CHATEAU AT RIFLE

Description of how Chateau at Rifle will correct the deficiency: The owner and ED are attempting to identify a smoking area in a safe accessible location that meets the CCIAA requirements. Fire resistant waste disposal containers will be provided. Monitoring plan to ensure deficiency is remedied and will not reoccur: Once an acceptable smoking area is identified or created, appropriate signage will be implemented and resident use of the area will be noted and monitored by staff and routine grounds inspections. ADDENDUM:Several ideas for moving the smoking area were considered but were determined to present safety concerns for the residents, such as designating an area of the parking lot, in/on uneven ground, or with insufficient space or accessway. In our efforts to identify an area complying with CRS 25-14-203 to 209 (Colorado Clean Indoor Air Act), we read the regulation itself closely as specified below, as well as all other related regulations we could find. With that information, the current location (outside a side door in an enclosed area) appears to comply with that regulation. At this point, after considering the relative safety and risks of the alternatives vs the current location, the fact that the left side door to the smoking area is not the front or main entry and is actually more than 50 feet from the main entryway, and the governing regulations as above, Chateau at Rifle respectfully plans to maintain the current location at this time. We will continue to monitor the front entryway area as staff come and go, and during exterior property inspections, for any resident smokers encroaching within 25 feet of the main entryway. Any resident so identified will be reminded and accompanied to the smoking area, and if a future problem arises additional monitoring and resolution will be addressed by the Executive Director and QAPI process as necessary. FOLLOWUP/UPDATE:The original citation referenced the designated smoking area on the east side of the building. The door adjacent to the smoking area does not meet the definition of "entryway" as set forth in the Colorado Clean Indoor Air Act, CRS 25-14-103(7) as stated above ('‘Entryway’ means the outside of the front or main doorway'). The citation refers to the side door as the "home entrance", which is inaccurate if that term is intended to refer to the front or main doorway entrance. The front or main entryway to the facility is on the north side, a larger entrance readily visible and easily available from the front resident and visitor parking area. That entry clearly meets the definition "entryway" established in the Colorado Clean Indoor Air Act. The side door close to the designated smoking area, however, does not meet that definition, is not a general public entrance and opens only into the employee parking lot. Therefore, although our POC responses and the citation do in fact refer to the same "entrance", that entrance appears not to be subject to the regulation since it is not an "entryway" covered by the Act, as detailed in the above regulatory citations. The existing smoking area is more than 50 feet from the facility's actual entryway which is subject to the Act. Unfortunately, our research only discovered this after the IDR deadline had expired, so we were unable to utilize that process to present that that opinion, and know of no other avenue to to do so. At the time of the survey, the Executive Director had not read the Colorado Clean Indoor Air Act and was relying on her understanding gained only from word of mouth. Her agreement that the designated smoking area was a violation of the CCIAA was in fact based solely on her understanding at the time, not what our research subsequently found. As stated above, we will continue to monitor the area around the front/main entryway for illegal smoking, through staff movement and regular exterior inspections. Residents or others observed smoking around the front/main entrance/entryway will be informed of and escorted to the designated smoking area as necessary. Although smoking in that area has not been a problem in the past, if it becomes so in the future, the Executive Director will implement corrective action and additional monitoring as necessary through the QAPI process.

Description of how Chateau at Rifle will correct the deficiency:ED has obtained verbal agreement with another facility as an evacuation site if residents require evacuation from Chateau at Rifle in response to an emergency or disaster; she is awaiting written confirmation from that facility. A location-specific hazard risk assessment is in progress, and emergency procedures are being consolidated into a new Emergency Preparedness and Response Policy and Procedure that will include all required elements. Emergency Response binders will continue to be maintained in each medication cart, and additional copies will be distributed throughout the facility for ready access at all times. Binders will be standardized to include the list of residents by room number; emergency contact information for each resident and procedures for communication with other providers; emergency contact numbers for external agencies or providers that may be need to be notified in an emergency; a copy of the evacuation map for the facility; policies & procedures for each emergency identified by the hazard risk assessment as well as medical and public health emergencies compliant with current regulations; emergency staffing measures; and a copy of the written relocation agreement with facility to which residents may be evacuated/relocated if necessary. The owner is currently researching and determining additional resources to supplement emergency power for essential functions and resident medical or essential auxiliary equipment. Inservice training will be conducted for all staff regarding use of the new binder and emergency policies & procedures, and the same will also be included in new employee orientation. Monitoring plan to ensure deficiency is remedied and will not reoccur: The ED and ED Assistant will be responsible for updating resident lists and emergency contact information as new residents are admitted. Emergency binders will be inspected by the ED and ED Assistant on a quarterly basis to ensure they are complete and up to date. The ED will ensure that any regulation changes involving emergency procedures are implemented in a timely manner and that the emergency binders are updated to meet any future regulatory changes. ADDENDUM:Staff were educated on the Emergency/Disaster Response Policy & Procedure updates by group chat and discussions on 12/7/25. All residents were given a copy of the new policy, and the ED explained the policy and answered resident questions in person on 12/7/25..

Description of how Chateau at Rifle will correct the deficiency:ED has obtained verbal agreement with another facility as an evacuation site if residents require evacuation from Chateau at Rifle in response to an emergency or disaster; she is awaiting written confirmation from that facility. A location-specific hazard risk assessment is in progress, and emergency procedures are being consolidated into a new Emergency Preparedness and Response Policy and Procedure that will include all required elements. Emergency Response binders will continue to be maintained in each medication cart, and additional copies will be distributed throughout the facility for ready access at all times. Binders will be standardized to include the list of residents by room number; emergency contact information for each resident and procedures for communication with other providers; emergency contact numbers for external agencies or providers that may be need to be notified in an emergency; a copy of the evacuation map for the facility; policies & procedures for each emergency identified by the hazard risk assessment as well as medical and public health emergencies compliant with current regulations; emergency staffing measures; and a copy of the written relocation agreement with facility to which residents may be evacuated/relocated if necessary. The owner is currently researching and determining additional resources to supplement emergency power for essential functions and resident medical or essential auxiliary equipment. Inservice training will be conducted for all staff regarding use of the new binder and emergency policies & procedures, and the same will also be included in new employee orientation. Monitoring plan to ensure deficiency is remedied and will not reoccur: The ED and ED Assistant will be responsible for updating resident lists and emergency contact information as new residents are admitted. Emergency binders will be inspected by the ED and ED Assistant on a quarterly basis to ensure they are complete and up to date. The ED will ensure that any regulation changes involving emergency procedures are implemented in a timely manner and that the emergency binders are updated to meet any future regulatory changes. Completion date NMT 30 days after issuance of deficiency list: 12/7/25ADDENDUM:Staff were educated on the Emergency/Disaster Response Policy & Procedure updates by group chat and discussions on 12/7/25. All residents were given a copy of the new policy, and the ED explained the policy and answered resident questions in person on 12/7/25..

