CALEY RIDGE ASSISTED LIVING COMMUNITY

A certification complaint, prompted by #CO41848 and #CO41824, was completed on 3/11/26. Deficiencies were cited.

Based on interview and record review, the facikity (residence) failed to ensure residents had the right to be free of sexual abuse, affecting two out of four current sample members (residents) (#1). Specifically, Resident #1,was admitted to the residence on 4/28/22 with diagnoses of insomnia and hypertension. Resident #1 contacted local police and stated Staff #2 had sexually assaulted her on 3/4/26 during the overnight shift. The resident had previously requested that no male staff enter her room after 10:00 p.m. and expressed a preference for female caregivers during night shifts. A documented statement dated 2/18/26 reflected this request however was not signed until 3/5/26 , which the residential care director noted and communicated to the night care team via text message on 2/18/26; however, Staff #2 (a male staff) continued to enter her room alone during overnight shifts despite the request and a posted sign outside her door instructing staff not to enter after the nighttime medication pass. Resident #1 stated Staff #2 had unrestricted access to the building and resident rooms during the night shift and frequently entered her room after she received her scheduled medications. She further reported that she believed Staff #2 administered additional medication while she was partially asleep. She stated that she would wake in unusual positions, notice items in her room had been moved, and experience unexplained vaginal, rectal, and neck pain prior to the incident reported on 3/4/26. Resident #1 stated that she believed the sexual abuse occurred on multiple occasions and contacted law enforcement on 3/4/26 after concluding that Staff #2 had sexually assaulted her more than once. After she filed a complaint with the local police Resident #1 was transported to the emergency room, where a specialized, voluntary medical forensic examination was completed by a Sexual Assault Nurse Examiner (SANE). The physician reported that the examination findings were consistent with sexual assault and Resident #1 sustained extensive trauma consistent with sexual assault, as well as blunt force trauma to the neck consistent with strangulation. The physician stated that Resident #1 was cognitively intact, provided consistent accounts identifying Staff #2 as the alleged perpetrator, and reported the assaults may have occurred on prior overnight shifts when Staff #2 was assigned to work. A staff schedule confirmed that Staff #2 worked overnight shifts from 10:00 p.m. to 6:00 a.m. from 3/1 through 3/4/26, and the administrator confirmed that Staff #2 worked his final shift on 3/4/26 before the residence placed him on administrative leave pending the internal investigation. Findings include:1. Record review:Resident #1 was admitted to the residence on 4/28/22 with diagnoses of insomnia and hypertension. A staff schedule for March 2026 showed that Staff #2 worked from March 1 through March 4, 2026, from 10:00 p.m. to 6:00 a.m. The administrator confirmed that Staff #2 worked his final shift on 3/4/26 and was then placed on administrative leave pending completion of the internal investigation. On 3/11/26 at 12:22 p.m., the residential care director shared a text message dated 2/18/26 at 9:24 p.m., that read, " Hello team, it has come to my attention that 331 (Resident #1) does not want a male caregiver after 10:00 p.m., helping or entering her room. Kindly help each other at night if you see her call light, even if you're not assigned. I believe I can count on you to accommodate her request. Thank you". A documented statement, dated 2/18/26, signed on 3/5/26, stated that Resident #1 expressed a preference for female caregivers during night shifts. Request noted by the residential care director and communicated to night care team via text message. 2. Observation:On 3/11/26 at 8:12 a.m., during an environmental tour, it was observed that Resident #1 had a sign outside her door that read, "please do not enter residents apartment after 10 p.m. med pass". 3, Interviews:On 3/11/26 at approximately 10:30 a.m., the physician stated that the hospital completed a SANE examination on Resident #1 on 3/4/26. The physician reported that the examination findings were consistent with sexual abuse and documented that Resident #1 sustained extensive trauma consistent with sexual assault, as well as blunt force trauma to the neck consistent with strangulation. The physician further stated that this was one of the worst cases of elderly sexual assault she had seen. The physician stated that Resident #1 was cognitively intact and provided varying accounts of the alleged sexual assault while consistently identifying Staff #2 as the alleged perpetrator. The physician further reported that Resident #1 stated this was not the first occurrence and alleged that, after receiving her 10:00 p.m. medication, Staff #2 would enter her room later in the night and administer an additional medication. On 3/11/26 at approximately 12:15 p.m., the RCD stated that staff informed her on 2/18/26 that Resident #1 did not want males in her room after 10:00 p.m. She further stated that she sent a text message to six staff members communicating this information. The RCD acknowledged that she did not follow up on the matter after being informed. On 3/11/26 at approximately 3:00 p.m., during a phone interview, Resident #1 reported concerns regarding Staff #2 and stated that he had access to keys to the building and entered hallways and resident rooms during the night shift without restriction. Resident #1 stated that Staff #2 frequently worked overnight, that other staff went downstairs during the shift, and that Staff #2 appeared to have free access throughout the residence without supervision. Resident #1 stated that