observations, interviews, and record reviews showed that the staff and residents did not know how to respond during an emergency. The building was not set up for "defend in place," which is their evacuation plan. A cross-reference to A0002 for observations and an interview regarding the fire alarm system showed that the fire alarm initiating/activation devices do not work throughout the facility, and the emergency voice message is incorrect. Cross-reference to A0003 for observations, interviews, and record review showed that the fire suppression system's dry system had been out of commission since 12/2/25, and work was being done on the system without being permitted. The administrator discussed deficient items at the exit conference.

A relicensure survey and complaint revisit was completed on 4/28/26 for all previous deficiencies cited on 2/18/26. The residence is in compliance with all regulations surveyed.

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

A licensure complaint, prompted by #CO42063 and #CO42169, was completed on 4/28/26. Deficiencies were cited.

Based on records review and interviews, the residence failed to immediately comply with all imposed conditions, affecting 64 current residents. Findings Include:A review of Department records on 4/28/26 revealed that a fine imposed on 2/18/26, with a due date of 4/10/26, had not been paid. On 4/28/26 at 3:35 p.m., the administrator stated that she was aware of the Department's fine imposed on 2/18/26. She explained that she was not aware of the 4/10/26 due date and that the fine had not yet been paid. She added that she was not the one who processed payments and would follow up with the accounting department to ensure the fine was paid.

Based on records review, and interviews, the residence failed to ensure that each staff member received orientation and training for emergency response policies and procedures and fire response, including facility evacuation procedures affecting 64 current residents. Specifically, the residence had ten residents who required two person assistance. Five to six residents who require two-person assistance live on the second floor. Three to four residents residing on the second floor required hoyer lifts. The administrator stated her expectation was that staff were to use specific measures and tools to evacuate residents when there was an emergency. However, staff did not know the procedure or the tools they would need on how to evacuate residents when there was an emergency. Staff interviews indicate that they had not been effectively trained on how to evacuate residents when there is an emergency. Staff interviews indicated that they were not able to verbalize or demonstrate their knowledge on evacuating high risk residents. Residence policy did not include the specific measures and tools that the administrator stated she expected the staff to know. This failure created an immediate jeopardy (IJ) risk of serious harm or death to all 64 current residents residing in the residence. On 4/28/26, the Department directed the residence to provide written evidence that the risk had been removed. Findings Include:1. Record ReviewThe residence ' s Emergency Preparedness Plan policy, dated 1/5/26 , read in part: "To ensure proper and adequate preparedness, it is the residence ' s policy to perform disaster preparedness training at least once per year, and upon hire for new Team Members, and testing drills at least twice per year, for all staff. Non-ambulatory residents are evacuated down stairs or fire escapes using two-man swing carries or three-and-four man blanket carries. Non-ambulatory residents are moved from the unsafe area either by an evacuation carry or blanket drag. The following techniques are used to evacuate residents confined to a wheelchair:Kneel Drop CarryTwo-Person Swing CarryTwo-Person Extremity CarryResidents who are confined to a bed are moved by using the Kneel Drop Carry. In an emergency, one or more team members may be responsible for moving residents. Depending on the situation they may need to choose the best of several methods of transport. Kneel Drop Carry is used when the rescuer is similar or larger in size than the resident. Two-Person Swing Carry is the best carry for two trained people to move any normal size resident. No blanket is needed for this carry. Two-Person Extremity Carry if it is difficult to move someone with any of the previously listed carries, the following method may be used. This carry can be used on any resident who can be placed in a sitting position. Two rescuers must do this carry. Each rescuer has specific moves to complete; rescuer (A) moves the upper part of the resident ' s body and rescuer (B) moves the lower part of the resident ' s body." 2. InterviewsOn 4/28/26 at 10:20 a.m., Resident #8 stated that she required the use of the hoyer lift to get out of bed and get her in the recliner. Resident #8 stated that she was not able to stand on her own. Resident #8 said she had not been evacuated for a fire drill. On 4/28/26 at 10:30 a.m., Resident #13 stated that he required the use of the hoyer lift to get him out of bed and into his wheelchair and from his wheelchair to his bed. Resident #13 said that he has not been evacuated for a fire drill. Resident #13 said when the residence had a fire drill that staff just closed his room door. On 4/28/26 at 10:35 a.m., Staff #3 stated that she had not received specific training on how to evacuate residents when there was an emergency. Staff #3 said that she did not know how to evacuate residents who required a two person assist. On 4/28/26 at 10:37 a.m., Staff #1 stated she did not know what to do if she needed to evacuate residents when there was an emergency. Staff #1 said she had not received training on how to evacuate residents. On 4/28/26 at 10:40 a.m., Resident #14 stated that she required the use of the hoyer lift to get her out of bed and into her wheelchair and from her wheelchair to her bed. Resident #14 stated she has not been evacuated for a fire drill. On 4/28/26 at 11:38 a.m., the administrator stated her expectation was that staff were to use specific measures and tools to evacuate residents when there was an emergency. The administrator said when the residence had to evacuate residents from the second floor that the residence had a three by three in size staging area room to put residents in and then staff would use a chair swing to get the residents downstairs. The administrator said staff could also use a draw sheet to move the residents. The administrator said one staff member could use the draw sheet. The administrator said if staff were using a hoyer lift that there should be two staff. The administrator said the second floor had five to six residents who required a two person assist. The administrator said staff could stage the residents until the residence had more hands on deck. 3. Immediate Jeopardy Risk (IJR)-Written Evidence, Immediate CorrectionThe investigation established that the findings above placed the 64 current residents at IJR in serious harm or death. The residence was directed to provide the Department with written evidence that the risk had been removed. Park 3.13 of the Chapter VII regulations requires residences to immediately correct the circumstances that gave rise to the IJ situation. On 4/28/26 at 2:05 p.m., the administrator submitted written evidence that read in pertinent part, "The residence will ensure that all staff are trained starting on 4/28/26 on the following topics:Fire ResponseEvacuation Response and ProceduresAll team members that were not present for the first two training sessions will berequired to attend one of two training sessions that will be scheduled fortomorrow 4/29/26 at 10:00 a.m. and 4:00 p.m. Any team members that did not attend any ofthe four provided training sessions will be removed from the schedule untiltraining is completed. 30 Day Plan of Correction:The community Executive Director and Maintenance Coordinator will scheduleand execute an evacuation drill for the community no later than May 28, 2026."This removal plan was not accepted, the administrator was asked to provide more specifics particularly, policy and procedures on exactly on what the residences plan to train on the egress device and what the egress device was. The administrator was directed to submit additional written evidence. On 4/28/26 at 2:30 p.m., the administrator submitted additional written evidence that read in pertinent part: "The administrator acknowledges the IJ (immediate jeopardy) that is in place. The residence moving forward would ensure that all staff were trained on the Fire Response Policy, Emergency Preparedness Checklist and Fire Evacuation Plan. However, the written evidence did not indicate the risk had been removed because it did not contain an acceptable plan on how staff were going to be trained on the egress device and what the egress device was. The administrator was directed to submit additional written evidence. On 4/28/26 at 2:55 p.m. the administrator submitted additional written evidence that read in part: "The administrator acknowledges the IJ that is in place. The administrator the document on the evacuation chair procedure, a link to the training video that would be used as a training tool for all team members. The procedure will remain in the emergency binder located at the concierge desk and will also be posted next to the devices. Each device also has a step-by-step photo guide located on the cushion of the chair for staff to use. The additional evidence that was received by the residence was approved and the immediate jeopardy was removed on 4/28/26 at 3:45 p.m.

