Colorado CDPHE · Facility Report

A CARING HEART LLC

📍 7465 W 48TH AVE, WHEAT RIDGE, CO 80033

ID 2304J0Assisted Living Residence/Alternative Care Facility (Medicaid)Active
19
Inspections
19
Deficiencies
0
Actual Harm or Above
1
Occurrences
June 12, 2026
Last Inspection
S/S B Minimal potential

The most recent inspection of A CARING HEART LLC on record is dated June 12, 2026. Across 19 published inspections, state surveyors cited 19 deficiencies, none of which reached the actual-harm level.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status
Active
Facility Type
Assisted Living Residence/Alternative Care Facility (Medicaid)
Administrator
CAWTHORN, ROZELLE
Owner
A CARING HEART LLC
Phone
(720) 301-1369
Payor Source
Medicaid, Private Pay
City
WHEAT RIDGE
ZIP
80033

Inspections & Citations

19 inspections · 19 deficiencies
6/12/2026Licensure (Re-licensure) · ID 0Q1L11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 6/26/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
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 existingprogram regulations found at 6 CCR 1011-1, Chapter 7. 10.2 Complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to: 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 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.
Plan of correction
The state did not require a plan of correction for this citation.
7/10/2025Licensure Complaint · ID V8NH11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An involuntary discharge appeal survey, prompted by #CO40569, was completed on 7/17/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: Licensure and Licensure Complaint (Combined) · ID 2TPH15No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/10/25 for all previous deficiencies cited on 10/30/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
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
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: Licensure (Re-licensure) · ID 43VH12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/10/25 for all previous deficiencies cited on 10/30/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: State Certification (Re-certification) · ID MU5F12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/10/25 for all previous deficiencies cited on 10/30/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: Licensure Complaint · ID RHFU16No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/10/25 for all previous deficiencies cited on 10/30/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: Licensure Complaint · ID T33Z14No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/10/25 for all previous deficiencies cited on 10/30/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
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
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: State Certification and State Certification Complaint (Combined) · ID VP4E15No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/10/25 for all previous deficiencies cited on 10/30/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
10/29/2024Revisit: Licensure Complaint · ID RHFU151 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 10/30/24 for all previous deficiencies cited on 7/2/24. Deficiencies were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 1/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. This deficiency was cited previously during a licensure revisit on 7/2/24. Although the residence corrected the deficiency, based on the findings below the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "You will be provided with the opportunity to use the general purpose rooms of Provider, such as family rooms, living rooms, dining rooms, shared bathrooms."2. Observationsa. Lower LevelOn 10/29/24 at approximately 9:29 a.m., in the lower level of the residence, there were four resident rooms, as well as a basement den. The den was filled with renovation tools and materials which was a shared living space for all residents. The sliding glass door that led out to the backyard from the basement den was broken and there was a large gap that allowed air to freely flow in from the outside which dropped the temperature in the den. On 10/30/24 at approximately 10:25 a.m., the temperature in the basement den was significantly lower than the upstairs temperature. On 10/30/24 at approximately 10:23 a.m., there was a large piece of plywood blocking the sliding glass door, thus making it unavailable as an exit. Additionally, the laundry room located on the lower level leaked water from the washer and had multiple towels around the base of the washer to soak up the water. B. Upper LevelOn 10/29/24 at approximately 10:25 a.m., dead bugs were observed in the medication administration room. On 10/30/24 at approximately 10:26 a.m., dead bugs were observed still in the medication administration room. 3. InterviewsOn 10/29/24 at 11:00 a.m., the administrator designee stated she was aware of all the dead bugs and would get this area cleaned up. Additionally, the administrator designee stated that the house manager is responsible for maintaining a sanitary environment. On 10/30/24 at 10:49 a.m., the administrator designee stated she was aware there was a lot of construction stuff and they are working on removing it. When questioned further the administrator designee stated there is stuff like construction materials and tools that we need to remove and the residence did just move a shed that was broken on the side yard and they did add chicken wire to an area on the side of the house with construction material and she believe the maintenance man that has been hired was working on the rest of the materials. Additionally, the administrator designee stated we have been doing checks but we may have missed some items. The administrator stated the resident is actively monitoring what needs to be done as far as cleaning up the home and was not aware of the dead bugs. On 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence does perimeter checks where staff are required to document the date, time, area, and comment on what was located and each staff must initial the perimeter check log document. The administrator designer stated that the residence does have a maintenance man coming to clean up the residence and also the residence is working on removing all construction materials and or fencing around the construction materials located in the residence yard. On 10/30/24 at 11:07 a.m., the administrator designee stated that she was aware of the dead bugs but the breaker went out and she was busy restoring power and forgot to vacuum up the dead bugs. She was busy getting caught up on the perimeter of the residence and making sure that trash was picked up and did not vacuum up the dead bugs. The administrator stated they will clean up the dead bugs immediately.
Plan of correction · submitted by the facility
The residence has maintained compliance by providing a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. The day the surveyor came onsite our maintenance person was onsite and was actively working in the subject area. They were finishing up the newly renovated bathroom in the basement. His tools were in an isolated corner out of the way of the pathway as he was working. He had to move the washing machine to access the plumbing to the adjacent bathroom that was being worked on. There are 2 doors to the basement. The exit door and the sliding glass door that has a wider entrance. The residents use the door marked exit. The maintenance person was using the sliding glass door to move in his materials. He may not have closed the door all the way but the door is not broken. The temperature is normally comfortable as it is temperature controlled. The residents have never complained about the temperature being to cold in the house. The washing machine does not leak water. The maintenance personnel was working in the adjacent bathroom and needed access to the plumbing within the wall. The water was because of the work effort and work site of the maintenance personnel. The renovation tools and the towel were removed when the maintenance personnel finished the job while the surveyor was still on site. The maintenance personnel also full closed the door when he left the premises. Upper level bugs – The house and carpet was clean. The flies observed were at the edge of the carpet between the floor board and the carpet. The flies were removed while surveyor was onsite. All exterior items mentioned have been appropriately removed. How will the facility be monitoring this moving forward to ensure on-going compliance. The monitoring plan:We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. How the monitoring will be included in the QAPI process. This will be an ongoing process. How will the monitoring be documented. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
10/29/2024Revisit: State Certification and State Certification Complaint (Combined) · ID VP4E141 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A recertification revisit was completed on 10/30/24 for all previous deficiencies cited on 7/2/24. A deficiency was citedThe regulations governing Assisted Living Residences were revised and the new regulations were implemented on 9/15/24.
Plan of correction
The state did not require a plan of correction for this citation.
1350Ben/Svc Req-ACF-PA-Env Standards▼
Findings
Based on observation and interview, the facility (residence) failed to maintain a home-like quality and feel for participants (residents) at all times, affecting seven current residents. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "You will be provided with the opportunity to use the general purpose rooms of Provider, such as family rooms, living rooms, dining rooms, shared bathrooms."2. Observationsa. Lower LevelOn 10/29/24 at approximately 9:29 a.m., the lower level of the residence, where there are four resident rooms, as well as a basement den. The den was filled with renovation tools and materials which is a shared living space for all residents. The sliding glass door that leads out to the backyard from the basement den was broken and there is a large gap that allows air to freely flow in from the outside dropping the temperature in the den. On 10/30/24 at approximately 10:25 a.m., the temperature in the basement den was significantly lower than the upstairs temperature of the skin of the surveyor. On 10/30/24 at approximately 10:23 a.m., there was a large piece of plywood blocking the sliding glass door, thus making it unavailable as an exit. Additionally, the laundry room located on the lower level was leaking water from the washer and had multiple towels around the base of the washer to soak up the water. B. Upper LevelOn 10/29/24 at approximately 10:25 a.m., dead bugs were observed in the medication administration room. This was mentioned to both the administrator designee and the house manager. On 10/30/24 at approximately 10:26 a.m., dead bugs were observed still in the medication administration room. c. Exterior environmentOn 10/29/24 at 8:38 a.m., an environmental tour of the external grounds revealed the following:The external grounds on the front entrance of the home had a folding table and a broken dishwasher to the right of the front door. To the left of the front door is a ramp for wheelchair access and it was blocked off by five small orange cones. The right side yard has a wooden fence with a sign that states "Restricted Area Do Not Enter Stop Employees Only." The wooden fence is only on the front side and the side is not fenced in. Located behind the half fence were broken construction materials, debris from trees and foliage, multiple blue tarps with additional pieces of broken wood, and a broken bike that was upside down. To the right of the fenced area was a shed being dismantled with four sides still partially up and other pieces down on the ground. Walking north from the half fence leads to the residence's backyard. A lighter was located on the walking path, a concrete addition to the house with no storage door or fence contained three bicycles, a shopping cart filled with garbage such as buckets, basketballs, broken wood, fencing, and chemicals such as oil and bug spray. To the right of the concrete addition prior to getting to the basement walk-out patio area two storage crates with 4 large paint buckets, a large wooden stump, and a ladder are being stored. Walking west of the concrete addition is the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following items were being stored, a large piece of plywood blocking the sliding glass door, a piece of sectional couch, two washers, a dolly to move the washers, a shovel, a bed frame, and piles of dead leaves, dirt, broken rock slabs from a retaining wall and a spray paint can. To the west of the patio is an outside staircase that leads to the upper level of the residence. The staircase had branches and leaves on each step. In the backyard are two jet skis on a trailer where the front wheel of the trailer is balancing on a piece of wood. On 10/29/24 at approximately 12:09 p.m., the five cones located in front of the wheelchair ramp access had been reduced to three cones. The dishwasher on the right of the front entrance had been removed. Metal wire fencing had been added around the open right side fence to keep residents out of the construction materials being stored in the half-wooden fenced area of the yard with the sign that stated: "Restricted Area Do Not Enter Stop Employees Only." The shed was fully dismantled and removed. On 10/30/24 at 10:22 a.m. the "Restricted Area Do Not Enter Stop Employees Only," area had plastic fencing with another sign on the plastic fencing that stated, "Restricted Area Do Not Enter Stop Employees Only," with additional construction materials such as siding, a pinball table and a broken table. Walking north from the half fence leads to the residence's backyard. The lighter had been removed but there were additional broken tree branches, yard tools such as a branch cutter as well as a serrated grass hook that was located on the top of a rock wall. A concrete addition to the house with no storage door had a wire fence with yellow tape on the fence that was not legible as it was facing the inside. Additional storage material was located in the concrete addition area including bicycles, yard tools, cables, wooden items, and a large extension cord on the outside of the wire fences strewn about. Walking west of the concrete addition is the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following item was still on the basement walkout patio, a large piece of plywood blocking the sliding glass door. Additionally, there were large puddles of water that were causing small flooding. In the backyard are two jet skis on a trailer where the front wheel of the trailer is balancing on a piece of wood as well as a staff member's vehicle was now parked next to the jet skis. On 10/30/24 at 10:23 a.m., the three cones located in front of the wheelchair ramp access were still there along with yellow tape blocking the wheelchair ramp access. 3. Interviews On 10/29/24 at 11:00 a.m., the administrator designee stated she was aware of all the dead bugs and would get this area cleaned up. Additionally, the administrator designee stated that the house manager is responsible for maintaining a sanitary environment. On 10/30/24 at 10:49 a.m., the administrator designee stated she was aware there was a lot of construction stuff and they are working on removing it. When questioned further the administrator designee stated there is stuff like construction materials and tools that we need to remove and the residence did just move a shed that was broken on the side yard and they did add chicken wire to an area on the side of the house with construction material and she believe the maintenance man that has been hired was working on the rest of the materials. Additionally, the administrator designee stated we have been doing checks but we may have missed some items. The administrator stated the resident is actively monitoring what needs to be done as far as cleaning up the home and was not aware of the dead bugs. On 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence does perimeter checks where staff are required to document the date, time, area, and comment on what was located and each staff must initial the perimeter check log document. The administrator designer stated that the residence does have a maintenance man coming to clean up the residence and also the residence is working on removing all construction materials and or fencing around the construction materials located in the residence yard. On 10/30/24 at 11:07 a.m., the administrator designee stated that she was aware of the dead bugs but the breaker went out and she was busy restoring power and forgot to vacuum up the dead bugs. She was busy getting caught up on the perimeter of the residence and making sure that trash was picked up and did not vacuum up the dead bugs. The administrator stated they would clean up the dead bugs immediately.
