GRANVILLE ASSISTED LIVING CENTER, THE

A revisit survey was completed on 3/25/26 for all previous deficiencies cited on 11/5/25. 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 11/5/25. No deficiencies were cited

A relicensure survey was completed on 11/5/25. Deficiencies were cited.

Based on interview and record review, the residence failed to review annually and update policies and procedures, affecting 109 current residents. Findings include: The involuntary discharge policy and visitation policy were requested but could not be provided by the residence. On 11/5/25 at approximately 2:30 p.m., the administrator stated that the residence failed to have a policy for involuntary discharge and visitation. He acknowledged he was unaware of new regulation changes.

Based on record review and interview, the residence failed to have a roster of current residents readily available, affecting 109 current residents. Findings include:On 11/5/25 at 7:00 a.m., the residence was asked to provide a resident roster with all current residents. However, a resident billing census had been provided by the receptionist. On 11/5/25 at 7:47 a.m., an outdated resident roster was provided by the accounting/marketing department. On 11/5/25 at 8:30 a.m., an outdated resident roster was provided by the Resident Services Director (RSD) no diagram was provided. On 11/5/25 at 2:10 p.m., the administrator acknowledged that the residence failed to maintain an up-to-date, readily available resident roster that included room assignments, emergency contacts, and a facility diagram showing room locations, available to all staff members.

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 109 current residents. Findings include:On 11/5/25, at approximately 7:45 a.m., all emergency preparedness documents were requested. On 11/5/25 at 9:25 a.m., an emergency binder was provided, but a policy or procedure could be provided on risk assessments and preparedness measures to address natural and human-caused crises. On 11/5/25 at approximately 1:25 p.m., the administrator was unable to find emergency preparedness documents, which included a risk assessment of all hazards and preparedness measures to address natural and human-caused crises. On 11/5/25 at 2:15 p.m., the administrator stated that there is no risk assessment of all hazards and preparedness measures to address natural and human-caused crises that include gas explosion, power outage, tornado, flooding, and threatened or actual acts of violence.

Based on record review and interview, the residence failed to develop written policies to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, including, but not limited to, a long-term power failure, affecting 109 current residents. Findings IncludeOn 11/5/25 at approximately 9:15 a.m., the residences 72 hour continuation of care policy was requested and not recieved. On 11/5/25 at approximately 1:00 p.m., Staff #4 and #5 stated that the staff did not receive training on the appropriate procedures to follow in the event of a long term power failure, which resulted in residents who rely on portable oxygen being left without access to this essential resource. Furthermore, no designated location was established for evacuation in the event that residents needed to leave the premises. On 11/5/25 at 2:15 p.m., the administrator acknowledged the failure to have a plan for relocating residents in the event of an emergency or prolonged power failure. He stated that he had previously had a contract with a location; however, this contract has not been updated in approximately ten years.

Based on record review and interviews the residence failed to identify the highest potential risk, hold, and document routine drills to facilitate staff and resident response to that risk, affecting 109 residents. Findings include: On 11/5/25 at 9:25 a.m., the residences risk assessment for the highest potential emergency risk and the documented drills for those risks was requested; however, the risk assessment that had been provided was dated for 2021 and no drills had been conducted or documented. On 11/5/25 at approximately 1:15 p.m., the administrator acknowledged that an updated risk assessment had not been completed and routine drills for those risks had not been conducted or documented.

Based on record review and interviews, the residence failed to have emergency policies addressing all required elements, affecting 109 current residents. Findings include: On 11/5/25 at 9:20 a.m., the emergency plans, policies, and procedures were requested however they did not include updated policies. The emergency preparedness binder did not include a predetermined means of communicating with residents, families, staff and other providers, storage and preservation of medications, protection and transfer of health information as needed to meet the care needs of residents, and written agreements with other health facilities and/or community agencies. On 11/5/25 at 2:15 p.m., the administrator stated that he had a contingency written contract about 10 years ago, but has failed to update it. He acknowledged that he was not prepared to provide 72 hours of continuous care to residents in an emergency.

THIS 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 program regulations found at 6 CCR 1011-1, Chapter 7.18.9 The face sheet shall be updated at least annually and contain the following information: (K) Resident ' s current diagnoses

A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 3/23/23. 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 9/19/23 for all previous deficiencies cited on 3/23/23. 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 3/23/23. A deficiency was cited.