she initially trusted Staff #2 and spoke with him because she felt lonely and did not have others to talk to. She reported that Staff #2 shared personal stories about living in his car, being gang affiliated, and later staying in an apartment with his brother. Resident #1 stated she encouraged him to improve his life and initially felt proud of him but later believed his behavior toward her changed. Resident #1 reported that Staff #2 began entering her room alone at night to administer medications and remained in the room to talk. Resident #1 stated she later became uncomfortable with him entering her room and requested that only female staff provide care. Resident #1 stated she informed staff, including the RCD, that she did not want Staff #2 in her room; however, Staff #2 continued to enter her room after medication pass. Resident #1 stated a sign was placed on her door requesting that no one enter after her 10:00 p.m. medications, but Staff #2 continued to enter her room during the night. Resident #1 reported that after Christmas, Staff #2 no longer interacted with her in the same manner but continued to enter her room alone during the overnight shift. She stated that she began noticing items in her room had been moved during the night, including objects on her nightstand and the position of her recliner chair, despite having no recollection of moving them. Resident #1 further reported waking in different or slumped positions in her recliner, which she stated was unusual for her. She stated that her recliner and surrounding objects were often found moved or disheveled. Resident #1 reported that she believed this occurred during the sexual assaults and stated that the force used pushed her recliner back into the wall. Resident #1 reported that for approximately one week prior to 3/4/26 she experienced pain in her vaginal and rectal areas. She stated that several days before 3/4/26, she told Staff #1 that she believed Staff #2 was sexually abusing her on the nights he worked. Resident #1 also reported to Staff #1 that she was experiencing neck pain, numbness on the left side of her face, and pain along the left carotid artery, which she later reported to medical staff at the hospital for evaluation. Resident #1 reported that she believed Staff #2 administered additional medication after her scheduled nighttime medications. Resident #1 stated she did not recognize the pill and reported that Staff #2 placed the medication in her mouth while she was partially asleep and gave her a drink. Resident #1 stated she normally received Ambien and Dilaudid at night but believed another medication had been given on multiple occasions. Resident #1 reported waking at approximately 3:00 a.m. at times and recalling that Staff #2 was in her room. Resident #1 stated she placed tape on her attends diaper and attempted to monitor her surroundings because she believed something was occurring while she slept. Resident #1 reported that clothing and blankets were found moved or pulled up when she woke up and stated she did not believe she had moved them herself. Resident #1 stated she contacted law enforcement after putting the events together and believing Staff #2 had sexually assaulted her on multiple occasions. Resident #1 stated that Staff #2 had unrestricted access to the building and reported that she was fearful he could return because he knew how to enter the residence. She became tearful during the interview and expressed strong fear and distress, stating she was afraid he would do the same thing to another resident. Resident #1 reported that the abuse occurred during the overnight shift and that she believed it had happened on prior occasions before 3/4/26. She stated that she contacted the police on 3/4/26 because she did not want the abuse to happen again to her or to anyone else in the residence. Resident #1 further stated that she had been struggling with nightmares and flashbacks related to the abuse since around Christmas and could no longer handle the emotional impact. Resident #1 stated that prior to reporting the incident, she repeatedly asked staff not to allow Staff #2 in her room, but the staff did not follow her requests. Resident #1 also stated that her physical discomfort improved on the days that Staff #2 was not working at the residence. On 3/11/26 at approximately 3:30 p.m., the administrator stated that the investigation regarding Resident #1 was incomplete. The administrator demonstrated an apathetic demeanor regarding the seriousness of this investigation. She reported the difficulty obtaining information from the hospital related to the SANE exam results and stated that the police report findings could take up to 6 months. She further indicated that she had been very busy investigating another incident that happened in the residence. During the interview the administrator was provided information regarding the SANE exam results that she had not previously obtained from the hospital. Upon learning the results of the SANE exam and that Resident #1 was sexually abused and had blunt force trauma to the neck consistent with strangulation, her demeanor changed, and she became tearful. On 3/11/26 at 3:58 p.m., a call was placed to Staff #1 to obtain an interview regarding Resident #1 ' s investigation. Staff #1 did not answer, a voicemail was left, and Staff #1 did not respond to the voicemail. On 3/11/26 at 6:22 p.m., the administrator stated that she was unsure whether Resident #1 had experienced harm because the investigation had not yet been completed. She stated that she immediately initiated the investigation on 3/4/26; however, she did not know the results of the SANE examination nor the full extent of the alleged sexual abuse. The administrator further stated that, based on the information she had received regarding the alleged assault, she would consider the incident to involve harm.

