NORD HOME CARE LLC

Plan of Correction: Resident Privacy and Telephone AccessFacility Name: We Care Colorado Assisted LivingDate of Survey: May 20, 2026Regulation Cited: 6 CCR 1011-1 Chapter 7, Part 13, Section 13.1(A)(2) – The right to private telephone calls or use of electronic communication I. Immediate Corrective Actions for Affected ResidentsThe administration added one more portal phone in addition to the existing primary phone line and pager system. These devices allow them to conduct calls in the privacy of their own sleeping rooms or any designated private common area. Residents #4 and #6 have also been provided with individual pagers. Staff have demonstrated to these residents how to use the pagers to signal a need for assistance in accessing the phone or for a staff member to vacate a room to ensure call privacy. Staff #4 and all other personnel have been instructed to immediately vacate any room where Resident #4 or #6 is utilizing a portable phone, unless the resident specifically requests assistance. II. Systemic Changes and Protective OversightThe facility has deployed a pager system accessible to every resident in the house. Residents may leverage these pagers to communicate with staff regarding any cooperation needed for their rights, specifically for requesting use of a phone or for staff to clear a private space for communication. This pager system serves as an auxiliary aid to ensure residents do not have to physically seek out staff in locked office areas to exercise their rights. To further enhance accessibility, the facility has added one additional portable phone extension that is kept in a designated, unlocked common area and is available to all residents at all times. III. Staff Training and Personnel PoliciesAll staff have received training on the mandatory response to Privacy Pages. When a resident pages for telephone or space access, staff must respond within 5 minutes to facilitate the request. A mandatory training session for all employees, including Staff #4, was held on the right to private and unrestricted communications under Part 13.1(A). The facility orientation program for new personal care workers now includes training on the pager system, the location of the universal portable extension, and the requirement to maintain distance during resident phone calls. IV. Quality Assurance and MonitoringDuring monthly resident meetings, the Administrator will specifically ask residents, including #4 and #6, if they feel their right to private calls is being respected and if the pager system and universal portable extension are helping them access private space. Resident Rights posters have been updated and placed in a publicly visible location, explicitly noting the right to private calls and the availability of the pager system and portable phones for assistance. Completion Date: Jun 29, 2026V. Addendum to Plan of CorrectionThe former medication room has been converted into a dedicated office unit for residents to conduct private phone calls. To further ensure privacy, residents have the option to take the portable phone to their individual sleeping rooms or utilize the designated office space. Given the facility's current census of 6 residents, many of whom also use personal mobile devices, the availability of one portable phone extension in addition to the primary facility unit provides sufficient and unrestricted access for all private communication needs. Ongoing monitoring of telephone access and privacy will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review resident feedback regarding communication rights during monthly meetings, with all findings, issues, and resolutions recorded in the QAPI log to ensure sustained compliance.

Plan of Correction: Resident Privacy and Telephone AccessFacility Name: We Care Colorado Assisted LivingDate of Survey: May 20, 2026 I. Immediate Corrective Actions for Affected ResidentsThe administration added one more portal phone in addition to the existing primary phone line and pager system. These devices allow them to conduct calls in the privacy of their own sleeping rooms or any designated private common area. Residents #4 and #6 have also been provided with individual pagers. Staff have demonstrated to these residents how to use the pagers to signal a need for assistance in accessing the phone or for a staff member to vacate a room to ensure call privacy. Staff #4 and all other personnel have been instructed to immediately vacate any room where Resident #4 or #6 is utilizing a portable phone, unless the resident specifically requests assistance. II. Systemic Changes and Protective OversightThe facility has deployed a pager system accessible to every resident in the house. Residents may leverage these pagers to communicate with staff regarding any cooperation needed for their rights, specifically for requesting use of a phone or for staff to clear a private space for communication. This pager system serves as an auxiliary aid to ensure residents do not have to physically seek out staff in locked office areas to exercise their rights. To further enhance accessibility, the facility has added one additional portable phone extension that is kept in a designated, unlocked common area and is available to all residents at all times. III. Staff Training and Personnel PoliciesAll staff have received training on the mandatory response to Privacy Pages. When a resident pages for telephone or space access, staff must respond within 5 minutes to facilitate the request. A mandatory training session for all employees, including Staff #4, was held on the right to private and unrestricted communications under Part 13.1(A). The facility orientation program for new personal care workers now includes training on the pager system, the location of the universal portable extension, and the requirement to maintain distance during resident phone calls. IV. Quality Assurance and MonitoringDuring monthly resident meetings, the Administrator will specifically ask residents, including #4 and #6, if they feel their right to private calls is being respected and if the pager system and universal portable extension are helping them access private space. Resident Rights posters have been updated and placed in a publicly visible location, explicitly noting the right to private calls and the availability of the pager system and portable phones for assistance. Completion Date: Jun 29, 2026V. Addendum to Plan of CorrectionThe former medication room has been converted into a dedicated office unit for residents to conduct private phone calls. To further ensure privacy, residents have the option to take the portable phone to their individual sleeping rooms or utilize the designated office space. Given the facility's current census of 6 residents, many of whom also use personal mobile devices, the availability of one portable phone extension in addition to the primary facility unit provides sufficient and unrestricted access for all private communication needs. Ongoing monitoring of telephone access and privacy will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review resident feedback regarding communication rights during monthly meetings, with all findings, issues, and resolutions recorded in the QAPI log to ensure sustained compliance.