Based on interview and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting four of nine sample participants (residents) (#1, #2, #5, #7). Findings include:1. Residence PoliciesThe residence's Medication Documentation policy, dated 2020, read, in part, "Upon administration of medications, the qualified medication administration person (QMAP) must document immediately in the electronic medication administration record (eMAR)."2. Chapter VII regulations governing assisted living residences, part 14.21, requires the assisted living residence to be responsible for complying with authorized practitioner orders associated with medication administration.a. Resident #1 was admitted to the residence on 3/7/21 with diagnoses including anemia and kidney disease. A written practitioner's order, dated 3/15/23, directed the residence to administer potassium chloride 10 meq once daily. However, the March 2023 eMAR for Resident #1 read the medication was not available and not in stock on 3/17-3/20/23, for a total of four missed doses. A written practitioner's order, dated 3/15/23, directed the residence to administer ferrous sulfate 325 mg once daily. However, the March 2023 eMAR for Resident #1 read the medication was not available and not administered on 3/16-3/17/23, for a total of two missed doses. A written practitioner's order, dated 3/15/23, directed the residence to administer lisinopril 2.5 mg once daily. However, the March 2023 eMAR for Resident #1 read the medication was not available and not administered on 3/17/23.b. Resident #2 was admitted to the residence on 9/17/21 with diagnoses including gastrointestinal reflux disease. A written practitioner's order, dated 11/1/22, directed the residence to administer esomeprazole 40 mg twice daily. However, the March 2023 eMAR for Resident #2 read the medication was available and not in stock on 3/4-3/6/23, for a total of six missed doses.c. InterviewsOn 3/23/23 at approximately 3:00 p.m., the medication coordinator (MC) stated if staff documented on a residents eMAR that a medication was not in, that meant the medication was not available. The MC said that the pharmacy delivered medications within two days of the order being sent. She acknowledged that the medications for Resident #1 and #2 were not administered, as required. On 3/23/23 at approximately 3:30 p.m., the administrator said she expected qualified medication administration persons (QMAPs) to administer medications to residents, as ordered and to not run out. 3. Chapter VII regulations governing assisted living residences, part 14.33, requires the assisted living residence to ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of a resident's pattern of refusal.a. Resident #5 was admitted to the residence on 1/17/17. A written practitioner's order, dated 5/11/22, directed the residence to administer ultra fresh(eye)ointment once daily. However, the March 2023 electronic medication administration record (eMAR) read the resident refused the medications on 3/2,3/4,3/9,3/11-3/12, and 3/14-3/17,23, for a total of nine refused doses. A written practitioner's order, dated 10/26/21, directed the residence to administer latanopost solution .0005% once daily. However, the March 2023 electronic medication administration record (eMAR) read the resident refused the medications on 3/17,23, for a total of one refused dose. A written practitioner's order, dated 4/6/22, directed the residence to administer omeprazole 20 mg once daily. However, the March 2023 electronic medication administration record (eMAR) read the resident refused the medications on 3/2-3/9,3/11-3/12, and 3/14-3/16/23, for a total of 13 refused doses. A written practitioner's order, dated 4/6/22, directed the residence to administer fluoxetine20 mg once daily. However, the March 2023 electronic medication administration record (eMAR) read the resident refused the medications on 3/2-3/9, and 3/11-3/13, for a total of 11 refused doses.b. Resident #7 was admitted to the residence on 4/4/22. A written practitioner's order, dated 4/6/22, directed the residence to administer diclofenac sodium gel four times a day. However, the March 2023 electronic medication administration record (eMAR) read the resident refused the medications on 3/14-3/18,3/20, and 3/22/23, for a total of 12 refused doses. 4. Chapter VII regulations governing assisted living residences, part 14.29, requires each QMAP, nurse, or practitioner to accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Resident #5 was admitted to the residence on 1/17/17 with diagnoses including unspecified dementia and asthma. A written practitioner's order, dated 4/6/22, directed the residence to administer artificial tears one drop in each eye once daily. However, the March medication administration record (MAR) contained no documentation on 3/19/23, for a total of one missed dose. A written practitioner's order, dated 4/6/22, directed the residence to administer calcium vitamin d 600 mg once daily. However, the March medication administration record (MAR) contained no documentation on 3/19/23, for a total of one missed dose. A written practitioner's order, dated 4/6/22, directed the residence to administer fluoxetine 20 mg once daily. However, the March medication administration record (MAR) contained no documentation on 3/19/23, for a total of one missed dose. On 3/23/23 at approximately 3:30 p.m., the administrator stated she expected the eMARs for residents to be accurate with no blank spaces. 5. Additional InterviewsOn 3/23/23 at 11:10 a.m., the medication coordinator stated Residents #5 and #7 had a pattern of refusing medications. She added, she was not aware if the practitioner was notified of the refusals for both residents. On 3/23/23 at approximately 3:30 p.m., the administrator stated she expected QMAP staff to notify the resident's practitioner after they refused their medications at least two times.