Plan of correction · submitted by the facility
The residence has maintained compliance by providing a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. The day the surveyor came onsite our maintenance person was onsite and was actively working in the subject area. They were finishing up the newly renovated bathroom in the basement. His tools were in an isolated corner out of the way of the pathway as he was working. He had to move the washing machine to access the plumbing to the adjacent bathroom that was being worked on. There are 2 doors to the basement. The exit door and the sliding glass door that has a wider entrance. The residents use the door marked exit. The maintenance person was using the sliding glass door to move in his materials. He may not have closed the door all the way but the door is not broken. The temperature is normally comfortable as it is temperature controlled. The residents have never complained about the temperature being to cold in the house. The washing machine does not leak water. The maintenance personnel was working in the adjacent bathroom and needed access to the plumbing within the wall. The water was because of the work effort and work site of the maintenance personnel. The renovation tools and the towel were removed when the maintenance personnel finished the job while the surveyor was still on site. The maintenance personnel also full closed the door when he left the premises. Upper level bugs – The house and carpet was clean. The flies observed were at the edge of the carpet between the floor board and the carpet. The flies were removed while surveyor was onsite. All exterior items mentioned have been appropriately removed. POC:How will the facility be monitoring this moving forward to ensure on-going compliance. The monitoring plan:We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. How the monitoring will be included in the QAPI process. This will be an ongoing process. How will the monitoring be documented. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
10/29/2024Revisit: Licensure Complaint · ID T33Z132 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 10/30/24 for all previous deficiencies cited on 7/2/24. Deficiencies were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 1/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. This deficiency was cited previously during a licensure revisit on 7/2/24. Although the residence corrected the deficiency, based on the findings below the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "You will be provided with the opportunity to use the general purpose rooms of Provider, such as family rooms, living rooms, dining rooms, shared bathrooms."2. Observationsa. Lower LevelOn 10/29/24 at approximately 9:29 a.m., in the lower level of the residence, there were four resident rooms, as well as a basement den. The den was filled with renovation tools and materials which was a shared living space for all residents. The sliding glass door that led out to the backyard from the basement den was broken and there was a large gap that allowed air to freely flow in from the outside which dropped the temperature in the den. On 10/30/24 at approximately 10:25 a.m., the temperature in the basement den was significantly lower than the upstairs temperature. On 10/30/24 at approximately 10:23 a.m., there was a large piece of plywood blocking the sliding glass door, thus making it unavailable as an exit. Additionally, the laundry room located on the lower level leaked water from the washer and had multiple towels around the base of the washer to soak up the water. B. Upper LevelOn 10/29/24 at approximately 10:25 a.m., dead bugs were observed in the medication administration room. On 10/30/24 at approximately 10:26 a.m., dead bugs were observed still in the medication administration room. 3. InterviewsOn 10/29/24 at 11:00 a.m., the administrator designee stated she was aware of all the dead bugs and would get this area cleaned up. Additionally, the administrator designee stated that the house manager is responsible for maintaining a sanitary environment. On 10/30/24 at 10:49 a.m., the administrator designee stated she was aware there was a lot of construction stuff and they are working on removing it. When questioned further the administrator designee stated there is stuff like construction materials and tools that we need to remove and the residence did just move a shed that was broken on the side yard and they did add chicken wire to an area on the side of the house with construction material and she believe the maintenance man that has been hired was working on the rest of the materials. Additionally, the administrator designee stated we have been doing checks but we may have missed some items. The administrator stated the resident is actively monitoring what needs to be done as far as cleaning up the home and was not aware of the dead bugs. On 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence does perimeter checks where staff are required to document the date, time, area, and comment on what was located and each staff must initial the perimeter check log document. The administrator designer stated that the residence does have a maintenance man coming to clean up the residence and also the residence is working on removing all construction materials and or fencing around the construction materials located in the residence yard. On 10/30/24 at 11:07 a.m., the administrator designee stated that she was aware of the dead bugs but the breaker went out and she was busy restoring power and forgot to vacuum up the dead bugs. She was busy getting caught up on the perimeter of the residence and making sure that trash was picked up and did not vacuum up the dead bugs. The administrator stated they will clean up the dead bugs immediately.
Plan of correction · submitted by the facility
The residence has maintained compliance by providing a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. The day the surveyor came onsite our maintenance person was onsite and was actively working in the subject area. They were finishing up the newly renovated bathroom in the basement. His tools were in an isolated corner out of the way of the pathway as he was working. He had to move the washing machine to access the plumbing to the adjacent bathroom that was being worked on. There are 2 doors to the basement. The exit door and the sliding glass door that has a wider entrance. The residents use the door marked exit. The maintenance person was using the sliding glass door to move in his materials. He may not have closed the door all the way but the door is not broken. The temperature is normally comfortable as it is temperature controlled. The residents have never complained about the temperature being to cold in the house. The washing machine does not leak water. The maintenance personnel was working in the adjacent bathroom and needed access to the plumbing within the wall. The water was because of the work effort and work site of the maintenance personnel. The renovation tools and the towel were removed when the maintenance personnel finished the job while the surveyor was still on site. The maintenance personnel also full closed the door when he left the premises. Upper level bugs – The house and carpet was clean. The flies observed were at the edge of the carpet between the floor board and the carpet. The flies were removed while surveyor was onsite. All exterior items mentioned have been appropriately removed. POC:How will the facility be monitoring this moving forward to ensure on-going compliance. The monitoring plan:We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. How the monitoring will be included in the QAPI process. This will be an ongoing process. How will the monitoring be documented. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
2510Ext Env GrndsS/S B▼
Findings
Based on observation and interview, the residence failed to keep the exterior grounds free of garbage and rubbish, affecting seven current residents. This deficiency was cited previously during a licensure revisit on 7/2/24. Although the residence corrected the deficiency, based on the findings below the residence has not maintained compliance with this regulatory requirement. Findings include: 1. ObservationsOn 10/29/24 at 8:38 a.m., an environmental tour of the external grounds revealed the following:The external grounds on the front entrance of the home had a folding table and a broken dishwasher to the right of the front door. To the left of the front door was a ramp for wheelchair access and it was blocked off by five small orange cones. The right side yard had a wooden fence with a sign that stated "Restricted Area Do Not Enter Stop Employees Only." The wooden fence was only on the front side and the side was not fenced in. Located behind the half fence were broken construction materials, debris from trees and foliage, multiple blue tarps with additional pieces of broken wood, and a broken bicycle that was upside down. To the right of the fenced area was a shed being dismantled with four sides still partially up and other pieces down on the ground. Walking north from the half fence led to the backyard of the residence. A lighter was located on the walking path, a concrete addition to the house with no storage door or fence contained three bicycles, a shopping cart filled with garbage such as buckets, basketballs, broken wood, fencing, and chemicals such as oil and bug spray. To the right of the concrete addition prior to getting to the basement walk-out patio area, were two storage crates with four large paint buckets, and a large wooden stump and a ladder were being stored. West of the concrete addition was the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following items were being stored, a large piece of plywood blocking the sliding glass door, a piece of sectional couch, two washers, a dolly to move the washers, a shovel, a bed frame, and piles of dead leaves, dirt, broken rock slabs from a retaining wall and a spray paint can. To the west of the patio was an outside staircase that led to the upper level of the residence. The staircase had branches and leaves on each step. In the backyard were two jet skis on a trailer where the front wheel of the trailer was balancing on a piece of wood. On 10/29/24 at approximately 12:09 p.m., the five cones located in front of the wheelchair ramp access had been reduced to three cones. The dishwasher on the right of the front entrance had been removed. Metal wire fencing had been added around the open right side fence to keep residents out of the construction materials being stored in the half-wooden fenced area of the yard with the sign that stated: "Restricted Area Do Not Enter Stop Employees Only." The shed was fully dismantled and removed. On 10/30/24 at 10:22 a.m. the "Restricted Area Do Not Enter Stop Employees Only," area had plastic fencing with another sign on the plastic fencing that stated, "Restricted Area Do Not Enter Stop Employees Only," with additional construction materials such as siding, a pinball table and a broken table. North of the half fence led to the residence's backyard. The lighter had been removed but there were additional broken tree branches, yard tools such as a branch cutter as well as a serrated grass hook that was located on the top of a rock wall. A concrete addition to the house with no storage door had a wire fence with yellow tape on the fence that was not legible as it was facing the inside. Additional storage material was located in the concrete addition area including bicycles, yard tools, cables, and wooden items, and a large extension cord was on the outside of the wire fences strewn about. West of the concrete addition was the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following item was still on the basement walkout patio, a large piece of plywood blocking the sliding glass door. Additionally, there were large puddles of water that were causing small flooding. In the backyard were two jet skis on a trailer where the front wheel of the trailer was balancing on a piece of wood as well as a staff member's vehicle was parked next to the jet skis. On 10/30/24 at 10:23 a.m., the three cones located in front of the wheelchair ramp access were still there along with yellow tape blocking the wheelchair ramp access. 2. InterviewOn 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence did perimeter checks where staff were required to document the date, time, area, and comment on what was misplaced and each staff must initial the perimeter check log document. The administrator acknowledged the items throughout the grounds that should have been picked up.
