WINSLOW COURT RETIREMENT COMMUNITY

A relicensure with complaints revisit was completed on 8/12/25 for the previous deficiencies cited on 2/4/25. Deficiencies were cited. Tags U1110 and U2232 were not cited in the previous event, however, the deficiencies were included in the previous event's informational 9999 tag. The deficiencies cited for Event JIC311 were cited prior to the regulation revision that was implemented on 3/17/25.

Based on record review, interview, and observations the residence failed to provide a physically safe environment,to include reducing the risk of potential hazards in the physical environment affecting two of nine sample residents(#12 and Former Resident #17). (Cross-reference U0430, U1010, U1150, U1068 and U2232)Specifically, Resident #12 was transferred to the emergency department via ambulance on 7/30/25 due to anattempted suicide by self-inflicted lacerations to his left arm and abdomen. Resident #12 returned to theresidence on 8/7/25. On 8/12/25, the resident care coordinator stated that the interventions for Resident #12 inplace to prevent further suicide attempts included removing harmful objects from Resident #12's room, such asrazor blades, along with continued two-hour checks. An observation of Resident #12's room on 8/12/25 revealed arazor blade on the bathroom sink that he and his roommate shared. This failure created an immediate jeopardyrisk of serious harm or death to Resident #12. On 8/12/25, the department directed the residence to providewritten evidence that the risk had been removed. Findings Include: 1. Record ReviewA change of condition assessment, dated 7/18/25 read that Resident #12 would receive daily checks every twohours at which time staff members would ensure that Resident #12 was hydrating and would address any fall risks. They did not include suicidal ideations or behavioral issues in the assessment. An observation note, dated 7/30/25 at 12:15 a.m., read that residence staff found Resident #12 in his roomattempting suicide. The observation read that Resident #12 had self-inflicted lacerations to his left arm andAbdomen. A hospital note, dated 7/30/25, read that Resident #12 was admitted to the hospital following suicidal ideations,laceration of left forearm, and laceration of the abdomen. A hospital note, dated 8/1/25, read that Resident #12 "attempted to un-alive himself with lacerations to his leftforearm and abdominal with a knife and a razor."An observation note, dated 8/7/25, read that Resident #12 returned to the residence and that the residencewould continue to do two hour checks on Resident #12. A care service update dated 8/11/25 read that Resident #12 had a history of depression and read: "Observe andreport to LN any hopelessness/despair, sleep disturbance, change of energy level, lack of motivation, or thoughtsof harming self. If a resident appears sad, fearful, self isolating, is giving away belongings, having mood swings,making statements of despair or suicidal desire, report to the nurse, coordinator, or ED". A care plan, dated 8/12/25, read that Resident #12 would not obtain access to harmful objects. They did notindicate what the harmful objects were 2. InterviewOn 8/12/25 at approximately 10:30 a.m., the resident care coordinator stated that the interventions that wereplaced to protect Resident #12 included two-hour checks throughout the day and removal of harmful objects fromhis room, such as razor blades. She stated they were doing room checks to ensure that there were no harmfulobjects like razor blades present. 3. ObservationsOn 8/12/25 at approximately 11:00 a.m., a tour of Resident #12's room revealed a razor blade lying on thebathroom sink that he and his roommate shared. The investigation established that the findings above placed Resident #12 at immediate jeopardy risk for seriousharm or death. The residence was directed to provide the department with written evidence that the risk hadbeen removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct thecircumstances that gave rise to the immediate jeopardy situation. On 8/12/25 at 1:23 p.m., the HWD (Health and Wellness Director) submitted written evidence that read inpertinent part: "(The residence will) remove all sharp objects from shared space, including razors and silver wear. Replace razors with electric razors and silver wear with plastic wear (silver). Residents (#12) room has been swept,with all sharp objects, including razors and silver wear being removed from shared spaces. Electric razors providedto resident (#12) and room mate and plastic wear being provided. Resident (#12) will have plastic silverware in thedining room for all meals, as well. POA of both residents have approved this. Safety checks to be updated toinclude checking shared spaces, such as bathroom and kitchen for sharp objects and documenting finding andremoval. Safety checks have been updated to include documentation and include sweep of shared spaces anddocumentation of findings. Performance monitoring tool: leadership will check twice a week x2 weeks, thenweekly x4 weeks, and then monthly x6 months. Leadership staff to monitor for compliance, with results beingforwarded to the QA committee for review and recommendations."However, the written evidence did not indicate the risk had been removed because it did not contain a timeframethat all staff would be trained on the parameters of Resident #12's changes and monitoring elements or whowould be performing the safety checks on Resident #12. Additionally, the frequency of the safety checks,symptoms staff members would look for, actions staff would take if symptoms were recognized, who would benotified of Resident #12's condition, where it would be documented, who would train staff, and when trainingwould be completed. Furthermore, details outlining if Resident #12 and his roommate approved of the changesmade in the plan, were not added. On 8/12/25 at approximately 2:46 p.m., the HWD submitted additional evidence that read in pertinent part: "Bothresident in compliance and agreement, as noted with signatures on this form and note is included in both chartsto acknowledge approval as well. If either resident refuses to continue to comply with interventions, residents willbe given the option of upgrading to a private apartment. Q2h safety checks to be updated to include checkingshared spaces, such as bathroom and kitchen for sharp objects. Med tech and caregivers will document findingsand removal of any dangerous objects. Resident (#12) continues on health checks qshift to include observingchanges in mental status or mood and/or behavior. Staff to report any s/s of depression, changes in mood, harmfulbehavior or thoughts of suicide to PCP, HWD, ED and POA immediately, as well as providing protective oversight and sending resident (#12) out for further care. Resident will also be provided the suicide hotlinenumber ...Resident (#12) safety to be reassessed after this time period (7.5 months) if resident (#12) continues toshow s/s of suicidal ideation, 1:1 protective oversight will be required. In service to be completed by 8/13/25."However, the written evidence did not indicate the risk had been removed because it did not include where safetychecks would be documented. It also had abbreviated jargon that the department requested be clarified. On 8/12/25 at approximately 3:09 p.m., the HWD submitted additional evidence that read in pertinent part:"Every two hour safety checks to be updated to include checking shared spaces, such as bathroom and kitchen forsharp objections ... documentation of findings in residents' observations used in conjunction with Health checksbeing done every shift. Resident (#12) continues on health checks every shift ..." The immediate jeopardy for Resident #12 was removed on 8/12/25 at approximately 3:09 p.m. Similar deficient practice was found for Former Resident #17.