I. Immediate Corrective Actions for Affected ResidentsThe Administrator has initiated a comprehensive re-assessment for Residents #2, #3, and #4 to capture their current physical, mental, and social status. For Resident #3, the care plan has been updated to specifically address documented behaviors, including verbal aggression, medication refusal, and unauthorized visitors. This updated plan includes specialized interventions for behavioral management and mental status monitoring. The Administrator has reached out to Resident #3’s representative to secure their input and signature, ensuring the plan now complies with Part 12.10(A). II. Systemic Changes to Prevent RecurrenceThe facility has implemented a "Significant Change Trigger" protocol. Effective immediately, any incident report involving behavioral volatility, physical aggression, or a change in functional status will automatically trigger a mandatory care plan review within 72 hours. III. Staff Education and TrainingOn June 15, 2026, a mandatory in-service will be held for all administrative and clinical staff regarding Part 12.10 requirements. Training will focus on "Thinking Transparency"—the necessity of translating incident report findings into actionable care plan interventions. Staff will be trained on the "Care Coordination" requirements of Part 12.11, emphasizing that resident care plans must detail specific staff tasks necessary to meet identified needs, including those related to behavioral health and social engagement. IV. Quality Assurance and MonitoringThe Administrator will conduct a 100% audit of all current resident care plans by June 30, 2026, to ensure they reflect the most current assessment data and contain required signatures. Following this, the Administrator will perform monthly audits of 25% of resident files for the next six months. These audits will cross-reference incident reports with care plan updates to verify that "significant changes" are being accurately captured. Results of these audits will be shared during quarterly staff meetings to ensure ongoing adherence to state standards. Completion Date: June 29, 2026V. Addendum to Plan of CorrectionOngoing monitoring of care plan accuracy and compliance will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review incident reports and care plan updates during monthly meetings, with all findings, issues, and resolutions recorded in the QAPI log to ensure sustained compliance.

I. Immediate Corrective Actions for Affected ResidentsThe Administrator has completed a comprehensive re-assessment of Residents #2, #3, and #4 to identify their current physical, mental, and social needs. For Resident #3, these specific behavioral needs—including interventions for verbal aggression and social engagement—have been formally added to the resident's electronic care plan profile. Effective immediately, these care plan interventions have been synced with the eMAR system, requiring staff to acknowledge and document the completion of these specific behavioral and engagement tasks during their shifts. II. Systemic Changes and Protective OversightThe facility has transitioned from paper-based engagement logs to a fully electronic documentation model. Engagement and activity requirements are now established as mandatory "tasks" within each resident's individualized care plan. These tasks are programmed to appear on the eMAR system on a regular basis according to the frequency defined in the care plan. This systemic change ensures that engagement is treated with the same clinical rigor as medication administration, providing a verifiable electronic trail of services rendered without the use of supplemental paperwork or separate checklist logs. III. Staff Training and Personnel PoliciesAll clinical and administrative staff have been trained on the updated eMAR interface and the requirement to document resident engagement and behavioral interventions electronically. Training focused on the "Thinking Transparency" mandate, ensuring staff understand how to translate care plan objectives into the specific electronic entries required by the system. Caregivers have been instructed that the successful completion of a shift now depends on the documentation of these integrated care plan tasks, emphasizing that engagement is a primary component of resident care. IV. Quality Assurance and MonitoringThe Administrator will perform weekly electronic audits of the eMAR system for the next 90 days to verify that activity and behavioral tasks are being documented as prescribed by the care plans. These digital audits replace previous physical log reviews and will be used to identify any residents who are frequently refusing engagement, thereby triggering a care plan review for significant change in status per Part 12.9. Completion Date: June 29, 2026V. Addendum to Plan of CorrectionOngoing monitoring of care plan accuracy and compliance will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review incident reports and care plan updates during monthly meetings, with all findings, issues, and resolutions recorded in the QAPI log to ensure sustained compliance. VI. Addendum: Staff Training and Resident EngagementStaff Training on Activities:The facility will conduct mandatory training for all staff regarding the implementation of community and in-house activities. This training will focus on individualizing engagement to match resident interests, preferences, and functional abilities, ensuring staff can effectively facilitate meaningful participation. Engagement Posting and Availability:The facility will maintain an up-to-date activity calendar posted in a visible, accessible common area. Activity schedules will be tailored to meet resident needs and preferences identified during the care plan process. Staff will proactively inform residents of upcoming activities and ensure engagement materials are readily available. Monitoring Engagement Needs:The Activity Coordinator will conduct bi-weekly observations of group and individual activities to evaluate resident participation and enjoyment. Additionally, resident satisfaction regarding engagement will be discussed during monthly resident council meetings to ensure needs are being met and to identify areas for adjustment. QAPI Integration:Monitoring of resident engagement effectiveness will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review engagement participation data, resident feedback, and activity logs during monthly QAPI meetings. Any identified gaps in engagement or activity implementation will be documented in the QAPI log, and corrective action plans will be developed and tracked to ensure continuous quality improvement.

I. Immediate Corrective Actions for Affected ResidentsThe Administrator has interviewed Residents #4 and #5 to formally determine their desire for overnight safety checks. For Resident #4, who utilizes a CPAP machine, a specific safety check requirement has been added to her care plan to verify device placement. These requirements have been entered into the eMAR system as mandatory ADL tasks. Staff have been instructed to follow these electronic ADLs strictly, and any verbal refusal by a resident will now be documented directly in the eMAR to provide an accurate record of care offered versus care received. II. Systemic Changes and Protective OversightThe facility has discontinued all paper-based "Overnight Safety Check" sheets and shift "To-Do" lists. All safety checks are now managed through the eMAR system as integrated ADLs. The frequency of these checks—implemented at intervals of every 2, 4, or 6 hours—is determined by the Administrator based on each resident’s specific clinical needs and preferences. By moving these checks into the eMAR, the facility ensures that staff cannot complete their electronic shift documentation without acknowledging and timestamping each safety check task, providing real-time oversight of resident well-being. III. Staff Training and Personnel PoliciesMandatory training was conducted for all overnight caregivers regarding the transition from paper logs to eMAR-based ADL tracking. Staff were trained on the new electronic interface and the specific requirement to document safety checks immediately upon completion. Training emphasized that safety checks are now a formal component of the resident's care plan and that adherence to the 2, 4, or 6-hour intervals is a mandatory job function. Caregivers were also instructed on how to properly document a resident's mid-night refusal of a check within the system to ensure clinical transparency. IV. Quality Assurance and MonitoringThe Administrator will conduct a weekly electronic audit of the eMAR ADL logs for the next 30 days to ensure that all scheduled safety checks are being performed and documented at the required intervals. These digital audits will cross-reference the eMAR timestamps with the resident care plans to verify that the frequency of checks (2, 4, or 6 hours) aligns with the resident's assessed needs. Any gaps in the electronic record will be addressed immediately with the responsible staff member. Completion Date: June 29, 2026V. Addendum: QAPI IntegrationMonitoring of overnight safety checks will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review eMAR audit results and safety check compliance data during monthly QAPI meetings. Any identified gaps in documentation or adherence to check intervals will be documented in the QAPI log, and corrective action plans will be developed and tracked to ensure continuous quality improvement.