Based on observations, record review and interviews, the residence failed to ensure staff documented, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them, affecting two of eight sample residents (#12 and #7). Findings Include:1. Resident #12 was admitted to the residence on 1/11/26 with a diagnosis of coronary angioplasty implant and graft and stage three chronic kidney disease. 2. Record ReviewA progress note dated 4/26/26, read in part, staff spoke to Resident #12 ' s power of attorney (POA) who was at the facility requesting entry into the residents room. The POA told staff that Resident #12 had two broken ribs and stitches on his forehead. POA told staff that they were heading to the hospital and would be returning Resident #12 back to the residence. A progress note dated 4/26/26, read in part, staff spoke with the hospital about discharge orders for Resident #12. Staff told the hospital that Resident #12 was ok to be sent back to the residence. A progress note dated 4/27/26, read in part, late entry, Resident #12 returned to the residence from the hospital with no changes to care of medications. Resident #12 ' s primary care physician notified of the return. No changes needed for a comprehensive re-evaluation at this time. The service plan had been reviewed and updated. Resident #12 was ambulating with a walker and attending meals and activities since returning from hospital. A progress note dated 4/27/26, read in part, Resident #12 had an unwitnessed fall in his bathroom on 4/25/26 at 11:00 p.m. Resident #12 ' s records revealed that there was no progress note on the date of the fall on 4/25/26. 4. InterviewsOn 4/28/26 at 7:45 a.m., Staff #5 stated Resident #12 had a fall and was sent out to the hospital two or three days ago. Staff #5 said Resident #12 had two fractured ribs and received five stitches above his eye. Staff #5 said this was the first time Resident #12 had fallen as he did not have a history of falling. On 4/28/26 at 4:05 p.m., the administrator stated Resident #12 fell on Friday or Saturday. The administrator acknowledged that a progress should have been written on the day Resident #12 fell. The administrator said the medication supervisor should be putting in the note before the end of their shift. There was similar deficient practice for failure for Resident #7.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter 7.(U2610) 22.1 All interior areas, including attics, basements, and garages, shall be free from accumulations of extraneous material such as refuse, unused or discarded furniture, and potential combustible materials. 25.26 A secure environment shall meet the following criteria:(U3144) (F) There shall be a secure outdoor area that is available for resident use year-round that:(2) Is independently accessible to residents without staff assistance for entrance or exit.