Based on record review and interview the residence failed to detail specific personal service needs andpreferences along with staff tasks necessary to meet those needs affecting four of nine sample residents (#12, #14,Former Resident #16, and Former Resident #17). (Cross-reference U1010, U1110, and U2232)Specifically, Resident #12 entered the residence as a high-risk fall resident on 4/25/25. Resident #12 then continued to have frequent falls with injuries, such as bruising and a broken rib, between 6/23/25 and 7/30/25. During that time the residence performed multiple updates to care plans and assessments but did not include specific personal interventions for falls or directions to staff tailored to Resident #12 and his fall patterns. Additionally, three other sample residents, #14, Former Resident #16, and Former Resident #17, also had frequent falls with injuries and the residence failed to update care plans for all three additional sample residents with specific personal interventions for falls or directions to staff. Resident #14 had a fall on 4/4/25, resulting in being sent to the hospital; no interventions or precautions were added to his care plan for how confusion or an unsteady gait contributed to the fall. Former Resident #16 sustained a right shoulder fracture after a fall on 4/13/25. Former Resident #17 sustained multiple falls, bruising and pain when he fell upon elopement from the residence. This deficiency was cited previously during a state licensure survey 2/4/25. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement. Findings Include 1. Record ReviewResident #12 was admitted to the residence on 4/25/25 with a diagnosis of Parkinson's disease, chronic pain, andrespiratory arrest. On 4/25/25 an initial assessment for Resident #12 was completed. The residence noted that Resident #12 was ahigh fall risk and that staff were to perform frequent safety checks and alert the licensed nurse to any observablechanges in Resident #12's condition. On 6/23/25 a physician assessment read that Resident #12's family reported many falls at his home in the pastyear and that Resident #12 fell on 6/23/25 in the residence. On 7/1/25 a change of condition assessment read to increase safety checks to 10:00 a.m., 3:00 p.m., and 8:00 p.m.daily to help to keep Resident #12 hydrated. The assessment did not note specific interventions for falls afterResident #12 fell on 6/23/25. On 7/3/25 an observation note read that Resident #12 had an unwitnessed fall. On 7/14/26 an observation note read that Resident #12 had an unwitness fall. On 7/14/25 a physician report stated that Resident #12 fell and hit his head and had an area of swelling on his leftforehead and was sent to the emergency room. On 7/14/25 an emergency room visit note read that Resident #12 was admitted to the hospital for a CT scan forhead trauma due to a fall that occurred at his residence. On 7/17/24 an observation note read that Resident #12 had an unwitnessed fall. On 7/18/25 an observation note read that Resident #12 had an unwitnessed fall. On 7/18/25 a change of condition assessment was performed. The changes made included an increase infrequency of falls and increased checks to every two hours daily. Use of a walker and pressing a pendant wasrecommended. The assessment did not note specific interventions for falls. On 7/21/25 an observation note read that Resident #12 had an unwitnessed fall. On 7/21/25 a medical encounter note read that Resident #12 sustained multiple falls over the last two weeks. Thenote read that Resident #12 had a rib fracture. On 7/26/25 an observation note read that Resident #12 lost his balance and fell in the restroom, and that hecontinued to show signs and symptoms of confusion. On 7/30/25 a care plan did not note any information for fall risk and interventions specific to Resident #12 and hisfrequent falls. 2. InterviewOn 8/12/25 at approximately 10:30 a.m., the resident care coordinator stated that Resident #12 was encouragedto use his pendant and walker to prevent falls. She stated that updates to interventions would be in theassessment and care plan. On 8/12/25 at approximately 2:30 p.m., the administrator stated that she did not believe that Resident #12'sfrequent falls were a safety concern. She stated that she expected care plans and assessments to be updated withinterventions and thought that they already had been. On 8/12/25 at approximately 2:30 p.m., the HWD stated that this was not corrected because the residence wasworking on updating assessments and care plans and just had not got to it yet. Similar deficient practice was found for Resident #14, Former Resident #16, and Former Resident #17.

