GREELEY VILLAGE LLC

A complaint revisit was completed on 5/6/26 for all previous deficiencies cited on 9/4/25. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO41851, was completed on 5/6/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40623 and #CO40876, was completed on 9/4/25. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to ensure an appropriately skilled professional, evaluated and didcumented each personal care worker (PCW) for competency before assisting residents with a mechanical lift and a colostomy bag for three sample staff (#4-#6), affecting four current residents (#4, #5, #13, #14) ReferenceChapter VII regulations governing assisted living residences, part 2.56, defines "staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. Record Review Personnel files for:Staff #4 revealed a hire date of 10/17/24; however, the file contained no mechanical sit-to-stand lift training competency. Staff #5 revealed a hire date of 9/3/24; however, the file contained no mechanical sit-to-stand lift or ostomy bag training competency. Staff #6 revealed a hire date of 8/1/24; however, the file contained no mechanical sit-to-stand lift or ostomy bag training competency. A residence schedule for August 2025 read in part:Staff #4 worked at the residence on 8/3-8/8, 8/10-8/14, 8/17-8/21, 8/24-8/28. Staff #5 worked at the residence on 8/5-8/10, 8/12-8/16, 8/19-8/24, 8/26-8/31. Staff #6 worked at the residence on 8/6-8/7,8/13-8/14, 8/20-8/21, 8/27-8/28. A progress note dated 8/24/25 for Resident #4 read, Staff #6 changed the ostomy bag because it wasn't sticking to the skin and feces was coming out from the sides. Used the last skin barrier so she called hospice for more supplies. InterviewsOn 9/3/25 at 9:05 a.m., Staff #4 stated that the residence used a mechanical lift for three residents, however no training or competencies had been completed for staff. She further stated, staff often had to change or help Resident #4 with the Ostomy bag however, no training or competency had been completed. On 9/3/25 at 10:45 a.m., Staff #5 stated the residence used a mechanical lift, staff were required to assist residents with the lift however, she stated no training had been completed regarding the mechanical lift. On 9/4/25 at 8:33 a.m., the Wellness Director (WD) stated she completed an inservice for ongoing training with staff on the use of the mechanical sit-to-stand lift and ostomy bag. She added she was not a skilled professional such as a nurse, physical or occupational therapist and had not completed training with a skilled professional.. She stated she did not complete the staff members ' competencies to perform the lift and was not aware of the requirement to did so. On 9/4/25 at approximately 1:40 p.m., the Executive Director (ED) stated that the WD trained new staff on the sit-to-stand lift and ostomy. She added she was not aware of the requirement for staff competency on a mechanical floor/sling lift or ostomy bag. She affirmed a sit-to-stand was a mechanical lift. She acknowledged staff did not complete competencies prior to using the sit-to-stand and ostomy bag.