Plan of correction · submitted by the facility
POC:How will the facility be monitoring this moving forward to ensure on-going compliance. The monitoring plan:We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. How the monitoring will be included in the QAPI process. This will be an ongoing process. How will the monitoring be documented. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
9999Final ObservationsSurveyor note▼
Findings
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
Plan of correction
The state did not require a plan of correction for this citation.
10/29/2024Licensure (Re-licensure) · ID 43VH113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure survey was completed on 10/30/24. Deficiencies were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 1/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "You will be provided with the opportunity to use the general purpose rooms of Provider, such as family rooms, living rooms, dining rooms, shared bathrooms."2. Observationsa. Lower LevelOn 10/29/24 at approximately 9:29 a.m., in the lower level of the residence, there were four resident rooms, as well as a basement den. The den was filled with renovation tools and materials which was a shared living space for all residents. The sliding glass door that led out to the backyard from the basement den was broken and there was a large gap that allowed air to freely flow in from the outside which dropped the temperature in the den. On 10/30/24 at approximately 10:25 a.m., the temperature in the basement den was significantly lower than the upstairs temperature. On 10/30/24 at approximately 10:23 a.m., there was a large piece of plywood blocking the sliding glass door, thus making it unavailable as an exit. Additionally, the laundry room located on the lower level leaked water from the washer and had multiple towels around the base of the washer to soak up the water. B. Upper LevelOn 10/29/24 at approximately 10:25 a.m., dead bugs were observed in the medication administration room. On 10/30/24 at approximately 10:26 a.m., dead bugs were observed still in the medication administration room. 3. InterviewsOn 10/29/24 at 11:00 a.m., the administrator designee stated she was aware of all the dead bugs and would get this area cleaned up. Additionally, the administrator designee stated that the house manager is responsible for maintaining a sanitary environment. On 10/30/24 at 10:49 a.m., the administrator designee stated she was aware there was a lot of construction stuff and they are working on removing it. When questioned further the administrator designee stated there is stuff like construction materials and tools that we need to remove and the residence did just move a shed that was broken on the side yard and they did add chicken wire to an area on the side of the house with construction material and she believe the maintenance man that has been hired was working on the rest of the materials. Additionally, the administrator designee stated we have been doing checks but we may have missed some items. The administrator stated the resident is actively monitoring what needs to be done as far as cleaning up the home and was not aware of the dead bugs. On 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence does perimeter checks where staff are required to document the date, time, area, and comment on what was located and each staff must initial the perimeter check log document. The administrator designer stated that the residence does have a maintenance man coming to clean up the residence and also the residence is working on removing all construction materials and or fencing around the construction materials located in the residence yard. On 10/30/24 at 11:07 a.m., the administrator designee stated that she was aware of the dead bugs but the breaker went out and she was busy restoring power and forgot to vacuum up the dead bugs. She was busy getting caught up on the perimeter of the residence and making sure that trash was picked up and did not vacuum up the dead bugs. The administrator stated they will clean up the dead bugs immediately.
Plan of correction · submitted by the facility
The residence has maintained compliance by providing a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. The day the surveyor came onsite our maintenance person was onsite and was actively working in the subject area. They were finishing up the newly renovated bathroom in the basement. His tools were in an isolated corner out of the way of the pathway as he was working. He had to move the washing machine to access the plumbing to the adjacent bathroom that was being worked on. There are 2 doors to the basement. The exit door and the sliding glass door that has a wider entrance. The residents use the door marked exit. The maintenance person was using the sliding glass door to move in his materials. He may not have closed the door all the way but the door is not broken. The temperature is normally comfortable as it is temperature controlled. The residents have never complained about the temperature being to cold in the house. The washing machine does not leak water. The maintenance personnel was working in the adjacent bathroom and needed access to the plumbing within the wall. The water was because of the work effort and work site of the maintenance personnel. The renovation tools and the towel were removed when the maintenance personnel finished the job while the surveyor was still on site. The maintenance personnel also full closed the door when he left the premises. Upper level bugs – The house and carpet was clean. The flies observed were at the edge of the carpet between the floor board and the carpet. The flies were removed while surveyor was onsite. All exterior items mentioned have been appropriately removed. POC:The monitoring plan: We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼
Findings
Based on interviews and record review, the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting seven current residents. Findings include:1. Record reviewOn 10/29/24 at approximately 8:30 a.m., quarterly medication audits were requested from the house manager. On 10/29/24 at approximately 10:07 a.m., quarterly audits were provided from the previous two months. However, the medication audits were not completed by the administrator and the qualified medication administration (QMAP) supervisor, they were completed by the administrator designee on 6/28/24 only. The medication audits were not completed by the administrator and the QMAP supervisor, they were completed by the QMAP supervisor on the following dates: 7/24/24, 8/10/24, 9/15/24, and 10/25/24.2. InterviewsOn 10/30/24 at approximately 11:55 a.m., the administrator designee stated that she was aware that the administrator and QMAP supervisor were required to conduct medication administration audits, however, she stated she was just not aware that the medication audits had to be documented.
Plan of correction · submitted by the facility
The administrator designee conducted the audits. She provided oversight but did not use her stamp. During the state survey the surveyor forgot to mention that there was no deficiency during her audit of the MARs or the meds. The administrator is onsite providing oversight at least 2 or 3 times per week. POC:The admin designee will perform the med audits at least quarterly. Monitoring will occur every month by the admin and by the house manager. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly."Medication monitoring" as:(B) Handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident;(C) Visual observation of the resident to ensure compliance. Quarterly Audit:Residence's quarterly medication audits are onsite and the staff has been educated on where to find them. The OM and Admin will conduct audits monthly. This will be an ongoing process. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
2510Ext Env GrndsS/S B▼
Findings
Based on observation and interview, the residence failed to keep the exterior grounds free of garbage and rubbish, affecting seven current residents. Findings include: 1. ObservationsOn 10/29/24 at 8:38 a.m., an environmental tour of the external grounds revealed the following:The external grounds on the front entrance of the home had a folding table and a broken dishwasher to the right of the front door. To the left of the front door was a ramp for wheelchair access and it was blocked off by five small orange cones. The right side yard had a wooden fence with a sign that stated "Restricted Area Do Not Enter Stop Employees Only." The wooden fence was only on the front side and the side was not fenced in. Located behind the half fence were broken construction materials, debris from trees and foliage, multiple blue tarps with additional pieces of broken wood, and a broken bicycle that was upside down. To the right of the fenced area was a shed being dismantled with four sides still partially up and other pieces down on the ground. Walking north from the half fence led to the backyard of the residence. A lighter was located on the walking path, a concrete addition to the house with no storage door or fence contained three bicycles, a shopping cart filled with garbage such as buckets, basketballs, broken wood, fencing, and chemicals such as oil and bug spray. To the right of the concrete addition prior to getting to the basement walk-out patio area, were two storage crates with four large paint buckets, and a large wooden stump and a ladder were being stored. West of the concrete addition was the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following items were being stored, a large piece of plywood blocking the sliding glass door, a piece of sectional couch, two washers, a dolly to move the washers, a shovel, a bed frame, and piles of dead leaves, dirt, broken rock slabs from a retaining wall and a spray paint can. To the west of the patio was an outside staircase that led to the upper level of the residence. The staircase had branches and leaves on each step. In the backyard were two jet skis on a trailer where the front wheel of the trailer was balancing on a piece of wood. On 10/29/24 at approximately 12:09 p.m., the five cones located in front of the wheelchair ramp access had been reduced to three cones. The dishwasher on the right of the front entrance had been removed. Metal wire fencing had been added around the open right side fence to keep residents out of the construction materials being stored in the half-wooden fenced area of the yard with the sign that stated: "Restricted Area Do Not Enter Stop Employees Only." The shed was fully dismantled and removed. On 10/30/24 at 10:22 a.m. the "Restricted Area Do Not Enter Stop Employees Only," area had plastic fencing with another sign on the plastic fencing that stated, "Restricted Area Do Not Enter Stop Employees Only," with additional construction materials such as siding, a pinball table and a broken table. North of the half fence led to the residence's backyard. The lighter had been removed but there were additional broken tree branches, yard tools such as a branch cutter as well as a serrated grass hook that was located on the top of a rock wall. A concrete addition to the house with no storage door had a wire fence with yellow tape on the fence that was not legible as it was facing the inside. Additional storage material was located in the concrete addition area including bicycles, yard tools, cables, and wooden items, and a large extension cord was on the outside of the wire fences strewn about. West of the concrete addition was the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following item was still on the basement walkout patio, a large piece of plywood blocking the sliding glass door. Additionally, there were large puddles of water that were causing small flooding. In the backyard were two jet skis on a trailer where the front wheel of the trailer was balancing on a piece of wood as well as a staff member's vehicle was parked next to the jet skis. On 10/30/24 at 10:23 a.m., the three cones located in front of the wheelchair ramp access were still there along with yellow tape blocking the wheelchair ramp access. 2. InterviewOn 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence did perimeter checks where staff were required to document the date, time, area, and comment on what was misplaced and each staff must initial the perimeter check log document. The administrator acknowledged the items throughout the grounds that should have been picked up.