(Cross-reference U2230)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on all survey findings, including those regarding care plans; staff was informed there would shortly be changes to the care plan format for all residents to ensure compliance with current regulations. Changes in resident needs will be assessed by the ED at least every 6 months, and in response to any new or altered diagnosis, or medical/behavioral changes, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. Between routine reassessments, ECP records will be reviewed by the ED to identify any hospitalizations, new diagnoses or medical/behavioral conditions, or unusual events that may require modification of the care plan, which will then be made. Monitoring plan to ensure deficiency is remedied and will not reoccur:ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED Assistant, and a resident-specific list of such events will be provided to the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. ADDENDUM:Care plan updates were made through December and communicated to staff via the ECP system as they were made. Corrections for sample resident's #16-#20 are summarized below. Resident #16: Resident’s care plan was modified 11/25/25 to include staff tasks for personal care needs; alcohol intake monitoring and reporting; need for personal interaction and socialization due to depression, TBI and cognitive deficit; and behavior that may reflect alcohol, seizures, TBI etc. As an example, personal care needs are addressed as, “Due to cognitive impairment, remind and assist if needed for all ADL tasks – brush teeth, brush hair, use deodorant, change clothing, etc. Staff to assist with reminding resident about showers. Offer assistance if needed but allow for independence. Note observations if resident refuses the reminders or does not shower. Also report to ED if care level needs to be increased.”Resident #17: Resident’s care plan was modified 11/13/25 identifying resident’s need and staff tasks to help with his fluid intake to improve hydration. Care plan was modified 12/3/25 to address resident needs and staff tasks related to dementia including ADL reminders and assistance, bladder/bowel incontinence management, fall risk, hospice care, interpersonal interaction and socialization management, mental health observations, and wandering risk. History of hyperlipidemia was addressed on 12/3/25 with staff monitoring and taking actions for potential stroke or heart attack. Pain management was addressed on 12/3/25 due to resident’s history of aches and pains plus dementia, with staff tasks as shown for Resident #16 above. As another example, the care plan for monitoring for stroke or heart attack is, “Due to the resident having a history of hyperlipidemia, monitor resident and observe any unusual behavior or actions. In case of an emergency, call 911. For a stroke: Use FAST – Face drooping, Arm weakness, Slurred speech, Time to call 911. For a heart attack: Chest pain that may feel like pressure, tightness, pain, squeezing or aching. Pain or discomfort that spreads to the shoulder, arm, back, neck, jar, teeth or sometimes the upper belly, cold sweat, fatigue, heartburn or indigestion, lightheadedness or sudden dizziness, nausea, and shortness of breath. Report to ED immediately after calling 911.”Resident #18: Resident’s care plan was modified 11/21/25 to include fall risk needs and associated staff tasks; on 12/3/25 to include needs and staff tasks related to personal care/ADL’s; meal reminders; alcohol dependence; skin care and assistance with donning/doffing compression socks; need for interactions and socialization due to his history of isolation; mental health monitoring/reporting needs related to his Parkinson’s Disease and depression; assistance needs related to urinary incontinence including assisting with extra supplies or extra laundry; and assistance needs related to his pain history and pain management. Needs related to oxygen needs and management added/modified on 1/7/26. As an example, the pain management task states, “Due to the history of pain/aches, observe the resident for pain management. Also, because of the resident having dementia, he may not know how to request medications. Remind the resident that he has orders in the system and what they are. Ask the resident if he would like to take anything to assist with his headaches. Remind the resident that he can go lay down in his room, with the blinds closed for a dark, calm environment. Follow up with the resident to see his pain level and write clear observations and report to ED. If pain does not go away or there is a need to change medications, call and report to his doctor.”Resident #19: Resident’s care plan added staff fall monitoring and walker reminders/prompts due to fall risk on 11/4/25. On 11/25/25, resident’s care plan was modified to address dementia with staff tasks including ADL reminders and assistance, meal reminders, interpersonal interactions and socialization. Also on 11/25/25, resident needs and associated staff tasks were modified/added regarding his history of tremors needing monitoring, observation and assistance if needed during ambulation, transfers and meals, and his receiving hospice care including nurse and CNA visits as well as case management. On 1/8/26, his changing ADL needs were addressed by care plan for staff to assist him with getting ready in the morning and into bed for the night: “Assist with getting dressed, brief changed in the morning and ready to come down for lunch. Assist with getting into bed for the night. Ask if the resident needs assistance getting ready for bed, changing brief or clothes or anything else.”Resident #20 was hospitalized before her care plan could be updated and remained in the hospital until she was discharged from Chateau at Rifle.

(Cross-reference U2230)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on all survey findings, including those regarding care plans; staff was informed there would shortly be changes to the care plan format for all residents to ensure compliance with current regulations. Changes in resident needs will be assessed by the ED at least every 6 months, and in response to any new or altered diagnosis, or medical/behavioral changes, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. Between routine reassessments, ECP records will be reviewed by the ED to identify any hospitalizations, new diagnoses or medical/behavioral conditions, or unusual events that may require modification of the care plan, which will then be made. Monitoring plan to ensure deficiency is remedied and will not reoccur:ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED Assistant, and a resident-specific list of such events will be provided to the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. Completion date NMT 30 days after issuance of deficiency list: 12/7/25ADDENDUM:Care plan updates were made through December and communicated to staff via the ECP system as they were made. Corrections for sample resident's #16-#20 are summarized below. Resident #16: Resident’s care plan was modified 11/25/25 to include staff tasks for personal care needs; alcohol intake monitoring and reporting; need for personal interaction and socialization due to depression, TBI and cognitive deficit; and behavior that may reflect alcohol, seizures, TBI etc. As an example, personal care needs are addressed as, “Due to cognitive impairment, remind and assist if needed for all ADL tasks – brush teeth, brush hair, use deodorant, change clothing, etc. Staff to assist with reminding resident about showers. Offer assistance if needed but allow for independence. Note observations if resident refuses the reminders or does not shower. Also report to ED if care level needs to be increased.”Resident #17: Resident’s care plan was modified 11/13/25 identifying resident’s need and staff tasks to help with his fluid intake to improve hydration. Care plan was modified 12/3/25 to address resident needs and staff tasks related to dementia including ADL reminders and assistance, bladder/bowel incontinence management, fall risk, hospice care, interpersonal interaction and socialization management, mental health observations, and wandering risk. History of hyperlipidemia was addressed on 12/3/25 with staff monitoring and taking actions for potential stroke or heart attack. Pain management was addressed on 12/3/25 due to resident’s history of aches and pains plus dementia, with staff tasks as shown for Resident #16 above. As another example, the care plan for monitoring for stroke or heart attack is, “Due to the resident having a history of hyperlipidemia, monitor resident and observe any unusual behavior or actions. In case of an emergency, call 911. For a stroke: Use FAST – Face drooping, Arm weakness, Slurred speech, Time to call 911. For a heart attack: Chest pain that may feel like pressure, tightness, pain, squeezing or aching. Pain or discomfort that spreads to the shoulder, arm, back, neck, jar, teeth or sometimes the upper belly, cold sweat, fatigue, heartburn or indigestion, lightheadedness or sudden dizziness, nausea, and shortness of breath. Report to ED immediately after calling 911.”Resident #18: Resident’s care plan was modified 11/21/25 to include fall risk needs and associated staff tasks; on 12/3/25 to include needs and staff tasks related to personal care/ADL’s; meal reminders; alcohol dependence; skin care and assistance with donning/doffing compression socks; need for interactions and socialization due to his history of isolation; mental health monitoring/reporting needs related to his Parkinson’s Disease and depression; assistance needs related to urinary incontinence including assisting with extra supplies or extra laundry; and assistance needs related to his pain history and pain management. Needs related to oxygen needs and management added/modified on 1/7/26. As an example, the pain management task states, “Due to the history of pain/aches, observe the resident for pain management. Also, because of the resident having dementia, he may not know how to request medications. Remind the resident that he has orders in the system and what they are. Ask the resident if he would like to take anything to assist with his headaches. Remind the resident that he can go lay down in his room, with the blinds closed for a dark, calm environment. Follow up with the resident to see his pain level and write clear observations and report to ED. If pain does not go away or there is a need to change medications, call and report to his doctor.”Resident #19: Resident’s care plan added staff fall monitoring and walker reminders/prompts due to fall risk on 11/4/25. On 11/25/25, resident’s care plan was modified to address dementia with staff tasks including ADL reminders and assistance, meal reminders, interpersonal interactions and socialization. Also on 11/25/25, resident needs and associated staff tasks were modified/added regarding his history of tremors needing monitoring, observation and assistance if needed during ambulation, transfers and meals, and his receiving hospice care including nurse and CNA visits as well as case management. On 1/8/26, his changing ADL needs were addressed by care plan for staff to assist him with getting ready in the morning and into bed for the night: “Assist with getting dressed, brief changed in the morning and ready to come down for lunch. Assist with getting into bed for the night. Ask if the resident needs assistance getting ready for bed, changing brief or clothes or anything else.”Resident #20 was hospitalized before her care plan could be updated and remained in the hospital until she was discharged from Chateau at Rifle.

(Cross-reference B020)Description of how Chateau at Rifle will correct the deficiency: Orientation and training procedures are being modified to provide greater documentation of training received on all topics required prior to resident unsupervised contact. New employees will not be placed on the schedule for independent duties unless the Executive Director (ED) or ED Assistant verifies all personnel and training documents have been completed and are on file, and the employee’s hire date as well as first independent work date is accurately recorded. An audit will be completed of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed. Completion date NMT 30 days after issuance of deficiency list: 12/7/25

(Cross-reference B020)Description of how Chateau at Rifle will correct the deficiency:Orientation and training procedures are being modified to provide greater documentation of training received on all topics required prior to resident unsupervised contact. New employees will not be placed on the schedule for independent duties unless the Executive Director (ED) or ED Assistant verifies all personnel and training documents have been completed and are on file, and the employee’s hire date as well as first independent work date is accurately recorded. An audit will be completed of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed.