Based on record review, observation, and interview, the residence failed to make a sanitary environment available, either directly or indirectly through a resident agreement, affecting 58 current residents. Residence agreement The residences 4/2025 residency agreement read in part, that the housekeeping manager would provide regular housekeeping services to the common area and weekly housekeeping services to your suite. Observation On 9/3/25 at 8:40 a.m., an environmental tour of Resident #4s room showed the carpet in front of her recliner had been machine washed that morning, the carpet was damp and had a musty odidr. The toilet seat had urine around it and the room had a pungent odidr of feces. There were colostomy bag tape, bandages and supplies used to change the bag on the table next to Resident #4s bed. The table was cluttered with supplies for the colostomy bag and two separate sheets of instructions on how to clean and change the bag. Record Review A pest control invoice dated 7/18/25 read in part, five rooms had been treated for bed bugs. Rooms 126, 146, 148, and 152. Room 150 had a spot treatment completed, and would have a full treatment on 7/21/25. A pest control invoice dated 7/22/25 read in part, three rooms had been treated for bed bugs, room 170,172 and 174. A pest control invoice dated 8/12/25 read in part, a chemical bed bug treatment had been completed for room 114. check in upon arrival, Chemical bed bug treatment for unit 114. Treated room 114 for bedbugs when I arrived to unit we found bed bugs on the couch pillows treated with an aerosol along allseams of couches, cracks and crevices, treated all cushions pillows in the Living Room tenant has two couches that were treated and in the bedroom as well the mattress was treated along the seams under the mattress on the metal legs and along the metal frame. 112 is a vacant unit that was treated along the baseboards and wall lines in this unit with a liquid treatment. A pest control invoice dated 8/22/25 read in part, Room 120 had been treated for bed bugs. On 9/3/25 at approximately 8:00 a.m., a housekeeping schedule with specific cleaning duties and location throughout the residence was requested however not received. Interview On 9/3/25 at approximately 8:40 a.m., Resident #4 stated that housekeeping had just come to her room ten minutes prior to the interview to clean the carpet and the bathroom as there had been a stain on the carpet from juice and urine for a month. Resident #4 stated her room always smelt like feces and it was hard for her to spend her days in the room. She stated her ostomy bag would rupture sometimes twice a day and there would be feces on her person, bed and sheets as well as the wall against the bed. Resident #4 further stated, housekeeping rarely came into her room to clean and felt her room and stated she was "at the end of her wits" with staff and housekeeping. On 9/3/25 at 9:05 a.m., Staff #3 stated she had just gone into Resident #4s room to clean the carpet and the bathroom approximately ten minutes prior to the environmental tour. Staff #3 stated there had been a large stain of juice and possibly urine that had been there for about a month, she stated housekeeping had not been able to get to it however, Resident #4 had complained multiple times about the stain and odor. Staff #3 stated there had been a bed bug issue for multiple months however the residence had contacted a pest control company and they had done multiple bed bug treatments in different rooms. On 9/4/25 at approximately 1:40 p.m., the Executive Director (ED) stated the residence had an ongoing bed bug infestation since January 2024 and had been completing treatments periodically, she further stated she had not received any recent complaints of bed bugs and believed the issue had been eliminated. The ED stated, housekeepers were responsible for cleaning resident rooms once a week, the housekeepers did not have a means of documenting what had been cleaned or completed. She acknowledged that Resident #4s room had not been cleaned periodically.

Based on record review and interview the residence failed to refrain from providing Ostomy care where the ostomy site is new or unstable, affecting one of one current resident (#4) with an Ostomy bag. Findings include: A progress note dated 8/24/25 for Resident #4 read, Staff #6 changed the ostomy bag because it wasn't sticking to the skin and feces was coming out from the sides. Used the last skin barrier they called hospice for more supplies. On 9/3/25 at approximately 2:48 p.m., Staff #4 stated she had changed Resident #4s ostomy bag because it became too full and burst, she stated hospice nurses often take multiple hours to come and change the bag and Resident #4 laid in the feces until they arrived. On 9/4/25 at 1:40 p.m., the Executive Director (ED) stated she expected staff to contact Resident #4s hospice nurse when the bag needed to be changed, she stated she was unaware Staff #4 had changed the bag and acknowledged the ostomy bag is required to only be changed by an external service provider.