Plan of correction · submitted by the facility
We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
10/29/2024State Certification (Re-certification) · ID MU5F111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey was completed on 10/30/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1350Ben/Svc Req-ACF-PA-Env Standards▼
Findings
Based on observation and interview, the facility (residence) failed to maintain a home-like quality and feel for participants (residents) at all times, affecting seven current residents. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "You will be provided with the opportunity to use the general purpose rooms of Provider, such as family rooms, living rooms, dining rooms, shared bathrooms."2. Observationsa. Lower LevelOn 10/29/24 at approximately 9:29 a.m., the lower level of the residence, where there are four resident rooms, as well as a basement den. The den was filled with renovation tools and materials which is a shared living space for all residents. The sliding glass door that leads out to the backyard from the basement den was broken and there is a large gap that allows air to freely flow in from the outside dropping the temperature in the den. On 10/30/24 at approximately 10:25 a.m., the temperature in the basement den was significantly lower than the upstairs temperature of the skin of the surveyor. On 10/30/24 at approximately 10:23 a.m., there was a large piece of plywood blocking the sliding glass door, thus making it unavailable as an exit. Additionally, the laundry room located on the lower level was leaking water from the washer and had multiple towels around the base of the washer to soak up the water. B. Upper LevelOn 10/29/24 at approximately 10:25 a.m., dead bugs were observed in the medication administration room. This was mentioned to both the administrator designee and the house manager. On 10/30/24 at approximately 10:26 a.m., dead bugs were observed still in the medication administration room. c. Exterior environmentOn 10/29/24 at 8:38 a.m., an environmental tour of the external grounds revealed the following:The external grounds on the front entrance of the home had a folding table and a broken dishwasher to the right of the front door. To the left of the front door is a ramp for wheelchair access and it was blocked off by five small orange cones. The right side yard has a wooden fence with a sign that states "Restricted Area Do Not Enter Stop Employees Only." The wooden fence is only on the front side and the side is not fenced in. Located behind the half fence were broken construction materials, debris from trees and foliage, multiple blue tarps with additional pieces of broken wood, and a broken bike that was upside down. To the right of the fenced area was a shed being dismantled with four sides still partially up and other pieces down on the ground. Walking north from the half fence leads to the residence's backyard. A lighter was located on the walking path, a concrete addition to the house with no storage door or fence contained three bicycles, a shopping cart filled with garbage such as buckets, basketballs, broken wood, fencing, and chemicals such as oil and bug spray. To the right of the concrete addition prior to getting to the basement walk-out patio area two storage crates with 4 large paint buckets, a large wooden stump, and a ladder are being stored. Walking west of the concrete addition is the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following items were being stored, a large piece of plywood blocking the sliding glass door, a piece of sectional couch, two washers, a dolly to move the washers, a shovel, a bed frame, and piles of dead leaves, dirt, broken rock slabs from a retaining wall and a spray paint can. To the west of the patio is an outside staircase that leads to the upper level of the residence. The staircase had branches and leaves on each step. In the backyard are two jet skis on a trailer where the front wheel of the trailer is balancing on a piece of wood. On 10/29/24 at approximately 12:09 p.m., the five cones located in front of the wheelchair ramp access had been reduced to three cones. The dishwasher on the right of the front entrance had been removed. Metal wire fencing had been added around the open right side fence to keep residents out of the construction materials being stored in the half-wooden fenced area of the yard with the sign that stated: "Restricted Area Do Not Enter Stop Employees Only." The shed was fully dismantled and removed. On 10/30/24 at 10:22 a.m. the "Restricted Area Do Not Enter Stop Employees Only," area had plastic fencing with another sign on the plastic fencing that stated, "Restricted Area Do Not Enter Stop Employees Only," with additional construction materials such as siding, a pinball table and a broken table. Walking north from the half fence leads to the residence's backyard. The lighter had been removed but there were additional broken tree branches, yard tools such as a branch cutter as well as a serrated grass hook that was located on the top of a rock wall. A concrete addition to the house with no storage door had a wire fence with yellow tape on the fence that was not legible as it was facing the inside. Additional storage material was located in the concrete addition area including bicycles, yard tools, cables, wooden items, and a large extension cord on the outside of the wire fences strewn about. Walking west of the concrete addition is the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following item was still on the basement walkout patio, a large piece of plywood blocking the sliding glass door. Additionally, there were large puddles of water that were causing small flooding. In the backyard are two jet skis on a trailer where the front wheel of the trailer is balancing on a piece of wood as well as a staff member's vehicle was now parked next to the jet skis. On 10/30/24 at 10:23 a.m., the three cones located in front of the wheelchair ramp access were still there along with yellow tape blocking the wheelchair ramp access. 3. Interviews On 10/29/24 at 11:00 a.m., the administrator designee stated she was aware of all the dead bugs and would get this area cleaned up. Additionally, the administrator designee stated that the house manager is responsible for maintaining a sanitary environment. On 10/30/24 at 10:49 a.m., the administrator designee stated she was aware there was a lot of construction stuff and they are working on removing it. When questioned further the administrator designee stated there is stuff like construction materials and tools that we need to remove and the residence did just move a shed that was broken on the side yard and they did add chicken wire to an area on the side of the house with construction material and she believe the maintenance man that has been hired was working on the rest of the materials. Additionally, the administrator designee stated we have been doing checks but we may have missed some items. The administrator stated the resident is actively monitoring what needs to be done as far as cleaning up the home and was not aware of the dead bugs. On 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence does perimeter checks where staff are required to document the date, time, area, and comment on what was located and each staff must initial the perimeter check log document. The administrator designer stated that the residence does have a maintenance man coming to clean up the residence and also the residence is working on removing all construction materials and or fencing around the construction materials located in the residence yard. On 10/30/24 at 11:07 a.m., the administrator designee stated that she was aware of the dead bugs but the breaker went out and she was busy restoring power and forgot to vacuum up the dead bugs. She was busy getting caught up on the perimeter of the residence and making sure that trash was picked up and did not vacuum up the dead bugs. The administrator stated they would clean up the dead bugs immediately.
Plan of correction · submitted by the facility
The residence has maintained compliance by providing a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. The day the surveyor came onsite our maintenance person was onsite and was actively working in the subject area. They were finishing up the newly renovated bathroom in the basement. His tools were in an isolated corner out of the way of the pathway as he was working. He had to move the washing machine to access the plumbing to the adjacent bathroom that was being worked on. Upper level bugs – The house and carpet was clean. The flies observed were at the edge of the carpet between the floor board and the carpet. The flies were removed while surveyor was onsite. All exterior items mentioned have been appropriately removed. We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. How the monitoring will be included in the QAPI process. This will be an ongoing process. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns.
