KAVOD SENIOR LIFE

A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 9/16/25. 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 revisit survey was completed on 1/13/26 for all previous deficiencies cited on 9/16/25. 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 recertification survey was completed on 9/16/25. Deficiencies were cited.

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 26 current residents. Findings include:On 9/15/25 at 7:45 a.m., the involuntary discharge grievance policy was requested; however, it was not provided. On 9/15/25 at 2:15 p.m., the residence provided a discharge notice letter that they gave to residents to notify of the discharge from the residence; however, the letter did not meet the required elements of Chapter VII, Regulation 9.3 (A-I). On 9/15/25 at 2:28 p.m., the administrator stated they did not have an involuntary discharge grievance policy due to always using the residences' discharge notice letter. She acknowledged the letter did not meet the required elements and stated she expected the residence to have a policy that met the requirements of Chapter VII, Regulation 9.3 (A-I).

Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises, including, but not limited to, fire(s), gas explosion, power outage, tornado, flooding, and threatened or actual acts of violence, affecting 26 current residents. Findings include:On 9/15/25 at 7:45 a.m., a risk assessment of all hazards and preparedness measures to address natural and human-caused crises was requested. However, no risk assessments were provided for fire, gas explosions, power outages, tornadoes, flooding, and threatened or actual acts of violence. On 9/16/25 at 3:26 p.m., the administrator stated that the residence did not have a risk assessment for all hazards. She stated she was aware of needing it and expected the residence to have it.

Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 26 current residents. Findings include:On 9/15/25 at 7:45 a.m., a 72-hour continuation of care policy and procedure was requested; however, it was not provided. On 9/16/25 at 3:26 p.m., the administrator stated that the residence did not have a 72-hour continuation of care policy and procedure. She stated she was aware of needing it and expected the residence to have it.

Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures, which included all required elements, affecting 26 current residents. Findings include:On 9/15/25, record review revealed the residence's emergency plans and procedures dated in March, April, May, and June of 2025 did not address all of the required elements of Chapter VII, Regulation 10.6. On 9/16/25 at 3:41 p.m., the administrator stated the residence did not have an emergency policy and procedure for a gas explosion and expected them to have one. She acknowledged that the emergency preparedness policies and procedures lacked all the required elements and expected them to meet the requirements.

Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting two of four sample residents (#1 and #3). Findings include:1. Resident #1 was admitted to the residence on 7/23/21. The August 2025 and September 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: ferrous gluconate, preserVision, and tamsulosin HCl. 2. Similar deficient practice was found for Resident #3. Additionally, Resident #3's MAR did not match the signed and dated practitioner orders provided. 3. InterviewOn 9/16/20 at 1:06 p.m., the wellness coordinator acknowledged they did not have all the practitioners' orders for the medications being administered by the residence. He explained that the residence received the medication orders from the practitioner, and what was listed on the MAR was correct. He stated he was unsure why they had missing orders for the medications being administered or why the MAR had not matched the practitioner's orders provided specifically for Resident #3. He stated he would expect the MAR to match the practitioner's order and to have all the practitioner's orders for medications being administered. On 9/16/25 at 3:16 p.m., the administrator explained that the residence received practitioners' orders from the practitioners, the residents had their medication list signed by the practitioner when they had a practitioner's appointment, or the residence received a signed medication list from the practitioner quarterly. The administrator stated she was aware the residence did not have all the practitioners' orders signed and dated, and would expect to have them.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residencewas advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.7000.8.7409 PersonnelA. Employee and Contractor records 1. The Provider Agency shall maintain records documenting the qualifications and training of employees and contractors who provide services to Members. 2. Provider Agencies shall maintain a personnel record for each employee or Contractor. The record shall contain: a. Documentation of qualifications. b. Documentation of trainings completed. c. Documentation of supervision and performance evaluation or contractor management and oversight. d. Documentation that the employee/Contractor was informed of all policies and procedures required by Section 8.7409. e. Documentation of the job description or signed contract. 8.7410 Rendering services according to the Person-Centered Support Plan 1 All Provider Agencies identified in the Person-Centered Support Plan shall develop a Provider Care Plan for each Member. 2. The Provider Care Plan should, at a minimum, identify the following: a. service and care needs of the Member; Provider Care Plan development date; b. Goals or Objectives of the service(s); c. A description of the specific services, supports, methodologies or interventions used to address the identified needs of the Member, written in plain language including; i. information about the Member ' s preferences ii.relevant medical information from medical and therapy providers (PCP, OT, PT, Speech, etc.)

A relicensure survey was completed on 9/16/25. Deficiencies were cited.

Based on record review and interview the residence failed to meet the required elements and had written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting 26 current residents. Findings include:On 9/15/25 at 7:45 a.m., the residence's visitation policy was requested; however, it was not provided. On 9/15/25 at 3:16 p.m., the administrator reported they did not have a visitation policy nor had restrictions on visitors. She reported the residence's doors were locked for safety, and residents had to let their visitors in by using their telephone. On 9/16/25 at 2:24 p.m., the administrator stated she expected the residence to have a policy that met the requirements in Chapter VII, Regulation 9.2 (A-H).

