FIVE STAR RESIDENCES OF DAYTON PLACE

A licensure complaint, prompted by #CO41557, was completed on 2/25/26. No deficiencies were cited.

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 7.14.27 (A) No stock medications shall be stored or administered by qualified medication administration persons. All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name.

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

A relicensure survey was completed on 7/23/25. Deficiencies were cited.

Based on observations, record review, and interviews, the residence failed to have sufficient staff in number to help residents needing or potentially needing assistance, affecting all 62 current residents. Findings Include:1. ObservationsOn 7/22/25 at 8:15 a.m., in the secure environment of the residence, Staff #3 requested assistance from the state surveyor to help lift Resident #7 out of bed. The state surveyor informed Staff #3 that they were not permitted to assist with resident care. Since Staff #3 did not have a radio, they asked the state surveyor to locate another staff member. The state surveyor then found Staff #4 supervising residents eating breakfast. Staff #4 asked the state surveyor to supervise the residents while they ate breakfast, so she could assist Staff #3 with Resident #7. On 7/22/25 at 2:11 p.m., a residence volunteer asked the state surveyor for assistance with wheeling Resident #1 back to her room from the activities room due to staff taking too long to get her. Resident #1 was advised to push her emergency call pendant to alert staff to come assist, as the state surveyor was not able to assist with resident care. On 7/23/25 at 9:06 a.m., Resident #3 asked the state surveyor for assistance with toileting due to needing help. Resident #3 was advised to push her emergency call pendant to alert staff to come assist, as the state surveyor was not able to assist with resident care. 2. Record ReviewOn 7/16/25 at 1:00 p.m., during the resident council meeting, Resident #10 stated waiting a while for staff to come to her due to staff walking from the third floor of the residence. The health and wellness director (HWD) stated that part of this is due to staffing in general, and we are still hiring more people. Resident #3 was admitted to the residence on 1/20/23 and required staff to provide standby supervision with transfers regularly. Resident #3 had emergency call pendant response times that exceeded 40 minutes on the following days:On 6/4/25, it took one hour and 22 minutes for staff to respond. On 6/6/25, it took one hour and 55 minutes for staff to respond. On 6/11/25, it took 55 minutes for staff to respond. On 6/12/25, it took two hours and 55 minutes for staff to respond. On 6/12/25, it took two hours and 10 minutes for staff to respond. On 6/13/25, it took one hour and two minutes for staff to respond. On 6/17/25, it took 41 minutes for staff to respond. On 6/18/25, it took one hour and 19 minutes for staff to respond. On 6/19/25 at 3:52 a.m., it took one hour and 52 minutes, and at 10:15 p.m., it took 52 minutes for staff to respond. On 7/2/25, it took three hours and 36 minutes for staff to respond. On 7/7/25, it took 42 minutes for staff to respond. On 7/15/25 at 3:29 a.m., it took two hours and 22 minutes, and at 5:56 p.m., it took 47 minutes for staff to respond. On 7/18/25, it took two hours and 40 minutes for staff to respond. On 7/19/25, it took two hours and 51 minutes for staff to respond. On 7/19/25, it took 41 minutes for staff to respond. Resident #1 was admitted to the residence on 11/30/23 and required two staff members to assist with transfers and complete assistance with bathing. Resident #1 had emergency call pendant response times that exceeded 40 minutes on the following days:On 6/15/25, it took 41 minutes for staff to respond. On 6/22/25, it took 59 minutes for staff to respond. On 6/30/25, it took 50 minutes for staff to respond. On 7/6/25 at 3:56 p.m., it took 40 minutes, at 6:09 p.m., it took two hours and 15 minutes, and at 10:13 p.m., it took 46 minutes for staff to respond. On 7/15/25, it took 46 minutes for staff to respond. On 7/18/25, it took one hour and 11 minutes for staff to respond. On 7/13/25 at 6:55 p.m., it took one hour and one minute, and at 8:10 p.m., it took 41 minutes for staff to respond. On 7/16/25, it took 55 minutes for staff to respond. Resident #2 was admitted to the residence on 5/30/24, was non-ambulatory, and required two staff members to assist with toileting, transfers, and evacuation. Resident #2 required complete assistance with dressing. Resident #2 had emergency call pendant response times that exceeded 40 minutes on the following days:On 7/19/25, it took one hour and 36 minutes for staff to respond. On 7/15/25, it took one hour and nine minutes for staff to respond. On 7/6/25, it took one hour for staff to respond. On 7/10/25, it took 57 minutes for staff to respond. On 7/9/25, it took 53 minutes for staff to respond. On 7/20/25, it took 51 minutes for staff to respond. On 7/21/25, it took 48 minutes for staff to respond. On 7/18/25, it took 45 minutes for staff to respond. On 7/1/25, it took 44 minutes for staff to respond. 3. InterviewOn 7/22/25 at 7:35 a.m., Staff #5 reported that Resident #1 and Resident #2 required two staff members to assist when completing personal care. She stated that completing care for Resident #2 can be difficult due to his size and her having a sore wrist. On 7/22/25 at approximately 8:30 a.m., Staff #3 stated residents in the secured environment get left alone in the common areas at times, as many residents in the secure environment need two-person assistance. She stated this happens during meal times, having to do medication administration, serving food, and getting residents out of bed at the same time. On 7/22/25 at 1:33 p.m., Resident #2 stated that he frequently had to wait long periods of time for staff members to assist with his care needs, particularly toileting. He reported that on one occasion, it had taken up to two hours for staff to respond. He noted that staff were often unable to meet his care needs due to being short-staffed. He stated that the two-hour checks were not completed, and he expressed a desire for these checks to be completed to help him sit up in bed, as he frequently slid down. He also reported that repositioning during care caused him pain, and that staff members often forgot he was unable to move his left leg. On 7/23/25 at 9:36 a.m., Resident #3 reported that the residence needed more staff due to an increase in the number of residents, which made it difficult for staff to respond to everyone promptly. She stated that she had experienced long wait times when using her emergency call pendant for assistance. She explained that she had a history of falls and had used her pendant about a month ago in the middle of the night for help with toileting. She stated that it took staff several hours for staff to respond, during which time she wet herself and remained in bed until a staff member arrived in the morning. On 7/22/25 at 2:56 p.m., the HWD reported Resident #2 required two staff members to assist with care and sometimes required three staff members when changing his bed sheets. She reported that all staff members were aware that he required two staff members to assist. The HWD reported they have had three staff members on shift in assisted living, but that was not enough. She acknowledged they are short-staffed and in the process of hiring more. She reported she expected call light times to be answered within 10 minutes. On 7/23/25 at 2:54 p.m., the administrator reported she expected the call light times to be answered within 10 minutes, and anything beyond 20 minutes would be too long.