10/29/2024Revisit: Licensure and Licensure Complaint (Combined) · ID 2TPH142 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 10/30/24 for all previous deficiencies cited on 7/2/24. Deficiencies were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 1/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. This deficiency was cited previously during a licensure revisit on 7/2/24. Although the residence corrected the deficiency, based on the findings below the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "You will be provided with the opportunity to use the general purpose rooms of Provider, such as family rooms, living rooms, dining rooms, shared bathrooms."2. Observationsa. Lower LevelOn 10/29/24 at approximately 9:29 a.m., in the lower level of the residence, there were four resident rooms, as well as a basement den. The den was filled with renovation tools and materials which was a shared living space for all residents. The sliding glass door that led out to the backyard from the basement den was broken and there was a large gap that allowed air to freely flow in from the outside which dropped the temperature in the den. On 10/30/24 at approximately 10:25 a.m., the temperature in the basement den was significantly lower than the upstairs temperature. On 10/30/24 at approximately 10:23 a.m., there was a large piece of plywood blocking the sliding glass door, thus making it unavailable as an exit. Additionally, the laundry room located on the lower level leaked water from the washer and had multiple towels around the base of the washer to soak up the water. B. Upper LevelOn 10/29/24 at approximately 10:25 a.m., dead bugs were observed in the medication administration room. On 10/30/24 at approximately 10:26 a.m., dead bugs were observed still in the medication administration room. 3. InterviewsOn 10/29/24 at 11:00 a.m., the administrator designee stated she was aware of all the dead bugs and would get this area cleaned up. Additionally, the administrator designee stated that the house manager is responsible for maintaining a sanitary environment. On 10/30/24 at 10:49 a.m., the administrator designee stated she was aware there was a lot of construction stuff and they are working on removing it. When questioned further the administrator designee stated there is stuff like construction materials and tools that we need to remove and the residence did just move a shed that was broken on the side yard and they did add chicken wire to an area on the side of the house with construction material and she believe the maintenance man that has been hired was working on the rest of the materials. Additionally, the administrator designee stated we have been doing checks but we may have missed some items. The administrator stated the resident is actively monitoring what needs to be done as far as cleaning up the home and was not aware of the dead bugs. On 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence does perimeter checks where staff are required to document the date, time, area, and comment on what was located and each staff must initial the perimeter check log document. The administrator designer stated that the residence does have a maintenance man coming to clean up the residence and also the residence is working on removing all construction materials and or fencing around the construction materials located in the residence yard. On 10/30/24 at 11:07 a.m., the administrator designee stated that she was aware of the dead bugs but the breaker went out and she was busy restoring power and forgot to vacuum up the dead bugs. She was busy getting caught up on the perimeter of the residence and making sure that trash was picked up and did not vacuum up the dead bugs. The administrator stated they will clean up the dead bugs immediately.
Plan of correction · submitted by the facility
The residence has maintained compliance by providing a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. The day the surveyor came onsite our maintenance person was onsite and was actively working in the subject area. They were finishing up the newly renovated bathroom in the basement. His tools were in an isolated corner out of the way of the pathway as he was working. He had to move the washing machine to access the plumbing to the adjacent bathroom that was being worked on. There are 2 doors to the basement. The exit door and the sliding glass door that has a wider entrance. The residents use the door marked exit. The maintenance person was using the sliding glass door to move in his materials. He may not have closed the door all the way but the door is not broken. The temperature is normally comfortable as it is temperature controlled. The residents have never complained about the temperature being to cold in the house. The washing machine does not leak water. The maintenance personnel was working in the adjacent bathroom and needed access to the plumbing within the wall. The water was because of the work effort and work site of the maintenance personnel. The renovation tools and the towel were removed when the maintenance personnel finished the job while the surveyor was still on site. The maintenance personnel also full closed the door when he left the premises. Upper level bugs – The house and carpet was clean. The flies observed were at the edge of the carpet between the floor board and the carpet. The flies were removed while surveyor was onsite. All exterior items mentioned have been appropriately removed. POC:How will the facility be monitoring this moving forward to ensure on-going compliance. The monitoring plan:We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. How the monitoring will be included in the QAPI process. This will be an ongoing process. How will the monitoring be documented. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
2510Ext Env GrndsS/S B▼
Findings
Based on observation and interview, the residence failed to keep the exterior grounds free of garbage and rubbish, affecting seven current residents. This deficiency was cited previously during a licensure revisit on 7/2/24. Although the residence corrected the deficiency, based on the findings below the residence has not maintained compliance with this regulatory requirement. Findings include: 1. ObservationsOn 10/29/24 at 8:38 a.m., an environmental tour of the external grounds revealed the following:The external grounds on the front entrance of the home had a folding table and a broken dishwasher to the right of the front door. To the left of the front door was a ramp for wheelchair access and it was blocked off by five small orange cones. The right side yard had a wooden fence with a sign that stated "Restricted Area Do Not Enter Stop Employees Only." The wooden fence was only on the front side and the side was not fenced in. Located behind the half fence were broken construction materials, debris from trees and foliage, multiple blue tarps with additional pieces of broken wood, and a broken bicycle that was upside down. To the right of the fenced area was a shed being dismantled with four sides still partially up and other pieces down on the ground. Walking north from the half fence led to the backyard of the residence. A lighter was located on the walking path, a concrete addition to the house with no storage door or fence contained three bicycles, a shopping cart filled with garbage such as buckets, basketballs, broken wood, fencing, and chemicals such as oil and bug spray. To the right of the concrete addition prior to getting to the basement walk-out patio area, were two storage crates with four large paint buckets, and a large wooden stump and a ladder were being stored. West of the concrete addition was the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following items were being stored, a large piece of plywood blocking the sliding glass door, a piece of sectional couch, two washers, a dolly to move the washers, a shovel, a bed frame, and piles of dead leaves, dirt, broken rock slabs from a retaining wall and a spray paint can. To the west of the patio was an outside staircase that led to the upper level of the residence. The staircase had branches and leaves on each step. In the backyard were two jet skis on a trailer where the front wheel of the trailer was balancing on a piece of wood. On 10/29/24 at approximately 12:09 p.m., the five cones located in front of the wheelchair ramp access had been reduced to three cones. The dishwasher on the right of the front entrance had been removed. Metal wire fencing had been added around the open right side fence to keep residents out of the construction materials being stored in the half-wooden fenced area of the yard with the sign that stated: "Restricted Area Do Not Enter Stop Employees Only." The shed was fully dismantled and removed. On 10/30/24 at 10:22 a.m. the "Restricted Area Do Not Enter Stop Employees Only," area had plastic fencing with another sign on the plastic fencing that stated, "Restricted Area Do Not Enter Stop Employees Only," with additional construction materials such as siding, a pinball table and a broken table. North of the half fence led to the residence's backyard. The lighter had been removed but there were additional broken tree branches, yard tools such as a branch cutter as well as a serrated grass hook that was located on the top of a rock wall. A concrete addition to the house with no storage door had a wire fence with yellow tape on the fence that was not legible as it was facing the inside. Additional storage material was located in the concrete addition area including bicycles, yard tools, cables, and wooden items, and a large extension cord was on the outside of the wire fences strewn about. West of the concrete addition was the basement walkout doors with a patio. Located on this patio were large piles of rubbish such as cut-down foliage and broken branches. On the patio the following item was still on the basement walkout patio, a large piece of plywood blocking the sliding glass door. Additionally, there were large puddles of water that were causing small flooding. In the backyard were two jet skis on a trailer where the front wheel of the trailer was balancing on a piece of wood as well as a staff member's vehicle was parked next to the jet skis. On 10/30/24 at 10:23 a.m., the three cones located in front of the wheelchair ramp access were still there along with yellow tape blocking the wheelchair ramp access. 2. InterviewOn 10/30/24 at approximately 11:00 a.m., the administrator designee stated the residence did perimeter checks where staff were required to document the date, time, area, and comment on what was misplaced and each staff must initial the perimeter check log document. The administrator acknowledged the items throughout the grounds that should have been picked up.
Plan of correction · submitted by the facility
The residence has maintained compliance by providing a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. The day the surveyor came onsite our maintenance person was onsite and was actively working in the subject area. They were finishing up the newly renovated bathroom in the basement. His tools were in an isolated corner out of the way of the pathway as he was working. He had to move the washing machine to access the plumbing to the adjacent bathroom that was being worked on. There are 2 doors to the basement. The exit door and the sliding glass door that has a wider entrance. The residents use the door marked exit. The maintenance person was using the sliding glass door to move in his materials. He may not have closed the door all the way but the door is not broken. The temperature is normally comfortable as it is temperature controlled. The residents have never complained about the temperature being to cold in the house. The washing machine does not leak water. The maintenance personnel was working in the adjacent bathroom and needed access to the plumbing within the wall. The water was because of the work effort and work site of the maintenance personnel. The renovation tools and the towel were removed when the maintenance personnel finished the job while the surveyor was still on site. The maintenance personnel also full closed the door when he left the premises. Upper level bugs – The house and carpet was clean. The flies observed were at the edge of the carpet between the floor board and the carpet. The flies were removed while surveyor was onsite. All exterior items mentioned have been appropriately removed. POC:How will the facility be monitoring this moving forward to ensure on-going compliance. The monitoring plan:We will ensure that residence keep the exterior grounds free of garbage and rubbish. Monitoring will occur every day by the staff and by the house manager. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. Monitoring will be conducted by the operation manager and administrator. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. This will be an ongoing process. How the monitoring will be included in the QAPI process. This will be an ongoing process. How will the monitoring be documented. We now have a maintenance log that includes exterior environmental items such as trash, debris, and any environmental concerns. The monitoring of this practice will be ongoing.
9999Final ObservationsSurveyor note▼
Findings
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
Plan of correction
The state did not require a plan of correction for this citation.