Based on record review, observation, and interview, the residence failed to promote resident choice, mobility, independence, and safety and failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs in a resident care plan, affecting five of five residents (#2, #3, #7, #8, #10 ). Specifically, Resident #7 had 17 falls since 6/1/25. On 6/8/25, an incident report read, Resident #7 had a skin tear on his lower left arm due to a fall. On 7/26/25, an incident report read, Resident #7 had hit his head with a visible cut and swelling. The care plan had not been updated since 9/13/24. The residence had not updated the residents care plans to include specific interventions implemented to ensure the residents safety. This failure created an immediate jeopardy risk of serious harm or death to Resident #7 and four sample residents. On 9/4/25, the department directed the residence to provide written evidence that the risk had been removed. Findings include:Reference and Resident AgreementChapter VII regulations governing assisted living residences, part 2.10, defines "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual' s need for personal assistance, services received from external providers, and the services to be provided by the residence in order to meet the individual' s needs. In order to deliver person-centered care, the care plan shall take into account the resident' s preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill. The residence's 4/2025 resident agreement, read in part, prior to the resident moving into the residence, a care plan or service agreement would be developed and reviewed annually or more often as the residents condition, preferences or service needs change. The service agreement would include the level of service and care You would receive, including, but not limited to assistance with activities of daily living; special accommodations; the amount, type and frequency of health-related services; staff responsible for the provisions of the Service Plan Agreement; whether You require supervision of self-administered medication or medication administration; and all support services provided or arranged for by Manager. Record Review Resident #7 was admitted to the residence on 9/9/24 with diagnoses of Encephalopathy, history of falling, muscle weakness (generalized), Difficulty in walking, need for assistance with personal care, and Repeated falls. The record for Resident #7 revealed the resident experienced 17 falls since 6/1/25 in which there was no evidence of individualized approaches necessary to address falls risks as follows:The care plan for Resident #7, dated 9/13/24, read in part: that Resident #7 needed to be monitored for behaviors such as remaining seated until care staff is present and able to assist out of the shower. Care staff would properly dry the floor and assist Resident #7 out of the shower each time. Monitor for at risk behaviors including proper use of assistive devices, proper foot wear, presence of trip hazards in the environment, participation in physical therapy program and level appropriate activities. Report to Resident Services Director if change in: gait; ability to balance; change in level of consciousness; increased confusion; refusal to use adaptive equipment (wheelchair, walker); or, if the resident falls. RSD would reevaluate fall risk as needed at change of condition and routine assessments. No reassessment or update to the care plan had been completed after Resident #7 ' s falls. InterviewsOn 9/3/25 at approximately 8:45 a.m., Staff #4 stated there are many residents that experience falls and staff are often told to keep an eye on those residents. She stated staff try to did consistent wellness checks on residents who are fall risks. Resident #7 falls often and it was difficult to ensure he is safe, we were not given any new interventions since his last few falls and any interventions staff were instructed to did included ensuring the room was not cluttered and the resident was using his walker. On 9/4/25 at approximately 8:30 a.m., the Wellness Director (WD) stated there was a care conference regarding Resident #7 with his power of attorney and his hospice nurse. The interventions discussed were medication changes and for hospice to visit Resident #7 more frequently however interventions were not documented. The WD stated his 17 falls since 6/1/25 constituted a change in condition; however, no update to the care plan or assessment was completed. On 9/4/25 at 1:20 p.m., the Executive Director (ED) agreed that Resident #7 ' s care plan should have been updated as he had experienced abnormally frequent falls. She stated she expected interventions to be implemented and documented in the residents ' service plans to ensure the residents safety. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The complaint established that the findings above placed the six residents at immediate jeopardy risk for harm due to an increase in falls and lack of interventions. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 9/4/25 at 9:38 a.m., the Executive Director (ED) submitted written evidence that read in pertinent part: A plan is set to review each resident listed and update the care plans by the end of the day on 9/4/25. The Wellness Director (WD) and Executive Director (ED) would oversee the completion for all residents on the Immediate Jeopardy list. For Residents #2, #3, #6, and #8, reassessments and Care Plan updates are scheduled to finish on 9/4/25. There would be communication with hospice and families to arrange care conferences, and progress notes would document the residence ' s efforts. For Resident #7, a care conference has already been scheduled due to several falls. The assessments and Care Plan would be updated by 9/4/25, with documentation added to progress notes. Resident #10 had been under hospice care since 9/1/25 and started comfort medications on the same day. The resident passed away on 9/3/25, with hospice present to assess and notify the family. However, the written evidence did not show that acceptable measures were put in place to ensure resident safety. It lacked documentation of the immediate actions taken by staff and did not provide evidence of staff training given to prevent it from happening again. The plan also did not explain how care plans would be updated consistently in the future, who would be responsible for these updates, or how monitoring would be done to ensure care plans are kept up to date. Additionally, the evidence failed to detail what specific training on fall prevention interventions would be given to staff, when this training would occur, and who would deliver it. The residences first attempt did not make clear who would monitor the plan's progress to prevent the issue from happening again, nor did it set a defined timeframe for when staff training would be completed. The documentation did not specify what interventions would be put in place for each resident until their care conferences are scheduled and completed. On 9/4/25 at 11:38 a.m., the Executive Director (ED) submitted additional written evidence that read in pertinent part: The ED would retrain the Wellness Director (ED) immediately. They would work together to ensure accuracy, and this would be monitored through competencies. Fall Prevention Training with Legacy Therapy is set for 9/9/25. This would be followed by quarterly fall training, with attendance recorded through a Falls Training Spreadsheet and staff sign-in sheets. TheWD would review all Care Plans and Assessments, starting with residents at higher risk of falls. Any changes would need to be communicated to the practitioner and family, with a care conference scheduled. The ED would check the completion of updates by the end of September 2025. The ED and WD would hold weekly meetings with the Wellness Director to review care notes, assessments, incident reports, and documentation with physicians or families to keep monitoring ongoing. The Chief Operations Officer would audit resident charts and the Eldermark system every quarter, and all updates and communications would be documented in resident progress notes. However, the written evidence did not indicate how often the increased checks by staff would be and how staff would document this. However, the written evidence did not demonstrate that the risk had been removed because it did not clarify how often increased checks would be conducted. Also, the submission did not indicate how the residence would ensure that these checks are consistently completed, monitored, and documented, nor did it address how staffing levels would be maintained to ensure that the implementation of the wellness checks did not affect the care of other residents. On 9/4/25 at 12:20 p.m., the Executive Director (ED) submitted additional written evidence that read in pertinent part: Increased status checks would begin every hour, 9/4/25, on residents listed in the Immediate Jeopardy to make sure they did not need help or are not at risk for future falls. The qualified medication administration personnel (QMAP) is in charge of hourly checks. Staff could request another care member for assistance or contact a lead if needed. All checks would be recorded in the residents ' chart and would continue until care conferences are held and fall risk interventions are put in place. The Immediate Jeopardy was removed on 9/4/25 at 1:15 p.m. Similar deficient practice presented with Residents #2, #3, #8, #10.

Based on observation, interview and record review the residence failed to develop and implement a fall management program affecting five of five sample residents with falls (#2, #3, #7, #8, #10). (Cross Reference S1110, S1180, 2230)Findings include:1. Residence PolicyThe residence's fall policy, dated 9/2024, read in part: Residents who reside in the community would be provided with an environment that reduces the hazards that can lead to falls. Residents who are aging are at a higher risk for falls due to aging related changes. Decreased visual acuity and depth perception present special needs for visual cues. This policy is to provide an environment that incorporates the needs of the residents who reside in the community. 