A relicensure survey with complaints #CO40625, #CO41505, and #CO41552 was completed on 2/18/26. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current certification in first aid from a nationally recognized organization, affecting 60 current residents. Findings include:Review of the residence's February 2026 schedule revealed the following shifts did not have at least one staff member onsite who had current certification in first aid from a nationally recognized organization: 2/6-2/7, 2/12, 2/19-2/20, and 2/26/26. On 2/18/26 at approximately 10:58 a.m., the resident care coordinator acknowledged that the shifts and times lacked someone with a first aid certification from a nationally recognized organization. Additionally, she expected the residence to have at least one staff member on-site with a first aid certification from a nationally recognized organization. On 2/18/26 at approximately 10:58 a.m., the administrator acknowledged that the residence lacked a staff member with a first aid certification from a nationally recognized organization, on the above dates. Additionally, she expected the residence to have at least one staff member on-site with a first aid certification from a nationally recognized organization.

Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current cardiopulmonary resuscitation (CPR) and obstructed airway techniques certification from a nationally recognized organization, affecting 60 current residents. Findings include:The residence's February 2026 schedule revealed the following shifts did not have at least one staff member onsite who had current CPR certification and obstructed airway techniques from a nationally recognized organization: 2/6-2/7, 2/12, 2/19-2/20, and 2/22/26. On 2/18/26 at approximately 10:58 a.m., the resident care coordinator acknowledged that the shifts and times lacked someone with a CPR certification from a nationally recognized organization. Additionally, she expected the residence to have at least one certified staff member on-site. On 2/18/26 at approximately 10:58 a.m., the administrator acknowledged that the residence lacked a staff member with a CPR and obstructed airway techniques certification from a nationally recognized organization, on the above dates. Additionally, she expected the residence to have at least one staff member on-site who was certified.

Based on record review and interview, the residence failed to ensure the qualified medication administration person (QMAP) supervisor conducted a competency assessment with direct observation of all medication administration tasks that the QMAP will be assigned to perform, before the initial assignment for four of eight sample staff (#1, #4, #5, #8) who were scheduled as QMAPs for 17 of 31 days in January 2026, affecting 60 current residents. (Cross-reference U1568 and U1632)Findings Include:1. Residence PolicyAn undated residence Medication Administration/Assistance Training and Skill Capability Evaluation Policy, provided by the residence on 2/17/26, read trained, authorized unlicensed team member that administer or assist with resident medications were observed for safe and accurate medication practices the first week after successful training completion, two through five weeks after successful training completion, months two and three following successful training completion, and will receive ongoing skill capability evaluation as needed. 2. Record ReviewA review of the January 2026 staff schedule revealed Former Staff #8 worked as a QMAP for the day shifts of January 1/1-1/3, 1/6-1/10, 1/14-1/17, 1/20-1/24, and 1/28/26. On 2/17/26 at 10:19 a.m., the personnel file for Former Staff #8, including the QMAP competency assessment,was requested from the administrator via electronic communication. A review of the personnel file for Former Staff #8, hired 6/30/09, revealed no evidence of a QMAP competencyassessment. On 2/17/26 at approximately 3:37 p.m., the QMAP competency assessment for Former Staff #8 was requestedagain. 3. InterviewsOn 2/17/26 at approximately 8:48 a.m., the resident care coordinator (RCC) stated it was the responsibility of theRCC to oversee and train medication administration personnel. The RCC went on to state that there were multipleRCC ' s in the month of January 2026 due to staffing changes, that she is now working to provide QMAPtraining and oversight, and acknowledged that this training was not adequately done prior. On 2/18/26 at approximately 2:44 p.m., the administrator stated the residence could not provide verification of aQMAP competency assessment performed for Former Staff #8 before conducting QMAP duties. The administratorconfirmed Former Staff #8 passed medications to residents on 1/1-1/3, 1/6-1/10, 1/14-1/17, 1/20-1/24, and1/28/26. The administrator acknowledged failure to provide verification that Former Staff #8 received a competencyassessment with direct observation from a QMAP supervisor of all medication administration tasks that the QMAPwill be assigned to perform, which is non-compliant with Chapter VII, 14.13. 4. Similar deficient practice was found for Staff #1, #4, and #5.

Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting two of eight sample residents (#3, #6), and one former resident (#8). (Cross-reference U1542)Specifically, the residence failed to comply with authorized practitioner orders to administer Torsemide, a diuretic. The residence was directed to administer Torsemide 40 mg every morning to Former Resident #8; however, the January 2026 medication administration record (MAR) revealed that the residence failed to administer the medication from 1/6-1/15/26, for a total of 10 missed doses. Subsequently, on 1/15/26, Former Resident #8's oxygen saturation was between 80-84%, and he exhibited increased confusion. When emergency medical responders (EMR) assessed, Former Resident #8 was determined to have fluid in his lungs. On 1/16/26, Former Resident #8 was admitted to hospice. Former Resident #8's practitioner, who assessed him on 1/16/26, confirmed that the missed doses of torsemide could be contributing to the fluid in the lungs, the wet-sounding cough, and slight 'gurgle' when breathing. On 1/17/26, Former Resident #8 passed away, and the practitioner's notes read the former resident's cause of death was related to chronic combined systolic and diastolic heart failure due to atherosclerotic cardiovascular disease. Former Resident #8's practitioner acknowledged that residence staff did not contact her prior to 1/16/26 regarding the missed doses of the scheduled Torsemide medication. The practitioner stated there were standing orders on Former Resident #8's medication list in the event he would require an emergency refill of medication, but it was not utilized. Former Resident #8's practitioner stated they believed that the residence's failure to administer the 10 doses of scheduled Torsemide medication led to the former resident's decline and ultimate death on 1/17/26. Findings Include:1. Reference and Residence Policiesa. According to MedLinePlus (revised 7/20/24), which is a service of the National Library of Medicine (NLM) and part of the National Institutes of Health (NIH), "Torsemide is used alone or in combination with other medications to treat high blood pressure. Torsemide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, or liver disease. Torsemide is in a class of medications called diuretics ('water pills'). It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. High blood pressure is a common condition, and when not treated it can cause damage to the brain, heart, blood vessels, kidneys and other parts of the body. Damage to these organs may cause heart disease, a heart attack, heart failure, stroke, kidney failure, loss of vision, and other problems."b. According to the Residence's Medication Errors and Reporting Policy, dated 3/1/23, a medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. (National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP)." The residence's policy details actions steps the residence staff will take in the event a medication error occurs, which includes reporting the medication error to the Resident Care Director (RCD) or the Licensed Nurse, conducting an assessment of the error and, "promptly notify the resident's authorized practitioner and legal representative of the medication error if there is a decline from a resident's baseline status; If the error otherwise affects the resident."c. The residence's Medication Reordering and Training, dated 1/20/26, outlines that "if a resident's family is providing medication for our resident, then we (the residence) can give a courtesy call 5-7 days prior to running out of medication." The training log goes on to outline "If a temporary fill needs to be ordered from (the residence's pharmacy) until family can bring in med, then we can request that."2. Record ReviewFormer Resident #8 was admitted to the residence on 8/15/2024, with diagnoses of acute on chronic diastolic congestive heart failure, atherosclerotic heart disease, non-rheumatic aortic valve stenosis, ventricular tachycardia, atrial fibrillation, rheumatic heart disease, and hypertension. A practitioner's order, dated 12/5/25, directed the residence to administer two tablets of 20 mg Torsemide, for a total of 40 mg by mouth every morning for congestive heart failure. A review of the January 2026 medication administration record (MAR) for Former Resident #8 revealed that he did not receive 40 mg of Torsemide for the scheduled doses on 1/6-1/15/26, for a total of 10 missed doses. A progress note, dated 1/15/26, read Former Resident #8's oxygen saturation was between 80-84%, appeared more confused, and when EMR were called to assess, Former Resident #8 was determined to have fluid in his lungs and possible pneumonia. A verbal order dated 1/16/26 from the former resident's primary practitioner, directed the residence to administer an additional one-time 40 mg dose of Torsemide for fluid overload related to acute on chronic diastolic(congestive) heart failure. The January 2026 MAR further read that an order was entered into Former Resident #8's chart to administer one tablet of 40 mg Torsemide by mouth one time only for Fluid overload related to Acute on Chronic Diastolic (Congestive) Heart Failure, and also read "This is an additional dose for today (1/16/2026)." A progress note, dated 1/16/26, read Former Resident #8 was being admitted to hospice. The progress note also read hospice inquired about Former Resident #8's Torsemide and why he had not received the medication. The note goes on to read that the residence staff explained the medication was on its way through a family member. A progress note, dated 1/16/26, written by Former Resident Care Director #2, who was also a registered nurse, read that Former Resident #8's practitioner came to the writer and asked about the resident's Torsemide and how long he had been without it. The writer looked in eMAR and informed PCP that resident had been without Torsemide since 1/6/2026, so for 10 days. The practitioner and writer discussed how this could be contributing to the fluid in the lungs, the wet-sounding cough, and slight 'gurgle' when breathing. PCP stated that the resident's SPO2 is 86%. A late-entry progress note, dated 1/21/26, read Former Resident #8 was found without vitals or breath sounds around 4:50 a.m. on 1/17/26 by care staff completing rounds. The hospice nurse for Former Resident #8 confirmed the former resident was deceased at around 5:45 a.m. 3. InterviewsOn 2/17/26 at approximately 8:48 a.m., the resident care coordinator (RCC) stated it was the responsibility of the RCC to oversee and train medication administration personnel. The RCC went on to state there have been past discrepancies with medication staff re-ordering medication in a timely manner that the residence is currently working to address, and there were multiple RCC's in the month of January 2026 due to staffing changes. On 2/17/26, at 9:45 a.m., Staff #1 acknowledged Former Resident #8 did not receive his scheduled Torsemide medication in January 2026 per the practitioner's order. Staff #1 stated this was due to confusion surrounding which medication staff were responsible for re-ordering, and the residence staff feeling "too intimidated" by Former Resident #8's family member to call them to request refills. On 2/18/26, at approximately 8:00 a.m., Former Resident #8's primary practitioner stated she had received a call on 1/15/26 from the residence requesting oxygen for him due to low oxygen levels. The practitioner stated that when residence staff re-checked Former Resident #8's oxygen levels and confirmed it wasat 84%, his practitioner recommended sending him to the hospital, but the resident refused. Former Resident #8's practitioner went on to state the former resident was in agreement with hospice services, and a referral was submitted 1/15/26. Former Resident #8 was admitted to hospice on 1/16/26. The practitioner stated that after hospice reviewed Former Resident #8's medications, it was determined he had missed 10 doses of Torsemide in the weeks leading up to the hospice admission. A one-time order was placed to administer 40 mg of Torsemide to Former Resident #8 on 1/16/26. The practitioner acknowledged that residence staff did not contact her prior to 1/16/26 regarding the missed doses of the scheduled Torsemide medication for Former Resident #8. The practitioner acknowledged there were standing orders on Former Resident #8's medication list in the event he would require an emergency refill of medication, but it was not utilized. The practitioner stated Former Resident #8 was cleared to have a tooth procedure a week prior, and acknowledged the admission to hospice on 1/16/26 was a sudden change in condition. Former Resident #8's practitioner also acknowledged that he did not receive his scheduled Torsemide medication between 1/6/26 and 1/15/26, and the residence's failure to administer 10 doses of scheduled Torsemide medication led to the decline and ultimate death of Former Resident #8. On 2/18/26, at 12:30 p.m., a staff member from the Medical Examiner's Office stated their report was still in progress; however, practitioner notes pertaining to Former Resident #8's cause of death read "chronic combined systolic and diastolic heart failure due to atherosclerotic cardiovascular disease." On 2/18/26, at approximately 3:00 p.m., the administrator acknowledged that residence staff did not inform Former Resident #8's practitioner of the missed Torsemide doses between 1/6/26 and 1/15, until 1/16/26. The administrator acknowledged that residence staff did not follow the residence's medication reordering and training policy, and that it was plausible this may have resulted in harm to Former Resident #8. The administrator acknowledged that failure of the residence staff to comply with the authorized practitioner's order associated with medication administration was non-compliant with Chapter VII, 14.21.4. There was similar deficient practice for Residents #3 and #6.