(Cross-reference B020)Description of how Chateau at Rifle will correct the deficiency:Orientation and training procedures are being modified to provide greater documentation of training received on all topics required prior to resident unsupervised contact. New employees will not be placed on the schedule for independent duties unless the Executive Director (ED) or ED Assistant verifies all personnel and training documents have been completed and are on file, and the employee’s hire date as well as first independent work date is accurately recorded. An audit will be completed of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed. Completion date NMT 30 days after issuance of deficiency list: 12/7/25

(Cross-reference B0880)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on 11/10/25 on results of the survey, and addressed not only proper documentation of unusual resident events, but also the imminent change of all care plans to address changes in personal needs and care tasks needed to meet those needs as well as other required care plan elements. The current ECP care plan format does not incorporate information from external providers, and the ED is actively researching how that information could be incorporated. Changes in resident needs will be assessed at least every 6 months, and in response to any new or altered diagnosis, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. ECP records will be reviewed to identify any hospitalizations, new diagnoses, or unusual events that may require modification of the care plan, which will then be made. If it proves not possible to include all required elements in the ECP care plan, an alternative paper or electronic format will be implemented for all residents, to ensure all required elements are included in the care plan. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED will complete efforts to incorporate all required elements into the ECP care plan; if those efforts prove ineffective due to limitations of the ECP system, she will implement an alternate paper or electronic system of care plans that include all elements and ensure conversion of each resident’s care plan to that format. ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED Assistant, and a resident-specific list of such events will be provided to the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. All required care plan elements will be incorporated into the ECP care plans by 12/7/25, if the ECP system proves able to adequately document those elements in a consolidated format. If the ECP system proves unable to do so, an alternate compliant format will be developed by 11/28/25, with a target date for complete conversion of 12/7/25. ADDENDUM: Resident #16: Resident’s care plan was modified 11/25/25 to include staff tasks for personal care needs; alcohol intake monitoring and reporting; need for personal interaction and socialization due to depression, TBI and cognitive deficit; and behavior that may reflect alcohol, seizures, TBI etc. As an example, personal care needs are addressed as, “Due to cognitive impairment, remind and assist if needed for all ADL tasks – brush teeth, brush hair, use deodorant, change clothing, etc. Staff to assist with reminding resident about showers. Offer assistance if needed but allow for independence. Note observations if resident refuses the reminders or does not shower. Also report to ED if care level needs to be increased.”Resident #17: Resident’s care plan was modified 11/13/25 identifying resident’s need and staff tasks to help with his fluid intake to improve hydration. Care plan was modified 12/3/25 to address resident needs and staff tasks related to dementia including ADL reminders and assistance, bladder/bowel incontinence management, fall risk, hospice care, interpersonal interaction and socialization management, mental health observations, and wandering risk. History of hyperlipidemia was addressed on 12/3/25 with staff monitoring and taking actions for potential stroke or heart attack. Pain management was addressed on 12/3/25 due to resident’s history of aches and pains plus dementia, with staff tasks as shown for Resident #16 above. As another example, the care plan for monitoring for stroke or heart attack is, “Due to the resident having a history of hyperlipidemia, monitor resident and observe any unusual behavior or actions. In case of an emergency, call 911. For a stroke: Use FAST – Face drooping, Arm weakness, Slurred speech, Time to call 911. For a heart attack: Chest pain that may feel like pressure, tightness, pain, squeezing or aching. Pain or discomfort that spreads to the shoulder, arm, back, neck, jar, teeth or sometimes the upper belly, cold sweat, fatigue, heartburn or indigestion, lightheadedness or sudden dizziness, nausea, and shortness of breath. Report to ED immediately after calling 911.”Resident #18: Resident’s care plan was modified 11/21/25 to include fall risk needs and associated staff tasks; on 12/3/25 to include needs and staff tasks related to personal care/ADL’s; meal reminders; alcohol dependence; skin care and assistance with donning/doffing compression socks; need for interactions and socialization due to his history of isolation; mental health monitoring/reporting needs related to his Parkinson’s Disease and depression; assistance needs related to urinary incontinence including assisting with extra supplies or extra laundry; and assistance needs related to his pain history and pain management. Needs related to oxygen needs and management added/modified on 1/7/26. As an example, the pain management task states, “Due to the history of pain/aches, observe the resident for pain management. Also, because of the resident having dementia, he may not know how to request medications. Remind the resident that he has orders in the system and what they are. Ask the resident if he would like to take anything to assist with his headaches. Remind the resident that he can go lay down in his room, with the blinds closed for a dark, calm environment. Follow up with the resident to see his pain level and write clear observations and report to ED. If pain does not go away or there is a need to change medications, call and report to his doctor.”Resident #19: Resident’s care plan added staff fall monitoring and walker reminders/prompts due to fall risk on 11/4/25. On 11/25/25, resident’s care plan was modified to address dementia with staff tasks including ADL reminders and assistance, meal reminders, interpersonal interactions and socialization. Also on 11/25/25, resident needs and associated staff tasks were modified/added regarding his history of tremors needing monitoring, observation and assistance if needed during ambulation, transfers and meals, and his receiving hospice care including nurse and CNA visits as well as case management. On 1/8/26, his changing ADL needs were addressed by care plan for staff to assist him with getting ready in the morning and into bed for the night: “Assist with getting dressed, brief changed in the morning and ready to come down for lunch. Assist with getting into bed for the night. Ask if the resident needs assistance getting ready for bed, changing brief or clothes or anything else.”Resident #20 was hospitalized before her care plan could be updated and remained in the hospital until she was discharged from Chateau at Rifle.

(Cross-reference B0880)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on 11/10/25 on results of the survey, and addressed not only proper documentation of unusual resident events, but also the imminent change of all care plans to address changes in personal needs and care tasks needed to meet those needs as well as other required care plan elements. The current ECP care plan format does not incorporate information from external providers, and the ED is actively researching how that information could be incorporated. Changes in resident needs will be assessed at least every 6 months, and in response to any new or altered diagnosis, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. ECP records will be reviewed to identify any hospitalizations, new diagnoses, or unusual events that may require modification of the care plan, which will then be made. If it proves not possible to include all required elements in the ECP care plan, an alternative paper or electronic format will be implemented for all residents, to ensure all required elements are included in the care plan. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED will complete efforts to incorporate all required elements into the ECP care plan; if those efforts prove ineffective due to limitations of the ECP system, she will implement an alternate paper or electronic system of care plans that include all elements and ensure conversion of each resident’s care plan to that format. ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED Assistant, and a resident-specific list of such events will be provided to the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. Completion date NMT 30 days after issuance of deficiency list: All required care plan elements will be incorporated into the ECP care plans by 12/7/25, if the ECP system proves able to adequately document those elements in a consolidated format. If the ECP system proves unable to do so, an alternate compliant format will be developed by 11/28/25, with a target date for complete conversion of 12/7/25. ADDENDUM: Resident #16: Resident’s care plan was modified 11/25/25 to include staff tasks for personal care needs; alcohol intake monitoring and reporting; need for personal interaction and socialization due to depression, TBI and cognitive deficit; and behavior that may reflect alcohol, seizures, TBI etc. As an example, personal care needs are addressed as, “Due to cognitive impairment, remind and assist if needed for all ADL tasks – brush teeth, brush hair, use deodorant, change clothing, etc. Staff to assist with reminding resident about showers. Offer assistance if needed but allow for independence. Note observations if resident refuses the reminders or does not shower. Also report to ED if care level needs to be increased.”Resident #17: Resident’s care plan was modified 11/13/25 identifying resident’s need and staff tasks to help with his fluid intake to improve hydration. Care plan was modified 12/3/25 to address resident needs and staff tasks related to dementia including ADL reminders and assistance, bladder/bowel incontinence management, fall risk, hospice care, interpersonal interaction and socialization management, mental health observations, and wandering risk. History of hyperlipidemia was addressed on 12/3/25 with staff monitoring and taking actions for potential stroke or heart attack. Pain management was addressed on 12/3/25 due to resident’s history of aches and pains plus dementia, with staff tasks as shown for Resident #16 above. As another example, the care plan for monitoring for stroke or heart attack is, “Due to the resident having a history of hyperlipidemia, monitor resident and observe any unusual behavior or actions. In case of an emergency, call 911. For a stroke: Use FAST – Face drooping, Arm weakness, Slurred speech, Time to call 911. For a heart attack: Chest pain that may feel like pressure, tightness, pain, squeezing or aching. Pain or discomfort that spreads to the shoulder, arm, back, neck, jar, teeth or sometimes the upper belly, cold sweat, fatigue, heartburn or indigestion, lightheadedness or sudden dizziness, nausea, and shortness of breath. Report to ED immediately after calling 911.”Resident #18: Resident’s care plan was modified 11/21/25 to include fall risk needs and associated staff tasks; on 12/3/25 to include needs and staff tasks related to personal care/ADL’s; meal reminders; alcohol dependence; skin care and assistance with donning/doffing compression socks; need for interactions and socialization due to his history of isolation; mental health monitoring/reporting needs related to his Parkinson’s Disease and depression; assistance needs related to urinary incontinence including assisting with extra supplies or extra laundry; and assistance needs related to his pain history and pain management. Needs related to oxygen needs and management added/modified on 1/7/26. As an example, the pain management task states, “Due to the history of pain/aches, observe the resident for pain management. Also, because of the resident having dementia, he may not know how to request medications. Remind the resident that he has orders in the system and what they are. Ask the resident if he would like to take anything to assist with his headaches. Remind the resident that he can go lay down in his room, with the blinds closed for a dark, calm environment. Follow up with the resident to see his pain level and write clear observations and report to ED. If pain does not go away or there is a need to change medications, call and report to his doctor.”Resident #19: Resident’s care plan added staff fall monitoring and walker reminders/prompts due to fall risk on 11/4/25. On 11/25/25, resident’s care plan was modified to address dementia with staff tasks including ADL reminders and assistance, meal reminders, interpersonal interactions and socialization. Also on 11/25/25, resident needs and associated staff tasks were modified/added regarding his history of tremors needing monitoring, observation and assistance if needed during ambulation, transfers and meals, and his receiving hospice care including nurse and CNA visits as well as case management. On 1/8/26, his changing ADL needs were addressed by care plan for staff to assist him with getting ready in the morning and into bed for the night: “Assist with getting dressed, brief changed in the morning and ready to come down for lunch. Assist with getting into bed for the night. Ask if the resident needs assistance getting ready for bed, changing brief or clothes or anything else.”Resident #20 was hospitalized before her care plan could be updated and remained in the hospital until she was discharged from Chateau at Rifle.