2. Resident #7 was admitted to the residence on 9/9/24 with diagnoses of Encephalopathy, history of falling, muscle weakness (generalized), Difficulty in walking, need for assistance with personal care, and Repeated falls. The record for Resident #7 revealed the resident experienced 17 falls since 6/1/25 in which there was no evidence of individualized approaches necessary to address falls risks as follows:The care plan for Resident #7, dated 9/13/24, read in part: that Resident #7 needed to be monitored for behaviors such as remaining seated until care staff is present and able to assist out of the shower. Care staff would properly dry the floor and assist Resident #7 out of the shower each time. Monitor for at risk behaviors including proper use of assistive devices, proper foot wear, presence of trip hazards in the environment, participation in physical therapy program and level appropriate activities. Report to Resident Services Director if change in: gait; ability to balance; change in level of consciousness; increased confusion; refusal to use adaptive equipment (wheelchair, walker); or, if the resident falls. RSD would reevaluate fall risk as needed at change of condition and routine assessments. From 6/3/25-9/2/25, 17 incident reports documented that Resident #7 was found on the floor of his room after a fall. Four of those falls resulted in injury. An incident report dated 6/8/25 read in part, Resident #7 fell in front of his recliner and experienced a skin tear. An incident report dated 6/18/25 read in part, Resident #7 was found on the floor across from bed, he hit his head and seemed confused. An incident report dated 7/26/25 read in part, Resident #7 had a cut on his head and swelling to the left side of his face after a fall. An incident report dated 8/15/25 read in part, Resident #7 fell backwards and was experiencing pain in his right arm. The record for Resident #7 revealed no evidence that the care plan was updated after Resident #7 fell with injury from 6/3/25- 9/2/25 with individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication .On 9/4/25 at approximately 8:30 a.m., the Wellness Director (WD) stated Resident #7 had a history of falls and the most recent fall was one week prior to the onsite visit. She stated she did routine checks on the resident to prevent falls and would add interventions to the care plan after a fall; however it was not documented and no update to the care plan was complete. On 9/4/25 at 1:40 p.m., the Executive Director (ED) stated Resident #7 was considered a fall risk and required continuous checks throughout the day, she stated an update to his care plan should have been completed after his falls. Similar deficient practice was found for Residents #2, #3, #8, #10.

Based on observation and interview, the residence failed to ensure laundry personnel or designated staff handle, store, process, transport, and return laundry in a way that prevents the spread of infection or cross contamination, affecting 58 current residents. Findings include:On 9/4/25 during an environmental tour, Staff #3 had entered Resident #5 ' s room to hand them their folded laundry. Staff #3 had given Resident #5 another resident's pillow case and towel. On 9/4/25 at approximately 12:00 p.m., Staff #3 stated laundry often gets mixed up, the night shift are the ones that take the laundry from residents, wash them and fold them back into the residents laundry bin. The morning staff then deliver the laundry to the residents. Staff #3 stated morning staff did not always know whose laundry gets mixed with others and this had been a problem when some residents had bed bugs. On 9/4/25 at 1:20 p.m., the Executive Director (ED) stated she was not aware residents' laundry was being mixed and acknowledged that it was unsafe and posed a health risk for cross contamination.

Based on record review and interview, the residence failed to ensure resident records contained documented progress notes, by staff before the end of their shift, of out of ordinary events or issues that affected a resident's physical, behavioral, cognitive, and/or functional condition, along with the action taken by staff to address that resident's changing needs documented, affecting three of three sample residents with bed bugs (#1, #2, 11). Findings include:Resident #2 was admitted to the residence, unit 174 on 7/26/24 with a diagnosis of dementia. A pest control invoice dated 7/22/25 read in part, three rooms had been treated for bed bugs, room 170,172 and 174. Review of Resident #1's record revealed no documentation of Resident #2 having had a bed bug issue. On 9/4/25 at 1:20 p.m., the Executive Director (ED) stated bed bugs were an out of ordinary situation for the residence, she acknowledged progress notes should have been documented in the residents ' charts regarding the bed bugs.

Based on record review and interview, the residence failed to have a written policy that provided for effective control and eradication of insects, rodents, and other pests, affecting 58 current residents. (Cross Reference S1110, S1720, S2230)Findings include: On 9/3/25 at 8:30 a.m., the residence's environmental pest control policy and procedure was requested; however, it was not provided. On 9/4/25 at 1:30 p.m., the administrator confirmed that the residence did not have a written pest control policy for effective pest control.

Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment residency that included detailed information from the resident's family and/or representative concerning the resident's recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, and any other known types of conduct; and, an evaluation by a licensed practitioner that described the residents' medical condition and any cognitive deficits that contributed to wandering, compromised safety awareness, and other types of conduct, affecting one of three sample residents (#2) who resided in the secure environment. Findings include:1. Reference Chapter VII regulations governing assisted living residences, part 12.7, requires the residence to ensure a comprehensive assessment include all the following items:(A) Information from the comprehensive pre-admission assessment described in Part 11.1;(B) Information regarding the resident's overall health and physical functioning ability;(D) Communication ability and any specific needs to facilitate effective communication;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses;(K) Safety awareness;(L) Types of physical, mental, and social support required; and(M) Personal background, including information regarding any other individuals who are supportive of the resident, cultural preferences, and spiritual needs. 2. Resident #2 was admitted to the residence on 7/26/24 with a diagnosis of dementia. Resident #2 was admitted to the secure environment of the residence on 8/31/25 with a diagnosis of dementia. The residence's 1/15/25 service agreement, read Resident #2 had mind confusion; followed a time and place orientation plan to support the resident to feel safe in his environment.. Follow a time and place orientation plan to support residents to feel safe in the environment and fulfill unmet needs.. The community provides assistance to manage orientation in a supportive environment. There was no evidence in Resident #2's record that the residence completed a pre-admission assessment to determine appropriateness for the secure environment, such as: detailed information from the resident's family regarding relevant history and an evaluation by a licensed practitioner that described the resident's need for a secure environment. On 9/4/25 at 1:20 p.m., the administrator stated she expected the Wellness Director (WD) to initiate and complete a pre-admission assessment for Resident #2 prior to moving him to the secure environment. The ED acknowledged, a pre-admissions assessment had not been completed per the regulation.

Based on observation, record review, and interview, the residence failed to ensure resident care plans contained documentation describing the personal grooming and hygiene items that were deemed safe for the resident and the residents ' access to the items, as well as documentation describing the continuous independent access to his or her individual room to protect the resident from unwanted visitation by other residents, affecting three of three sample residents (#2,#10,#11) residing in the secure environment. Findings include:Record Review Resident #10 was admitted to the residence ' s secure environment on 6/1/25 with a diagnosis of dementia and Parkinson's disease. The undated care plan for Resident #10 revealed no documentation with a description of the resident ' s wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact. A description of how the resident would have continuous independent access to his or her individual room, along with the residence ' s plan to protect the resident from unwanted visitation by other residents. Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the residence deems necessary to meet the needs of the resident within the secure environment and secure outdoor area. Additionally, no documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents. InterviewsOn 9/4/25 at 10:50 a.m., Staff #25 stated Resident #20 had a key to her room so that she felt safe. On 9/4/25 at approximately 4:35 p.m., the administrator stated she was not aware of the requirement for the residence to address hygiene items in the enhanced care plan. Furthermore, she stated she was aware that Resident #20 had a key to her individual room, and the residence should have included this in the enhanced care plan. Additionally, the residence failed to ensure resident care plans contained documentation required of the enhanced care plan for Residents #10 and #11.

A revisit survey was completed on 1/23/25 for all previous deficiencies cited on 9/19/24. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey with complaint #CO33027 was completed on 9/19/24. A deficiency was cited.