Based on interview and record review, the facility (residence) failed to provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities affecting 102 current members (residents). Findings Include: 1. Record Review:On 3/11/26 at 8:34 a.m., the following items were requested from the residence:Access to electronic health records (EHR)Staff Schedule, December- Current 2026Incident/Internal Investigations, last 90 daysMedication audits Dec 25 - CurrentQMPs Dec-CurrentAbuse/Neglect investigations, last 90 daysOn 3/11/26 at 10:40 a.m., the residence provided the abuse policy/procedure, two hours and six minutes after the request. On 3/11/26 at 10:41 a.m., access to EHR was provided, two hours and seven minutes after the request. On 3/11/26 at 11:04 a.m., five personnel files were requested from the residenceOn 3/11/26 at 11:37 a.m., five more personnel files were requested from the residence, totaling ten. On 3/11/26 at 12:06 p.m., a second request was submitted to the residence for the following items with a 12:30 p.m. deadline:Medication audits December 2025 to current. Quality Monitoring Program (QMP) from December 2025 to current. Abuse/Neglect investigations, last 90 days. On 3/11/26 at 12:46 p.m., an email was submitted to the residence due to the requested items due at 12:30 p.m. and had not been received. On 3/11/26 at 12:46 p.m., the residence provided QMPs. This was four hours and twelve minutes after the original request and after the third email request. On 3/11/26, at 1:02 p.m., the residence provided medication cart audits. The administrator stated the residence had no medication audits. On 3/11/26 at 1:30 p.m., the residence provided three personnel files, four hours and fifty minutes after the original request. On 3/11/26 at 1:39 p.m., the residence provided one personnel file, five hours and five minutes after the original request. On 3/11/26 at 2:00 p.m., the residence provided one personnel file, five hours and twenty-six minutes after the original request. On 3/11/26 at 3:14 p.m., an email was sent to the administrator requesting the outstanding personnel files. On 3/11/26 at 3:14 p.m., a follow-up email was sent to the residence requesting missing items from collected personnel files. On 3/11/26 at 3:59 p.m., the administrator responded that there were no CAPs for the residential care provider, seven hours and fifteen minutes after the original request. On 3/11/26 at 4:05 p.m., one personnel file was provided, seven hours and thirty-six minutes after the original request. On 3/11/26 at 4:16 p.m., one personnel file was provided, seven hours and forty-seven minutes after the original request. On 3/11/26 at 4:35 p.m., one personnel file was provided, eight hours and one minute after the original request. On 3/11/26 at 4:53 p.m., one personnel file was provided, seven hours and thirty-six minutes after the original request. On 3/11/26 at 4:54 p.m., a follow-up email was sent to the administrator and requested items that were still outstanding, which included missing items from the personnel file of staff #7, Policy on background checks, blank resident agreement, and items missing from Staff #8 ' s personnel file. Requested items by 5:15 p.m. On 3/11/26 by 5:18 p.m. requested items had been received, which was eight hours and forty-four minutes after the original request. 2. InterviewOn 3/11/26 at approximately 6:15 p.m., the administrator stated they were aware of the requirement that the residence shall provide documentation upon request. The administrator stated between their revolving door, making copies, and being one person, they got them as fast as they could.

Based on record review and interview, the facility (residence) failed to develop policies and procedures regarding the hiring of any staff member whose criminal history records did not reveal good, moral, and responsible character that could pose a risk to the health, safety, and welfare of the residents. Eight staff members were sampled; one staff member was identified as a concern, staff #2, affecting 102 current members (residents). Findings Include: 1. Record review:On 3/11/26 at 8:34 a.m., the residence ' s background checks policy was requested and reviewed. The policy did not include policy or procedures regarding the continued service of a staff member whose criminal history records could pose a risk to the health, safety, or welfare of the residents. On 3/11/26, the personnel file for staff #2 revealed they were a qualified medication administration person (QMAP), hired on 9/10/25. The personnel file revealed a background check dated 9/4/25, read Staff #2 was arrested on 12/22/2009 for a misdemeanor, trespassing. 2. Interview: On 3/11/26 at 1:39 p.m., the administrator stated they were not aware of the background check policy requirements regarding the need for policy and procedures for continued service for those hired with a criminal record.

Based on observations, records review, and interviews, the facility (residence) failed to ensure each members (resident ' s) care plans were detailed with specific personal needs and the staff tasks necessary to meet those needs, affecting three of six sampled residents (#2, #5, and #6). Record Review:Resident #2 was admitted on 4/1/25 with a diagnosis of heart disease, heart failure, diabetes type II, kidney disease, and hypertension. Last assessment was completed on 8/27/25; last care plan modification was 8/27/25. Resident #2 has had falls on 10/3/25, 3/1/26, and 3/6/26 with no updates on their care plan to reflect increased fall risk or staff tasks necessary to meet Resident #2 ' s needs. Resident #5 was admitted on 7/12/25 with a diagnosis of anxiety disorder and insomnia. The recent care plan did not address the specific needs of insomnia and anxiety or staff tasks that are necessary to meet Resident #2 ' s needs. Resident #6 was admitted on 4/6/2018 with a diagnosis of developmental disabilities and depression. Last care plan modification was 11/23/25. Care plan does not address individualized needs regarding their developmental disability and staff tasks necessary to meet Resident #6 ' s needs. Interview: On 3/11/26 at approximately 6:20 p.m., the administrator acknowledged that preferences and staff tasks were not in all resident care plans. On 3/11/26 at approximately 2:15 p.m. Resident care director stated they assisted with updating the care plans and acknowledged they were not updated.