Based on record review and interview, the residence failed to comply with authorized practitioner ordersassociated with medication administration except for those medications which a resident self-administer, affectingthree ( #7, #8 and #15) sample residents. (Cross-reference U1604)This deficiency was cited previously during a state licensure survey 2/4/25. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement. Resident #7 admitted to the residence on 3/8/22, diagnoses included osteoarthritis. A written practitioners order, initially dated 4/7/22 and updated on 6/2/25, directed the residence to administerdiclofenac sodium 1% gel topically to the right hip three times daily. However, the July 2025 medicationadministration records (MAR) read the medication was out of stock and not administered at 8:00 a.m. or 2:00 p.m.or 7/3 and 7/4. On 8/12/25 at 3:10 p.m., the resident care coordinator (RCC) said after the residence was cited for this in Februaryof 2025 a process was developed for ordering or obtaining medication before running out of stock. The RCC said he was unsure why the process had not been successful. On 8/12/25 at 4:00 p.m. the administrator said the residence was responsible for complying with practitionerorders and was unaware the process had not been successful. Similar deficient practice was found for resident's #8 and #15.

Based on record review and interview the residence failed to document, investigate, and resolve irregularities of the medication administration record audit affecting 110 current residents. (Cross-reference U1568)This deficiency was cited previously during a state licensure survey 2/4/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory Requirement. Findings include:The following medications were noted on the various medication audit cart forms were found to have irregularities with no evidence of an investigation on the following dates:7/29/25 for cart #200, there were loose pills in the medication cart. The notes read, "loose pills destroyed, med cart good otherwise."7/29/25 for cart #400, there were expired or discontinued medications found in the cart. The notes read, "there was one expired medication removed and destroyed. Otherwise the medication cart was good."6/30/25 for cart #200, the medication cart was disorganized, some medications had excessive quantities of medications, and multiple loose pills were found in the cart. The notes read, "organized cart ...removed excessive quantity, and destroyed loose pills in cart."6/30/25 for cart #300, the medication cart has excessive quantities of medications. The notes read, "cart was exceptional, besides finding a few PRN medications that were expired or discontinued. They were removed from the cart."6/30/25 for cart #400, the medication cart audit did not document anything amiss. However, the notes read, "all expired and discontinued medications removed, there were only a couple. Some medications had excessive quantities; those were also removed. Other than that, the med cart was good."The residence was asked to provide investigations for the irregularities listed above. On 8/12/25 at approximately 3:30 p.m., the assisted living care coordinator (ALCC) stated that he did the medication audits, and the health and wellness director reviewed them. He continued to say that he was unaware that the audits needed to include the "who, why, etc." of the investigation and a description of the medications moving forward. On 8/12/25 at approximately 4:45 p.m., during the exit interview, the ALCC stated they believed they corrected the citation because when they were cited, they did not do any medication audits. He also said that he believed it was not corrected due to the residence's failure to train him on all the elements and details that needed to be completed in an investigation of a medication audit.

Based on record review and interview the residence failed to ensure each resident had an updated face sheet with the required components, affecting two current (#12 and #13) and one former #17 resident(s). (Cross-referenceU1110 and U1150)Resident #13 was admitted to the residence on 5/19/25, no diagnoses were listed on the facesheet. An external provider's progress note, dated 8/1/25, read Resident #13 had a past medical history of Alzheimer'sdisease, constipation, gastroesophageal reflux disease, bradycardia and hypertension. On 8/12/25 at 3:10 p.m., the resident care coordinator (RCC) said it was difficult to retrieve documented diagnosesfrom some practitioners. Specifically for Resident #13, the RCC said adding the diagnoses to the facesheet was anoversight. On 8/12/25 at 4:00 p.m., the administrator said existing and new diagnoses were expected to be added to the residents' facesheet sheets. Similar deficiency was found for Residents #12 and #17.

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

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.22.35 Assisted living residences shall comply with the Colorado Clean Indoor Air Act at Sections 25-14201 through 25-14-209, C.R.S.