Description of how Chateau at Rifle will correct the deficiency:The walking path tripping hazard will be blocked off with fencing and/or hazard tape by 11/25/25 until local weather allows removal/repair of the broken pathway. The facility owner will perform or contract such removal/repair as soon as possible given weather constraints. Monitoring plan to ensure deficiency is remedied and will not reoccur: Condition of external grounds will be inspected at least monthly, and reported to the Quality Management Program which will monitor the correction of any hazards identified. Completion date NMT 30 days after issuance of deficiency list: Updated completion date is no later than 5/16/26. ADDENDUM:Contract with Chapparal Quality Construction was signed 12/1/25, stating, “Repair uneven ground/broken sidewalk in the location damaged by prior tree growth. Remove existing broken concrete and level underlying ground even with the adjacent ground. Replace sidewalk section, or finish the ground in a solid smooth surface that permits walking without trip and fall hazards to pedestrians using canes, walkers or wheelchairs. Work is to be performed as soon as weather conditions permit, allowing for temperature and moisture limitations affecting either excavation or surface replacement procedures for duration of the project.” Due to winter weather conditions, final repair has not yet been possible. In the meantime, as of 11/24/25 a storm fence barrier has been placed blocking the damaged sidewalk. The Executive Director or her designee will visually check the barrier every day, ensuring it remains in place until the contracted repairs have been completed. FOLLOWUP:Completion date has been modified above as directed. The contract with Chaparral Quality Construction has been modified to specify the requested information as follows:Estimate date for project completion: "Work is to be performed as soon as weather conditions permit, but no later than 5/15/26 allowing for temperature and moisture limitations affecting either excavation or surface replacement procedures for duration of the project."Timeline: "Complete timeline is expected to take approximately 1 week of weather consistently dry and warm enough to complete all portions of the project." Project includes repairing uneven ground/broken sidewalk, i.e. removing existing broken concrete, leveling underlying ground to match the surrounding ground, and replacing the concrete sidewalk with new concrete or an alternate solid smooth surface that will not present walking hazards.

(Cross-reference B0290)Description of how Chateau at Rifle will correct the deficiency:The ED is the designated infection prevention and control manager. The ED has started the required training for that role, specifically the CO-TRAIN 24-module training for infection control program managers, and will complete the full training as soon as possible. The Infection Control policy will be revised to include the requirement for a designated and appropriately trained infection prevention and control program manager. A requirement will be added to the ED job description that the ED is responsible for designating an infection prevention and control program manager and ensuring his/her training in accordance with current regulations. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED will periodically review regulations to ensure that any future revisions with regard to infection prevention and control are implemented.

Description of how Chateau at Rifle will correct the deficiency:The ED is the designated infection prevention and control manager. The ED has started the required training for that role, specifically the CO-TRAIN 24-module training for infection control program managers, and will complete the full training as soon as possible. The Infection Control policy will be revised to include the requirement for a designated and appropriately trained infection prevention and control program manager. A requirement will be added to the ED job description that the ED is responsible for designating an infection prevention and control program manager and ensuring his/her training in accordance with current regulations. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED will periodically review regulations to ensure that any future revisions with regard to infection prevention and control are implemented. Completion date NMT 30 days after issuance of deficiency list: 12/7/25

Description of how Chateau at Rifle will correct the deficiency:Steps are being taken as detailed in various Tags of this survey, to ensure all required policies and procedures are readily available to surveyors. The ED Assistant will review and ensure all personnel records are organized in such a way as to allow required documentation to be readily accessible to authorized persons including CDPHE. An audit will be completed by the ED and/or ED Assistant of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed. Completion date NMT 30 days after issuance of deficiency list: 12/7/25

Description of how Chateau at Rifle will correct the deficiency:Steps are being taken as detailed in various Tags of this survey, to ensure all required policies and procedures are readily available to surveyors. The ED Assistant will review and ensure all personnel records are organized in such a way as to allow required documentation to be readily accessible to authorized persons including CDPHE.An audit will be completed by the ED and/or ED Assistant of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed.

(Cross-reference B0290 & U0664)Description of how Chateau at Rifle will correct the deficiency: Orientation and training procedures are being modified to provide greater documentation of training received on all topics required prior to resident unsupervised contact. New employees will not be placed on the schedule for independent duties unless the Executive Director (ED) or ED Assistant verifies all personnel and training documents have been completed and are on file, and the employee’s hire date as well as first independent work date is accurately recorded. An audit will be completed of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed. Completion date NMT 30 days after issuance of deficiency list: 12/7/25

(Cross-reference B0290 & U0664)Description of how Chateau at Rifle will correct the deficiency:Orientation and training procedures are being modified to provide greater documentation of training received on all topics required prior to resident unsupervised contact. New employees will not be placed on the schedule for independent duties unless the Executive Director (ED) or ED Assistant verifies all personnel and training documents have been completed and are on file, and the employee’s hire date as well as first independent work date is accurately recorded. An audit will be completed of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed.

(Cross-reference B0290 & U0640)Description of how CSSH will correct the deficiency: Orientation and training procedures are being modified to provide greater documentation of training received on all topics required prior to resident unsupervised contact. New employees will not be placed on the schedule for independent duties unless the Executive Director (ED) or ED Assistant verifies all personnel and training documents have been completed and are on file, and the employee’s hire date as well as first independent work date is accurately recorded. An audit will be completed of all employee records to identify missing documentation so it can be generated, or missing training can be provided. The existing Orientation Checklist for All New Employees is being modified to meet the current regulation requirements; it will be used to document the employee file/training audit as well as ongoing training updates. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED Assistant will update training and personnel documentation as it occurs, and monitor ongoing compliance with required training and documentation for new employees, existing employees whose documentation was found deficient on audit, and any required annual training or renewal of other personnel documents. Compliance status will be reviewed and documented through the Quality Management Program, and additional or modified corrective action will be taken as needed. Completion date NMT 30 days after issuance of deficiency list: 12/7/25

(Cross-reference B0290)Description of how Chateau at Rifle will correct the deficiency:Section 25-3-125(3)(a), C.R.S. has been obtained and a new Visitation Policy is being formulated based the required elements contained in that regulation. The resident agreement will also be modified to include compassionate visits in addition to the current “family and friends”.Monitoring plan to ensure deficiency remedied and will not reoccur: The new Visitation Policy will be made available to residents, their families and visitors as requested. ADDENDUM:Staff was informed of the Visitor/Visitation Policy on 12/7/25, in person or by group chat also covering the Emergency/Disaster Response Policy. Copies of the Visitor/Visitation Policy were distributed to residents along with the Emergency/Disaster Response Policy on 12/7/25, questions answered and explained by the ED. It will be discussed again at the next resident meeting on 1/13/26 so it will be documented in those minutes for reference.