Based on records review and interviews, the residence failed to develop an involuntary discharge grievance policy that included all required elements affecting 62 current residents. Findings Include:The residence ' s Discharges (Move Out) Voluntary and Involuntary policy, dated 7/8/24 and undated 7/1/25; Resident Grievance policy, dated 4/1/19; and Complaints and Grievances policy, dated 1/1/01 and updated 1/30/19, failed to include the following required elements:(1) A requirement that no later than 5 business days after the submission of a grievance under subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall respond to the grievance as follows:(a) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) The written response shall include the following statement regarding the filing of an appeal:"If the resident, or other person who submitted this grievance, is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge, and supporting documentation given to the resident as part of that notification, and any additional information or documentation."(3) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal under this Part.(4) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(a) The stated reason for the involuntary discharge in the notice of involuntary discharge provided under Part 11.17 is nonpayment of monthly services or room and board.(b) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and(c) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. On 7/23/25 at 3:00 p.m., the administrator stated that she was aware of the general requirements for involuntary discharge; however, she stated that she was unaware of the required elements missing from the residence's policies.

Based on records review and interviews, the residence failed to have readily available a roster of current residents, which included their emergency contact information, and included a facility diagram showing room locations, affecting 62 current residents. Findings Include:On 7/22/25 at 7:57 a.m., the emergency preparedness resident roster, including the residents' names, room numbers, emergency contact, and a diagram of the facility, was requested from the administrator. On 7/22/25 at approximately 9:00 a.m., a roster of residents, which did not include emergency contact information and a facility diagram, was provided by the administrator. On 7/23/25 at 3:04 p.m., the administrator stated that she was aware of the requirements for the emergency preparedness resident roster to include residents' names, room assignments, and emergency contact information. She agreed that the roster provided did not meet the requirements. She explained that the residence kept all of the residents' face sheets readily available outside of the wellness office.