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 26 current residents. Findings include:On 9/15/25 at 7:45 a.m., the involuntary discharge grievance policy was requested; however, it was not provided. On 9/15/25 at 2:15 p.m., the residence provided a discharge notice letter that they gave to residents to notify of the discharge from the residence; however, the letter did not meet the required elements of Chapter VII, Regulation 9.3 (A-I). On 9/15/25 at 2:28 p.m., the administrator stated they did not have an involuntary discharge grievance policy due to always using the residences' discharge notice letter. She acknowledged the letter did not meet the required elements and stated she expected the residence to have a policy that met the requirements of Chapter VII, Regulation 9.3 (A-I).

Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises, including, but not limited to, fire(s), gas explosion, power outage, tornado, flooding, and threatened or actual acts of violence, affecting 26 current residents. Findings include:On 9/15/25 at 7:45 a.m., a risk assessment of all hazards and preparedness measures to address natural and human-caused crises was requested. However, no risk assessments were provided for fire, gas explosions, power outages, tornadoes, flooding, and threatened or actual acts of violence. On 9/16/25 at 3:26 p.m., the administrator stated that the residence did not have a risk assessment for all hazards. She stated she was aware of needing it and expected the residence to have it.

Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 26 current residents. Findings include:On 9/15/25 at 7:45 a.m., a 72-hour continuation of care policy and procedure was requested; however, it was not provided. On 9/16/25 at 3:26 p.m., the administrator stated that the residence did not have a 72-hour continuation of care policy and procedure. She stated she was aware of needing it and expected the residence to have it.

Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures, which included all required elements, affecting 26 current residents. Findings include:On 9/15/25, record review revealed the residence's emergency plans and procedures dated in March, April, May, and June of 2025 did not address all of the required elements of Chapter VII, Regulation 10.6. On 9/16/25 at 3:41 p.m., the administrator stated the residence did not have an emergency policy and procedure for a gas explosion and expected them to have one. She acknowledged that the emergency preparedness policies and procedures lacked all the required elements and expected them to meet the requirements.

Based on observation and interview, the residence failed to maintain a physically safe and sanitary environment, affecting 26 current residents. Findings include:On 9/15/25 at approximately 7:36 a.m., Resident #5 was observed ambulating with a walker out of elevator two on the third floor. On 9/15/25, during an on-site environmental tour, the following was observed:Elevator one had a warped metal floor that made a banging noise when walking across the elevator. Elevator two had flooring that was partly raised up, which created a bubble. On 9/16/25 at 7:36 a.m., the administrator agreed elevator two had raised flooring that created a "bubble" in the middle of the elevator, and it needed to be fixed. She stated it looked like someone had tried to poke the bubble to pop it, but the bubble was still there. She stated several residents had mentioned their concerns about the flooring in the elevators to her, and that she needed to talk to maintenance about getting it fixed. On 9/16/25 at 8:32 a.m., the administrator stated the residence was budgeting for the elevator floors to be fixed. The administrator stated residents had safety concerns about the elevator floor.

Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting two of four sample residents (#1 and #3). (Cross Reference U1568, U1604)Findings include:1. Resident #1 was admitted to the residence on 7/23/21. The August 2025 and September 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: ferrous gluconate, preserVision, and tamsulosin HCl. 2. Similar deficient practice was found for Resident #3. Additionally, Resident #3's MAR did not match the signed and dated practitioner orders provided. 3. InterviewOn 9/16/20 at 1:06 p.m., the wellness coordinator acknowledged they did not have all the practitioners' orders for the medications being administered by the residence. He explained that the residence received the medication orders from the practitioner, and what was listed on the MAR was correct. He stated he was unsure why they had missing orders for the medications being administered or why the MAR had not matched the practitioner's orders provided specifically for Resident #3. He stated he would expect the MAR to match the practitioner's order and to have all the practitioner's orders for medications being administered. On 9/16/25 at 3:16 p.m., the administrator explained that the residence received practitioners' orders from the practitioners, the residents had their medication list signed by the practitioner when they had a practitioner's appointment, or the residence received a signed medication list from the practitioner quarterly. The administrator stated she was aware the residence did not have all the practitioners' orders signed and dated, and would expect to have them.