(Cross-reference B0290)Description of how Chateau at Rifle will correct the deficiency: An Involuntary Discharge Policy & Procedure is being developed to meet the requirements of that regulation, including notification and grievance procedures. The Resident Agreement is also being reviewed and revised as necessary to address involuntary discharges more clearly. An Involuntary Discharge Checklist will be developed to ensure all appropriate notifications, reports and timelines are met. Monitoring plan to ensure deficiency is remedied and will not reoccur: The ED will provide copies of the Involuntary Discharge Checklist to the Quality Management Committee for all involuntary discharges, along with a list of all discharges since the last QMP meeting. The Quality Management Committee will review and monitor the discharge list and any Checklist(s) to verify compliance with the policy and regulation.

(Cross-reference B0290)Description of how Chateau at Rifle will correct the deficiency: Section 25-27-104.3, C.R.S. has been obtained and reviewed by the ED. An Involuntary Discharge Policy & Procedure is being developed to meet the requirements of that regulation, including notification and grievance procedures. The Resident Agreement is also being reviewed and revised as necessary to address involuntary discharges more clearly. An Involuntary Discharge Checklist will be developed to ensure all appropriate notifications, reports and timelines are met. Monitoring plan to ensure deficiency is remedied and will not reoccur: The ED will provide copies of the Involuntary Discharge Checklist to the Quality Management Committee for all involuntary discharges, along with a list of all discharges since the last QMP meeting. The Quality Management Committee will review and monitor the discharge list and any Checklist(s) to verify compliance with the policy and regulation. Completion date NMT 30 days after issuance of deficiency list: 12/4/25

(Cross-reference B0290)Description of how Chateau at Rifle will correct the deficiency:A consolidated list of residents, their room numbers, and their emergency contact information is being generated. It will be included in the emergency binders and updated by the ED or the ED assistant as residents are admitted, discharged or changes occur. A list of residents by room number can be generated at any time by ECP for non-emergency situations. Existing staff will be trained on both the emergency list as well as how to generate the ECP list, and the same information will be included in new employee orientation along with the training on the emergency information binder. Monitoring plan to ensure deficiency is remedied and will not reoccur: The ED and ED Assistant will be responsible for updating resident lists and emergency contact information as residents are moved, discharged, or new residents are admitted. Emergency binders will be inspected by the ED and ED Assistant on a quarterly basis to ensure they are complete and up to date. ADDENDUM:There is now one list containing the resident’s name, room number, and contact name and phone numbers for emergency contact. The list is in room order and is included in the emergency binders.

(Cross-reference B0290 & U0920)Description of how Chateau at Rifle will correct the deficiency: A location-specific hazard risk assessment is in progress, and emergency procedures are being consolidated into a new Emergency Preparedness and Response Policy and Procedure that will include all required elements. Emergency Response binders will continue to be maintained in each medication cart, and additional copies will be distributed throughout the facility for ready access at all times. Binders will be standardized to include the list of residents by room number; emergency contact information for each resident and procedures for communication with other providers; emergency contact numbers for external agencies or providers that may be need to be notified in an emergency; a copy of the evacuation map for the facility; policies & procedures for each emergency identified by the hazard risk assessment as well as medical and public health emergencies compliant with current regulations; emergency staffing measures; and a copy of the written relocation agreement with facility to which residents may be evacuated/relocated if necessary. The owner is currently researching and determining additional resources to supplement emergency power for essential functions and resident medical or essential auxiliary equipment. Inservice training will be conducted for all staff regarding use of the new binder and emergency policies & procedures, and the same will also be included in new employee orientation. Monitoring plan to ensure deficiency is remedied and will not reoccur: The ED and ED Assistant will be responsible for updating resident lists and emergency contact information as new residents are admitted. Emergency binders will be inspected by the ED and ED Assistant on a quarterly basis to ensure they are complete and up to date. The ED will ensure that any regulation changes involving emergency procedures are implemented in a timely manner and that the emergency binders are updated to meet any future regulatory changes. ADDENDUM:There is now one list containing the resident’s name, room number, and contact name and phone numbers for emergency contact. The list is in room order and contained in the emergency binders.

(Cross-reference B0290 & U0920)Description of how Chateau at Rifle will correct the deficiency:A location-specific hazard risk assessment is in progress, and emergency procedures are being consolidated into a new Emergency Preparedness and Response Policy and Procedure that will include all required elements. Emergency Response binders will continue to be maintained in each medication cart, and additional copies will be distributed throughout the facility for ready access at all times. Binders will be standardized to include the list of residents by room number; emergency contact information for each resident and procedures for communication with other providers; emergency contact numbers for external agencies or providers that may be need to be notified in an emergency; a copy of the evacuation map for the facility; policies & procedures for each emergency identified by the hazard risk assessment as well as medical and public health emergencies compliant with current regulations; emergency staffing measures; and a copy of the written relocation agreement with facility to which residents may be evacuated/relocated if necessary. The owner is currently researching and determining additional resources to supplement emergency power for essential functions and resident medical or essential auxiliary equipment. Inservice training will be conducted for all staff regarding use of the new binder and emergency policies & procedures, and the same will also be included in new employee orientation. Monitoring plan to ensure deficiency is remedied and will not reoccur:The ED and ED Assistant will be responsible for updating resident lists and emergency contact information as new residents are admitted. Emergency binders will be inspected by the ED and ED Assistant on a quarterly basis to ensure they are complete and up to date. The ED will ensure that any regulation changes involving emergency procedures are implemented in a timely manner and that the emergency binders are updated to meet any future regulatory changes. ADDENDUM:There is now one list containing the resident’s name, room number, and contact name and phone numbers for emergency contact. The list is in room order and contained in the emergency binders.

(Cross-reference B0290 & U0916)Description of how Chateau at Rifle will correct the deficiency: The Executive Director (ED) has obtained verbal agreement with another facility as an evacuation site if residents require evacuation from Chateau at Rifle in response to an emergency or disaster; she is awaiting written confirmation from that facility. A location-specific hazard risk assessment is in progress, and emergency procedures are being consolidated into a new Emergency Preparedness and Response Policy and Procedure that will include all required elements. Emergency Response binders will continue to be maintained in each medication cart, and additional copies will be distributed throughout the facility for ready access at all times. Binders will be standardized to include the list of residents by room number; emergency contact information for each resident and procedures for communication with other providers; emergency contact numbers for external agencies or providers that may be need to be notified in an emergency; a copy of the evacuation map for the facility; policies & procedures for each emergency identified by the hazard risk assessment as well as medical and public health emergencies compliant with current regulations; emergency staffing measures; and a copy of the written relocation agreement with facility to which residents may be evacuated/relocated if necessary. The owner is currently researching and determining additional resources to supplement emergency power for essential functions and resident medical or essential auxiliary equipment. Inservice training will be conducted for all staff regarding use of the new binder and emergency policies & procedures, and the same will also be included in new employee orientation. Monitoring plan to ensure deficiency is remedied and will not reoccur: The ED and ED Assistant will be responsible for updating resident lists and emergency contact information as new residents are admitted. Emergency binders will be inspected by the ED and ED Assistant on a quarterly basis to ensure they are complete and up to date. The ED will ensure that any regulation changes involving emergency procedures are implemented in a timely manner and that the emergency binders are updated to meet any future regulatory changes. Completion date NMT 30 days after issuance of deficiency list: 12/7/25

(Cross-reference B0290 & U0916)Description of how Chateau at Rifle will correct the deficiency:The Executive Director (ED) has obtained verbal agreement with another facility as an evacuation site if residents require evacuation from Chateau at Rifle in response to an emergency or disaster; she is awaiting written confirmation from that facility. A location-specific hazard risk assessment is in progress, and emergency procedures are being consolidated into a new Emergency Preparedness and Response Policy and Procedure that will include all required elements. Emergency Response binders will continue to be maintained in each medication cart, and additional copies will be distributed throughout the facility for ready access at all times. Binders will be standardized to include the list of residents by room number; emergency contact information for each resident and procedures for communication with other providers; emergency contact numbers for external agencies or providers that may be need to be notified in an emergency; a copy of the evacuation map for the facility; policies & procedures for each emergency identified by the hazard risk assessment as well as medical and public health emergencies compliant with current regulations; emergency staffing measures; and a copy of the written relocation agreement with facility to which residents may be evacuated/relocated if necessary. The owner is currently researching and determining additional resources to supplement emergency power for essential functions and resident medical or essential auxiliary equipment. Inservice training will be conducted for all staff regarding use of the new binder and emergency policies & procedures, and the same will also be included in new employee orientation. Monitoring plan to ensure deficiency is remedied and will not reoccur:The ED and ED Assistant will be responsible for updating resident lists and emergency contact information as new residents are admitted. Emergency binders will be inspected by the ED and ED Assistant on a quarterly basis to ensure they are complete and up to date. The ED will ensure that any regulation changes involving emergency procedures are implemented in a timely manner and that the emergency binders are updated to meet any future regulatory changes.