A licensure complaint, prompted by #CO40697 and #CO40662, was completed on 8/12/25. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of nine sample residents (#17). (Cross-reference U1010 and U1110)Findings include:1. Referencea. According to the Occurrence Reporting Manual, dated May 2018, "Any time that a resident or patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident's health, safety or welfare at risk or, regardless of whether such circumstances exist, the patient." Section 25-1-124 (2)(c), C.R.S. One element needed: At risk and missing after search conducted."At risk: a patient or resident of a facility who is susceptible to mistreatment, self-neglect, or exploitation because s/he is unable to perform or obtain services necessary for his or her health, safety, or welfare, or lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his or her person or affairs. 2. Resident #17 was admitted to the residence on 2/16/25 with a diagnosis of dementia. An external practitioner's assessment completed on 3/19/25 by Resident #17's practitioner read that Resident #17 needed to be in a secure environment. Two occurrence report documents were provided onsite by the residence. Neither occurrence included the elopement of Resident #17 on 4/13/25. On 4/13/25 an observation note read that Former Resident #17 had an increased decline with cognitive behavior. It stated that Former Resident #17 left the community and fell while he was out, and a motorist stopped him andtook him to his former family home. The note stated that the power of attorney would begin looking for memorycare. On 8/11/25, the department database revealed that the residence reported no occurrences on or around 4/13/25. On 8/12/25 at 4:18 p.m., during the exit interview, the administrator stated she did not have an answer as to why the first elopement was not reported to the state health department. She added that the only thing she could think of was that the residence was not aware of Resident 17's diagnosis of dementia. She continued to add that the staff and family did look for the resident back then too. On 8/12/25 at approximately 4:22 p.m., the resident service coordinator (RCC) stated that the residence failed to ask the provider for clarification when the practitioner assessment was received back in March. The health and wellness director added that she would expect that the facility would have asked the practitioner for clarification but she had not been hired at the residence yet to ensure this was completed.

Based on record review and interview the residence failed to discharge Former Resident #17 who required moreservices that could be routinely provided by the assisted living residence, affecting one of nine sample residents.(Cross-reference U0430, U1110, and U1150)Specifically, Former Resident #17 entered the residence on 2/16/25 and on 3/19/25 a signed practitioner'sstatement read that Former Resident #17 required a secure environment; the residence did not have a securedenvironment. A physician notification dated 4/7/25 read that Former Resident #17 eloped from the residence andhad a fall which resulted in pain to his right shoulder joint. On 4/10/25 Former Resident #17 sustained a fall in theresidence. On 4/11/25 a change of condition assessment read that Former Resident #17 was a moderate risk forfalls and that two hour checks of Former Resident #17 would be performed daily. On 4/13/25 Former Resident #17eloped from the facility, was found by a motorist and his family member and then returned to the residence. Thechange of condition assessment performed on 4/17/25 had no mention of elopement or wandering behaviors aswell as the correlating care plans. On 5/17/25 Former Resident #17 eloped from the residence and was found by acyclist on an urban trail unconscious. Former Resident #17 was taken to the emergency department and placed inintensive care a few days later Former Resident #17 died of blunt force head trauma. Findings Include 1. Record ReviewFormer Resident #17 was admitted to the residence on 2/16/25. On 3/19/25 a signed practitioners statement stated that Former Resident #17 required a secure environment. On 4/7/25 a signed physician notification read that Former Resident #17 eloped from the residence and had a fallwhile out, which resulted in pain in his right shoulder joint. On 4/10/25 an observation note read that Former Resident #17 sustained a fall. On 4/11/25 a change of condition assessment was performed. The assessment noted a change of condition due tofalls. Fall risk interventions were changed to moderate risk. Two hour safety checks were started throughout theDay. On 4/13/25 an observation note read that Former Resident #17 had an increased decline with cognitive behavior. It stated that Former Resident #17 left the community and fell while he was out, and a motorist stopped him andtook him to his former family home. The note stated that the power of attorney would begin looking for memorycare. Between 4/13/25 and 5/17/25 no updated care plan or assessment mentioned a change in behaviors or updatedInterventions to prevent Former Resident #17 from eloping. A death certificate dated 5/23/25, read that Former Resident #17's cause of death was blunt force head trauma. An autopsy report dated 5/24/25, read that a final diagnosis of Former Resident #17 was Blunt fore head traumaand dementia and blood thinner use for atrial fibrillation. On 6/1/25 an observation note read that Former Resident #17 eloped from the facility on 5/17/25. A police report dated 6/13/25, read that Former Resident #17 was found on an urban trail after falling. It statedthat Former Resident #17 was taken to the emergency department, where he was then placed in the intensivecare unit. An updated police report dated 6/18/25, read that an interview with the residence administrator revealed thatwhile Former Resident #17 did not enter the residence with a diagnosis of dementia, the administrator recognizedearly on that Former Resident #17 had signs and symptoms of dementia. The administrator continued to informthe police officer that there were two cases of elopement from the residence. The administrator emphasized tothe officer that the residence was not a memory care facility and did not provide 24-hour supervision forResidents. 2. InterviewOn 8/11/25 at approximately 9:30 a.m., a family member of Former Resident #17 stated that Former Resident #17was placed in the residence because while living at his family home, he eloped and fell, and his family wasconcerned that it would happen again. They stated that when Former Resident #17 arrived at the residence, heeloped twice. The first time he returned to his family home by a motorist taking him there and then was takenback to the residence by another family member. The second elopement resulted in his death. On 8/12/25 at approximately 10:30 a.m., the resident care coordinator stated that wandering behaviors andelopement risk would be noted in the care plan and assessment with interventions in the care plan andassessments. She stated that after the residence staff recognized that Former Resident #17 was a better fit formemory care, they spoke with his power of attorney about moving him to a more secure environment. She statedthat they continued the two hour checks that were already in place from his fall assessment as a means to ensurehe did not elope and that staff were expected to inform the nurse if they recognized that he was declining further. She stated that she expected Former Resident #17's power of attorney to find an alternative residence, with asecure environment, for Former Resident #17.