I. Immediate Corrective Actions for Affected ResidentsThe Administrator has initiated a comprehensive re-assessment for Residents #2, #3, and #4 to capture their current physical, mental, and social status. For Resident #3, the care plan has been updated to specifically address documented behaviors, including verbal aggression, medication refusal, and unauthorized visitors. This updated plan includes specialized interventions for behavioral management and mental status monitoring. The Administrator has reached out to Resident #3’s representative to secure their input and signature, ensuring the plan now complies with Part 12.10(A). II. Systemic Changes to Prevent RecurrenceThe facility has implemented a "Significant Change Trigger" protocol. Effective immediately, any incident report involving behavioral volatility, physical aggression, or a change in functional status will automatically trigger a mandatory care plan review within 72 hours. To ensure compliance with Part 12.9, the Administrator will maintain a master "Assessment Tracker" to flag annual updates and ensure no resident's care plan remains static when their baseline status shifts. Furthermore, the Resident Agreement has been clarified to state that while a resident may be "uncooperative," staff must still document attempts to gain input and consult with the resident's representative to finalize the plan. III. Staff Education and TrainingOn June 15, 2026, a mandatory in-service will be held for all administrative and clinical staff regarding Part 12.10 requirements. Training will focus on "Thinking Transparency"—the necessity of translating incident report findings into actionable care plan interventions. Staff will be trained on the "Care Coordination" requirements of Part 12.11, emphasizing that resident care plans must detail specific staff tasks necessary to meet identified needs, including those related to behavioral health and social engagement. IV. Quality Assurance and MonitoringThe Administrator will conduct a 100% audit of all current resident care plans by June 30, 2026, to ensure they reflect the most current assessment data and contain required signatures. Following this, the Administrator will perform monthly audits of 25% of resident files for the next six months. These audits will cross-reference incident reports with care plan updates to verify that "significant changes" are being accurately captured. Completion Date: June 29, 2026V. Addendum to Plan of CorrectionOngoing monitoring of care plan accuracy and compliance will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review incident reports and care plan updates during monthly meetings, with all findings, issues, and resolutions recorded in the QAPI log to ensure sustained compliance. VI. Addendum: Staff Training and Resident EngagementStaff Training on Activities:The facility will conduct mandatory training for all staff regarding the implementation of community and in-house activities. This training will focus on individualizing engagement to match resident interests, preferences, and functional abilities, ensuring staff can effectively facilitate meaningful participation. Engagement Posting and Availability:The facility will maintain an up-to-date activity calendar posted in a visible, accessible common area. Activity schedules will be tailored to meet resident needs and preferences identified during the care plan process. Staff will proactively inform residents of upcoming activities and ensure engagement materials are readily available. Monitoring Engagement Needs:The Activity Coordinator will conduct bi-weekly observations of group and individual activities to evaluate resident participation and enjoyment. Additionally, resident satisfaction regarding engagement will be discussed during monthly resident council meetings to ensure needs are being met and to identify areas for adjustment. QAPI Integration:Monitoring of residentengagement effectiveness will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) process. The Administrator will review engagement participation data, resident feedback, and activity logs during monthly QAPI meetings. Any identified gaps in engagement or activity implementation will be documented in the QAPI log, and corrective action plans will be developed and tracked to ensure continuous quality improvement.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 10 CCR 2505-10 8.7409(C)(1) (Medication Administration Competency)Corrective Action for Affected ResidentsAudit & Assessment: The Administrator or QMAP Supervisor has already conducted a retrospective competency assessment with direct observation for Staff #2 regarding all assigned medication administration tasks to ensure the safety of Residents #1, #3, and #5. Documentation: A completed competency evaluation form, including direct observation of preparation and administration, will be placed in Staff #2’s personnel file. Completion Date: April 2, 2026. Identification of Other Potentially Affected ResidentsFull Personnel Audit: The Administrator will audit the personnel files of all employees acting as QMAPs to identify any others lacking documented competency assessments. Remediation: Any QMAP found without a documented assessment will undergo a direct observation competency evaluation by the QMAP Supervisor before their next scheduled shift. Systemic Changes to Prevent RecurrenceQMAP Supervisor Designation: The facility has designated a QMAP Supervisor (RN or qualified manager) responsible for conducting and documenting all initial and ongoing competency assessments. New Hire Protocol: The "Staff Onboarding Checklist" has been updated to require a signed competency assessment with direct observation before any QMAP is permitted to administer medications independently. Policy Enforcement: The facility will strictly adhere to 6 CCR 1011-1 Chapter 24 standards, ensuring all QMAPs are verified on the State’s registry and have demonstrated practical skills in a clinical setting. Monitoring of Corrective ActionQuarterly Audits: The Administrator and QMAP Supervisor will conduct quarterly audits of medication administration records (MARs) and personnel files to ensure sustained compliance with competency requirements. Completion Date: April 15, 2026.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 10 CCR 2505-10 8.7409(E) (CAPS and Criminal Background Checks)Corrective Action for Affected StaffImmediate CAPS Request: The Administrator submitted a CAPS check request for Staff #2 on Mar 26, 2026. Result Verification: On Apr 02, 2026, the facility received notification that Staff #2 has NOT been substantiated as a perpetrator in an APS case. This documentation has been placed in the personnel file. Completion Date: Apr 02, 2026. Addendum: Monitoring PlanA. Monitoring Method: The Administrator will conduct a 100% audit of all current employee and volunteer personnel files to ensure a valid CAPS check and criminal background check are on file for every individual providing direct care. Verification will be cross-referenced against the Staff Onboarding Checklist to ensure no new hire begins orientation or independent shifts without a requested check. B. Monitoring Sample: The monitoring will include a 100% audit of all active personnel files for staff and contractors, which is representative of the total facility census and the individuals responsible for resident care. C. Frequency: A 100% initial audit will be completed by May 15, 2026. Additionally, the Administrator will perform a monthly review of all new hire files for the next 6 months. D. Documentation: Compliance will be documented via a tracking log in the Administrator’s office and by adding physical or digital confirmation of results directly into each individual's personnel file. E. Length of Monitoring: Monitoring will continue for a minimum of 3 months, concluding no earlier than July 02, 2026, to ensure sustained compliance with systemic changes. F. Inclusion in QAPI Process: Compliance statistics and findings from the monthly background check audits will be reported and reviewed during Quarterly Quality Management Program (QMP/QAPI) meetings to identify any recurring gaps and ensure long-term oversight.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 10 CCR 2505-10 8.7506(F) (Alternative Care Facility Provider Agency Requirements)Corrective Action for Affected ResidentsImmediate Access: The locks on the kitchen entrance and all resident-accessible refrigerators have been made accessible to ensure all residents have unrestricted access to the kitchen and their stored food items 24 hours a day. Storage Policy Update: Residents #2 and #4, and all other residents, are now permitted to store personal food items in designated sections of the kitchen refrigerators and freezers. Completion Date: Mar 28, 2026. Systemic Changes to Prevent RecurrencePolicy Alignment: The facility has updated its "Member Engagement" and "Access to Food" policies to strictly comply with 10 CCR 2505-10 8.7506(F)(5), ensuring a home-like environment with 24-hour access to food and cooking areas. Staff Retraining: All staff, including the Administrator and Staff #2, will complete retraining by Apr 15, 2026, on the HCBS Settings Final Rule, focusing on resident rights to autonomy, privacy, and unrestricted access to facility common areas. Monitoring of Corrective ActionQuarterly QMP Review: Audit findings regarding kitchen access will be reviewed during Quarterly Quality Management Program meetings to ensure sustained compliance. Completion Date: April 25, 2026.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026 Corrective Action for Affected StaffImmediate CBI Request: The Administrator submitted a CBI criminal background check request for Staff #2 on Mar 26, 2026. Result Verification: On Apr 02, 2026, the facility received the results confirming Staff #2 is eligible for employment. This documentation has been placed in the personnel file. Completion Date: Apr 02, 2026. Internal Process Analysis and Systemic ChangesRoot Cause Analysis: The deficient practice occurred because the primary Administrator was out of town and unable to perform the required CBI check while traveling for a new hire. This highlighted a gap in administrative coverage for mandatory background screenings during travel or absences. Systemic Changes and Prevention: To ensure continuous compliance, the facility has hired and designated an additional Administrator Designee. This designee is authorized to process CBI and CAPS checks, ensuring screenings are requested prior to any staff member providing direct care, regardless of the primary Administrator's availability. Monitoring PlanA. Monitoring Method: The Administrator will conduct a 100% audit of all current employee and volunteer personnel files to ensure a valid CBI and CAPS check are on file. Verification will be cross-referenced against the Staff Onboarding Checklist to ensure no new hire begins orientation or independent shifts without a requested check. B. Monitoring Sample: The monitoring will include a 100% audit of all active personnel files for staff and contractors, which is representative of the total facility census and the individuals responsible for resident care. C. Frequency: A 100% initial audit will be completed by April 30, 2026. Additionally, the Administrator will perform a monthly review of all new hire files for the next 3 months. D. Documentation: Compliance will be documented via a tracking log in the Administrator’s office and by adding physical or digital confirmation of results directly into each individual's personnel file. E. Length of Monitoring: Monitoring will continue for a minimum of 3 months, concluding no earlier than Jul 02, 2026, to ensure sustained compliance with systemic changes.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 10 CCR 2505-10 8.7409(E) (CAPS and Criminal Background Checks)Corrective Action for Affected StaffImmediate CAPS Request: The Administrator submitted a CAPS check request for Staff #2 on Mar 26, 2026. Result Verification: On Apr 02, 2026, the facility received notification that Staff #2 has NOT been substantiated as a perpetrator in an APS case. This documentation has been placed in the personnel file. Completion Date: Apr 02, 2026. Internal Process Analysis and Systemic ChangesRoot Cause Analysis: The deficient practice occurred because the primary Administrator was out of town and unable to perform the required CAPS check while traveling. This highlighted a gap in administrative coverage for mandatory background screenings during travel or absences. Systemic Changes and Prevention: To ensure continuous compliance, the facility has hired and designated an additional Administrator Designee. This designee is authorized to process CAPS and criminal background checks, ensuring screenings are requested prior to any staff member providing direct care, regardless of the primary Administrator's availability. Monitoring PlanA. Monitoring Method: The Administrator will conduct a 100% audit of all current employee and volunteer personnel files to ensure a valid CAPS and criminal background check are on file. Verification will be cross-referenced against the Staff Onboarding Checklist to ensure no new hire begins orientation or independent shifts without a requested check. B. Monitoring Sample: The monitoring will include a 100% audit of all active personnel files for staff and contractors, which is representative of the total facility census and the individuals responsible for resident care. C. Frequency: A 100% initial audit will be completed by April 30th, 2026. Additionally, the Administrator will perform a monthly review of all new hire files for the next 6 months. D. Documentation: Compliance will be documented via a tracking log in the Administrator’s office and by adding physical or digital confirmation of results directly into each individual's personnel file. E. Length of Monitoring: Monitoring will continue for a minimum of 3 months, concluding no earlier than Jul 02, 2026, to ensure sustained compliance with systemic changes.

