Gardens at St Elizabeth

A life safety code survey, prompted by #CO40608, was completed on 7/14/2025. Two deficiencies were cited. The facility is a three (3) story, Type II (000) (II B) concrete and steel structure and licensed for forty (40) residents. The facility has a National Fire Protection Association (NFPA) 13 automatic fire suppression system. This survey, conducted on July 14, 2025, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities. Based on observation and an interview, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for fire drill. The facility failures had the potential to affect all occupants of the building.Findings include:Please refer to A0001 for observations and interviews, and record review showed less than 12 fire drills in the last calendar year.This deficiency may potentially affect residents and staff due to the absence of required fire drills that complies with regulations. The administrator and maintenance director discussed the deficiencies during the exit conference. Based on staff interviews and record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code NFPA 101 and 101a. The deficient practice affected all smoke compartments.compartments. The deficient practice could affect all smoke zones,40 of 40 residents, and an indeterminable number of staff and visitors.Record review and interviews with the administrator and maintenance director confirmed that the facility had performed two of the twelve required fire drills for the calendar year.33.7.3 Emergency Egress and Relocation Drills.Emergency egress and relocation drills shall be conducted in accordance with 33.7.3.1 through 33.7.3.6.33.7.3.1 Emergency egress and relocation drills shall be conducted not less than six times per year on a bimonthly basis, with not less than two drills conducted during the night when residents are sleeping, as modified by 33.7.3.5 and 33.7.3.6.33.7.3.2 The emergency drills shall be permitted to be announced to the residents in advance.33.7.3.3 The drills shall involve the actual evacuation of all residents to an assembly point, as specified in the emergency plan, and shall provide residents with experience in egressing through all exits and means of escape required by this Code.33.7.3.4 Exits and means of escape not used in any drill shall not be credited in meeting the re..

9999 INFORMATIONAL ADVISMENTTHIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing.. A relicensure survey with complaints #CO40185, #CO40414, and #CO40456 was completed on 6/26/25. Deficiencies were cited. Based on interview and record review, the residence failed to thoroughly investigate allegations of abuse in accordance with the residence' s written policy, affecting one sample resident (#14). (Cross-reference T410)Specifical.. Based on observation and interview, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting 97 current residents. Findings Include:During the on-site visit on 6/25-6/26/25, resident.. Based on observation, record review and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique charact.. Based on observations and interviews, the residence failed to maintain the grounds free of garbage and rubbish, affecting 97 current residents.Findings include: On 6/26/25 at 12:20 p.m., during an environmental tour of the resid.. Based on record review and interview the residence failed to develop and follow written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency,.. Based on record review and interview the residence failed to investigate and identify resident injuries for which the origin of the injury was not observed by or otherwise known by staff affecting two of 12 sample residents (#4 and #7).. Based on record review and interview the residence failed to provide, upon request, copies of the resident records requested by the department affecting 12 of 12 sample residents. This deficiency was cited previously during a licens.. Based on record review and interview the residence failed to, on a quarterly basis, audit the accuracy andcompleteness of the medication administration records, controlled substance list, medication error reports, and.. Based on record review and interview, the residence failed to complete progress notes at the end of each shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident' s physical, behavi.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting six of six sample residents (#2, #4, #6, #7, #10, #12).Findings include:1. Re.. Based on record review and interview, the residence failed to report allegations of physical abuse of an at-risk person to law enforcement within 24 hours of discovery, affecting one current resident #14. (Cross-reference T1410)Findings.. Based on record review, observations, and interview, the residence failed to document and implement effective actions that were to be taken by staff to prevent reoccurrence of falls for two of four residents (#10, #11) who fell. (..

A licensure complaint revisit was completed on 6/26/25 for all previous deficiencies cited on 3/21/25. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The Chapter 7 regulations were implemented on 3/17/25.The deficiencies cited for Event FGOD11 were cited prior to the regulation revision that was implemented on 3/17/25. Based on observation, record review and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 25 residents in the east side of the residence.This deficiency was cited previously during a licensure complaint on 3/21/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Physically Safe Environmenta. ObservationOn 6/25/25 at 9:53 a.m. the fire panel in the east side of the residence displayed three yellow lights that indicated there was trouble in the fire panel system.b. Record ReviewAn external email sent to the administrator, dated 3/18/25 confirmed the residence was on fire watch.The residence' s fire watch logs for the east side of the residence revealed fire watch was still occurring due to the fire panel being down from March 2025 to the onsite visit on 6/25/25.c. InterviewsOn 6/25/25 at 9:54 a.m., the resident service coordinator said the fire panel in the residence' s east side had been down since March 2025 and that the residence had been doing fire watch checks every 15 minutes, as required. On 6/26/25 at approximately 1:00 p.m., the administrator acknowledge.. Based on record review and interview the residence failed to provide, upon request, copies of the resident records requested by the department affecting 12 of 12 sample residents. This deficiency was cited previously during a licensure complaint on 3/21/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings Include:On 6/25/25 at approximately 2:30 p.m., incident reports for twelve sample residents were requested. On 6/25/25 at approximately 1:00 p.m., the administrator stated that he was not aware that incident reports were part of resident records. He stated that he was directed by his corporate office to not provide the department the incident reports that were requested.