THIS 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 program regulations found at 10 CCR 2505-10 8.400.8.495.2 B. 1. An assessment will be conducted prior to admission, annually, and whenever there is a significant change in physical, cognitive, or behavioral needs, or as requested by the participant. The annual assessment must be completed by the team outlined in 10 CCR 2505-10, Sections 8.495.2. B.8.495.6F. Care Plan 1. The following information must be documented in the Care Plan:c. Any other special health or behavioral management needs that supports the participant ' s individual needs.iii. Any modifications to the participants rights, with the required supporting documentation

A relicensure survey was completed on 3/23/23. Deficiencies were cited.

Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, affecting 8 of 10 sample residents (#1-#4, #6-#8, #10). Findings include:1. References a. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult."b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 18 years of age or older and meets one or more of the following criteria: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Record Reviewa. StaffPersonnel files for Staff #3, #4 and #6 revealed they were hired on 8/26/16, 5/22/13 and 1/24/23, respectively. Review of the personnel files for Staff #3, #4 and #6 revealed no evidence a CAPS check had been completed. Review of the staff schedule for March 2023 revealed the following Staff #3, #4 and #6 worked a the residence as follows:Staff #3 worked on 3/9-3/14, 3/16/ and 3/19-3/21/23. Staff #4 worked on 3/6-3/9, 3/12-3/16 and 3/19-3/23/23. Staff #6 worked on 3/7-3/8, 3/12, 3/15-3/15, 3/19 and 3/21-3/22/23. b. ResidentsResident #1 was 94 years old. Resident #2 was 80 years old with diagnoses including dementia and bipolar. Resident #3 was 75 years old. Resident #4 was 81 years old with diagnoses including mild cognitive impairment. Resident #6 was 85 years old. Resident #7 was 95 years old. Resident #8 was 73 years old. Resident #10 was 84 years old. 3. InterviewOn 3/23/23 at approximately 3:30 p.m., the administrator was aware the day of the onsite visit on 3/23/23 that Staff #3, #4, and #6 did not have CAPS checks. She said CAPS checks should have been initiated prior to hire.

Based on record review and interview, the residence failed to ensure a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI) was obtained prior to hire, for seven of eight sample staff (#1-#3, #5-#8), affecting 114 current residents. Findings include:1. Record ReviewPersonnel files for sample staff revealed they were hired on the following dates:Staff #1 was hired on 9/2/21Staff #2 was hired on 1/11/22Staff #3 was hired on 8/26/23Staff #5 was hired on 2/14/23Staff #6 was hired on 1/24/23Staff #7 was hired on 11/10/20Staff #8 was hired on 8/2/22Staff #1-#3 and #5-#8's personnel files did not include any evidence that a name-based criminal history report had been obtained by the CBI.Review of the staff schedule for March 2023 revealed:Staff #1 worked on 3/6-3/11, 3/13-3/18 and 3/20-3/23/23. Staff #2 worked on 3/8-3/9, 3/16-3/17 and 3/23/23. Staff #3 worked on 3/9-3/14, 3/16/ and 3/19-3/21/23. Staff #5 worked on 3/9-3/12, 3/16-3/19 and 3/23/23. Staff #6 worked on 3/7-3/8, 3/12, 3/15-3/15, 3/19 and 3/21-3/22/23. Staff #7 worked on 3/7-3/8, 3/14-3/15 and 3/21-3/22/23. Staff #8 worked on 3/10-3/12 and 3/17-3/19/23. 2. InterviewOn 3/23/23 at approximately 3:30 p.m., the administrator stated she was aware a CBI was required to be completed on staff prior to hire.

Based on observation and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 114 current residents. Findings include: 1. Residence PoliciesThe residence's Cardiopulmonary Resuscitation policy dated January 2019 read, in part: "This assisted living residence places a list of all staff who have current certification in first aid or CPR in a visible location so that the information is readily available to staff at all times." On 3/23/23 at 8:08 a.m., Staff #3 stated a list of staff who had current certification in first aid and CPR used to be posted in the medication room, and she acknowledged there was not one posted during the on-site visit. On 3/23/23 at approximately 1:10 p.m., Staff #4 stated, "It's not posted anywhere."On 8/25/22 at 11:40 a.m., the medication coordinator stated she was aware of the requirement to post a list of staff with current first aid and CPR certification in a visible location, but the residence did not have it posted. On 3/23/23 at 3:33 p.m., the administrator stated she was aware of the requirement to post a list of staff with current first aid and CPR certification in a visible location, and she confirmed that it was not posted.