Based on record review and interview the residence failed to evaluate a resident after transfer and discharge toanother health care entity for additional care prior to re-admission to the residence affecting one of nine sampleresidents. (#12) (Cross-reference U1110)Findings Include 1. Record ReviewResident #12 was admitted to the residence on 4/25/25 with a diagnosis of Parkinson's disease, chronic pain, andrespiratory arrest. An assessment dated 7/1/25, did not include details of Resident #12's mental health. On 7/30/25 an observation note read that Resident #12 was found in his room with self inflicted laceration to hisleft arm and to his abdomen and that Resident #12 was sent to the emergency department. A hospital note, dated 7/30/25, read that Resident #12 was admitted to the hospital following suicidal ideations,laceration of left forearm and laceration of the abdomen. A hospital note, dated 8/1/25, read that Resident #12 "attempted to un-alive himself with lacerations to his leftforearm and abdominal with a knife and a razor."An observation note, dated 8/7/25, read that Resident #12 returned to the residence and that the residencewould continue to do two hour checks on Resident #12. There was no assessment performed after Resident #12 returned from the hospital on 8/7/25. 2. InterviewOn 8/12/25 at approximately 2:30 p.m., the HWD stated that assessments and care plans were not updated andcurrent because the residence was working on updating assessments and care plans and just had not got to it yet. She stated that an assessment should have been completed upon Resident #12's return from the hospital.

Based on record review, interview, and observations the residence failed to provide a physically safe environment,to include reducing the risk of potential hazards in the physical environment affecting two of nine sample residents(#12 and Former Resident #17). (Cross-reference U0430, U1010, U1150, U1068 and U2232)Specifically, Resident #12 was transferred to the emergency department via ambulance on 7/30/25 due to anattempted suicide by self-inflicted lacerations to his left arm and abdomen. Resident #12 returned to theresidence on 8/7/25. On 8/12/25, the resident care coordinator stated that the interventions for Resident #12 inplace to prevent further suicide attempts included removing harmful objects from Resident #12's room, such asrazor blades, along with continued two-hour checks. An observation of Resident #12's room on 8/12/25 revealed arazor blade on the bathroom sink that he and his roommate shared. This failure created an immediate jeopardyrisk of serious harm or death to Resident #12. On 8/12/25, the department directed the residence to providewritten evidence that the risk had been removed. Findings Include: 1. Record ReviewA change of condition assessment, dated 7/18/25 read that Resident #12 would receive daily checks every twohours at which time staff members would ensure that Resident #12 was hydrating and would address any fall risks. They did not include suicidal ideations or behavioral issues in the assessment. An observation note, dated 7/30/25 at 12:15 a.m., read that residence staff found Resident #12 in his roomattempting suicide. The observation read that Resident #12 had self-inflicted lacerations to his left arm andAbdomen. A hospital note, dated 7/30/25, read that Resident #12 was admitted to the hospital following suicidal ideations,laceration of left forearm, and laceration of the abdomen. A hospital note, dated 8/1/25, read that Resident #12 "attempted to un-alive himself with lacerations to his leftforearm and abdominal with a knife and a razor."An observation note, dated 8/7/25, read that Resident #12 returned to the residence and that the residencewould continue to do two hour checks on Resident #12. A care service update dated 8/11/25 read that Resident #12 had a history of depression and read: "Observe andreport to LN any hopelessness/despair, sleep disturbance, change of energy level, lack of motivation, or thoughtsof harming self. If a resident appears sad, fearful, self isolating, is giving away belongings, having mood swings,making statements of despair or suicidal desire, report to the nurse, coordinator, or ED". A care plan, dated 8/12/25, read that Resident #12 would not obtain access to harmful objects. They did notindicate what the harmful objects were 2. InterviewOn 8/12/25 at approximately 10:30 a.m., the resident care coordinator stated that the interventions that wereplaced to protect Resident #12 included two-hour checks throughout the day and removal of harmful objects fromhis room, such as razor blades. She stated they were doing room checks to ensure that there were no harmfulobjects like razor blades present. 3. ObservationsOn 8/12/25 at approximately 11:00 a.m., a tour of Resident #12's room revealed a razor blade lying on thebathroom sink that he and his roommate shared. The investigation established that the findings above placed Resident #12 at immediate jeopardy risk for seriousharm or death. The residence was directed to provide the department with written evidence that the risk hadbeen removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct thecircumstances that gave rise to the immediate jeopardy situation. On 8/12/25 at 1:23 p.m., the HWD (Health and Wellness Director) submitted written evidence that read inpertinent part: "(The residence will) remove all sharp objects from shared space, including razors and silver wear. Replace razors with electric razors and silver wear with plastic wear (silver). Residents (#12) room has been swept,with all sharp objects, including razors and silver wear being removed from shared spaces. Electric razors providedto resident (#12) and room mate and plastic wear being provided. Resident (#12) will have plastic silverware in thedining room for all meals, as well. POA of both residents have approved this. Safety checks to be updated toinclude checking shared spaces, such as bathroom and kitchen for sharp objects and documenting finding andremoval. Safety checks have been updated to include documentation and include sweep of shared spaces anddocumentation of findings. Performance monitoring tool: leadership will check twice a week x2 weeks, thenweekly x4 weeks, and then monthly x6 months. Leadership staff to monitor for compliance, with results beingforwarded to the QA committee for review and recommendations."However, the written evidence did not indicate the risk had been removed because it did not contain a timeframethat all staff would be trained on the parameters of Resident #12's changes and monitoring elements or whowould be performing the safety checks on Resident #12. Additionally, the frequency of the safety checks,symptoms staff members would look for, actions staff would take if symptoms were recognized, who would benotified of Resident #12's condition, where it would be documented, who would train staff, and when trainingwould be completed. Furthermore, details outlining if Resident #12 and his roommate approved of the changesmade in the plan, were not added. On 8/12/25 at approximately 2:46 p.m., the HWD submitted additional evidence that read in pertinent part: "Bothresident in compliance and agreement, as noted with signatures on this form and note is included in both chartsto acknowledge approval as well. If either resident refuses to continue to comply with interventions, residents willbe given the option of upgrading to a private apartment. Q2h safety checks to be updated to include checkingshared spaces, such as bathroom and kitchen for sharp objects. Med tech and caregivers will document findingsand removal of any dangerous objects. Resident (#12) continues on health checks qshift to include observingchanges in mental status or mood and/or behavior. Staff to report any s/s of depression, changes in mood, harmfulbehavior or thoughts of suicide to PCP, HWD, ED and POA immediately, as well as providing protective oversight and sending resident (#12) out for further care. Resident will also be provided the suicide hotlinenumber ...Resident (#12) safety to be reassessed after this time period (7.5 months) if resident (#12) continues toshow s/s of suicidal ideation, 1:1 protective oversight will be required. In service to be completed by 8/13/25."However, the written evidence did not indicate the risk had been removed because it did not include where safetychecks would be documented. It also had abbreviated jargon that the department requested be clarified. On 8/12/25 at approximately 3:09 p.m., the HWD submitted additional evidence that read in pertinent part:"Every two hour safety checks to be updated to include checking shared spaces, such as bathroom and kitchen forsharp objections ... documentation of findings in residents' observations used in conjunction with Health checksbeing done every shift. Resident (#12) continues on health checks every shift ..." The immediate jeopardy for Resident #12 was removed on 8/12/25 at approximately 3:09 p.m. Similar deficient practice was found for Former Resident #17.