Based on records review and interviews, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises, including but not limited to fire(s), gas explosion, power outage, tornado flooding, and threatened or actual acts of violence, affecting 62 current residents. (Cross-reference T0920)Findings Include:The residence ' s Emergency Operations Plan policy, dated 2025, failed to include a risk assessment of all hazards and preparedness measures to address natural and human-caused crises, including but not limited to fire(s), gas explosion, power outage, tornado flooding, and threatened or actual acts of violence. On 7/23/25 at 3:06 p.m., the administrator stated that the residence did not have an emergency preparedness risk assessment of all hazards and preparedness measures. She stated she expected the residence's policies to include this risk assessment and agreed that their emergency preparedness plan did not meet expectations.

Based on records review and interviews, the residence failed to have emergency policies addressing the identified risk of fire, ensuring auxiliary power, and written agreements with other healthcare facilities for relocation, affecting 62 current residents. (Cross-reference T0912)Specifically, the residence failed to develop a policy directing the staff of the residence on the process for when a fire occurred in the residence. Staff members and administrative staff of the residence provided inconsistent explanations of the residence's emergency plan when a fire occurred. Additionally, members of the administration failed to know any of the emergency preparedness procedures. Furthermore, in 2021 the state fire authority code changed so all private pay assisted living residence were to fully evacuate anytime the fire alarm sounded. The state fire authority attempted to enforce this change in 2022 and 2023 each time during the onsite inspection the residence failed to provide emergency preparedness plans. This failure created an immediate jeopardy risk of serious injury or death to all 62 current residents residing in the residence. On 7/23/25, the department directed the residence to provide written evidence that the risk had been removed. Findings Include:1. Record reviewA fire drill report, dated 4/13/25 at 7:45 p.m., read in part: Six staff members from third shift participated in the evacuation of all residents. The alarm was pulled my maintenance at 7:45 p.m., staff had residents ready in the staging areas by 7:50 p.m., and were evacuated to the safety point by 7:53 p.m. for a total of eight minutes to safely evacuate all residents. Residents were returned to the residence by 7:59 p.m. A fire drill report, dated 5/26/25 at 3:10 p.m., read in part: 13 staff members from second shift participated in the evacuation of all residents. The alarm was pulled by maintenance at 3:10 p.m., staff had residents ready in the staging areas by 3:14 p.m., and were evacuated to the safety point by 3:19 p.m. for a total of nine minutes to safely evacuate all residents. A new employee orientation checklist, dated 6/25/25, revealed that Staff #1 was trained on the residence's emergency procedures including fire evacuation procedures. On 7/22/25 at 7:57 a.m., the residence's emergency preparedness plan, policies, and procedures were requested from the administrator. On 7/22/25 at approximately 9:00 a.m., the administrator provided an orange binder that read "Five Star Senior Living Emergency Operations Plan Five Star Residence of Dayton Place 2025"The residence ' s Emergency Operations Plan policy, dated 2025, failed to include a procedure addressing steps to be taken in the event of a fire within the residence. On 7/23/25 at 10:30 a.m., the residence's fire procedures for their emergency preparedness plan were requested from the administrator. On 7/23/25 at 11:45 p.m., the administrator provided a "General Fire Procedures" policy dated June 2012. This policy indicated that the residents were to shelter-in-place and be moved within the residence in the event of a fire. 2. InterviewsOn 7/22/25 at 1:20 p.m., Staff #3 stated that, during an active fire, staff would work to get residents out of their rooms within the secure environment and gather in the common area of the secure environment. Staff would then contact a supervisor for direction on where to exit the building. Staff #3 stated she was not familiar with a designated meeting point for the residents and staff once outside of the residence. She also added fire drill training was to be conducted every quarter but she had not been involved in one in quite some time during her shift. On 7/22/25 at 2:40 p.m., the memory care director stated she was hired in April 2025, and fire drills occur every quarter. She stated she had not been involved in a fire drill since she started in the secure environment and was not familiar with the emergency plan within the secure environment. She stated she had not beentrained on the fire procedures, only resident elopement procedures. On 7/23/25 approximately 9:00 a.m., the health and wellness director stated the residence was a "shelter in place" during emergency situations. She stated the staff was in charge of making sure all residents were in their rooms with the doors locked. She stated the last fire drill had been conducted in April 2025. When the state surveyor told her there were many different conflicting procedures given by the staff on what the emergency procedures are and what the specific staff duties are. She stated the residence was in dire need of conducting a new fire drill so the staff could all be on the same page with the correct emergency procedures. On 7/23/25 at 9:25 a.m., the facilities director stated he was in charge of the fire emergency procedures. He stated the emergency plan was not in the emergency preparedness plan after being given to him to review by the state surveyor. He stated the plan previously was to "shelter in place", but that was changed in 2023 by the state fire authority, and they were requested to change their policy. The updated plan was for staff to locate the fire when the fire alarms sounded by checking the fire panel and calling 911. Staff would then evacuate residents if needed and deemed necessary. He also stated fire drills were conducted every quarter, and the evacuation plan should have been given to the residents within the residence by the administrative staff. On 7/23/25 at approximately 10:45 a.m., the administrator stated that she was unaware that the emergency