Based on record review and interview, the residence failed to have a readily available roster of current residents with their emergency contact information, affecting 114 residents. Findings include: On 3/23/23 at approximately 7:30 a.m. a roster of the current residents was requested. On 3/23/23 at approximately 8:30 a.m., a list of residents was provided. However, the list did not include the residents' emergency contact information, along with a facility diagram. On 3/23/23 at approximately 9:30 a.m., the coordinator was asked to provide the resident roster that included current residents, their room number and emergency contact information, along with a facility diagram showing room locations. However, none was provided. On 3/23/23 at 10:55 a.m., the coordinator stated the residence had resident emergency contact information on each resident's face sheet and had a facility diagram showing room locations in the emergency book. However, the coordinator said there was no document that had residents' names, room assignments, emergency contact information as well as a facility diagram showing room locations. On 3/23/23 at approximately 3:35 p.m., the administrator stated she was aware of the above referenced requirements, however, she added "I just did not get a chance to update" the resident roster.

Based on record review and interview, the residence failed to ensure the grievance policy contained all required contact information, affecting 114 residents. Findings include: The residence's posted Grievance Procedure did not contain any contact information for the advocacy services of the area's agency on aging and the Colorado Department of Health Care Policy and Financing. On 3/23/23 at 3:43 p.m., the administrator stated she was not aware the required contact information was not included on the grievance policy, and stated she would need to update it.

Based on record review and interview, the residence failed to ensure the written policy regarding allegations of abuse, neglect, or exploitation contained all the required elements, affecting 114 residents. Findings include: The residence's Abuse Investigations Guideline policy, dated January 2019, did not include information regarding how the residence would document investigations to provide evidence that a thorough investigation was conducted. The policy also did not include a requirement that a copy of the report with the investigation findings would be retained and available for department review. On 3/23/23 at 3:33 p.m., the administrator acknowledged the residence's Abuse Investigations Guideline policy did not contain the required information.

Based on observation and interview, the residence failed to develop and implement a policy for investigation of injuries with unknown origin affecting 114 residents. Findings includeOn 3/23/23 at approximately 8:50 a.m., the residence's policy on investigating injuries with unknown origin was requested from the administrator. However, the administrator was unable to provide the requested policy. On 3/23/23 at approximately 3:30 p.m., the administrator stated she was responsible for all policy updates. The administrator acknowledged the residence's policy for investigation of injuries with unknown origin was not provided. She stated she was aware the residence was required to have a policy for investigating injuries of unknown origin and added she may have forgotten to provide the policy. She stated the policy for investigating injuries of unknown origin was to complete an incident report, report the injury to the practitioner, notify the family, document what steps were taken and implement interventions for the resident. The administrator stated she would provide the residence's policy. However, a policy was not provided.

Based on observation, interview and record review, the residence failed to ensure all bathtubs/shower floors had proper safety features to prevent slips and falls, affecting five of eight sample residents (#1, #3, #5, #9-#10). Findings include:1. ObservationsOn 3/23/23 at approximately 2:00 p.m., an environmental tour of Resident #1, #3, #5 and #9-10's bathroom shower floors revealed none had any safety features to prevent slips and falls. On 3/23/23 at approximately 2:30 p.m., Resident #9 was seated in his recliner with his left arm in a sling. 2. Record ReviewResident #9 was admitted to the residence on 2/8/22 with diagnoses including mononeuropathy (nerve damage) of upper limb, history of TIA's (transient ischemic attack) and pain/stiffness in left shoulder. Resident #1 was admitted to the residence on 3/7/21 with diagnoses including falls, macular degeneration, fatigue, urinary incontinence, muscle weakness and shortness of breath. An incident report in Resident #1's record read on 3/22/23 Resident #1 fell in her bathroom. 3. InterviewsOn 3/23/23 at 2:30 p.m., Resident #9 stated he took showers independently. On 3/23/23 at approximately 3:30 p.m., the administrator said she was not aware the shower floors of Resident #1, #3, #5 and #9-10 did not have safety features to prevent slips and falls. The administrator acknowledged that Resident #9 should have a safety feature to prevent him from falling on the floor.

THIS 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 program regulations found at 6 CCR 1011-1, Chapter 7.6.8 The administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(J) Complying with all applicable federal, state, and local laws concerning licensure and certification. 7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties;(F) Tuberculin test results, if applicable. 7.13 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee's or volunteer's personnel file:(A) Documentation that the individual's name appears on the Department's list of individuals who have successfully completed the medication administration competency evaluation. 11.15 In the event a resident is transferred to another health care entity for additional care, the assisted living residence shall arrange to evaluate the resident prior to re-admission or discharge the resident in accordance with the discharge procedures specified below. 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 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. 13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(D) The right to choice and personal involvement regarding care and services, including:(1) The right to be informed and participate in decision making regarding care and services, in coordination with family members who may have different opinions. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 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.(A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.(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. 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of:(B) A resident's pattern of refusal.