Plan of CorrectionCorrection of Specific DeficiencyThe residence will immediately require Staff #2 and all other currently employed QMAPs to sign the required disclosure stating they have not had a professional medical, nursing, or pharmacy license revoked in any state for reasons related to medication administration. These signed disclosures will be placed in each QMAP's respective personnel file no later than Apr 30, 2026. Identification of Affected ResidentsA full audit of all current resident files (including Residents #1, #3, and #5) and employee personnel files will be conducted to ensure all staff administering medications are properly credentialed and have the necessary documentation on file. Systemic ChangesThe Personnel File Checklist will be updated to explicitly include the QMAP Signed Disclosure as a required document for all staff with medication administration duties. The Administrator/Owner will receive retraining on the specific requirements of 6 CCR 1011-1, Chapter 7, Part 7.14, focusing on the necessity of signed disclosures beyond just verifying credentials via the department portal. Monitoring ProcedureThe Administrator will conduct a monthly audit of all new hire personnel files for the next three months to ensure 100% compliance with disclosure requirements. The results of these audits will be documented and reviewed during quarterly Quality Assurance meetings to ensure the practice remains corrected. Responsible PartyThe Administrator/Owner is responsible for the implementation and ongoing monitoring of this Plan of Correction. Completion Date: Apr 30, 2026