Based on observations and interviews, the residence failed to have a locked medication cart to store medications when unattended by qualified medication administration persons (QMAP) or other licensed staff, affecting 13 current residents residing in a secured environment. (Cross-reference U1542)Findings include:1. ObservationsOn 2/17/26 at 9:10 a.m., a medication cart, located in a secured environment, was observed unlocked and unattended while residents wandered the halls. Residence staff were not observed near the medication cart. On 2/18/26 at approximately 9:00 a.m., Staff #4 was observed administering medications in a secured environment. Staff #4 failed to lock the medication cart prior to leaving the cart to administer medications to a resident. The medication cart was unlocked and unattended while residents wandered the halls. 2. InterviewsOn 2/18/26, at approximately 9:10 a.m., Staff #4 stated her position as a qualified medication administration personnel (QMAP) started three weeks prior, and received training from the resident care coordinator (RCC). Staff #4 went on to state she has not received a competency evaluation since the start of her position. Staff #4 acknowledged medication carts should be locked when unattended. On 2/18/26, at approximately 2:45 p.m., the administrator stated she expected the medication cart to be always locked when unattended by staff. The administrator acknowledged that during the day shift on 2/17/26 and 2/18/26, a medication cart located in a secured environment was unlocked and unattended while residents wandered the halls. The administrator acknowledged that failure to have a locked cart to store medications when unattended by qualified medication administration persons (QMAP) or other licensed staff was non-compliant with Chapter VII, 14.38.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.29 All prescribed and PRN 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, any known 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 of administration, 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 the record 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 is completed 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 to medications. 21.2 The assisted living residence grounds shall be maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction. 24.4 All garbage and rubbish that is not disposed of as sewage shall be collected in impervious containers in such a manner as not to become a nuisance or a health hazard and shall be removed to an outside storage area at least once a day. (B) A sufficient number of impervious containers with tight fitting lids shall be provided, and kept clean and in good repair.