7/2/2024Revisit: Licensure and Licensure Complaint (Combined) · ID 2TPH132 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 7/2/24 for all previous deficiencies cited on 12/21/22. Deficiences were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 11/15/23.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation, record review and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "(The) provider will maintain (the) resident's room in a clean, sanitary and orderly condition."2. ObservationsA staff cleaning schedule read every Sunday staff were to clean the residence and every Wednesday staff were to assist Resident #1 with room cleaning. On 7/2/24 from approximately 7:00 a.m. to 11:30 a.m., an environmental tour of the residence revealed the following:a. Resident #8's RoomResident #8's room located on the top floor of the residence had a foul odor that reeked of sewage. The smell was observed to have originated in Resident #8's bathroom. The bathroom in Resident #8's room had no toilet; instead, there was an empty hole where a toilet would be along with a black residue and wet toilet paper surrounding the hole. b. Lower LevelThe lower level of the residence, where Resident #2-#4's rooms were located, revealed dried paint flakes and chips, dirt and debris on the floor by the door which led to the backyard. The wooden baseboards in the hallway between Resident #2-#4's rooms were unsecured and detached from the wall. The railing along the stairs leading down to the basement had dried paint that peeled and flaked off of it. 3. InterviewsOn 7/2/24 at 8:14 a.m., Confidential Resident #1 stated staff did not assist him/her with room cleaning, so Resident #2 assisted him/her instead since it was difficult for him/her to clean their room by themselves. On 7/2/24 at approximately 8:16 a.m., Resident #8 stated the toilet in his bathroom "makes my room stink and has a foul odor." Resident #8 further stated he had brought the issue up to Staff #10; however, it had been two months since the toilet had been removed entirely, and he was still awaiting it to be replaced. On 7/2/24 at 11:44 a.m., contrary to Resident #8's statement, the administrator designee (AD) stated Resident #8'stoilet had only been inoperable for two days and an external maintenance company was working on getting a new toilet. She stated all staff were responsible for cleaning the residence at least once weekly in accordance with the cleaning schedule. The AD stated she had observed issues with staff not cleaning as required. She further stated she expected staff to provide a safe and sanitary environment to all residents; however, this deficiency that was previously cited was not corrected due to the residence's financial constraints.
Plan of correction · submitted by the facility
Resident 8’s toilet was clogged. Our maintenance person tried to unclog the toilet the night before and had to pull the toilet off to remedy the issue. The maintenance person could not unclog the toilet so a professional company was called. A sign was put on the door that the toilet was closed for repairs. While state was still there they saw the professional plumbing arrive and fix the toilet while they were there. Chip of paint missing on the floor:The entire floor has been repainted and the original baseboards have been restored. There was a 2inch chip of paint on the floor. This addresses the paint chip afore mentioned between Resident #2-#4's rooms. Exterior Environmental:6 boards behind the employee only fence from a new fence label employees only has been removed.two empty soda cans - Removed,one empty food container - Removedthree plastic wrappers - RemovedThe landscaping has about 25 feet of rock from the walking path and vegetation along the fence (i.e Russian sage) along the fence. I just cut it all down. The residence has a sign in chart for when the rooms are being cleaned. This chart is to be signed by the staff and the resident to acknowledge that the room has been cleaned. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. The adherence of the room cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. The monitoring will be documented in the scheduled room cleaning log in the residents room. The external environment is to be checked and logged daily by the 2 pm shift. Monitoring will be done weekly by the manager and bi-weekly by the AD. The monitoring of this practice will be ongoing.
2510Ext Env GrndsS/S B▼
Findings
Based on observation and interview, the residence failed to keep the exterior grounds free of garbage and rubbish, affecting seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. ObservationsOn 7/2/24 at 7:53 a.m., an environmental tour of the external grounds revealed the following:The external grounds on front and side of the residence had pile of six panels of plastic boards, a plastic cup, two empty soda cans, one empty food container, three plastic wrappers and weeds that measured up to two and a half feet in height. The external grounds in the backyard of the residence had a pile of broken construction materials, a middle compartment of a sectional couch, a rolled up mat and a block of wood by the outdoor staircase that led to the upper level of the residence. 2. InterviewOn 7/2/24 at 11:44 a.m., the administrator designee stated the administrator was responsible for maintaining the exterior environment. She stated she expected the exterior environment to be free of high weeds, garbage and rubbish, and she was unsure why the deficiency had not been corrected.
Plan of correction · submitted by the facility
Exterior Environmental:6 boards behind the employee only fence from a new fence label employees only has been removed.two empty soda cans - Removed,one empty food container - Removedthree plastic wrappers - RemovedThe landscaping has about 25 feet of rock from the walking path and vegetation along the fence (i.e Russian sage) along the fence. I just cut it all down. The residence has a sign in chart for when the rooms are being cleaned. This chart is to be signed by the staff and the resident to acknowledge that the room has been cleaned. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. The external environment is to be checked and logged daily by the 2 pm shift. Monitoring - Weekly by the manager and bi-weekly by the AD. The monitoring of this practice will be ongoing
9999Final ObservationsSurveyor note▼
Findings
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
Plan of correction
The state did not require a plan of correction for this citation.
7/2/2024Revisit: Licensure Complaint · ID IQ5I12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 7/2/24 for all previous deficiencies cited on 12/21/22. The facility is in compliance with all regulations surveyed. The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 11/30/23. The deficiencies cited for Event IQ5I11 were cited prior to the regulation revision that was implemented 11/30/23.
Plan of correction
The state did not require a plan of correction for this citation.
7/2/2024Revisit: Licensure Complaint · ID RHFU141 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint revisit was completed on 7/2/24 for all previous deficiencies cited on 12/21/22. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation, record review and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "(The) provider will maintain (the) resident's room in a clean, sanitary and orderly condition."2. ObservationsA staff cleaning schedule read every Sunday staff were to clean the residence and every Wednesday staff were to assist Resident #1 with room cleaning. On 7/2/24 from approximately 7:00 a.m. to 11:30 a.m., an environmental tour of the residence revealed the following:a. Resident #8's RoomResident #8's room located on the top floor of the residence had a foul odor that reeked of sewage. The smell was observed to have originated in Resident #8's bathroom. The bathroom in Resident #8's room had no toilet; instead, there was an empty hole where a toilet would be along with a black residue and wet toilet paper surrounding the hole. b. Lower LevelThe lower level of the residence, where Resident #2-#4's rooms were located, revealed dried paint flakes and chips, dirt and debris on the floor by the door which led to the backyard. The wooden baseboards in the hallway between Resident #2-#4's rooms were unsecured and detached from the wall. The railing along the stairs leading down to the basement had dried paint that peeled and flaked off of it. 3. InterviewsOn 7/2/24 at 8:14 a.m., Confidential Resident #1 stated staff did not assist him/her with room cleaning, so Resident #2 assisted him/her instead since it was difficult for him/her to clean their room by themselves. On 7/2/24 at approximately 8:16 a.m., Resident #8 stated the toilet in his bathroom "makes my room stink and has a foul odor." Resident #8 further stated he had brought the issue up to Staff #10; however, it had been two months since the toilet had been removed entirely, and he was still awaiting it to be replaced. On 7/2/24 at 11:44 a.m., contrary to Resident #8's statement, the administrator designee (AD) stated Resident #8'stoilet had only been inoperable for two days and an external maintenance company was working on getting a new toilet. She stated all staff were responsible for cleaning the residence at least once weekly in accordance with the cleaning schedule. The AD stated she had observed issues with staff not cleaning as required. She further stated she expected staff to provide a safe and sanitary environment to all residents; however, this deficiency that was previously cited was not corrected due to the residence's financial constraints.
Plan of correction · submitted by the facility
Resident 8’s toilet was clogged. Our maintenance person tried to unclog the toilet the night before and had to pull the toilet off to remedy the issue. The maintenance person could not unclog the toilet so a professional company was called. A sign was put on the door that the toilet was closed for repairs. While state was still there they saw the professional plumbing arrive and fix the toilet while they were there. Chip of paint missing on the floor:The entire floor has been repainted and the original baseboards have been restored. There was a 2inch chip of paint on the floor. This addresses the paint chip afore mentioned between Resident #2-#4's rooms. Exterior Environmental:6 boards behind the employee only fence from a new fence label employees only has been removed.two empty soda cans - Removed,one empty food container - Removedthree plastic wrappers - RemovedThe landscaping has about 25 feet of rock from the walking path and vegetation along the fence (i.e Russian sage) along the fence. I just cut it all down. The residence has a sign in chart for when the rooms are being cleaned. This chart is to be signed by the staff and the resident to acknowledge that the room has been cleaned. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. The adherence of the room cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. The monitoring will be documented in the scheduled room cleaning log in the residents room. The external environment is to be checked and logged daily by the 2 pm shift. Monitoring Weekly by the manager and bi-weekly by the AD. The monitoring of this practice will be ongoing
7/2/2024Revisit: Licensure Complaint · ID T33Z124 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint revisit was completed on 7/2/24 for all previous deficiencies cited on 12/21/22. Deficiences were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 11/15/23.
Plan of correction
The state did not require a plan of correction for this citation.