Plan of CorrectionCorrection of Specific DeficiencyThe residence will immediately implement a mandatory overnight safety check protocol for Resident #4 and all other consenting residents. Staff #1 and all other overnight personnel have been directed that they must remain awake and alert during their shifts to perform these checks. A specific safety check for Resident #4, including assistance with her CPAP machine as requested, will be performed at least once per night between 10PM and 6AM.Identification of Affected ResidentsThe Administrator will meet with all five current residents by Apr 30, 2026, to confirm their consent for overnight safety checks and to identify any specific needs, such as CPAP assistance or fall risk concerns. Resident care plans and the master safety check roster will be updated to reflect these preferences and requirements. Systemic ChangesThe facility will implement a formal "Overnight Safety Check Log" that requires staff to document the specific time and results of the check for each consenting resident. The staff training curriculum will be revised to clarify that all residents, regardless of their perceived level of independence, are entitled to at least one safety check per night under state regulation. The Administrator has established a new policy explicitly prohibiting staff from sleeping during overnight shifts to ensure all safety obligations are met. Monitoring ProcedureThe Administrator will conduct unannounced overnight spot checks twice per month for the next three months to verify that staff are awake and performing duties as required. The Overnight Safety Check Logs will be reviewed daily by the Administrator to ensure 100% documentation compliance. Any discrepancies or failures to document checks will result in immediate corrective action for the responsible staff member. Completion Date: Apr 30, 2026

This Plan of Correction (PoC) addresses the citation regarding the failure to provide personal services sufficient to meet the resident's needs, specifically for bathing assistance, as required by 6 CCR 1011-1, Chapter 7, Part 12.1. Plan of CorrectionCorrection of Specific DeficiencyThe residence has immediately reinstated supervised bathing for Resident #5 in accordance with the established care plan. All staff have been explicitly instructed that they may not refuse to provide services documented in a resident's care plan. The Administrator has personally met with Resident #5 to apologize for the lapse in service and to confirm that standby assistance for safety and hygiene will be provided every Mon and Fri as scheduled. Identification of Affected ResidentsThe Administrator will conduct a 100% audit of all current resident ADL flowsheets and care plans by Apr 30, 2026, to ensure that all required personal services, including bathing, are being delivered as scheduled. Residents and their representatives will be interviewed to verify that no other services were missed during the manager's recent absence. Monitoring ProcedureThe Administrator or designee will conduct a weekly review of all ADL flowsheets for the next three months to ensure 100% completion of scheduled showers and baths. Monthly resident satisfaction interviews will be conducted to proactively identify and report concerns regarding the delivery of personal services. Any instance of staff refusal to provide required care will result in immediate disciplinary action. Completion Date: Apr 30, 2026

Plan of CorrectionCorrection of Specific DeficiencyThe residence has designated a QMAP supervisor who meets the regulatory requirements. This supervisor will immediately conduct a retrospective competency assessment with direct observation for Staff #2, covering all assigned medication administration tasks. This assessment will be documented and placed in the personnel file for Staff #2 no later than Apr 30, 2026. Identification of Affected ResidentsThe Administrator will conduct a full audit of the personnel files for all employees acting as QMAPs to ensure that Residents #1, #3, and #5, and all other residents, are being served by staff who have documented competency assessments. Any QMAP found without a documented assessment will undergo a direct observation competency evaluation by the QMAP supervisor before their next scheduled shift. Systemic ChangesThe facility has updated its "Staff Onboarding Checklist" to mandate that a signed competency assessment with direct observation is completed and filed before any QMAP is permitted to administer medications independently. Additionally, the QMAP supervisor will conduct a new competency assessment with direct observation whenever a QMAP is assigned any additional medication administration tasks. Monitoring ProcedureThe Administrator and QMAP supervisor will conduct quarterly audits of medication administration records and personnel files for the next 3 months to ensure sustained compliance with competency and observation requirements. The results of these audits will be reviewed during facility quality assurance meetings to identify and correct any trends in non-compliance. Completion Date: Apr 30, 2026