A licensure complaint, prompted by #CO39933, was completed on 5/12/25. No deficiencies were cited.

A revisit survey was completed on 8/15/23 for all previous deficiencies cited on 1/13/23. The agency is in compliance with all regulations surveyed.

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

A relicensure survey was completed on 1/13/23. Deficiencies were cited. A change of ownership occurred on 1/16/2020.

Based on observation, record review, and interview, the residence failed to ensure a list of all staff who had current certification in first aid and/or cardiopulmonary resuscitation (CPR) was placed in a visible location, affecting 54 current residents. Findings include:1. ObservationOn 1/13/23, during the onsite visit, a list of staff members that were certified in first aid and CPR was not posted in a visible location within the building. 2. Record ReviewReview of staffs' personnel files revealed Staff #1-#3 were certified in CPR and first aid on 4/28/22, 1/4/23, and 4/27/21 respectively. 3. InterviewOn 1/13/23 at 12:30 p.m., the resident care director confirmed that a list of first aid/CPR certified staff was not posted anywhere in the residence. The resident care director stated that she was unaware that this was a requirement.

Based on record review and interview, the residence failed to ensure the resident roster contained a residence diagram that showed room locations, affecting 54 residents. Findings include:On 1/13/23 at approximately 9:00 a.m., the resident care director was asked to provide a copy of the current resident roster. On 1/13/23 at approximately 11:00 a.m., the resident care director provided an updated resident roster and an emergency contact list. On 1/13/23 at approximately 11:00 a.m., the resident care director stated that she had provided the current resident roster. She stated the residence did not have a diagram that showed room locations. The resident care director stated she was unaware the roster was required to contain a residence diagram.

Based on observation and interview, the residence failed to ensure rooms occupied by smokers had fire resistant wastebaskets, affecting two of two residents who smoked cigarettes (#4, #5). Findings include: On 1/13/23 at approximately 4:00 p.m., an environmental tour of resident #4 and #5's rooms revealed the waste baskets in the residents' rooms were not fire resistant. Both of these room had a small white plastic wastebasket. On 1/13/23 at 4:00 p.m., Resident #4 stated he was aware of the smoking area and stated he only smoked in the designated location. On 1/13/23 at approximately 4:20 p.m., Resident #5 stated she only smoked outdoors in the designated smoking area. On 1/13/23 at approximately 5:00 p.m., the resident care director confirmed Resident #4 and #5 smoked. The resident care director stated she was not aware resident wastebaskets were required to be fire resistant if they were identified as smokers. She stated that the residents used the designated smoking area which had fire resistant containers.

9999THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 2.2.10.5 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.