(Cross-reference U2230)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on 11/10/25 on results of the survey, and addressed not only proper documentation of unusual resident events, but also the imminent change of all care plans to address changes in personal needs and care tasks needed to meet those needs as well as other required care plan elements. The current ECP care plan format does not incorporate information from external providers, and the ED is actively researching how that information could be incorporated. Changes in resident needs will be assessed at least every 6 months, and in response to any new or altered diagnosis, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. ECP records will be reviewed to identify any hospitalizations, new diagnoses, or unusual events that may require modification of the care plan, which will then be made. If it proves not possible to include all required elements in the ECP care plan, an alternative paper or electronic format will be implemented for all residents, to ensure all required elements are included in the care plan. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED will complete efforts to incorporate all required elements into the ECP care plan; if those efforts prove ineffective due to limitations of the ECP system, she will implement an alternate paper or electronic system of care plans that include all elements and ensure conversion of each resident’s care plan to that format. ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. Completion date NMT 30 days after issuance of deficiency list: All required care plan elements will be incorporated into the ECP care plans by 12/7/25, if the ECP system proves able to adequately document those elements in a consolidated format. If the ECP system proves unable to do so, an alternate compliant format will be developed by 11/28/25, with a target date for complete conversion of 12/7/25. ADDENDUM:Resident #16: Resident’s care plan was modified 11/25/25 to include staff tasks for personal care needs; alcohol intake monitoring and reporting; need for personal interaction and socialization due to depression, TBI and cognitive deficit; and behavior that may reflect alcohol, seizures, TBI etc. As an example, personal care needs are addressed as, “Due to cognitive impairment, remind and assist if needed for all ADL tasks – brush teeth, brush hair, use deodorant, change clothing, etc. Staff to assist with reminding resident about showers. Offer assistance if needed but allow for independence. Note observations if resident refuses the reminders or does not shower. Also report to ED if care level needs to be increased.”Resident #17: Resident’s care plan was modified 11/13/25 identifying resident’s need and staff tasks to help with his fluid intake to improve hydration. Care plan was modified 12/3/25 to address resident needs and staff tasks related to dementia including ADL reminders and assistance, bladder/bowel incontinence management, fall risk, hospice care, interpersonal interaction and socialization management, mental health observations, and wandering risk. History of hyperlipidemia was addressed on 12/3/25 with staff monitoring and taking actions for potential stroke or heart attack. Pain management was addressed on 12/3/25 due to resident’s history of aches and pains plus dementia, with staff tasks as shown for Resident #16 above. As another example, the care plan for monitoring for stroke or heart attack is, “Due to the resident having a history of hyperlipidemia, monitor resident and observe any unusual behavior or actions. In case of an emergency, call 911. For a stroke: Use FAST – Face drooping, Arm weakness, Slurred speech, Time to call 911. For a heart attack: Chest pain that may feel like pressure, tightness, pain, squeezing or aching. Pain or discomfort that spreads to the shoulder, arm, back, neck, jar, teeth or sometimes the upper belly, cold sweat, fatigue, heartburn or indigestion, lightheadedness or sudden dizziness, nausea, and shortness of breath. Report to ED immediately after calling 911.”Resident #18: Resident’s care plan was modified 11/21/25 to include fall risk needs and associated staff tasks; on 12/3/25 to include needs and staff tasks related to personal care/ADL’s; meal reminders; alcohol dependence; skin care and assistance with donning/doffing compression socks; need for interactions and socialization due to his history of isolation; mental health monitoring/reporting needs related to his Parkinson’s Disease and depression; assistance needs related to urinary incontinence including assisting with extra supplies or extra laundry; and assistance needs related to his pain history and pain management. Needs related to oxygen needs and management added/modified on 1/7/26. As an example, the pain management task states, “Due to the history of pain/aches, observe the resident for pain management. Also, because of the resident having dementia, he may not know how to request medications. Remind the resident that he has orders in the system and what they are. Ask the resident if he would like to take anything to assist with his headaches. Remind the resident that he can go lay down in his room, with the blinds closed for a dark, calm environment. Follow up with the resident to see his pain level and write clear observations and report to ED. If pain does not go away or there is a need to change medications, call and report to his doctor.”Resident #19: Resident’s care plan added staff fall monitoring and walker reminders/prompts due to fall risk on 11/4/25. On 11/25/25, resident’s care plan was modified to address dementia with staff tasks including ADL reminders and assistance, meal reminders, interpersonal interactions and socialization. Also on 11/25/25, resident needs and associated staff tasks were modified/added regarding his history of tremors needing monitoring, observation and assistance if needed during ambulation, transfers and meals, and his receiving hospice care including nurse and CNA visits as well as case management. On 1/8/26, his changing ADL needs were addressed by care plan for staff to assist him with getting ready in the morning and into bed for the night: “Assist with getting dressed, brief changed in the morning and ready to come down for lunch. Assist with getting into bed for the night. Ask if the resident needs assistance getting ready for bed, changing brief or clothes or anything else.”Resident #20 was hospitalized before her care plan could be updated, and remained in the hospital until she was discharged from Chateau at Rifle.

(Cross-reference U2230)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on 11/10/25 on results of the survey, and addressed not only proper documentation of unusual resident events, but also the imminent change of all care plans to address changes in personal needs and care tasks needed to meet those needs as well as other required care plan elements. The current ECP care plan format does not incorporate information from external providers, and the ED is actively researching how that information could be incorporated. Changes in resident needs will be assessed at least every 6 months, and in response to any new or altered diagnosis, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. ECP records will be reviewed to identify any hospitalizations, new diagnoses, or unusual events that may require modification of the care plan, which will then be made. If it proves not possible to include all required elements in the ECP care plan, an alternative paper or electronic format will be implemented for all residents, to ensure all required elements are included in the care plan. Monitoring plan to ensure deficiency is remedied and will not reoccur:ED will complete efforts to incorporate all required elements into the ECP care plan; if those efforts prove ineffective due to limitations of the ECP system, she will implement an alternate paper or electronic system of care plans that include all elements and ensure conversion of each resident’s care plan to that format. ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. All required care plan elements will be incorporated into the ECP care plans by 12/7/25, if the ECP system proves able to adequately document those elements in a consolidated format. If the ECP system proves unable to do so, an alternate compliant format will be developed by 11/28/25, with a target date for complete conversion of 12/7/25. ADDENDUM:Resident #16: Resident’s care plan was modified 11/25/25 to include staff tasks for personal care needs; alcohol intake monitoring and reporting; need for personal interaction and socialization due to depression, TBI and cognitive deficit; and behavior that may reflect alcohol, seizures, TBI etc. As an example, personal care needs are addressed as, “Due to cognitive impairment, remind and assist if needed for all ADL tasks – brush teeth, brush hair, use deodorant, change clothing, etc. Staff to assist with reminding resident about showers. Offer assistance if needed but allow for independence. Note observations if resident refuses the reminders or does not shower. Also report to ED if care level needs to be increased.”Resident #17: Resident’s care plan was modified 11/13/25 identifying resident’s need and staff tasks to help with his fluid intake to improve hydration. Care plan was modified 12/3/25 to address resident needs and staff tasks related to dementia including ADL reminders and assistance, bladder/bowel incontinence management, fall risk, hospice care, interpersonal interaction and socialization management, mental health observations, and wandering risk. History of hyperlipidemia was addressed on 12/3/25 with staff monitoring and taking actions for potential stroke or heart attack. Pain management was addressed on 12/3/25 due to resident’s history of aches and pains plus dementia, with staff tasks as shown for Resident #16 above. As another example, the care plan for monitoring for stroke or heart attack is, “Due to the resident having a history of hyperlipidemia, monitor resident and observe any unusual behavior or actions. In case of an emergency, call 911. For a stroke: Use FAST – Face drooping, Arm weakness, Slurred speech, Time to call 911. For a heart attack: Chest pain that may feel like pressure, tightness, pain, squeezing or aching. Pain or discomfort that spreads to the shoulder, arm, back, neck, jar, teeth or sometimes the upper belly, cold sweat, fatigue, heartburn or indigestion, lightheadedness or sudden dizziness, nausea, and shortness of breath. Report to ED immediately after calling 911.”Resident #18: Resident’s care plan was modified 11/21/25 to include fall risk needs and associated staff tasks; on 12/3/25 to include needs and staff tasks related to personal care/ADL’s; meal reminders; alcohol dependence; skin care and assistance with donning/doffing compression socks; need for interactions and socialization due to his history of isolation; mental health monitoring/reporting needs related to his Parkinson’s Disease and depression; assistance needs related to urinary incontinence including assisting with extra supplies or extra laundry; and assistance needs related to his pain history and pain management. Needs related to oxygen needs and management added/modified on 1/7/26. As an example, the pain management task states, “Due to the history of pain/aches, observe the resident for pain management. Also, because of the resident having dementia, he may not know how to request medications. Remind the resident that he has orders in the system and what they are. Ask the resident if he would like to take anything to assist with his headaches. Remind the resident that he can go lay down in his room, with the blinds closed for a dark, calm environment. Follow up with the resident to see his pain level and write clear observations and report to ED. If pain does not go away or there is a need to change medications, call and report to his doctor.”Resident #19: Resident’s care plan added staff fall monitoring and walker reminders/prompts due to fall risk on 11/4/25. On 11/25/25, resident’s care plan was modified to address dementia with staff tasks including ADL reminders and assistance, meal reminders, interpersonal interactions and socialization. Also on 11/25/25, resident needs and associated staff tasks were modified/added regarding his history of tremors needing monitoring, observation and assistance if needed during ambulation, transfers and meals, and his receiving hospice care including nurse and CNA visits as well as case management. On 1/8/26, his changing ADL needs were addressed by care plan for staff to assist him with getting ready in the morning and into bed for the night: “Assist with getting dressed, brief changed in the morning and ready to come down for lunch. Assist with getting into bed for the night. Ask if the resident needs assistance getting ready for bed, changing brief or clothes or anything else.”Resident #20 was hospitalized before her care plan could be updated, and remained in the hospital until she was discharged from Chateau at Rifle.