A licensure complaint, prompted by #CO39280 and #CO39595, was completed on 3/21/25. Deficiencies were cited. Based on interview and record review the residence failed to have a readily available resident roster, along with a residence diagram showing room locations, affecting 49 current residents.Findings include:On 3/20/25 at 3:00 p.m., the administrator provided the resident roster with the resident names and room numbers; however, it failed to include a diagram showing the room locations and was not readily available.On 3/21/25 at 1:50 p.m., the administra.. Based on interview and record review, the residence failed to update a comprehensive assessment whenever a resident' s condition changed from baseline status, affecting one of five sample residents (#2). Findings include:1. Residence policyThe residence' s Evaluations policy, dated 1/1/24, read in part when a resident change in condition is identified, the nurse will complete the appropriate assessment.2. Record ReviewResident #2 was admitted to the res.. Based on observation, interview, and record review, the residence failed to ensure that the residence' s emergency policies included the circumstances and procedures to evacuate the premises, assignment of specific staff duties on each shift using triage to identify the most vulnerable residents, or agreements with other residences in the event of relocation of residents, affecting 49 current residents. (Cross Reference S0540, S1110)Specifically, the facility had no.. Based on observation, record review, and interview, the residence failed to either directly or indirectly provide protective oversight, personal services and a physically safe and sanitary environment, affecting 49 current residents. (Cross-reference S0540)Specifically, on 3/20/25 the residence' s fire panel read there was trouble with the system, affecting the smoke detectors and the fire suppression system throughout the entire residence. Therefore, the smok.. Based on observation, record review, and interview, the residence failed to ensure the administrator managed the day-to-day delivery of services, affecting 49 current residents. (Cross Reference S0430, S910, S918, S920, S1110, S1146)Findings include: 1. References and Resident Agreementa. Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administr.. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of two sample residents (#2). Findings include:1. References a. According to the Health Facilities and Emergency Medical Services Division Occurrence Reporting Manual (2018), "Any occurrence involving physical...abuse of a patient or resident, as described in section...18-3-402, 18-3-403, 18-3-404, or 18-3-405 C.R.S., by another patien.. Based on record review and interview, the residence failed to identify the highest potential risk as well as hold and document routine drills to facilitate staff and resident response to that risk, affecting 49 current residents. (Cross-reference S0540)Specifically, the residence was required to conduct monthly fire drills, as mandated by regulations. There was no written documentation of routine drills being conducted and staff reported they had not p.. Based on record review and interview, the residence failed to provide, upon request, access to requested documents, affecting 49 current residents.Findings include:1. Record review On 3/21/25 at 9:00 a.m., complete incident reports were requested.On 3/21/25 at 1:12 p.m., an electronic communication was received from the administrator read in part, the residence' s corporate office would not provide the department with incident reports as they were for intern..

A complaint survey, prompted by CO#39494 and CO#39495, exited on 3/21/2025. Four deficiencies were cited.The facility is a two (2) story, Type V (111) wood frame structure with a basement and licensed for one hundred five (105) residents. The facility has a National Fire Protection Association (NFPA) 13-R automatic fire suppression system. This survey, conducted on March 21, 2025, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities. Based on observation and staff interviews, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 Section 9.6 and NFPA 72. The deficient practice affected 9 of 9 smoke compartments.1. The fire alarm panel and magnetic door holders were observed with the administrator. The administrator confirmed that the fire alarm panel was not functioning and displayed 16 trouble alarms. The administrator agreed the magnetic door holders were not working because of the inoperative fire alarm panel.2. The maintenance director was observed to not know how to sound the fire alarm for fire drills. Additionally, the maintenance director reported he did not know what keys operate the pull stations. The administrator acknowle.. Based on observation, interview, and record review, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining the life safety code, fire alarm, and fire doors. The facility failures had the potential to affect all occupants of the building.Findings include:Cross-reference to A0001 for record review and interviews evidencing the facility' s failure to assess resident evacuation rating; develop and maintain emergency plans; provide staff training at required intervals, and conduct fire drills. Cross-reference to A0002 for observations and interviews documenting the facility' s failure to maintain fire.. Based on observation, record review, and staff interviews, it was determined that the facility failed to arrange and maintain fire doors in accordance with Life Safety Code 101 and NFPA 80. The deficient practice affected 9 of 9 smoke compartments1. Record review revealed the facility had no documentation of annual fire door inspections. The administrator confirmed the facility had not completed annual fire door inspections.2. Rooms 248 and 149 were observed to be held open with a door stop. The administrator confirmed the presence of the door stops for rooms 248 and 149.3. The fire door closer for room 261 was observed to be detached from the door. The administrator confirmed the detached closure device on room 261' s fire door.4. The delayed egress function of the basement memory care wa.. Based on staff interviews and record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code NFPA 101 and 101a. The deficient practice affected 9 of 9 smoke compartments.1. Record review of all resident evacuation rating sheets were requested from the administrator. The administrator interview revealed the residence had no rating sheets for the residents. The administrator was unaware that the residence had to have resident rating sheets available for existing buildings rated impractical.2. Record review revealed the facility had no emergency plans available for review. The administrator confirmed there were no emergency plans readily available for staff.3. Record review of staff training revealed the facility did not conduct sta..