0732Stf Req-First Aid 1 Stf Onsite CrtfdS/S B▼
Findings
Based on observation, interview, and record review, the residence failed to ensure that at all times, at least one staff member who had current certification in first aid from a nationally recognized organization was onsite, which affected seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Observation On 7/2/24 at approximately 10:30 a.m., the residence had a posting on the wall that read all staff were certified in first aid. 2. Record Review A review of staff records for Staff #10 and Staff #11 revealed no documentation that they had current certification in first aid from a nationally recognized organization. The staff schedule, dated 6/17/24 to 7/1/24, read the following shifts had no staff members onsite with current certification in first aid from a nationally recognized organization 20 times as follows:The staff schedule, dated 6/17/24 to 7/1/24, revealed that only Staff #11 were onsite during the following shifts:6/17/24 from 2:00 p.m. to 10:00 p.m. 6/17/24 from 10:00 p.m. to 6:00 a.m. 6/21/24 from 2:00 p.m. to 10:00 p.m. 6/21/24 from 10:00 p.m. to 6:00 a.m. 6/23/24 from 6:00 a.m. to 2:00 p.m. 6/23/24 from 2:00 p.m. to 10:00 p.m. 6/23/24 from 10:00 p.m. to 6:00 a.m. 6/24/24 from 2:00 p.m. to 10:00 p.m. 6/24/24 from 10:00 p.m. to 6:00 a.m. 6/28/24 from 2:00 p.m. to 10:00 p.m. 6/28/24 from 10:00 p.m. to 6:00 a.m. 6/30/24 from 6:00 a.m. to 2:00 p.m. 6/30/24 from 2:00 p.m. to 10:00 p.m. 6/30/24 from 10:00 p.m. to 6:00 a.m. 7/1/24 from 2:00 p.m. to 10:00 p.m. 7/1/24 from 10:00 p.m. to 6:00 a.m. The staff schedule, dated 6/17/24 to 7/1/24, revealed that only Staff #10 were onsite during the following shifts:6/19/24 from 2:00 p.m. to 10:00 p.m. 6/20/24 from 2:00 p.m. to 10:00 p.m. 6/26/24 from 2:00 p.m. to 10:00 p.m. 6/27/24 from 2:00 p.m. to 10:00 p.m. 3. InterviewOn 7/2/24 at 11:44 a.m., the administrator designee (AD) said she knew the residence always needed one staff member onsite with a current first aid certification. The AD said she was unaware that Staff #10 and Staff #11 did not have current certification in first aid from a nationally recognized organization. The AD said the residence had not corrected this because she thought the staff had first aid certification from a nationally recognized organization, but they did not.
Plan of correction · submitted by the facility
Staff #10 and Staff #11 had their CPR certifications but these were NOT on the list of nationally recognized organizations. We have done an audit of all of our employee files to ensure all files required by the department are physical on site and available for the department including but not limited to the list below. We are especially making sure that the CPR/1st Aid are from a Nationally recognized organization. We will audit our employee files with our employee file audit tool which will cover the following: PHOTO IDSOCIAL SECURITY CARDQMAP VERIFICATIONQMAP COMPETENCYQMAP DISCLOSURECPR CARD1ST AID CARDFOOD CERTIFICATECBI/BACKGROUNDCAPS REPORTJOB DESCRIPTIONTB/QUESTIONNAIREFLU VACCINECOVID CARDTRAINING CHECKLIST W/ HIRE DATE/START DATEAPPLICATION W/ HEALTH FORMRESPIRATORY FIT TEST/HEALTH FORMOTHER CERTS The monitoring will be documented in our auditing tool which will be in each employee’s file. We will document this on the employee’s file checklist. This practice will be ongoing.
0734Stf Req-First Aid 1 Stf Onsite CPRS/S B▼
Findings
Based on observation, interview, and record review, the residence failed to ensure that at all times, at least one staff member who had current certification in first aid from a nationally recognized organization was onsite, which affected seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Observation On 7/2/24 at approximately 10:30 a.m., the residence had a posting on the wall that read all staff were certified in first aid. 2. Record Review A review of staff records for Staff #10 and Staff #11 revealed no documentation that they had current certification in first aid from a nationally recognized organization. The staff schedule, dated 6/17/24 to 7/1/24, read the following shifts had no staff members onsite with current certification in first aid from a nationally recognized organization 20 times as follows:The staff schedule, dated 6/17/24 to 7/1/24, revealed that only Staff #11 were onsite during the following shifts:6/17/24 from 2:00 p.m. to 10:00 p.m. 6/17/24 from 10:00 p.m. to 6:00 a.m. 6/21/24 from 2:00 p.m. to 10:00 p.m. 6/21/24 from 10:00 p.m. to 6:00 a.m. 6/23/24 from 6:00 a.m. to 2:00 p.m. 6/23/24 from 2:00 p.m. to 10:00 p.m. 6/23/24 from 10:00 p.m. to 6:00 a.m. 6/24/24 from 2:00 p.m. to 10:00 p.m. 6/24/24 from 10:00 p.m. to 6:00 a.m. 6/28/24 from 2:00 p.m. to 10:00 p.m. 6/28/24 from 10:00 p.m. to 6:00 a.m. 6/30/24 from 6:00 a.m. to 2:00 p.m. 6/30/24 from 2:00 p.m. to 10:00 p.m. 6/30/24 from 10:00 p.m. to 6:00 a.m. 7/1/24 from 2:00 p.m. to 10:00 p.m. 7/1/24 from 10:00 p.m. to 6:00 a.m. The staff schedule, dated 6/17/24 to 7/1/24, revealed that only Staff #10 were onsite during the following shifts:6/19/24 from 2:00 p.m. to 10:00 p.m. 6/20/24 from 2:00 p.m. to 10:00 p.m. 6/26/24 from 2:00 p.m. to 10:00 p.m. 6/27/24 from 2:00 p.m. to 10:00 p.m. 3. InterviewOn 7/2/24 at 11:44 a.m., the administrator designee (AD) said she knew the residence always needed one staff member onsite with a current first aid certification. The AD said she was unaware that Staff #10 and Staff #11 did not have current certification in first aid from a nationally recognized organization. The AD said the residence had not corrected this because she thought the staff had first aid certification from a nationally recognized organization, but they did not.
Plan of correction · submitted by the facility
Staff #10 and Staff #11 had their CPR certifications but these were NOT on the list of nationally recognized organizations. We have done an audit of all of our employee files to ensure all files required by the department are physical on site and available for the department including but not limited to the list below. We are especially making sure that the CPR/1st Aid are from a Nationally recognized organization. We will audit our employee files with our employee file audit tool which will cover the following:PHOTO IDSOCIAL SECURITY CARDQMAP VERIFICATIONQMAP COMPETENCYQMAP DISCLOSURECPR CARD1ST AID CARDFOOD CERTIFICATECBI/BACKGROUNDCAPS REPORTJOB DESCRIPTIONTB/QUESTIONNAIREFLU VACCINECOVID CARDTRAINING CHECKLIST W/ HIRE DATE/START DATEAPPLICATION W/ HEALTH FORMRESPIRATORY FIT TEST/HEALTH FORMOTHER CERTSThe monitoring will be documented in our auditing tool which will be in each employee’s file. We will document this on the employee’s file checklist. This practice will be ongoing.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation, record review and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated resident agreement read in part: "(The) provider will maintain (the) resident's room in a clean, sanitary and orderly condition."2. ObservationsA staff cleaning schedule read every Sunday staff were to clean the residence and every Wednesday staff were to assist Resident #1 with room cleaning. On 7/2/24 from approximately 7:00 a.m. to 11:30 a.m., an environmental tour of the residence revealed the following:a. Resident #8's RoomResident #8's room located on the top floor of the residence had a foul odor that reeked of sewage. The smell was observed to have originated in Resident #8's bathroom. The bathroom in Resident #8's room had no toilet; instead, there was an empty hole where a toilet would be along with a black residue and wet toilet paper surrounding the hole. b. Lower LevelThe lower level of the residence, where Resident #2-#4's rooms were located, revealed dried paint flakes and chips, dirt and debris on the floor by the door which led to the backyard. The wooden baseboards in the hallway between Resident #2-#4's rooms were unsecured and detached from the wall. The railing along the stairs leading down to the basement had dried paint that peeled and flaked off of it. 3. InterviewsOn 7/2/24 at 8:14 a.m., Confidential Resident #1 stated staff did not assist him/her with room cleaning, so Resident #2 assisted him/her instead since it was difficult for him/her to clean their room by themselves. On 7/2/24 at approximately 8:16 a.m., Resident #8 stated the toilet in his bathroom "makes my room stink and has a foul odor." Resident #8 further stated he had brought the issue up to Staff #10; however, it had been two months since the toilet had been removed entirely, and he was still awaiting it to be replaced. On 7/2/24 at 11:44 a.m., contrary to Resident #8's statement, the administrator designee (AD) stated Resident #8's toilet had only been inoperable for two days and an external maintenance company was working on getting a new toilet. She stated all staff were responsible for cleaning the residence at least once weekly in accordance with the cleaning schedule. The AD stated she had observed issues with staff not cleaning as required. She further stated she expected staff to provide a safe and sanitary environment to all residents; however, this deficiency that was previously cited was not corrected due to the residence's financial constraints.
Plan of correction · submitted by the facility
Resident 8’s toilet was clogged. Our maintenance person tried to unclog the toilet the night before and had to pull the toilet off to remedy the issue. The maintenance person could not unclog the toilet so a professional company was called. A sign was put on the door that the toilet was closed for repairs. While state was still there they saw the professional plumbing arrive and fix the toilet while they were there. Chip of paint missing on the floor:The entire floor has been repainted and the original baseboards have been restored. There was a 2inch chip of paint on the floor. This addresses the paint chip afore mentioned between Resident #2-#4's rooms. Exterior Environmental:6 boards behind the employee only fence from a new fence label employees only has been removed.two empty soda cans - Removed,one empty food container - Removedthree plastic wrappers - RemovedThe landscaping has about 25 feet of rock from the walking path and vegetation along the fence (i.e Russian sage) along the fence. We will cut it all down. The residence has a sign in chart for when the rooms are being cleaned. This chart is to be signed by the staff and the resident to acknowledge that the room has been cleaned. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. The adherence of the room cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. The monitoring will be documented in the scheduled room cleaning log in the residents room. The external environment is to be checked and logged daily by the 2 pm shift. Weekly by the manager and bi-weekly by the AD. The monitoring of this practice will be ongoing.