plan did not include a procedure for fires and stated, "Where did you get that orange binder from?" when presented with the binder as evidence of not having the procedures. On 7/23/25 at 11:45 a.m., the administrator stated the residence as "shelter-in-place" concerning fire evacuation procedures. She stated that the residence had always been "shelter-in-place". Indicating this is how she intended staff to be trained. She explained that the residence has room for improvement in training staff on proper fire evacuation procedures. She stated that she would be meeting with each outgoing and oncoming shift at "cross-over" to ensure all staff are aware of the correct procedures for when a fire occurs. She further agreed that there was a discrepancy among the administration on the correct procedures for when a fire occurs. She explained that she had been attempting to contact the local fire authority to determine the proper procedure. The administrator indicated that she would be training staff on the procedure indicated by the local fire authority. On 7/23/25 at 11:54 a.m., a telephone call was made between a representative from the state fire authority and the state surveyor. The representative from the state fire authority stated that in 2021, the residence changed from a shelter-in-place residence to a full evacuation when their fire alarms sounded throughout the building. He explained that this was due to a national fire code change which came into effect in 2021. The representative explained that the state fire authority went to the residence in 2022 to enforce the change from a shelter-in-place to a full evacuation for all private-pay assisted-living facilities; however, during that visit, the residence failed to provide an emergency plan that included a full fire emergency plan. The representative reported that the state fire authority went to the residence again in 2023; however, during that visit, the residence failed to provide a fire emergency plan once again. The representative from the state fire authority stated that the current residence's facility director, back in 2023, was advised to submit an emergency plan to the state fire authority. That plan read, to evacuate all residents during an emergency situation and have all staff and residents meet at a muster station located within the main parking lots for a head count. On 7/23/25 at approximately 12:15 p.m., the administrator stated that she was unaware of a state fire code change in 2021 that directed all private pay assisted living residences to fully evacuate the residence in the event of a fire alarm. She explained that she had only been the administrator since 2023, and the previous administrator informed her the residence was to "shelter-in-place" in the event of a fire. The administrator stated that she could not make changes to policies and procedures if she had never been informed about the change. On 7/23/25 at approximately 1:00 p.m., the facilities director stated he was not involved in the change with the state fire authority, and the residence did not have any record of the emergency plan changing in 2023. On 7/23/25 at 3:08 p.m., the administrator stated she agreed that the residence did not have a policy addressing instructions for how to handle a fire, how the residence would guarantee auxiliary power in a power outage, and agreements with other healthcare facilities for relocation of residents. She agreed that the emergency preparedness plan did not meet regulatory requirements. 3. Immediate Jepardy Risk - Written Evidence, Immediate CorrectionThe survey established that the findings above placed the 62 current residents at immediate jeopardy of serious injury or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of Chapter VII regulations requires residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 7/23/25 at 2:14 p.m., the administrator submitted written evidence that read:A. With respect to the specific resident/situation cited: Regional Team updated Emergency Preparedness Policy and Procedures related to fire prevention and evacuation to reflect [Colorado] State Fire Marshall directives on 7/23/25. The Executive Director (ED) was retrained on this updated community emergency preparedness policy and procedures, specifically related to fire prevention and evacuation, by the Regional Director of Operations (RDO) on 7/23/25. B. With respect to how the facility identifies resident/situation with the potential for the identified concerns: This has the potential to impact all residents. C. With respect to what systematic measures have been put into place to address the stated concerns: ED retrained the community leadership team on community emergency preparedness policy and procedures specifically related to fire prevention and evacuation on 7/23/25. The leadership team will initiate conducting retraining during the daily cross-over on community emergency preparedness policy and procedures, specifically related to fire prevention and evacuation, with frontline team members starting 7/23/25. The leadership team will additionally conduct retraining with the entire community team on community emergency preparedness policy and procedures, specifically related to fire prevention and evacuation by 7/25/25. The ED/Life Enrichment Director will host meetings with all current residents of the community to reeducate on community emergency preparedness policy and procedures, specifically related to fire prevention and evacuation starting 7/24/25; moving forward, the Facilities Director (FD) and Life Enrichment Director (LED) will review quarterly during resident council. ED/designee will share this information with any new residents/family of the community on emergency preparedness, specifically related to fire prevention and evacuation. The FD will host fire drills for all 3 shifts by 7/26/25. D. With respect to how the plan of correction will be monitored: FD to present results of the fire drills during Quality Assurance and Performance Improvement (QAPI) monthly for the next 90 days. During and at the conclusion of the 3 months, the QAPI team will reevaluate and initiate any necessary action or extend the review period. The ED or designee is responsible for confirming implementation and ongoing compliance with the components of the plan of correction and addressing and resolving variances that may occur."The residence immediately corrected the circumstances that gave rise to the immediate jeopardy situation, as required.