Based on record review and interview the residence failed to detail specific personal service needs andpreferences along with staff tasks necessary to meet those needs affecting four of nine sample residents (#12, #14,Former Resident #16, and Former Resident #17). (Cross-reference U1010, U1110, and U2232)Specifically, Resident #12 entered the residence as a high-risk fall resident on 4/25/25. Resident #12 then continued to have frequent falls with injuries, such as bruising and a broken rib, between 6/23/25 and 7/30/25. During that time the residence performed multiple updates to care plans and assessments but did not include specific personal interventions for falls or directions to staff tailored to Resident #12 and his fall patterns. Additionally, three other sample residents, #14, Former Resident #16, and Former Resident #17, also had frequent falls with injuries and the residence failed to update care plans for all three additional sample residents with specific personal interventions for falls or directions to staff. Resident #14 had a fall on 4/4/25, resulting in being sent to the hospital; no interventions or precautions were added to his care plan for how confusion or an unsteady gait contributed to the fall. Former Resident #16 sustained a right shoulder fracture after a fall on 4/13/25. Former Resident #17 sustained multiple falls, bruising and pain when he fell upon elopement from the residence. This deficiency was cited previously during a state licensure survey 2/4/25. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement. Findings Include 1. Record ReviewResident #12 was admitted to the residence on 4/25/25 with a diagnosis of Parkinson's disease, chronic pain, andrespiratory arrest. On 4/25/25 an initial assessment for Resident #12 was completed. The residence noted that Resident #12 was ahigh fall risk and that staff were to perform frequent safety checks and alert the licensed nurse to any observablechanges in Resident #12's condition. On 6/23/25 a physician assessment read that Resident #12's family reported many falls at his home in the pastyear and that Resident #12 fell on 6/23/25 in the residence. On 7/1/25 a change of condition assessment read to increase safety checks to 10:00 a.m., 3:00 p.m., and 8:00 p.m.daily to help to keep Resident #12 hydrated. The assessment did not note specific interventions for falls afterResident #12 fell on 6/23/25. On 7/3/25 an observation note read that Resident #12 had an unwitnessed fall. On 7/14/26 an observation note read that Resident #12 had an unwitness fall. On 7/14/25 a physician report stated that Resident #12 fell and hit his head and had an area of swelling on his leftforehead and was sent to the emergency room. On 7/14/25 an emergency room visit note read that Resident #12 was admitted to the hospital for a CT scan forhead trauma due to a fall that occurred at his residence. On 7/17/24 an observation note read that Resident #12 had an unwitnessed fall. On 7/18/25 an observation note read that Resident #12 had an unwitnessed fall. On 7/18/25 a change of condition assessment was performed. The changes made included an increase infrequency of falls and increased checks to every two hours daily. Use of a walker and pressing a pendant wasrecommended. The assessment did not note specific interventions for falls. On 7/21/25 an observation note read that Resident #12 had an unwitnessed fall. On 7/21/25 a medical encounter note read that Resident #12 sustained multiple falls over the last two weeks. Thenote read that Resident #12 had a rib fracture. On 7/26/25 an observation note read that Resident #12 lost his balance and fell in the restroom, and that hecontinued to show signs and symptoms of confusion. On 7/30/25 a care plan did not note any information for fall risk and interventions specific to Resident #12 and hisfrequent falls. 2. InterviewOn 8/12/25 at approximately 10:30 a.m., the resident care coordinator stated that Resident #12 was encouragedto use his pendant and walker to prevent falls. She stated that updates to interventions would be in theassessment and care plan. On 8/12/25 at approximately 2:30 p.m., the administrator stated that she did not believe that Resident #12'sfrequent falls were a safety concern. She stated that she expected care plans and assessments to be updated withinterventions and thought that they already had been. On 8/12/25 at approximately 2:30 p.m., the HWD stated that this was not corrected because the residence wasworking on updating assessments and care plans and just had not got to it yet. Similar deficient practice was found for Resident #14, Former Resident #16, and Former Resident #17.