Based on record review and interviews, the residence failed to ensure the right to choice and personal involvement regarding care and services, affecting three of five sample residents (#1, #2, #4). Findings:1. Record Review:On 2/18/26, Resident #1 requested that only female staff members be in Resident #1 ' s room after 10:00 p.m. The staff schedule for February 2026 was reviewed; male staff members remained on the night shift as care providers. On 3/11/26 at approximately 12:30 p.m., the residential care director (RCD) sent a text message dated 2/18/26 to five of 20 staff members, which stated Resident #1 wants only female caregivers after 10:00 p.m., helping Resident #1, or entering Resident #1 ' s room. On 3/11/26, at 11:50 a.m., Resident #2 ' s care plan was reviewed. The fall management care plan had not been developed, regardless of Resident #2 ' s multiple falls. 2. Interviews:On 3/11/26, Resident #1 stated male staff member continued to go into the room after 10:00 p.m. and provided care with no other staff member in the room. On 3/11/26 at approximately 6:40 p.m., the administrator acknowledged Resident #1 should have the choice to have female only staff member provide care. The administrator also stated that they felt the resident care director sent a text to the staff. The resident care director should have gone to the administrator immediately. On 3/11/26 at approximately 12:15 p.m., the RCD stated that on 2/18/16, a staff member informed them that Resident #1 did not want males in the room after 10:00 p.m. during the night shift; RDC stated a text was sent out to the night care team by text. Similar deficiencies occurred with Resident #4.

Based on the interview and record review, the facility (residence) failed to ensure staff documented in progress notes all out-of-the-ordinary events or issues that affect the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address the member's (resident's) changing needs, affecting two of the five sampled residents (#1 and #2). Findings included:2. Record ReviewOn 3/11/26 at approximately 1:30 p.m., the incident log was reviewed; Resident #2 was observed on the floor on 3/1/26 at approximately 9:45 a.m. No progress note addressed this event. On 3/11/26, at approximately 11:30 p.m., Resident #2 ' s family member provided three different concerns that were reported to the residence, which are: On 7/10/25, a family member stated that after medication distribution family located a loose pill in Resident #2 ' s room and reported to staff. On 11/2/25, the family found a pill on the floor of Resident #2 after morning medication distribution and again reported the concern to staff. On 3/6/26, two pills were found on Resident #2 ' s floor and reported again to staff, including the administrator, by email. There were no progress notes regarding these out-of-the-ordinary events. 2. Interview:On 3/11/26 at approximately 3:45 p.m., the residential care director (RCD) stated they would expect staff to enter progress notes if there were an incident, such as a fall; they acknowledged Resident #2 ' s fall on 3/1/26 was an out-of-the-ordinary event that should be documented in progress notes. On 3/11/26 at approximately 3:55 p.m., the residential care director acknowledged that medications found on the floor were reported to multiple staff members on three different occasions by family, and staff should have documented these concerns in progress notes. Similar deficiencies occurred with Resident #1.

A licensure complaint, prompted by prompted by #CO41847, #CO41823 was completed on 3/11/2026. Deficiencies were cited.