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Corrective Action for Affected ResidentsCounseling & Professional Boundaries: The Admin and involved staff will receive immediate 1:1 counseling on the Resident Rights policy, focusing on treating residents with dignity and maintaining professional boundaries during financial discussions. Privacy & Property: Staff have been instructed to knock and request permission before entering rooms for Resident 2 and to refrain from touching personal property without explicit consent. Communication: The Admin has been directed to cease all raised-voice or confrontational interactions. All future discussions regarding concerns or payments will be conducted privately and respectfully. Identification of Other Potentially Affected ResidentsPrivate Audit: A complete audit of all current residents will be conducted via private interviews to determine if other individuals felt disrespected or had their privacy breached. Grievance Review: A review of the grievance log will be performed to ensure all past concerns regarding staff conduct were addressed according to facility policy. Systemic Changes to Prevent RecurrenceMandatory Retraining: All staff, including the Admin, will complete mandatory retraining by Apr 15, 2026, on the HCBS Settings Final Rule (privacy, dignity, freedom from coercion), professional communication, conflict resolution, and documentation standards for behavioral or confrontational incidents. Updated Postings: All Resident Rights postings will be reviewed and updated to include the current revision date and contact information for the Long-Term Care Ombudsman. Monitoring Plan Addendum(a) Monitoring Process: An impartial Corporate Quality Consultant or designated Manager will conduct Dignity and Respect Audits. This includes observing the Admin and staff during financial/discharge discussions and meal times to verify professional communication and adherence to privacy protocols (e.g., knocking before entry).(b) Monitoring Sample: The audit will include 100% of the Admin’s documented financial or resident status discussions and a representative sample of 20% of the facility census for random interaction observations.(c) Frequency: Observations of Admin interactions will occur weekly, while general staff-resident interaction audits will occur monthly.(d) Documentation: Findings will be recorded and maintained in the Quality Management folder.(e) Duration: Monitoring will continue for a minimum of 3 months, ending no earlier than July 31, 2026.(f) QAPI Integration: Results will be reviewed at the monthly Quality Management meeting. If compliance falls below 100%, the monitoring period will be extended by 3 months, and additional disciplinary action or retraining will be initiated. Completion Date: April 23 2026

Plan of CorrectionRegulatory Reference: 10 CCR 2505-10 8.7408(A)(4) Mistreatment, Abuse, Neglect, and Exploitation (MANE). Corrective Action for Affected ResidentsResident 1: The Administrator initiated a retrospective investigation into the reported theft on Feb 09, 2026, and the verbal/physical altercations with Resident 2 and Resident 3. Interviews with all involved parties and witnesses are being documented, and a summary of findings and actions taken will be placed in the resident’s record by Apr 15, 2026. Resident 2: A thorough investigation into the Jan 31, 2026, altercation is underway. This includes staff/resident interviews and a review of progress notes to determine the root cause and implement necessary care plan interventions. Resident 3: The Administrator is investigating the allegations of theft and the physical push involving Resident 1. Reporting to the Case Management Agency and Legally Authorized Representative for all three residents will be completed by Apr 15, 2026. Identification of Other Potentially Affected ResidentsThe Administrator will conduct a complete audit of all incident reports and progress notes to identify any other undocumented or uninvestigated allegations of MANE.Any newly identified concerns will be investigated and reported to the appropriate agencies, Legally Authorized Representatives, and Case Management Agencies within 24 hours of discovery. Systemic Changes to Prevent RecurrenceStaff Training: All staff will complete mandatory retraining by Apr 15, 2026, on recognizing MANE, immediate reporting requirements to the Administrator, and the 24-hour notification mandate for Legally Authorized Representatives and Case Managers. Monitoring of Corrective ActionsThe Administrator or designee will audit all incident reports to verify that every allegation of MANE has a corresponding completed investigation file containing the incident report, investigative summary, findings, and actions taken. Audit results will be reviewed during quarterly Quality Assurance meetings to ensure sustained compliance. Completion DateAll corrective actions and systemic changes will be fully implemented by Apr 15, 2026. Monitoring Plan Addendum(a) Monitoring Process: The Administrator or a Quality Assurance designee will conduct a "MANE Compliance Audit" to review all incident reports and progress notes to ensure every allegation of mistreatment, abuse, neglect, or exploitation has a completed investigation file including the incident report, summary, findings, and evidence of required 24-hour notifications.(b) Monitoring Sample: The audit will include 100% of all incident reports and a representative 20% sample of the facility census to cross-reference progress notes for any unreported concerns.(c) Frequency: These audits will occur monthly.(d) Documentation: Audit findings will be documented on the "Monthly MANE Investigation Compliance Log" and maintained in the Quality Management folder.(e) Duration: Monitoring will continue for a minimum of 3 months, ending no earlier than Jul 30, 2026.(f) QAPI Integration: Audit results will be presented at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. If compliance is found to be below 100%, the monitoring duration will be extended for another 3 months and additional staff retraining will be initiated.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Corrective Action for Affected ResidentsAssessment: The Administrator will conduct immediate 1:1 interviews with the five affected residents to identify their specific social, physical, and spiritual interests. Care Plan Update: Individualized engagement goals based on these interests will be documented in each resident's Person-Centered Care Plan by Apr 15, 2026. Immediate Implementation: A temporary daily activity schedule has been implemented, ensuring at least three structured engagement opportunities that include exercise, games, or music are offered daily. Identification of Other Potentially Affected ResidentsFacility-Wide Audit: The Administrator will review the records of all current residents to ensure their activity participation is documented and that their interests are reflected in their current care plans. Interest Survey: An updated "Activities and Interests" survey will be distributed to all residents and/or legal representatives by Apr 15, 2026, to ensure no other resident’s wishes are being overlooked. Systemic Changes to Prevent RecurrenceStaff Training: All staff, including Staff 1, will complete mandatory retraining by April 15, 2026, on Resident Rights (specifically the right to participate in community activities) and the "Resident Engagement Policy."Cell Phone Policy: The facility will enforce a strict personnel policy prohibiting the use of personal cell phones for non-emergency purposes during direct care hours. Evaluation: The engagement program will be evaluated every 3 months to ensure activities remain relevant and well-received based on resident feedback. Monitoring of Corrective ActionDaily Log Review: The Administrator or designee will review the "Activity Attendance Forms" and "ADL Flowsheets" daily to verify that scheduled activities occurred. Reporting: Findings from these monitors will be reviewed during the Quarterly House Meetings and integrated into the facility's Quality Management Program. Monitoring Plan Addendum(a) Monitoring Process: The Administrator or a designated Quality Assurance member will conduct "Activity Engagement Audits" to review daily engagement logs and observe live activity sessions to ensure social, physical, and intellectual opportunities are offered and documented.(b) Monitoring Sample: The audit will include 100% of the daily engagement logs and a representative sample of 20% of the facility census to verify participation.(c) Frequency: Activity logs will be reviewed daily by EOD, and live session observations will occur 3 times per week.(d) Documentation: Findings will be recorded on the "Weekly Engagement Compliance Tracker" and maintained in the Quality Management folder.(e) Duration: Monitoring will continue for a minimum of 3 months, ending no earlier than Jul 31, 2026.(f) QAPI Integration: Audit results will be presented at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. If compliance falls below 100%, the monitoring duration will be extended and additional staff training will be initiated. Completion Date: Apr 15, 2026