A relicensure survey with complaints #CO38975, #CO37685, #CO37340, #CO37057, and #CO35923 was completed on 2/4/25. Deficiencies were cited.

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 87 current residents. Findings include: On 2/3/25 at 2:00 p.m., the involuntary discharge grievance policy was requested from the administrator. The administrator provided the residence's discharge policy; however, it did not comply with the requirements under Section 25-27-104.3, C.R.S.On 2/4/25 at 2:00 p.m., the administrator and the regional registered nurse stated they were aware of the involuntary discharge grievance policy; however, were unaware that the previous administrator had not created the policy.

Based on observation, record review, and interview the residence failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting two of 11 sample residents (#2, #8). Findings include:1. Record ReviewResident #8 was admitted on 5/31/21 with a diagnosis including stage four chronic kidney diseases, and pain in left and right shoulders. An assessment, dated 1/29/25, indicated that Resident #8 was at risk for falls and required high care. However, the assessment failed to mention that Resident #8 had a limited range of motion in both shoulder and arms and could not stand independently due to swollen feet. The care plan for Resident #8 was last updated on 7/17/24 and did not reflect the assessment on 1/29/25. Additionally, the care plan did not include that Resident #8 had a limited range of motion for both shoulders and arms and inability to stand on his own because of swollen feet. An incident report dated 1/22/25 documented that the resident had an unwitnessed fall in his bathroom. Resident #8 reported that he hurt his shoulder and his arm. Resident #8 was transported to the hospital. 2. ObservationOn 2/4/25 at approximately 8:44 a.m., during the onsite observation, Resident #8 was observed alone in his apartment, undressed and had a nighttime catheter while he held an activated call light pendant. On 2/4/25 at approximately 8:46 a.m., Staff #2 dressed Resident #8. Resident #8 was observed to have experienced discomfort of both shoulders and arms while dressing. Resident #8 was observed to have experienced discomfort while putting on socks and shoes. Resident #8 verbally informed the caregiver that he had painful shoulders, and swollen feet and could not stand on his own. 3. InterviewOn 2/4/25 at approximately 9:16 a.m., Staff #2 stated that she was unaware of Resident #8 ' s shoulder pain and swollen feet. She stated that Resident #8 had a fall, and that could have contributed to the shoulder pain, but she also noted that she did not know that Resident #8 had a catheter. On 2/4/25 at approximately 11:58 a.m., the health and wellness director and the regional registered nurse acknowledged that the residence had not updated Resident #8 ' s care plan to reflect the most current assessment. 4. Additional deficient practice was found for Resident #2.