(Cross-reference B0290 & U1150)Description of how Chateau at Rifle will correct the deficiency: Inservice staff training was conducted on 11/10/25 on results of the survey, and addressed not only proper documentation of unusual resident events, but also the imminent change of all care plans to address changes in personal needs and care tasks needed to meet those needs as well as other required care plan elements. The current ECP care plan format does not incorporate information from external providers, and the ED is actively researching how that information could be incorporated. Changes in resident needs will be assessed at least every 6 months, and in response to any new or altered diagnosis, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. ECP records will be reviewed to identify any hospitalizations, new diagnoses, or unusual events that may require modification of the care plan, which will then be made. If it proves not possible to include all required elements in the ECP care plan, an alternative paper or electronic format will be implemented for all residents, to ensure all required elements are included in the care plan. Staff training will be conducted regarding the new care plan process as soon as it has been determined. Monitoring plan to ensure deficiency is remedied and will not reoccur: ED will complete efforts to incorporate all required elements into the ECP care plan; if those efforts prove ineffective due to limitations of the ECP system, she will implement an alternate paper or electronic system of care plans that include all elements and ensure conversion of each resident’s care plan to that format. ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. Completion date NMT 30 days after issuance of deficiency list: All required care plan elements will be incorporated into the ECP care plans by 12/7/25, if the ECP system proves able to adequately document those elements in a consolidated format. If the ECP system proves unable to do so, an alternate compliant format will be developed by 11/28/25, with a target date for complete conversion of 12/7/25.

(Cross-reference B0290 & U1150)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on 11/10/25 on results of the survey, and addressed not only proper documentation of unusual resident events, but also the imminent change of all care plans to address changes in personal needs and care tasks needed to meet those needs as well as other required care plan elements. The current ECP care plan format does not incorporate information from external providers, and the ED is actively researching how that information could be incorporated. Changes in resident needs will be assessed at least every 6 months, and in response to any new or altered diagnosis, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. ECP records will be reviewed to identify any hospitalizations, new diagnoses, or unusual events that may require modification of the care plan, which will then be made. If it proves not possible to include all required elements in the ECP care plan, an alternative paper or electronic format will be implemented for all residents, to ensure all required elements are included in the care plan. Staff training will be conducted regarding the new care plan process as soon as it has been determined. Monitoring plan to ensure deficiency is remedied and will not reoccur:ED will complete efforts to incorporate all required elements into the ECP care plan; if those efforts prove ineffective due to limitations of the ECP system, she will implement an alternate paper or electronic system of care plans that include all elements and ensure conversion of each resident’s care plan to that format. ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED. The ED will review each such case, as well as ensure any necessary reassessments are completed (including routine 6-month reassessments) and necessary care plan updates have been or are performed in a timely manner. The ED will keep an ongoing record of care plans reviewed and updated to meet content requirements for review by the Quality Management Program. The Quality Management Program will also monitor compliance with the care plan element requirements via a randomly selected 25% of care plans quarterly. All required care plan elements will be incorporated into the ECP care plans by 12/7/25, if the ECP system proves able to adequately document those elements in a consolidated format. If the ECP system proves unable to do so, an alternate compliant format will be developed by 11/28/25, with a target date for complete conversion of 12/7/25.

Description of how Chateau at Rifle will correct the deficiency:The walking path tripping hazard will be blocked off with fencing and/or hazard tape by 11/25/25 until local weather allows removal/repair of the broken pathway. The facility owner will perform or contract such removal/repair as soon as possible given weather constraints. Monitoring plan to ensure deficiency is remedied and will not reoccur:Condition of external grounds will be inspected at least monthly, and reported to the Quality Management Program which will monitor the correction of any hazards identified. Completion date 30 days after issuance of deficiency list. Updating to reflect POC as directed, new completion date is no later than 5/15/26. ADDENDUM:Contract with Chapparal Quality Construction was signed 12/1/25. Contract states, “Repair uneven ground/broken sidewalk in the location damaged by prior tree growth. Remove existing broken concrete and level underlying ground even with the adjacent ground. Replace sidewalk section, or finish the ground in a solid smooth surface that permits walking without trip and fall hazards to pedestrians using canes, walkers or wheelchairs. Work is to be performed as soon as weather conditions permit, allowing for temperature and moisture limitations affecting either excavation or surface replacement procedures for duration of the project.” Due to winter weather conditions, final repair has not yet been possible. In the meantime, a storm fence barrier has been placed blocking the damaged sidewalk as of 11/24/25, and the Executive Director or her designee will visually check the barrier every day, ensuring it remains in place until the contracted repairs have been completed. FOLLOWUP:Completion date has been modified above as directed. The contract with Chaparral Quality Construction has been modified to specify the requested information as follows:Estimate date for project completion: "Work is to be performed as soon as weather conditions permit, but no later than 5/15/26 allowing for temperature and moisture limitations affecting either excavation or surface replacement procedures for duration of the project."Timeline: "Complete timeline is expected to take approximately 1 week of weather consistently dry and warm enough to complete all portions of the project." Project includes repairing uneven ground/broken sidewalk, i.e. removing existing broken concrete, leveling underlying ground to match the surrounding ground, and replacing the concrete sidewalk with new concrete or an alternate solid smooth surface that will not present walking hazards.