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Corrective Action for Affected ResidentsResident 1: The Administrator will update the care plan to include current behavioral health needs and identify specific formal/informal engagement opportunities. Resident 2: An initial comprehensive care plan will be developed immediately, specifically documenting the resident's preference for hospital gowns and use of a dog bowl as identified in staff interviews. Resident 3: The care plan will be revised to include detailed personal choices, needs, and specific engagement opportunities. Participation: The Administrator will meet with all three residents or their representatives to review these updates and obtain required signatures to evidence their participation in the development process. Completion Date: Apr 02, 2026. Identification of Other Potentially Affected ResidentsAudit: The Administrator will conduct a complete audit of all current resident records to ensure every resident has a signed, current care plan that includes medical info, eMAR references, and social preferences. Survey: An Interests and Preferences survey will be re-administered to all residents by Apr 15, 2026, to ensure care plans accurately reflect current personal choices. Systemic Changes to Prevent RecurrencePolicy Enforcement: The facility will strictly adhere to its policy of developing care plans upon admission and reviewing them as needed thereafter. Staff Training: The Administrator and Manager will receive retraining on 10 CCR 2505-10 8.7506. F.4 requirements, specifically focusing on documenting member goals, choices, and evidence of resident participation. Monitoring Plan Addendum(a) Monitoring Process: The Administrator or a Quality Assurance designee will conduct Care Plan Compliance Audits to review new and existing resident files for updated assessments, documented personal preferences, and evidence of resident participation signatures.(b) Monitoring Sample: The audit will include 100% of all new admissions and a random 20% sample of the existing facility census.(c) Frequency: These audits will occur monthly.(d) Documentation: Findings will be recorded on the Monthly Care Plan Audit Log and maintained in the Quality Management folder.(e) Duration: Monitoring will continue for a minimum of 3 months, ending no earlier than Jul 30, 2026.(f) QAPI Integration: Audit results will be presented at the monthly Quality Assurance and Performance Improvement meetings. If compliance falls below 100%, the monitoring duration will be extended and additional staff training will be initiated. Completion Date: Apr 20, 2026.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareRegulation: 6 CCR 1011-1 Chapter 7, Part 6.8 (Administrator Duties)Corrective Action for Affected ResidentsCare Plan Completion: The Administrator will complete the full resident care plan for Resident #2 and update incomplete sections for Resident #1 and Resident #2, specifically addressing behavioral health needs and safety risk management. Resident Engagement: The Administrator will conduct 1:1 interviews with the five affected residents to identify physical, mental, and social interests to update their Person-Centered Care Plans. Participation Evidence: The Administrator will meet with the residents or their legal representatives to review updates and obtain signatures verifying their participation. Completion Date: April 20, 2026. Systemic Changes to Prevent RecurrenceStaff Training: All staff (including Staff #1, #2, and #3) will undergo mandatory retraining on emergency policies, fire drills, and resident engagement. Onboarding Protocol: A new admission and hire checklist will be implemented to ensure no resident is admitted without a care plan and no staff works independently without documented orientation. Administrator Oversight: The Administrator will establish a written organizational chart and a schedule to ensure day-to-day delivery of services, including activities, is not neglected due to administrative tasks. Monitoring of Corrective ActionMonthly Quality Review: The Administrator will review all new admissions to verify care plans and training records remain compliant. Completion Date: April 20, 2026

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 6 CCR 1011-1 Chapter 7, Part 7.9 (Staff and Volunteer Orientation and Training)Corrective Action for Affected StaffMandatory Retraining: Staff #1, Staff #2, and Staff #3 will complete a full initial orientation and competency-based training. Required Topics: Training will cover all mandated areas, including:Infection control and hand hygiene. Emergency response policies (fire response, evacuation, basic first aid, and AED use). Occurrence reporting requirements and procedures. Resident rights, house rules, and location of advance directives. Documentation: Proof of completion for each staff member will be signed and placed in their respective personnel files. Completion Date: April 10, 2026. Systemic Changes to Prevent RecurrenceOnboarding Protocol: A revised "Staff Onboarding Checklist" will be implemented, requiring the Administrator’s signature to certify that all orientation topics were covered before a new hire begins independent shifts. Monitoring of Corrective ActionMonthly Personnel Review for the coming 3 months: The Administrator will conduct a monthly review of all new hire files to ensure 100% compliance with initial orientation requirements. Completion Date: April 20, 2026