2510Ext Env GrndsS/S B▼
Findings
Based on observation and interview, the residence failed to keep the exterior grounds free of garbage and rubbish, affecting seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. ObservationsOn 7/2/24 at 7:53 a.m., an environmental tour of the external grounds revealed the following:The external grounds on front and side of the residence had a pile of six panels of plastic boards, a plastic cup, two empty soda cans, one empty food container, three plastic wrappers and weeds that measured up to two and a half feet in height. The external grounds in the backyard of the residence had a pile of broken construction materials, a middle compartment of a sectional couch, a rolled up mat and a block of wood by the outdoor staircase that led to the upper level of the residence. 2. InterviewOn 7/2/24 at 11:44 a.m., the administrator designee stated the administrator was responsible for maintaining the exterior environment. She stated she expected the exterior environment to be free of high weeds, garbage and rubbish, and she was unsure why the deficiency had not been corrected.
Plan of correction · submitted by the facility
Exterior Environmental:6 boards behind the employee only fence from a new fence label employees only has been removed.two empty soda cans - Removed,one empty food container - Removedthree plastic wrappers - RemovedThe landscaping has about 25 feet of rock from the walking path and vegetation along the fence (i.e Russian sage) along the fence. I just cut it all down. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. The adherence of the cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. The external environment is to be checked and logged daily by the 2 pm shift. Weekly by the manager and bi-weekly by the AD. The monitoring of this practice will be ongoing.
9999Final ObservationsSurveyor note▼
Findings
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
Plan of correction
The state did not require a plan of correction for this citation.
7/2/2024Revisit: State Certification and State Certification Complaint (Combined) · ID VP4E132 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification revisit was completed on 7/2/24 for all previous deficiencies cited on 12/21/22. Deficiencies were cited. The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 11/15/23.
Plan of correction
The state did not require a plan of correction for this citation.
0626Acf-Prov Role/Resp Env Stnds▼
Findings
Based on observation and interview, the facility (residence) failed to maintain a home-like quality and feel for participants (residents) at all times, affecting seven current residents. This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence Policya. The residence's undated Resident Agreement read in part: "(the) provider will maintain (the) resident's room in a clean, sanitary and orderly condition."2. ObservationsA staff cleaning schedule read every Sunday staff were to clean the residence and every Wednesday staff were to assist Resident #1 with room cleaning. On 7/2/24 from approximately 7:00 a.m. to 11:30 a.m., an environmental tour of the residence revealed the following:a. Resident #8's RoomResident #8's room located on the top floor of the residence had a foul odor that reeked of sewage. The smell was observed to have originated in Resident #8's bathroom. The bathroom in Resident #8's room had no toilet; instead, there was an empty hole where a toilet would be along with a black residue and wet toilet paper surrounding the hole. b. Lower LevelThe lower level of the residence, where Resident #2-#4's rooms were located, revealed dried paint flakes and chips, dirt and debris on the floor by the door which led to the backyard. The wooden baseboards in the hallway between Resident #2-#4's rooms were unsecured and detached from the wall. The railing along the stairs leading down to the basement had dried paint that peeled and flaked off of it.c. Exterior environmentA pile of six panels of plastic boards, a plastic cup, two empty soda cans, one empty food container, three plastic wrappers, a pile of broken construction materials, a middle compartment of a sectional, a rolled up mat and a block of wood by the staircase that led to the upstairs of the residence, and weeds that measured up to two and a half feet in height. 3. InterviewsOn 7/2/24 at 8:14 a.m., confidential Resident #1 stated residence staff did not assist him/her with room cleaning, so Resident #2 would assist him/her instead since it was difficult for him/her to clean their room. On 7/2/24 at approximately 8:16 a.m., Resident #8 stated the toilet in his bathroom "makes my room stink and has a foul odor." Resident #8 further stated he had brought the issue up to Staff #10; however, it had been two months since the toilet had been operable and it was removed entirely, and he was still awaiting it to be replaced. On 7/2/24 at 11:44 a.m., contrary to Resident #8's statement, the administrator designee (AD) stated Resident #8'stoilet had only been inoperable for two days and an external maintenance company was working on getting a new toilet. She stated all staff were responsible for cleaning the residence at least once weekly in accordance with the cleaning schedule. The AD stated she had observed issues with staff not cleaning as required. The administrator designee stated the administrator was responsible for maintaining the exterior environment. She further stated she expected staff to provide a homelike environment to all residents; however, this deficiency that was previously cited was not corrected due to the residence's financial constraints.
Plan of correction · submitted by the facility
Resident 8’s toilet was clogged. Our maintenance person tried to unclog the toilet the night before and had to pull the toilet off to remedy the issue. The maintenance person could not unclog the toilet so a professional company was called. A sign was put on the door that the toilet was closed for repairs. While state was still there they saw the professional plumbing arrive and fix the toilet while they were there. Chip of paint missing on the floor:The entire floor has been repainted and the original baseboards have been restored. There was a 2inch chip of paint on the floor. This addresses the paint chip afore mentioned between Resident #2-#4's rooms. Exterior Environmental:6 boards behind the employee only fence from a new fence label employees only has been removed.two empty soda cans - Removed,one empty food container - Removedthree plastic wrappers - RemovedThe landscaping has about 25 feet of rock from the walking path and vegetation along the fence (i.e Russian sage) along the fence. I just cut it all down. The residence has a sign in chart for when the rooms are being cleaned. This chart is to be signed by the staff and the resident to acknowledge that the room has been cleaned. The external environment is to be checked daily by the 2pm shift to look for debris and to disregard it. The adherence of the room cleaning schedule will be reviewed and monitored by the house manager weekly and the AD biweekly. The monitoring will be documented in the scheduled room cleaning log in the residents room. The external environment is to be checked and logged daily by the 2 pm shift. Weekly by the manager and bi-weekly by the AD. The monitoring of this practice will be ongoing
0630Acf-Prov Role/Resp-Svc Req Med admn Pol/Pr▼
Findings
Based on record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting four of four sample participants (residents) whose medication were reviewed (#3, #4, #8 and #9). This deficiency was cited previously during a state licensure survey on 12/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.29, requires that the assisted living residence to ensure that each QMAP accurately documents each medication or monitoring event at the time the event is completed for each resident.a. Residence PolicyThe residence's undated General Procedures of Administering Medications policy, read in part that qualified medication administration persons (QMAPs) must document the administration of a medication at the time of administration by initialing in the designated box on the medication administration record (MAR).b. List of QMAP names on MARsA review of the June and July 2024 MARs for Residents #3, #4, #8 and #9, revealed the residence failed to maintain a legible list of the names, signatures and initials of the persons utilizing the MARs.c. Resident #3 was admitted to the residence on 1/13/12 with a diagnosis of diabetes mellitus. A written practitioner's order, dated 1/19/24, directed the residence to administer the following medications:Metformin 500 mg two tablets twice dailyZiprasidone 80 mg twice dailyGlycopyrrolate 2 mg twice dailyGabapentin 100 mg at bedtimeAtorvastatin 20 mg at bedtimeHowever, the July 2024 MAR contained blank spaces on 7/1/24 in the evening, for the above medications.d. InterviewOn 7/2/24 at 11:44 a.m., the administrator designee stated a blank space in the MAR meant staff failed to document whether a medication was administered at the time of administration. The administrator designee stated she was unsure what happened to the staff initials and signature page that was part of the June and July 2024 MARs for Residents #3, #4, #8 and #9. She further stated she expected staff to accurately document on MARs and complete the required signature and staff initials page.e. There was similar deficient practice for Residents #4, #8 and #9.
Plan of correction · submitted by the facility
PROVIDER ROLES AND RESPONSIBILITIES "H. Provider Service Requirements 2. Alternative Care Facility Providers shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII and XXIV, Medication Administration Regulations. The residence has done an audit and has verified that we have a legible list of the names, signatures and initials of the persons utilizing the MARs. Plan of Correction:Med audits are to be conducted weekly by the house manager and monthly by the administrator. Exactly how and what will be reviewed as part of the monitoring;The following questions are asked on our med audits. CYCLE DATE FOR THIS LOCATION:_____________________ ANY DISCONTINUED MEDS IN CART?____________________IF SO REASON?___________________________WAS IT ADDRESSED?______ ANY EXPIRED MEDS IN CART?_______IF SO REASON_____________________________ WAS IT ADDRESSED?_______ ANY DISCHARGED/DECEASED RESIDENTS MEDS IN CART?________________ ALL MEDICATIONS ORDERED WERE PRESENT?________________________IF ANY MISSING ,WAS IT ADDRESSED?_______________________ ANY MISSING INITIALS FROM MARS?____________WERE PRN’S/REFUSALS DOCUMENTED?______________ANY MEDICATIONS NEEDED TO BE REORDERED PRIOR TO CYCLE DATE?____IF SO FOR WHOM AND WAS IT RESOLVED?______________________________ ANY MEDS LEFT UNATTENDED ON MED CART?____________________NAME OF PERSON COMPLETED AUDIT:________________________TITLE:________________________DOES THE MAR, ORDER, AND MEDICATION MATCH? ARE THERE ANY NEW ORDERS AWAITING ANY CLARIFICATIONS/CHECK ORDER FOR ANY CLARIFICATIONS OR CHANGESThis is documented on our med audits. This monitoring is ongoing

Reportable Occurrences

1 records
3/6/2025Sexual Abuse · ID 252304J0002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/10/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Client (B) alleged client (A) grabbed them by the hips without consent. During the course of the investigation, the healthcare entity separated the clients, notified law enforcement, and conducted interviews. Client (A) denied the allegations. The facility encouraged the clients to stay separated, monitored interactions between the clients, and ultimately client (B) discharged from the facility. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 9/16/2025 · released to the public 9/23/2025.