SPRINGS RANCH MEMORY CARE COMMUNITY

Tag 0510: No QMP in placeCommunity will conduct a monthly QMP meeting immediately following the current monthly Safety Meeting, identifying a minimum of three trendsQMP Summary will be submitted to Regional Director by the 5th of each month for previous monthTimeline is no later than the 29th of each monthInitial QMP will be May 22, 2025 w/ submission to RDO June 5, 2025This will be an indefinite monthly meetingADDENDUM:#1 – A description of how the licensee will correct each identified deficiency. If the deficient practice was cited for a specific resident(s) or staff, the description shall include the measures that will be put in place or systemic changes made to ensure the deficient practice will not reoccur for the affected resident(s)/staff and/or other residents/staff having the potential to be affected.#2 – A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. The monitoring plan must identify all of the following:(a) Exactly how and what will be reviewed as part of the monitoring; top 3 negative trends such as falls, change in behaviors, safety issue(b) The sample, representative of the facility census, included in the monitoring; (c) How often the monitoring will occur; monthly(d) How the monitoring will be documented; meeting minutes for each QMP(e) The total minimum length of time the monitoring will continue (a minimum of 3 months is required); and- each trend identified for the QMP process will be monitored until desired resolution is achieved; QMP Summary will be submitted to Regional Director by the 5th of each month for previous month; (f) How the monitoring will be included in the QAPI process.- documentation of each meeting and qualitative measures included#3 – A completion date that shall be no longer than thirty (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department.- Initial QMP will be May 27th, 2025 w/ submission to RDO June 5, 2025. This will be an indefinite monthly meeting

Tag 0640: CCR 1011-1 ALR Part 7- Personnel- 7.9 Staff and Volunteer TrainingPersonnel files will contain all documentation as outlined in CCR 1011-1 Chapter 7 Part 7Current employee files will be reviewed and any missing documentation noted and recovered from various binders. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first. New employee files will have the correct documents and will be audited monthly by the ED or designeeADDENDUM:#1 – A description of how the licensee will correct each identified deficiency. If the deficient practice was cited for a specific resident(s) or staff, the description shall include the measures that will be put in place or systemic changes made to ensure the deficient practice will not reoccur for the affected resident(s)/staff and/or other residents/staff having the potential to be affected. Sample #1 through #4-The personnel files for the sample group listed above and current employee Personnel files will contain all documentation as outlined in CCR 1011-1 Chapter 7 Part 7. New hires will be utilizing the new Orientation Training checklist from hire date forward which encompasses the documentation outlined in CCR 1011-1 Chapter 7 Part 7 at a minimum.#2 – A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. As a top trend now at the community, this will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first. The monitoring plan must identify all of the following:(a) Exactly how and what will be reviewed as part of the monitoring; Personnel files will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation(b) The sample, representative of the facility census, included in the monitoring;(c) How often the monitoring will occur; current personnel- review of files will be completed by 06/22/2025. New hires forward, will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation(d) How the monitoring will be documented; After each file review, ED or designee will sign off and date(e) The total minimum length of time the monitoring will continue (a minimum of 3 months is required); and Ongoing process(f) How the monitoring will be included in the QAPI process. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first#3 – A completion date that shall be no longer than thirty (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. Upon approval from CDPHI, current employee files will be audited and updated by 06/22/2025. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first All new hires will be completed correctly and reviewed during orientation and annually during their performance review. The completion date is the date the entity deems it can achieve compliance. When ongoing monitoring or other activity is part of the plan, the completion date would be when the first cycle is completed, and the corrective action has been applied to all active residents/participants having the potential to be affected by the deficient practice. ADDENDUM PT 2:Systemic Change:New hires will be utilizing the new Orientation Training checklist from hire date forward which encompasses the documentation outlined in CCR 1011-1 Chapter 7 Part 7 at a minimumNew hires forward, will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation

Tag 0664: CCR 1011-1 Chapter 7 ALR Part 7- Personnel FilesPersonnel files will contain all documentation as outlined in CCR 1011-1 Chapter 7 Part 7Current employee files will be reviewed and any missing documentation noted and recovered from various binders. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first. New employee files will have the correct documents and will be audited monthly by the ED or designeeADDENDUM:#1 – A description of how the licensee will correct each identified deficiency. If the deficient practice was cited for a specific resident(s) or staff, the description shall include the measures that will be put in place or systemic changes made to ensure the deficient practice will not reoccur for the affected resident(s)/staff and/or other residents/staff having the potential to be affected. Sample #1 through #4-The personnel files for the sample group listed above and current employee Personnel files will contain all documentation as outlined in CCR 1011-1 Chapter 7 Part 7. New hires will be utilizing the new Orientation Training checklist from hire date forward which encompasses the documentation outlined in CCR 1011-1 Chapter 7 Part 7 at a minimum.#2 – A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. As a top trend now at the community, this will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first. The monitoring plan must identify all of the following:(a) Exactly how and what will be reviewed as part of the monitoring; Personnel files will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation(b) The sample, representative of the facility census, included in the monitoring;(c) How often the monitoring will occur; current personnel- review of files will be completed by 06/22/2025. New hires forward, will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation(d) How the monitoring will be documented; After each file review, ED or designee will sign off and date(e) The total minimum length of time the monitoring will continue (a minimum of 3 months is required); and Ongoing process(f) How the monitoring will be included in the QAPI process. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first#3 – A completion date that shall be no longer than thirty (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. Upon approval from CDPHI, current employee files will be audited and updated by 06/22/2025. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first All new hires will be completed correctly and reviewed during orientation and annually during their performance review. The completion date is the date the entity deems it can achieve compliance. When ongoing monitoring or other activity is part of the plan, the completion date would be when the first cycle is completed, and the corrective action has been applied to all active residents/participants having the potential to be affected by the deficient practice. ADDENDUM PT 2:Systemic Change:New hires will be utilizing the new Orientation Training checklist from hire date forward which encompasses the documentation outlined in CCR 1011-1 Chapter 7 Part 7 at a minimumNew hires forward, will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation

Tag 3050: CCR 1011-1 ALR Part 25- Secure Environment- 25.9 Re-AssessmentFor Resident #5, 1, and 11 in sample and all others moving forward:Licensee will follow Community Policy BM01Memory Care staff will examine individual resident’s patterns of challenging behaviors and triggers that could identify the root cause(s) for resident aggression or other disruptive behaviors. Memory Care staff will report residents who exhibit aggressive or disruptive behaviors to their supervisor and Director of Resident Services. The Director of Resident Services will review the circumstances, notify care staff and other appropriate parties of identified triggers or potential causes of the behavioral problems. The Director of Resident Services will evaluate the need for the create a twenty-four (24) hour Behavior Monitoring Log and establish immediate interventions. The Director of Resident Services will monitor the resident's and effectiveness of interventions. When behavioral interventions are successful:The resident will remain on behavior management for the following week to determine if the intervention is permanent. The resident’s Care Plan is updated with noted behaviors and interventions. Behavior monitoring is discontinued and documented in the resident’s record. The resident’s responsible party, physician, and care staff are notified of the discontinuance of behavior monitoring. When behavioral interventions are NOT successful (after several attempts):The responsible party, and physician are notified. Medication management will be considered as a last resort for managing behaviors if determined to be a comfort measure for the resident. A consulting psychologist and/or psychiatrist will be notified for recommendations, if appropriate. Care staff will report any changes in resident affect, personality or behavior to the Community Nurse, QMAP, Director of Resident Services, or Executive Director as appropriate. The Resident Behavior Monitoring form may be used to track behaviors. The resident’s physician or other appropriate mental health professional is contacted regarding the change in status. The resident’s responsible party is notified of a change in status. If necessary, the resident Care Plan is updated or amended to reflect any change in the resident's care needs. Other departments expected to be in contact with the resident (e.g., dining services, activities, housekeeping) will be appraised of the need for heightened observations of the resident.#2 Implementation of Policy BM01. All residents reported to appropriate leadership as having new behaviors will be reviewed to ensure BMP process has been put into practice and will be added to the monthly QMP for a minimum of 90 days. For resident #6 listed in sample and all others moving forward:Licensee will follow Community Policy AS01 and PO08Assessments are completed and updated as frequently as necessary to ensure they reflect current resident care needs and preferences. The information from an Assessment is used to develop an appropriate plan of care. The resident Assessment is completed/updated: (1)Prior to move-in. 30-days after move-in. The Director of Resident Services meets with the resident and/or their responsible party to determine if the residents needs are met. The Director of Resident Services consults with care staff and other Community staff members to ensure the resident’s needs are met.a. Whenever there is significant change in resident status.b. Prior to return from a hospital or other health facility. (3)c. Memory Care Residents – every six (6) monthsPO08: Care Plans will be developed for each resident. The Care Plans will address the resident’s clinical and social needs with consideration for their remaining strengths and response(s) to behavior management techniques. Care Plans will include any behavioral management techniques specified as effective, such as re-direction or activity engagement. The Director of Resident Services will in-service staff on the current and any updated changes to the resident’s individualized Care Plan and notify the respective departments.#2 Implementation of Policy AS01 and PO08. All residents reported as having a significant change in care needs requiring a reassessment will have an updated Care Plan to reflect needed changes and will have been reviewed by all with direct care responsibilities prior to them working with resident. This will be added to the QMP and tracked for a minimum of 90 days.

Tag 3074: CCR 1011-1 ALR Part 25- Secure Environment- 25.14 Staff TrainingPersonnel files will contain all documentation as outlined in CCR 1011-1 Chapter 7 Part 7Current employee files will be reviewed and any missing documentation noted and recovered from various binders. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first. New employee files will have the correct documents and will be audited monthly by the ED or or designeeADDENDUM: For current employees, all documented training will be moved from binders and placed in their individual personnel files no later than 06/22/2025. For new hires, we will utilize the new Orientation Training checklist that will be in their file. These will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation

Tag 3080: CCR 1011-1 ALR Part 25- Secure Environment- 25.16 Staff TrainingPersonnel files will contain all documentation as outlined in CCR 1011-1 Chapter 7 Part 7Current employee files will be reviewed and any missing documentation noted and recovered from various binders. This will become part of the QMP for 3 months or until all files have been reviewed and corrected, whichever occurs first. New employee files will have the correct documents and will be audited monthly by the ED or designeeADDENDUM:For current employees, all documented training will be moved from binders and placed in their individual personnel files no later than 06/22/2025. For new hires, we will utilize the new Orientation Training checklist that will be in their file. These will be reviewed by ED or designee after initial orientation and annually during their annual performance evaluation