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 6 CCR 1011-1 Chapter 7, Part 12.10 (Resident Care Plan)Corrective Action for Affected ResidentsResident #1: The Administrator will update the care plan to reflect current behavioral health needs and identify specific formal and informal engagement opportunities. Resident #2: A comprehensive initial care plan will be developed immediately. This plan will specifically document the resident's preferences, such as wearing hospital gowns and using a dog bowl, as identified in staff interviews. Resident #3: The care plan will be revised to include detailed personal choices, needs, and specific engagement opportunities. Resident Participation: The Administrator will meet with all three residents (or their representatives) to review these updates and obtain required signatures to evidence their participation in the development process. Completion Date: April 15, 2026. Identification of Other Potentially Affected ResidentsComprehensive Audit: The Administrator will conduct a complete audit of all current resident records to ensure every resident has a signed, current care plan that includes medical info, eMAR references, and social preferences. Systemic Changes to Prevent RecurrencePolicy Enforcement: The facility will strictly adhere to its policy of developing care plans upon admission and reviewing them at least 30 days after admission and annually thereafter. Staff Retraining: The Administrator and Manager will receive retraining on 10 CCR 2505-10 8.7506. F.4 requirements, specifically focusing on documenting member goals, choices, and evidence of resident participation. Admission Checklist: A new admission checklist will be implemented to ensure no resident is admitted without a completed assessment and signed care plan. Monitoring of Corrective ActionMonthly Quality Audit for three months: The Administrator will conduct a monthly review of all new admissions and 20% of existing residents to verify they are updated and reflect resident preferences and engagement opportunities. Updates will be available on eMAR under each resident care planCompletion Date: April 20, 2026.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 6 CCR 1011-1 Chapter 7, Part 12.27 (Resident Engagement Management)Corrective Action for Affected ResidentsImmediate Engagement: The Administrator will immediately resume responsibility for organizing and conducting daily engagement activities for the five affected residents. Activity Audit: The Administrator will review the current activities calendar to ensure it includes social, physical, and intellectual opportunities as required by resident care plans. Staff Correction: Staff 1 will receive an immediate formal counseling session regarding the facility's "No Personal Cell Phone" policy during active duty hours and the requirement to actively engage with residents. Completion Date: April 20, 2026Identification of Other Potentially Affected ResidentsPreference Assessment: The Administrator will conduct 1:1 interviews with all residents to identify specific interests (social, mental, and physical) to ensure the activities program matches their personal choices. Systemic Changes to Prevent RecurrenceStaff Training: All staff will undergo retraining on Resident Engagement (Part 12.27), focusing on the requirement that activities must be offered daily, regardless of administrative presence. Redundant Facilitation: The Administrator will designate and train a Lead Engagement Staff member to conduct activities if the Administrator or Manager is occupied with administrative duties. Monitoring of Corrective ActionDaily Observations: The Administrator will conduct daily unannounced "floor walks" to ensure staff are engaging with residents rather than using personal electronic devices. Completion Date: April 20, 2026. Monitoring Plan Addendum(a) Monitoring Process: The Administrator or Designee will conduct "Activity Engagement Audits" to review daily engagement logs and observe live activity sessions to ensure social, physical, and intellectual opportunities are offered and documented.(b) Monitoring Sample: The audit will include 100% of the daily engagement logs and a random sample of 20% of the facility census to verify participation and engagement.(c) Frequency: Activity logs will be reviewed daily by EOD, and live session observations will occur 3 times per week.(d) Documentation: Findings will be recorded on the "Weekly Engagement Compliance Tracker" and maintained in the Quality Management folder.(e) Duration: Monitoring will continue for a minimum of 3 months, ending no earlier than Aug 31, 2026.

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 6 CCR 1011-1 Chapter 7, Part 13.1(B)(1) (Resident Rights: Dignity and Respect)Corrective Action for Affected ResidentsCounseling & Professional Boundaries: Admin and staff will receive 1:1 counseling on Resident Rights, focusing on dignity and professional boundaries during financial/discharge talks. Privacy Protocols: Staff must knock and request permission before entering Resident 2’s room and cannot touch personal property without consent. Communication Standards: Admin will cease all raised-voice or confrontational interactions. All future talks regarding concerns or payments will be private and respectful. Completion Date: April 15, 2026. Identification of Other Potentially Affected ResidentsPrivate Audit: Manager or designee will interview all residents regarding respect, payment pressure, or privacy breaches. Grievance Review: Comprehensive review of grievance logs to ensure past conduct concerns were addressed per policy. Systemic Changes to Prevent RecurrenceMandatory Retraining: All staff and Admin will complete retraining by April 15, 2026, on HCBS Settings Final Rule, professional communication, conflict resolution, and documentation standards for behavioral incidents. Updated Postings: Resident Rights postings will be updated with current revision dates and Ombudsman contact info. Monitoring and Quality Assurance (QA)Observation Audits: Admin or designee will conduct weekly random observations of staff-resident interactions (e.g., meals, med passes) to ensure dignity. Resident Satisfaction Interviews: Two random residents interviewed monthly to verify they feel respected. Completion Date: April 23, 2026. Monitoring AddendumMonitoring Authority: Manager or Corporate Quality Consultant will monitor Admin to ensure residents are treated with dignity. Monitoring Duration: Minimum of 3 months, ending no earlier than Aug 31, 2026. Documentation: Findings recorded and will be documented in employee files

Plan of CorrectionFacility: WeCare Colorado Assisted Living & Memory CareDate: Mar 28, 2026Regulation: 6 CCR 1011-1 Chapter 7, Part 13.11 (Investigation of Abuse and Neglect Allegations)Corrective Action for Affected ResidentsRetrospective Investigations: The Administrator will immediately initiate and document thorough investigations for the following: Resident 1 (necklace/T-shirt theft on Feb 09, 2026, and altercation with Resident 3 on Mar 03, 2026); Resident 2 (fighting on Jan 31, 2026, and cane strike in Jan 2026); and Resident 3 (altercation and alleged property misappropriation). April 3, 2026Systemic Changes to Prevent RecurrenceMandatory Reporting Training: Staff will be retrained on the "Resident Abuse/Neglect and Exploitation Policy," emphasizing that altercations and missing property require immediate investigation. Completion Date: Apr 24, 2026. Monitoring Plan Addendum(a) Monitoring Process: The Administrator or Designee will conduct "Signage and Incident Audits" to verify emergency plans are posted and all incidents have required investigative documentation.(b) Monitoring Sample: Audits include 100% of reported incidents and a 20% monthly census sample to check for undocumented injuries or property loss.(c) Frequency: Audits will occur monthly.(d) Documentation: Findings will be recorded on the "Monthly Signage and Incident Compliance Log"(e) Duration: Monitoring will continue for 3 months, ending no earlier than Jul 30, 2026.