Based on interviews and record review, the residence failed to ensure that each resident's care plan reflected current personal services, needs, and preferences, along with staff tasks necessary to meet the needs of the resident (#4, #6, #7, and #9) who required updates to the care plans. Findings Include:The residence ' s Fall Management and Investigation policy, dated 12/1/02 and undated 5/12/23, read in part: "A services plan regarding falls addressing potential fall risk factors and suggested interventions is developed within 24 hours of move-in and is updated with level of care (LOC) and significant change in status, post-fall, or otherwise if required by state law or regulation."Resident #9 was admitted to the residence on 5/21/24 with a diagnosis of alzheimer's disease. A progress note, dated 6/24/25, read in part, Resident #9 was found on the floor next to her bed with no injury or pain. A progress note, dated 6/25/25, read in part, Resident #9 was found by a vendor on the floor next to her bed with no injury or pain. A progress note, dated 7/16/25, read in part, Resident #9 was found on the floor of her room, stating she was trying to use the bathroom when she lost her balance and fell. Resident #9 denied injury or pain. A care plan for Resident #9 was initiated on 5/22/24, stating the resident was a fall risk. The care plan was last revised on 5/21/2025, with a fall intervention of "my caregivers will become familiar with my daily routine and will try to anticipate and meet my needs daily". On 7/22/25 at 12:40 p.m., Staff #4 stated, the interventions for Resident #9 were to keep an eye on them throughout the day and try to perform two-hour checks. On 7/22/25 at 2:10 p.m., the memory care director stated she was not aware that care plans needed to be updated with fall interventions after falls to reflect the most recent fall assessments. She also stated she was unaware that care plans were not being updated. On 7/23/25 at 3:11 p.m., the administrator stated she would expect care plans to be updated after falls to reflect the fall assessments. She also stated she was unaware that care plans were not being updated after falls with updated interventions. Similarly, deficient practice was found for residents #4, #6, and #7.

Based on record review and interviews, the residence failed to accurately document each medication administration event at the time the event was completed, affecting one of nine sample residents (#1). Findings Include:Resident #1 was admitted to the residence on 11/30/25 with diagnoses of essential hypertension, influenza due to an identified novel influenza virus with other respiratory manifestations, difficulty in walking, enterocolitis due to clostridium difficile, and urinary tract infection. A practitioner's order, dated 1/17/25, directed the residence to administer levothyroxine sodium 75 mcg once daily. The June 2025 medication administration record (MAR) for resident #1 revealed the qualified medication administration person (QMAP) failed to document the medication administration event on 6/18/25 at 6:00 a.m. and 6/25/25 at 6:00 a.m. On 7/23/25 at 1:50 p.m., the health and wellness director stated that blank spaces on the MAR meant the QMAP did not document the medication administration event. She stated that the MAR was not accurate if the QMAP does not document the administration event because there is no way to know if the medication was administered, refused, or unavailable. She agreed this was ineffective practice and would expect documentation after each administration. On 7/23/25 at 3:13 p.m., the administrator stated she agreed that the black spaces on the MAR indicate that the medication administration event was not documented by the QMAP. She agreed that the MAR is inaccurate if QMAPs do not document each medication administration event.