Based on interview and record review, the residence failed to provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities affecting 102 current residents. Findings Include: 1. Record Review:On 3/11/26 at 8:34 a.m., the following items were requested from the residence:Access to electronic health records (EHR)Staff Schedule, December- Current 2026Incident/Internal Investigations, last 90 daysMedication audits Dec 25 - CurrentQMPs Dec-CurrentAbuse/Neglect investigations, last 90 daysOn 3/11/26 at 10:40 a.m., the residence provided the abuse policy/procedure, two hours and six minutes after the request. On 3/11/26 at 10:41 a.m., access to EHR was provided, two hours and seven minutes after the request. On 3/11/26 at 11:04 a.m., five personnel files were requested from the residenceOn 3/11/26 at 11:37 a.m., five more personnel files were requested from the residence, totaling ten. On 3/11/26 at 12:06 p.m., a second request was submitted to the residence for the following items with a 12:30 p.m. deadline:Medication audits December 2025 to current. Quality Monitoring Program (QMP) from December 2025 to current. Abuse/Neglect investigations, last 90 days. On 3/11/26 at 12:46 p.m., an email was submitted to the residence due to the requested items due at 12:30 p.m. and had not been received. On 3/11/26 at 12:46 p.m., the residence provided QMPs. This was four hours and twelve minutes after the original request and after the third email request. On 3/11/26, at 1:02 p.m., the residence provided medication cart audits. The administrator stated the residence had no medication audits. On 3/11/26 at 1:30 p.m., the residence provided three personnel files, four hours and fifty minutes after the original request. On 3/11/26 at 1:39 p.m., the residence provided one personnel file, five hours and five minutes after the original request. On 3/11/26 at 2:00 p.m., the residence provided one personnel file, five hours and twenty-six minutes after the original request. On 3/11/26 at 3:14 p.m., an email was sent to the administrator requesting the outstanding personnel files. On 3/11/26 at 3:14 p.m., a follow-up email was sent to the residence requesting missing items from collected personnel files. On 3/11/26 at 3:59 p.m., the administrator responded that there were no CAPs for the residential care provider, seven hours and fifteen minutes after the original request. On 3/11/26 at 4:05 p.m., one personnel file was provided, seven hours and thirty-six minutes after the original request. On 3/11/26 at 4:16 p.m., one personnel file was provided, seven hours and forty-seven minutes after the original request. On 3/11/26 at 4:35 p.m., one personnel file was provided, eight hours and one minute after the original request. On 3/11/26 at 4:53 p.m., one personnel file was provided, seven hours and thirty-six minutes after the original request. On 3/11/26 at 4:54 p.m., a follow-up email was sent to the administrator and requested items that were still outstanding, which included missing items from the personnel file of staff #7, Policy on background checks, blank resident agreement, and items missing from Staff #8 ' s personnel file. Requested items by 5:15 p.m. On 3/11/26 by 5:18 p.m. requested items had been received, which was eight hours and forty-four minutes after the original request. 2. InterviewOn 3/11/26 at approximately 6:15 p.m., the administrator stated they were aware of the requirement that the residence shall provide documentation upon request. The administrator stated between their revolving door, making copies, and being one person, they got them as fast as they could.

Based on observation, record review, and interview, the residence failed to ensure that applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring a staff member (Residential Care Coordinator) who provided care to the residents, affecting 102 current residents. Findings Include: 1. Record ReviewThe personnel file for the residential care coordinator showed a hire date of 7/1/25; however, it did not include a CAPS check. 2. InterviewOn 3/11/26 at 6:18 p.m., the administrator stated that she did not have a CAPS check on the Residential Care Director (RCD). She further stated that the RCD had started working prior to her employment but that it was her goal to audit staff files, including CAPS checks.

Based on record review and interview, the residence failed to develop policies and procedures regarding the hiring of any staff member whose criminal history records did not reveal good, moral, and responsible character that could pose a risk to the health, safety, and welfare of the residents. Eight staff members were sampled; one staff member was identified as a concern, staff #2, affecting 102 current residents. Findings Include: 1. Record review:On 3/11/26 at 8:34 a.m., the residence ' s background checks policy was requested and reviewed. The policy did not include policy or procedures regarding the continued service of a staff member whose criminal history records could pose a risk to the health, safety, or welfare of the residents. On 3/11/26, the personnel file for staff #2 revealed they were a qualified medication administration person (QMAP), hired on 9/10/25. The personnel file revealed a background check dated 9/4/25, read Staff #2 was arrested on 12/22/2009 for a misdemeanor, trespassing. 1. Interview: On 3/11/26 at 1:39 p.m., the administrator stated they were not aware of the background check policy requirements regarding the need for policy and procedures for continued service for those hired with a criminal record.

Based on observations, records review, and interviews, the residence failed to ensure each resident ' s care plans were detailed with specific personal needs and the staff tasks necessary to meet those needs, affecting three of six sampled residents (#2, #5, and #6). 1. Record Review:Resident #2 was admitted on 4/1/25 with a diagnosis of heart disease, heart failure, diabetes type II, kidney disease, and hypertension. Last assessment was completed on 8/27/25; last care plan modification was 8/27/25. Resident #2 has had falls on 10/3/25, 3/1/26, and 3/6/26 with no updates on their care plan to reflect increased fall risk or staff tasks necessary to meet Resident #2 ' s needs. Resident #5 was admitted on 7/12/25 with a diagnosis of anxiety disorder and insomnia. The recent care plan did not address the specific needs of insomnia and anxiety or staff tasks that are necessary to meet Resident #2 ' s needs. Resident #6 was admitted on 4/6/2018 with a diagnosis of developmental disabilities and depression. Last care plan modification was 11/23/25. Care plan does not address individualized needs regarding their developmental disability and staff tasks necessary to meet Resident #6 ' s needs. 2. Interview: On 3/11/26 at approximately 6:20 p.m., the administrator acknowledged that preferences and staff tasks were not in all resident care plans. On 3/11/26 at approximately 2:15 p.m. Resident care director stated they assisted with updating the care plans and acknowledged they were not updated.