Based on interviews and record review, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 59 current residents. Specifically, the residence failed to have at least one staff member onsite at all times who had current certification in obstructed airway techniques from a nationally recognized organization, affecting all 59 current residents in the event of an obstructed airway emergency and for two sample residents (#1, #3) who required CPR in the event of an emergency for at least five shifts from 9/1-9/18. Additionally, from 9/18-9/24/24 there was no CPR certified staff scheduled for five shifts. This failure created an immediate jeopardy risk of harm to all 59 current residents in the residence. On 9/18/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. Residence PolicyThe residence's resident agreement, dated June 2024, read in part that all residents have the right to receive CPR unless otherwise indicated. 2. Record ReviewFace sheets for two of five sample residents (#1, #3) required CPR in the event of an emergency. A review of the staff's CPR certification documentation revealed that four staff members (#2-#7) had a current certificate from a nationally recognized organization. Additionally, the administrator and health and wellness director (HWD) had certifications from nationally recognized organizations. The August and September 2024 schedules revealed the residence failed to have at least one staff member certified in CPR from a nationally recognized organization on duty at all times. Staff without certification or expired certifications worked on the following shifts:9/1/24 from 10:00 p.m. - 6:00 a.m. 9/6/24 from 6:00 a.m. - 8:00 a.m. 9/10/24 from 5:00 p.m. -10:00 p.m. 9/13/24 from 6:00 a.m.-8:00 a.m. 9/17/24 from 5:00 p.m. - 6:00 a.m. The administrator and the HWD, who had certificates from a recognized organization, were unavailable to perform CPR from 9/17/24, Monday through Friday between 5:00 p.m. and 8:00 a.m. and Saturday and Sunday all day. 3. InterviewsOn 9/18/24 at 11:00 a.m., the administrator stated a majority of the staff did not have current CPR certifications. She said the former HWD had scheduled a class in May 2024; however, the HWD was unwilling to fulfill her responsibilities, resulting in the class's cancellation. On 9/18/24, at approximately 1:00 p.m., the administrator provided one additional staff member (#7) CPR certificate. On 9/18/24 at approximately 1:00 p.m., the administrator stated that if an emergency occurred in which a resident required CPR or an obstructed airway technique, the staff would have had to call emergency responders because no other staff had current certification (except Staff #2-#7). She acknowledged that waiting for emergency responders to arrive could lead to potential injury, up to and including death. On 9/19/24 at 10:05 a.m., the business office manager acknowledged the failure of the residence to have only seven staff members with current CPR certificates. On 9/19/14 at 10:15 a.m., the resident care coordinator acknowledged that not having more staff with current CPR certifications created a failure if a resident required CPR. On 9/19/24 at approximately 10:30 a.m., the administrator stated that she did not know how many of her staff had current CPR certificates. Additionally, she acknowledged the failure to have at least one staff member with a current CPR certification on the schedule at all times. 4. Immediate Jeopardy Risk- Written Evidence, Immediate CorrectionThe investigation established that the findings above placed current residents at immediate jeopardy risk for the failure to ensure at least one staff member who was CPR-certified through a nationally recognized organization was onsite at all times. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 9/18/24 at 2:36 p.m., the administrator submitted an email with a staff schedule that read, "A class with a nationally recognized organization on 9/23/24." Additionally, other classes would be held until all staff were CPR-certified. On 9/18/24, at approximately 2:40 p.m., the administrator was asked to create a formal document of a plan of correction on company letterhead and sign it. On 9/18/24 at 3:00 p.m., the administrator submitted additional written evidence that read, in part, that the residence would require ten staff members to take a class on 9/23/24 and would schedule more employees to get all staff current CPR certificates. Additionally, the business office manager would oversee an electronic database and would be responsible for communicating with the administrator if classes were needed. All staff were required to have a certificate, or they would be removed from the schedule and replaced with staff with a certificate. However, the written evidence did not indicate the risk had been removed because it did not include details of which staff would be certified for upcoming shifts. On 9/18/24 at 4:17 p.m., the administrator submitted additional written evidence that read, in part, that the new schedule had been posted and Staff #2-#7, who had current certificates, were added to the schedule with shifts on 9/18, 9/20, 9/24, 9/27, and 9/29/24.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. 8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both. 10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; 18.12 Records of former residents shall be complete and maintained for at least three (3) years following the termination of the resident ' s stay in the assisted living residence. 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident ' s condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident ' s attending practitioner, family, and/or resident ' s representative and review service documentation dating back to the most recent comprehensive assessment.