Description of how Chateau at Rifle will correct the deficiency:Fire resistant waste disposal containers will be provided. The owner and ED are attempting to identify a smoking area in a safe accessible location that meets the CCIAA requirements. Monitoring plan to ensure deficiency is remedied and will not reoccur:Once an acceptable smoking area is identified or created, appropriate signage will be implemented and resident use of the area will be noted and monitored by staff and routine grounds inspections. ADDENDUM:Several ideas for moving the smoking area were considered but were determined to present safety concerns for the residents, such as designating an area of the parking lot, in/on uneven ground, or with insufficient space or accessway. In our efforts to identify an area complying with CRS 25-14-203 to 209 (Colorado Clean Indoor Air Act). We read the regulation itself closely as specified below, as well as all other related regulations we could find. With that information, the current location (outside a side door in an enclosed area) appears to comply with that regulation. At this point, after considering the relative safety and risks of the alternatives vs the current location, the fact that the left side door to the smoking area is not the front or main entry and is actually more than 50 feet from the main entryway, and the governing regulations as above, Chateau at Rifle respectfully plans to maintain the current location at this time. We will continue to monitor the front entryway area as staff come and go, and during exterior property inspections, for any resident smokers encroaching within 25 feet of the main entryway. Any resident so identified will be reminded and accompanied to the smoking area, and if a future problem arises additional monitoring and resolution will be addressed by the Executive Director and QAPI process as necessary. FOLLOWUP:The original citation referenced the designated smoking area on the east side of the building. The door adjacent to the smoking area does not meet the definition of "entryway" as set forth in the Colorado Clean Indoor Air Act, CRS 25-14-103(7) as stated above ('‘Entryway’ means the outside of the front or main doorway'). The citation refers to the side door as the "home entrance", which is inaccurate if that term is intended to refer to the front or main doorway entrance. The front or main entryway to the facility is on the north side, a larger entrance readily visible and easily available from the front resident and visitor parking area. That entry clearly meets the definition "entryway" established in the Colorado Clean Indoor Air Act. However, the side door close to the door is not a general public entrance and opens only into the employee parking lot. Therefore, although our POC responses and the citation do in fact refer to the same "entrance", that entrance appears not to be subject to the regulation since it is not an "entryway" covered by the Act, as detailed in the above regulatory citations. The existing smoking area is more than 50 feet from the facility's entryway which is subject to the Act. Unfortunately, our researches only discovered this after the IDR deadline had expired, so we were unable to utilize that process to present that that opinion, and know of no other avenue to to do so. As stated above, we will continue to monitor the area around the front/main entryway for illegal smoking, through staff movement and exterior inspections. Residents or others observed smoking around the front/main entrance/entryway will be informed of and escorted to the designated smoking area as necessary. Although smoking in that area has not been a problem in the past, if it does so in the future, the Executive Director will implement corrective action and additional monitoring as necessary through the QAPI process.

Description of how Chateau at Rifle will correct the deficiency:The walking path tripping hazard will be blocked off with fencing and/or hazard tape by 11/25/25 until local weather allows removal/repair of the broken pathway. The facility owner will perform or contract such removal/repair as soon as possible given weather constraints. Monitoring plan to ensure deficiency is remedied and will not reoccur: Condition of external grounds will be inspected at least monthly, and reported to the Quality Management Program which will monitor the correction of any hazards identified. Completion date 30 days after issuance of deficiency list: As directed, completion date is updated to no later than 5/15/26. ADDENDUM:Contract with Chapparal Quality Construction was signed 12/1/25, stating, “Repair uneven ground/broken sidewalk in the location damaged by prior tree growth. Remove existing broken concrete and level underlying ground even with the adjacent ground. Replace sidewalk section, or finish the ground in a solid smooth surface that permits walking without trip and fall hazards to pedestrians using canes, walkers or wheelchairs. Work is to be performed as soon as weather conditions permit, allowing for temperature and moisture limitations affecting either excavation or surface replacement procedures for duration of the project.” Due to winter weather conditions, final repair has not yet been possible. In the meantime, as of 11/24/25 a storm fence barrier has been placed blocking the damaged sidewalk. The Executive Director or her designee will visually check the barrier every day, ensuring it remains in place until the contracted repairs have been completed. FOLLOWUP:Completion date has been modified above as directed. The contract with Chaparral Quality Construction has been modified to specify the requested information as follows:Estimate date for project completion: "Work is to be performed as soon as weather conditions permit, but no later than 5/15/26 allowing for temperature and moisture limitations affecting either excavation or surface replacement procedures for duration of the project."Timeline: "Complete timeline is expected to take approximately 1 week of weather consistently dry and warm enough to complete all portions of the project." Project consists of repairing uneven ground/broken sidewalk, i.e. removing existing broken concrete, leveling underlying ground to match the surrounding ground, and replacing the concrete sidewalk with new concrete or an alternate solid smooth surface that will not present walking hazards.

(Cross-reference U2230)Description of how Chateau at Rifle will correct the deficiency:Inservice staff training was conducted on all survey findings, including those regarding care plans as well as proper expected documentation of unusual events in resident observation documentation. Staff was informed there would shortly be changes to the care plan format for all residents to ensure compliance with current regulations. Changes in resident needs will be assessed by the ED at least every 6 months, and in response to any new or altered diagnosis, or medical/behavioral changes, or after a hospitalization or ER visit to ensure the resident’s care plan is updated accordingly. Between routine reassessments, ECP records will be reviewed by the ED to identify any hospitalizations, new diagnoses or medical/behavioral conditions, or unusual events that may require modification of the care plan, which will then be made. Monitoring plan to ensure deficiency is remedied and will not reoccur:ECP and paper documentation of resident hospitalizations, new diagnoses, or unusual events will be reviewed weekly by the ED. The ED will review each case and ensure any appropriate assessment and/or care plan modifications have been or are performed. The Quality Management Program will monitor compliance with the care plan content requirements via the ED’s list of events and related modifications, and/or by a review of a randomly selected 25% of care plans quarterly. ADDENDUM:Resident #16: Resident’s care plan was modified 11/25/25 to include staff tasks for personal care needs; alcohol intake monitoring and reporting; need for personal interaction and socialization due to depression, TBI and cognitive deficit; and behavior that may reflect alcohol, seizures, TBI etc. As an example, personal care needs are addressed as, “Due to cognitive impairment, remind and assist if needed for all ADL tasks – brush teeth, brush hair, use deodorant, change clothing, etc. Staff to assist with reminding resident about showers. Offer assistance if needed but allow for independence. Note observations if resident refuses the reminders or does not shower. Also report to ED if care level needs to be increased.”Resident #17: Resident’s care plan was modified 11/13/25 identifying resident’s need and staff tasks to help with his fluid intake to improve hydration. Care plan was modified 12/3/25 to address resident needs and staff tasks related to dementia including ADL reminders and assistance, bladder/bowel incontinence management, fall risk, hospice care, interpersonal interaction and socialization management, mental health observations, and wandering risk. History of hyperlipidemia was addressed on 12/3/25 with staff monitoring and taking actions for potential stroke or heart attack. Pain management was addressed on 12/3/25 due to resident’s history of aches and pains plus dementia, with staff tasks as shown for Resident #16 above. As another example, the care plan for monitoring for stroke or heart attack is, “Due to the resident having a history of hyperlipidemia, monitor resident and observe any unusual behavior or actions. In case of an emergency, call 911. For a stroke: Use FAST – Face drooping, Arm weakness, Slurred speech, Time to call 911. For a heart attack: Chest pain that may feel like pressure, tightness, pain, squeezing or aching. Pain or discomfort that spreads to the shoulder, arm, back, neck, jar, teeth or sometimes the upper belly, cold sweat, fatigue, heartburn or indigestion, lightheadedness or sudden dizziness, nausea, and shortness of breath. Report to ED immediately after calling 911.”Resident #18: Resident’s care plan was modified 11/21/25 to include fall risk needs and associated staff tasks; on 12/3/25 to include needs and staff tasks related to personal care/ADL’s; meal reminders; alcohol dependence; skin care and assistance with donning/doffing compression socks; need for interactions and socialization due to his history of isolation; mental health monitoring/reporting needs related to his Parkinson’s Disease and depression; assistance needs related to urinary incontinence including assisting with extra supplies or extra laundry; and assistance needs related to his pain history and pain management. Needs related to oxygen needs and management added/modified on 1/7/26. As an example, the pain management task states, “Due to the history of pain/aches, observe the resident for pain management. Also, because of the resident having dementia, he may not know how to request medications. Remind the resident that he has orders in the system and what they are. Ask the resident if he would like to take anything to assist with his headaches. Remind the resident that he can go lay down in his room, with the blinds closed for a dark, calm environment. Follow up with the resident to see his pain level and write clear observations and report to ED. If pain does not go away or there is a need to change medications, call and report to his doctor.”Resident #19: Resident’s care plan added staff fall monitoring and walker reminders/prompts due to fall risk on 11/4/25. On 11/25/25, resident’s care plan was modified to address dementia with staff tasks including ADL reminders and assistance, meal reminders, interpersonal interactions and socialization. Also on 11/25/25, resident needs and associated staff tasks were modified/added regarding his history of tremors needing monitoring, observation and assistance if needed during ambulation, transfers and meals, and his receiving hospice care including nurse and CNA visits as well as case management. On 1/8/26, his changing ADL needs were addressed by care plan for staff to assist him with getting ready in the morning and into bed for the night: “Assist with getting dressed, brief changed in the morning and ready to come down for lunch. Assist with getting into bed for the night. Ask if the resident needs assistance getting ready for bed, changing brief or clothes or anything else.”ADDENDUM:Resident #20 was hospitalized before her care plan could be updated, and remained in the hospital until she was discharged from Chateau at Rifle.