Based on interview and record review, the residence failed to ensure residents had the right to be free of sexual abuse, affecting one out of four current sample residents (#1). Specifically, Resident #1,was admitted to the residence on 4/28/22 with diagnoses of insomnia and hypertension. Resident #1 contacted local police and stated Staff #2 had sexually assaulted her on 3/4/26 during the overnight shift. The resident had previously requested that no male staff enter her room after 10:00 p.m. and expressed a preference for female caregivers during night shifts. A documented statement dated 2/18/26 reflected this request however was not signed until 3/5/26 , which the residential care director noted and communicated to the night care team via text message on 2/18/26; however, Staff #2 (a male staff) continued to enter her room alone during overnight shifts despite the request and a posted sign outside her door instructing staff not to enter after the nighttime medication pass. Resident #1 stated Staff #2 had unrestricted access to the building and resident rooms during the night shift and frequently entered her room after she received her scheduled medications. She further reported that she believed Staff #2 administered additional medication while she was partially asleep. She stated that she would wake in unusual positions, notice items in her room had been moved, and experience unexplained vaginal, rectal, and neck pain prior to the incident reported on 3/4/26. Resident #1 stated that she believed the sexual abuse occurred on multiple occasions and contacted law enforcement on 3/4/26 after concluding that Staff #2 had sexually assaulted her more than once. After she filed a complaint with the local police Resident #1 was transported to the emergency room, where a specialized, voluntary medical forensic examination was completed by a Sexual Assault Nurse Examiner (SANE). The physician reported that the examination findings were consistent with sexual assault and Resident #1 sustained extensive trauma consistent with sexual assault, as well as blunt force trauma to the neck consistent with strangulation. The physician stated that Resident #1 was cognitively intact, provided consistent accounts identifying Staff #2 as the alleged perpetrator, and reported the assaults may have occurred on prior overnight shifts when Staff #2 was assigned to work. A staff schedule confirmed that Staff #2 worked overnight shifts from 10:00 p.m. to 6:00 a.m. from 3/1 through 3/4/26, and the administrator confirmed that Staff #2 worked his final shift on 3/4/26 before the residence placed him on administrative leave pending the internal investigation. Findings include:1. Record review:Resident #1 was admitted to the residence on 4/28/22 with diagnoses of insomnia and hypertension. A staff schedule for March 2026 showed that Staff #2 worked from March 1 through March 4, 2026, from 10:00 p.m. to 6:00 a.m. The administrator confirmed that Staff #2 worked his final shift on 3/4/26 and was then placed on administrative leave pending completion of the internal investigation. On 3/11/26 at 12:22 p.m., the residential care director shared a text message dated 2/18/26 at 9:24 p.m., that read, " Hello team, it has come to my attention that 331 (Resident #1) does not want a male caregiver after 10:00 p.m., helping or entering her room. Kindly help each other at night if you see her call light, even if you're not assigned. I believe I can count on you to accommodate her request. Thank you". A documented statement, dated 2/18/26, signed on 3/5/26, stated that Resident #1 expressed a preference for female caregivers during night shifts. Request noted by the residential care director and communicated to night care team via text message. 2. Observation:On 3/11/26 at 8:12 a.m., during an environmental tour, it was observed that Resident #1 had a sign outside her door that read, "please do not enter residents apartment after 10 p.m. med pass". 3. Interviews:On 3/11/26 at approximately 10:30 a.m., the physician stated that the hospital completed a SANE examination on Resident #1 on 3/4/26. The physician reported that the examination findings were consistent with sexual abuse and documented that Resident #1 sustained extensive trauma consistent with sexual assault, as well as blunt force trauma to the neck consistent with strangulation. The physician further stated that this was one of the worst cases of elderly sexual assault she had seen. The physician stated that Resident #1 was cognitively intact and provided varying accounts of the alleged sexual assault while consistently identifying Staff #2 as the alleged perpetrator. The physician further reported that Resident #1 stated this was not the first occurrence and alleged that, after receiving her 10:00 p.m. medication, Staff #2 would enter her room later in the night and administer an additional medication. On 3/11/26 at approximately 12:15 p.m., the RCD stated that staff informed her on 2/18/26 that Resident #1 did not want males in her room after 10:00 p.m. She further stated that she sent a text message to six staff members communicating this information. The RCD acknowledged that she did not follow up on the matter after being informed. On 3/11/26 at approximately 3:00 p.m., during a phone interview, Resident #1 reported concerns regarding Staff #2 and stated that he had access to keys to the building and entered hallways and resident rooms during the night shift without restriction. Resident #1 stated that Staff #2 frequently worked overnight, that other staff went downstairs during the shift, and that Staff #2 appeared to have free access throughout the residence without supervision. Resident #1 stated that she initially trusted Staff #2 and spoke with him because she felt lonely and did not have others to talk to. She reported that Staff #2 shared personal stories about living in his car, being gang affiliated, and later staying in an apartment with his brother. Resident #1 stated she encouraged him to improve his life and initially felt proud of him but later believed his behavior toward her changed. Resident #1 reported that Staff #2 began entering her room alone at night to administer medications and remained in the room to talk. Resident #1 stated she later became uncomfortable with him entering her room and requested that only female staff provide care. Resident #1 stated she informed staff, including the RCD, that she did not want Staff #2 in her room; however, Staff #2 continued to enter her room after medication pass. Resident #1 stated a sign was placed on her door requesting that no one enter after her 10:00 p.m. medications, but Staff #2 continued to enter her room during the night. Resident #1 reported that after Christmas, Staff #2 no longer interacted with her in the same manner but continued to enter her room alone during the overnight shift. She stated that she began noticing items in her room had been moved during the night, including objects on her nightstand and the position of her recliner chair, despite having no recollection of moving them. Resident #1 further reported waking in different or slumped positions in her recliner, which she stated was unusual for her. She stated that her recliner and surrounding objects were often found moved or disheveled. Resident #1 reported that she believed this occurred during the sexual assaults and stated that the force used pushed her recliner back into the wall. Resident #1 reported that for approximately one week prior to 3/4/26 she experienced pain in her vaginal and rectal areas. She stated that several days before 3/4/26, she told Staff #1 that she believed Staff #2 was sexually abusing her on the nights he worked. Resident #1 also reported to Staff #1 that she was experiencing neck pain, numbness on the left side of her face, and pain along the left carotid artery, which she later reported to medical staff at the hospital for evaluation. Resident #1 reported that she believed Staff #2 administered additional medication after her scheduled nighttime medications. Resident #1 stated she did not recognize the pill and reported that Staff #2 placed the medication in her mouth while she was partially asleep and gave her a drink. Resident #1 stated she normally received Ambien and Dilaudid at night but believed another medication had been given on multiple occasions. Resident #1 reported waking at approximately 3:00 a.m. at times and recalling that Staff #2 was in her room. Resident #1 stated she placed tape on her attends diaper and attempted to monitor her surroundings because she believed something was occurring while she slept. Resident #1 reported that clothing and blankets were found moved or pulled up when she woke up and stated she did not believe she had moved them herself. Resident #1 stated she contacted law enforcement after putting the events together and believing Staff #2 had sexually assaulted her on multiple occasions. Resident #1 stated that Staff #2 had unrestricted access to the building and reported that she was fearful he could return because he knew how to enter the residence. She became tearful during the interview and expressed strong fear and distress, stating she was afraid he would do the same thing to another resident. Resident #1 reported that the abuse occurred during the overnight shift and that she believed it had happened on prior occasions before 3/4/26. She stated that she contacted the police on 3/4/26 because she did not want the abuse to happen again to her or to anyone else in the residence. Resident #1 further stated that she had been struggling with nightmares and flashbacks related to the abuse since around Christmas and could no longer handle the emotional impact. Resident #1 stated that prior to reporting the incident, she repeatedly asked staff not to allow Staff #2 in her room, but the staff did not follow her requests. Resident #1 also stated that her physical discomfort improved on the days that Staff #2 was not working at the residence. On 3/11/26 at approximately 3:30 p.m., the administrator stated that the investigation regarding Resident #1 was incomplete. The administrator demonstrated an apathetic demeanor regarding the seriousness of this investigation. She reported the difficulty obtaining information from the hospital related to the SANE exam results and stated that the police report findings could take up to 6 months. She further indicated that she had been very busy investigating another incident that happened in the residence. During the interview the administrator was provided information regarding the SANE exam results that she had not previously obtained from the hospital. Upon learning the results of the SANE exam and that Resident #1 was sexually abused and had blunt force trauma to the neck consistent with strangulation, her demeanor changed, and she became tearful. On 3/11/26 at 3:58 p.m., a call was placed to Staff #1 to obtain an interview regarding Resident #1 ' s investigation. Staff #1 did not answer, a voicemail was left, and Staff #1 did not respond to the voicemail. On 3/11/26 at 6:22 p.m., the administrator stated that she was unsure whether Resident #1 had experienced harm because the investigation had not yet been completed. She stated that she immediately initiated the investigation on 3/4/26; however, she did not know the results of the SANE examination nor the full extent of the alleged sexual abuse. The administrator further stated that, based on the information she had received regarding the alleged assault, she would consider the incident to involve harm.