Based on observations and interviews, the residence failed to store all medications in a locked cabinet, cart, or storage area when unattended, affecting 62 current residents. Findings Include:On 7/22/25 at 7:29 a.m., observation of the residence's unlocked wellness office revealed three over-the-counter medications prescribed to resident #5 stored on the floor. An environmental tour of the residence on 7/22/25 at 7:47 a.m. revealed that an inhaler prescribed to resident #6 was left unattended on the second-floor medication storage cart. On 7/23/25 at 1:50 p.m., the health and wellness director stated that the wellness office was always accessible to residents. She explained that she does not lock the door to the wellness office when she was not present. She stated she expected all medications to be locked in a closet, cart, or other spaces not accessible to residents. She agreed that medications left on the floor of the wellness office were not an acceptable storage location for medication. On 7/23/25 at 3:13 p.m., the administrator stated that all medications should be locked when unattended by trained staff. She agreed that the inhaler should not have been left unattended on the medication storage cart.

Based on observations and interviews, the residence failed to ensure oxygen tanks are secured upright at all times and in a manner that prevents tanks from falling over, being dropped, or striking each other, affecting 62 current residents. Findings Include:An environmental tour of the residence on 7/22/25 at 7:41 a.m. revealed 16 oxygen tanks in an unoccupied resident room. One oxygen tank was on its side in a carrying bag on a couch, one was on its side in a reclining chair, and 15 were stored upright but unsecured in an open closet space. On 7/23/25 at 1:50 p.m., the health and wellness director stated that oxygen tanks must be stored in a secure upright manner to prevent them from falling over. She agreed that the oxygen tanks were not stored correctly in the unoccupied resident room. On 7/23/25 at 3:16 p.m., the administrator stated she was made aware of the oxygen tanks stored in the unoccupied resident room and agreed that the oxygen tanks were not stored correctly and that the current storage was unsafe.

Based on observations and interviews, the residence failed to ensure it had designated outdoor smoking areas with fire-resistant waste disposal containers, affecting 18 current residents. Findings Include:An environmental tour of the memory care unit on 7/22/25 at approximately 8:15 a.m. revealed a designated smoking section with a cigarette disposal that was plastic with a tin pail inside, full of cigarettes that had not been emptied. The disposal read, "to avoid fire hazard, pail must be emptied". On 7/22/25 at approximately 8:30 a.m., Staff #3 stated the memory care unit had two residents who currently smoked in the memory care courtyard. On 7/22/25 at 3:15 p.m., the memory care director acknowledged that the cigarette disposal containers were not fire-resistant and that the containers should have been emptied more often. She also stated they would need to be replaced. On 7/23/25 at 3:17 p.m., the administrator stated she was not aware that the cigarette waste disposal needed to be fire-resistant. She acknowledged that fire safe and fire resistant are not the same thing, as the containers said they were fire safe.

Based on record review and interview, the residence failed to reassess residents every six months for the need of a secure environment, and or having residents' representative signatures affecting three of five sample residents (#6, #8, #11). Findings Include:Resident #11 was admitted to the residence on 12/29/23 with a diagnosis of dementia. The record for Resident #11 contained an initial practitioner's evaluation for placement in a secure environment, dated 12/29/23. However, the record contained no further evidence that the residence included the attending practitioner to reassess the resident every 6 months for the continued need of a secure environment. On 7/23/25 at 10:00 a.m., the health and wellness director stated she was not aware residents needed a re-assessment every six months for a secure environment. She also stated the residence had attempted to get power of attorney (POA) signatures on the legal document admission form but had been unable to do so. On 7/23/25 at 3:18 p.m., the administrator stated she was not aware residents residing in the secure environment needed to be reassessed every six months for appropriateness for the secure environment by the resident's practitioner and (POA). Similar deficient practice was found for residents #6 and #8.

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 7.13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(D) The right to choice and personal involvement regarding care and services, including:(8) The right to receive services in accordance with the resident agreement and the care plan; and13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements: The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either: (1) The resident cannot explain how the injury occurred; or The resident can explain the source of the injury, but the source could be addressed to prevent future injuries. 18.8 Resident records shall contain, but not be limited to, the following items:(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 changing needs; (1) The assisted living residence shall require staff members to document, 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. 22.4 Designated areas where smoking is allowed shall be equipped with fire resistant wastebaskets. Resident rooms occupied by smokers, even when house rules prohibit smoking in resident rooms, shall have fire resistant wastebaskets.