Based on record review and interview, the residence failed to comply with the authorized practitioner's orders associated with medication administration, affecting one of four sample residents (#3) (Cross Reference U1530, U1604)Findings include 1. Resident #3 was admitted to the residence on 2/9/19 with a diagnosis of gastro-esophageal reflux disease without esophagitis, unspecified macular degeneration, and a pathological fracture.a. calcitonin nasal solutionA written practitioner's order dated 6/26/25 directed the residence to administer calcitonin nasal solution one spray alternating nostrils one time a day for pain-severe, give one spray daily in alternating nostrils every left, on even days, right on odd days; however, the August 2025 and September 2025 medication administration record (MAR) failed to list the medication. b. venlafaxineA written practitioner's order dated 8/28/25 directed the residence to administer venlafaxine 37.5 mg one capsule by mouth daily with breakfast; however, the August 2025 MAR failed to list the medication, and the September 2025 MAR did not administer the medication until 9/6/25.2. InterviewOn 9/16/20 at 1:06 p.m., the wellness coordinator acknowledged having a practitioner's order for calcitonin nasal solution and venlafaxine, and the medications were not on the MAR. He stated he would expect the residence to comply with the practitioner's orders. On 9/16/25 at 3:16 p.m., the administrator explained that the residence received practitioners' orders from the practitioners, the residents had their medication list signed by the practitioner when they had a practitioner's appointment, or the residence received a signed medication list from the practitioner quarterly. On 9/16/25 at 3:35 p.m., the administrator stated she was unaware the residence had orders for medications,and the medications were not on the MAR. She stated being unsure if the residence was complying with the practitioner's orders and would have to review. She stated she would expect the residence to comply with the practitioner's orders.

Based on observation and interview the residence failed to ensure that qualified medication administration persons (QMAP) are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting 26 current residents. Findings include:1. ObservationDuring medication administration on 9/15/25 from 7:36 a.m. to 8:35 a.m., Staff #2 failed to perform proper hand hygiene before beginning the medication administration. Staff #2 administered medications to Resident #6 and assisted her with dressing and completing two blood pressure checks. After providing this assistance, Staff #2 did not wash their hands and proceeded to touch multiple surfaces, including doorknobs, keys, the medication cart, and also picked up a set of keys from the floor. Without performing hand hygiene, Staff #2 then administered medications to Resident #7 and Resident #8. Handwashing was not performed between residents. 2. InterviewOn 9/15/25 at approximately 8:48 a.m., the administrator explained that when a QMAP administered medications, they were expected to wash their hands with soap and water and sanitize in between residents. She confirmed that staff had been trained in nationally recognized protocols for basic infection control and prevention when preparing and administering medications. On 9/15/25 at 9:00 a.m., Staff #2 acknowledged that she did not wash her hands before starting medication administration at 7:36 a.m., nor after passing medications to Residents #6-#8. She stated she would expect to wash her hands in the resident's apartment after passing the medication and to use hand sanitizer. Staff #2 confirmed she had been trained in nationally recognized protocols for basic infection control and prevention when preparing and administering medications.

Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records on a quarterly basis, affecting 26 current residents. Findings includeOn 9/15/25 at 7:45 a.m., documentation of the last two quarterly medication administration record audits was requested; however, they were not provided. On 9/15/25 at 2:31 p.m., the administrator stated she would review a weekly printout of the late medications, refusals, and medications unavailable with staff. She stated that neither she nor the wellness coordinator had kept any documentation of the medication audits, and were expected to. On 9/15/25 at 3:08 p.m., the wellness coordinator confirmed that a report, which included late medications, refusals, and medications unavailable, would be pulled from their electronic system and reviewed with staff. He confirmed that they did not keep documentation of the audit.

Based on record review and interview, the residence failed to ensure two individuals who were qualified medication administration persons (QMAP), nurses, or practitioners jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting two of the seven sample residents prescribed controlled substances (#2-#3). Findings include:1. Record ReviewA review of the controlled substance count sheets revealed the following:8/28/25 at 6:00 a.m., no signature for incoming staff. 8/28/25 at 7:30 a.m., no signature for outgoing staff. 8/28/25 at 10:00 p.m., no signature for outgoing staff. 8/29/25 at 10:00 p.m., no signature for incoming staff. 2. InterviewOn 9/15/25 at 12:41 p.m., the wellness coordinator acknowledged the lack of two signatures on 8/28-8/29/25 and stated he expected two QMAPs or a QMAP and the nurse to jointly count all the controlled substances at the beginning and end of each shift and sign off. On 9/16/25 at 3:39 p.m., the administrator stated she expected two qualified medication administration personnel (QMAP) to jointly count and sign off at the beginning and end of their shift to confirm the controlled substance count. She reported being unaware that this was not always being done.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residencewas advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter VII.7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including, but not limited to the following, as applicable: 2) Proof of portable training(s) accepted by the assisted living residence, including documentation of the acceptance conditions at Part 7.9(D) being met. 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. 12.10 Each resident care plan shall: (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs; 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. 18.8 Resident records shall contain, but not be limited to, the following items: (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. 22.32 The assisted living residence shall ensure that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other.

A certification revisit was completed on 7/20/23 for previous deficiency cited on 9/28/22. The facility is in compliance with all regulations surveyed.

A licensure revisit was completed on 7/20/23 for all previous deficiencies cited on 9/28/23. The residence is in compliance with all regulations surveyed.

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