Based on record review and interviews, the residence failed to ensure the right to choice and personal involvement regarding care and services, affecting three of five sample residents (#1, #2, #4). Findings:Record Review:On 2/18/26, Resident #1 requested that only female staff members be in Resident #1 ' s room after 10:00 p.m. The staff schedule for February 2026 was reviewed; male staff members remained on the night shift as care providers. On 3/11/26 at approximately 12:30 p.m., the residential care director (RCD) sent a text message dated 2/18/26 to five of 20 staff members, which stated Resident #1 wants only female caregivers after 10:00 p.m., helping Resident #1, or entering Resident #1 ' s room. On 3/11/26, at 11:50 a.m., Resident #2 ' s care plan was reviewed. The fall management care plan had not been developed, regardless of Resident #2 ' s multiple falls. Interviews:On 3/11/26, Resident #1 stated male staff member continued to go into the room after 10:00 p.m. and provided care with no other staff member in the room. On 3/11/26 at approximately 6:40 p.m., the administrator acknowledged Resident #1 should have the choice to have female only staff member provide care. The administrator also stated that they felt the resident care director sent a text to the staff. The resident care director should have gone to the administrator immediately. On 3/11/26 at approximately 12:15 p.m., the RCD stated that on 2/18/16, a staff member informed them that Resident #1 did not want males in the room after 10:00 p.m. during the night shift; RDC stated a text was sent out to the night care team by text. Similar deficiencies occurred with Resident #4.