Based on interview and record review the residence failed to comply with practitioner's orders for three sample residents (#3, #6, #7) and one former resident (#10). (Cross-Reference S1604) Specifically, Former Resident #10 was prescribed fentanyl for severe pain on 1/13/24. The order read to place two 25 mcg patches and remove the old ones. The medication administration record (MAR) read the patches were placed on the resident on 4/18, 4/21, and 4/24/24. Then on 4/23/24, Former Resident #27 experienced a change in condition that included a fall and altered mental status. The former resident was subsequently transferred to an outside provider service provider. Upon admission, the external service provider-registered nurse (ESP-RN) observed six fentanyl patches on Former Resident #10's body. The ESP-RN stated that an increase in medication caused harm to Former Resident #10 due to the decline in his mental cognition that led to a fall. Findings include:1. Former Resident #10 was admitted to the residence on 6/22/23 with a diagnosis including hypotension. An external service provider registered nurse (ESP-RN) note dated 4/27/24 read in part that during a head-to-toe assessment, Former Resident #10 was observed to have six fentanyl patches with no dates on his upper back. She also noted that his cognitive function was observed to be impacted due to the fentanyl overdose. A written practitioner's order, dated 1/13/24, directed the residence to administer two 25 mcg fentanyl patches (50 mcg) topically and change every 72 hours. Remove the old patch before applying a new one (total dose of 50 mg). An April 2024 medication administration record (MAR) and narcotic count sheet read in part that patches were placed on 4/18, 4/21, and 4/24/24. On 2/4/25 at 8:56 a.m., an external service provider registered nurse (ESP-RN) #2 stated that she was informed by ESP-RN #1 that she had found six fentanyl patches on Former Resident #27 during an assessment on 4/27/24. She said that the family and ESP-RN #1 observed a change of condition with Former Resident #10. The ESP-RN #2 stated that Former Resident #10's mental status declined to the point where he fell on 4/23/24. On 2/4/25 at 1:24 p.m., the administrator acknowledged that Former Resident #10 had a change in condition before he was discharged. She stated that she was aware of the six fentanyl patches that were left on the resident. She stated that Staff #5 was terminated after an investigation by local law enforcement. The administrator acknowledged failure to comply with practitioner orders when staff failed to remove the patches. 2. Resident #3 was admitted to the residence on 12/16/14 with a diagnosis including depression, anxiety, and hypothyroidism. A written practitioner order dated 1/14/24 directed the residence to administer tramadol 50 mg three times a day for pain. However, the residence failed to ensure the medication was available to be administered on 1/8 and 1/13-1/14/25 for a total of seven missed doses. The residence assessment and care plan dated 1/27/24 read in part that Resident #3 had chronic pain and complained of knee pain often. On 2/4/25 at 10:24 a.m., the regional registered nurse acknowledged that tramadol was for pain and that the residence failed to have the medication available for Resident #3. On 2/4/25 at 12:50 p.m., Resident #3 stated that she had chronic knee pain and took tramadol to help the pain. She said that she was unaware of missing pills but had pain in her knees in January 2025. On 2/4/25 at 1:07 p.m., Resident #3's practitioner stated that he had prescribed tramadol for pain in her knees. 3. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with authorized practitioner's orders associated with medication administration for Resident #6 and Resident #7.

Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting four of nine sample residents (#3, #6, #7) and one former resident (#10). (Cross-reference S1568)Findings include: On 2/3/25 at 2:00 p.m., the quarterly medication cart audits were requested from the administrator. However, the administrator was unable to provide the requested documentation. On 2/4/25 at 2:12 p.m., the administrator stated the health and wellness director (HWD) was responsible for conducting the quarterly medication cart audits. However, she had just become aware that medication cart audits had not been completed as required. She stated the former HWD assured her the audits had been completed. On 2/4/25 at 2:12 p.m., the regional registered nurse confirmed the administrator's statement and acknowledged that the medication cart audits had not been completed as required.

Based on observation and interview, the residence failed to keep the residence ramps in good repair, affecting 87 current residents. Findings include:1. ObservationOn 2/3/25 throughout the onsite visit from approximately 7:00 a.m. to 4:30 p.m., the ramp for the "b lot entrance" to the residence was observed to have broken and crumbling concrete at the front portion of the ramp supporting the metal grate covering the sump pump. On 2/4/25 throughout the onsite visit from approximately 7:00 a.m. to 2:30 p.m, the ramp for the "b lot entrance" to the residence was observed to have broken and crumbling concrete at the front portion of the ramp supporting the metal grate, that crumbled when walked on. 2. InterviewOn 2/4/25 at approximately 2:00 p.m., the maintenance director (MD) confirmed that the residence's ramp for the b lot entrance was not in good repair and could be a tripping hazard for residents. On 2/5/25 at approximately 4:00 p.m., the administrator confirmed that the residence's ramp for the b lot entrance was not in good repair and could be a tripping hazard for residents.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.6.5 An administrator training program shall meet all of the following requirements: (B) Completing a 30-hour administrator training program on or before December 31, 2018, and documenting an additional 10 hours of training in topics related to the assisted Living administrator's responsibilities, regulatory updates, and/or best practices before June 30, 2024. 7.4 Qualified medication administration persons shall not administer medication through a gastrostomy tube or administer insulin unless specifically authorized to do so pursuant to rules adopted by the Department of Health Care Policy and Financing or the Department of Human Services. 7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items: (C) Orientation and training. 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; 12.11 The assisted living residence shall be responsible for the coordination of resident care services with known external service providers. 18.9 The face sheet shall be updated at least annually and contain the following information: (K) Resident's current diagnoses. 18.12 Records of former residents shall be complete and maintained for at least three (3) years following the termination of the resident's stay in the assisted living residence.

A licensure complaint and COVID-19 Infection Control focused revisit was completed on 2/4/25 for the previous deficiency cited on 1/27/21. The residence is in compliance with all regulations surveyed.

A licensure complaint revisit was completed on 2/4/25 for the previous deficiency cited on 1/27/21. 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