Based on record review and interviews, the residence failed to ensure that the administrator and the qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration records, affecting 102 current residents. Findings include:1. Record ReviewOn 3/11/26 at 1:03 p.m., a medication cart audit dated 1/15/26, 1/29/26, and 2/5/26 was conducted by a qualified medication administration personnel (QMAP); however, the audit did not reflect the accuracy or completeness of the medication administration records, controlled substance list, medication error reports, or disposal records. The administrator did not conduct or review the audits. 2. InterviewOn 3/11/26 at approximately 1:00 p.m., the administrator acknowledged that the residence did not complete medication audits in accordance with regulatory standards. She stated that she did not consistently review the audits and confirmed that the audits did not include verification of the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records

Based on the interview and record review, the residence failed to ensure staff documented in progress notes all out-of-the-ordinary events or issues that affect the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address the resident's changing needs, affecting two of the five sampled residents (#1 and #2). Findings included:1. Record ReviewOn 3/11/26 at approximately 1:30 p.m., the incident log was reviewed; Resident #2 was observed on the floor on 3/1/26 at approximately 9:45 a.m. No progress note addressed this event. On 3/11/26, at approximately 11:30 p.m., Resident #2 ' s family member provided three different concerns that were reported to the residence, which are: On 7/10/25, a family member stated that after medication distribution family located a loose pill in Resident #2 ' s room and reported to staff. On 11/2/25, the family found a pill on the floor of Resident #2 after morning medication distribution and again reported the concern to staff. On 3/6/26, two pills were found on Resident #2 ' s floor and reported again to staff, including the administrator, by email. There were no progress notes regarding these out-of-the-ordinary events. 2. Interview:On 3/11/26 at approximately 3:45 p.m., the residential care director (RCD) stated they would expect staff to enter progress notes if there were an incident, such as a fall; they acknowledged Resident #2 ' s fall on 3/1/26 was an out-of-the-ordinary event that should be documented in progress notes. On 3/11/26 at approximately 3:55 p.m., the residential care director acknowledged that medications found on the floor were reported to multiple staff members on three different occasions by family, and staff should have documented these concerns in progress notes. Similar deficiencies occurred with Resident #1.

A revisit survey was completed on 11/7/25 for all previous deficiencies cited on 5/13/25. The facility is in compliance with all deficiencies that were cited.

A certification complaint, prompted by #CO40354 was completed on 6/16/25. No deficiencies were cited.

A licensure complaint, prompted by #CO40353, was completed on 6/16/25. A deficiency was cited.

Based on interview and record review, the residence failed to ensure a controlled substance sheet contained the dosage and authorized practitioner's name, affecting one of seven sample residents (#6). Findings include:Resident #6A written practitioner's order, dated 4/22/25, directed the residence to administer oxycontin 10 mg three times daily. However, the controlled substance sheet for Resident #6 from the oxycontin administered from 5/5-5/22/25 did not include the dosage or the practitioner's name. On 6/16/25 at approximately 3:15 p.m., the regional director of health and wellness acknowledged the controlled substance sheet for Resident #6 did not contain the practitioner's name and dosage of medication, as required.

A revisit survey was completed on 5/6/24 for all previous deficiencies cited on 12/21/23. 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 5/6/24 for all previous deficiencies cited on 12/21/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 5/6/24 for all previous deficiencies cited on 12/21/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 5/6/24 for all previous deficiencies cited on 12/21/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 5/6/24 for all previous deficiencies cited on 12/21/23. The facility is in compliance with all deficiencies that were cited.