15
Inspections
18
Deficiencies
0
Actual Harm or Above
11
Occurrences
June 29, 2026
Last Inspection
S/S A/B Minimal potential
The most recent inspection of COLORADO SPRINGS SENIOR HOMES on record is dated June 29, 2026. Across 15 published inspections, state surveyors cited 18 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
Batey, Cynthia
Owner
TRUSTCARE OPERATORCO LLC
Phone
(719) 636-2731
Payor Source
Medicaid, Private Pay
City
COLORADO SPRINGS
ZIP
80907
Inspections & Citations
15 inspections · 18 deficiencies6/29/2026Licensure (Re-licensure) · ID CEFV11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 6/29/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/21/2026Licensure Complaint · ID 1Z4Z11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO41855 was completed on 5/21/2026. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/21/2026Licensure Complaint · ID N3LC11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO41856, was completed on 5/19/2026. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/11/2025Revisit: Licensure Complaint · ID 7H1R12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 4/11/25 for all previous deficiencies cited on 8/6/24. 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.
4/11/2025Revisit: Licensure Complaint · ID 7WNS12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 4/11/25 for all previous deficiencies cited on 8/6/24. 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.
8/6/2024State Certification Complaint · ID 7H1R112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO36715 was completed on 8/6/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0414Acf-Part Rts Infrm/Post/Incld▼
Findings
Based on record review and interview, the residence failed to ensure the residents' right to be treated with dignity and respect, affecting one (#2) of two sample residents. Findings include:1 Residence PolicyThe residence's undated residence rights policy read in part, "The right to civil and religious liberties, including, the right to be treated with dignity and respect."2. Record ReviewResident #2 was admitted to the residence on 11/3/05 with diagnoses of schizophrenia, seizure disorder, hypothyroidism and depression. A functional assessment and assistance care document dated 9/29/23, indicated that the resident required assistance with activities of daily living (ADLs) such as dressing, grooming, and meals. The document also read, "staff need to remind Resident #2 to use (a) walker and to keep (the) walker close by (to) prevent falls." An investigation report, dated 6/14/24, revealed Resident #2 reported Staff #5 grabbed and hit her, which caused bruises. Resident #2 also reported that Staff #5 did not assist her with her ADLs and refused to provide her with assistance when she fell. 3. InterviewsOn 8/6/24 at 1:00 p.m., the administrator confirmed that the residence assessed Resident #2 when bruises were discovered on her arm; she added an investigation was conducted with Staff #5 which resulted in the residence's decision by to move Staff #5 to a different work location. On 8/6/24 at 12:07 p.m., Resident #2 said staff did not help her with her ADLs. She said Staff #5 always yelled at her, and did not assist her when she fell. Resident #2 added that Staff #5 grabbed her arm and caused bruises. On 8/6/24 at 1:00 p.m., Resident #3 said she disliked that Staff #5 always yelled at Resident #2. She said she was happy Staff #5 was moved to a different residence and was not allowed to return to work at theirs. On 8/6/24 at 4:15 p.m., Resident #9 said that some staff members treated him with respect but Staff #5 who was transferred from a different residence did not care about his needs. He added that Staff #5 never responded to his needs. On 8/6/24 at 4:15 p.m., Resident #10 said Staff #5 always talked down to him. He said, "expected the staff member to be his caregiver but the staff cared less about my needs."Based on interview and record review, the residence failed to maintain a documented care plan of current personal services needs and preferences along with staff tasks necessary to meet the needs of residents, affecting one (#1) of two sample residents whose care plans were reviewed.
Plan of correction · submitted by the facility
Description of how CSSH will correct the deficiency: ED further investigated reported staff failure to observe resident rights, by personally interviewing other residents as well. Two staff members were placed on administrative suspension pending completion of that investigation, and were subsequently terminated due to the results of that investigation as well as previous counseling. Staff #5 was verbally counseled as to providing assistance and responding to residents’ needs in accordance with their care plan or current observation, and regarding maintaining professional and respectful interactions with residents. No other staff members were reported by residents to have similar issues. Monitoring plan to ensure deficiency remedied and will not reoccur: Every two months, residents will be asked to complete a satisfaction survey designed to identify any problems with staff treating them with dignity, respect and other resident rights, as well as staff not following through with residents’ care plans. Residents will be asked to indicate their House number if they choose, but not their name, in order to provide resident privacy while allowing the ED to target any further investigation or research indicated in response to the survey results. The Individual surveys will be reviewed by the Executive Director (ED), and the aggregate satisfaction data will be shared with the staff at All-Staff meetings. Potentially negative trends will result in refresher training for all staff, and targeted training for individual staff member(s) if indicated. Once two surveys have demonstrated compliance, the frequency of surveys and monitoring may be decreased, but will continue for another year so that continued compliance can be tracked. The ED will follow up on Staff 5’s counseling by observing and talking with residents under Staff #5’s care at least monthly. Should results of that or other investigation(s) or research identify repeated or egregious disrespect or failure of care on the part of a specific staff member, appropriate disciplinary action will be taken, up to and including termination. Completion date NMT 30 days after issuance of deficiency list: 9/30/24
0418Acf-Part Rts CarePln▼
Findings
Findings include:1. Residence PolicyThe right to choice and personal involvement regarding care and services, including:The right to be informed and participate in decision making regarding your care and services, in coordination with family members who may have different opinions;The right to be informed about and formulate advance directives;The right to freedom of choice in selecting a health care service or provider; andThe right to expect the cooperation of the residence in achieving the maximum degree of benefit from services we provide you. If you have limited English proficiency or impairments that inhibit communication, residence will find a way to facilitate communication of care needs. 2. Record ReviewResident #1 was admitted to the residence on 12/18/23 with diagnoses of delusions and paranoia, a history of medical treatment noncompliance, and diabetes mellitus II.The resident record for Resident #1 contained a care plan created by the resident's external service provider. On 8/6/24 at 8:46 a.m., a care plan for Resident #1 was requested. However, the administrator was unable to provide the requested document. 3. InterviewOn 8/6/24 at 4:20 p.m., the administrator acknowledged the residence did not maintain a documented care plan of current personal services needs and preferences along with staff tasks necessary to meet Resident #1's needs. She added that the residence did not create a care plan specific to Resident #1's medical needs.
Plan of correction · submitted by the facility
Description of how CSSH will correct the deficiency: (1) Since Resident #1 no longer resides at the facility, a care plan cannot be reconstructed for her at this point. (2) The Executive Director (ED) and/or Admin Assistant will review all resident charts for current care plans, to identify any other missing Assessment & Care Plans (“care plans“). Once identified as missing, the care plan will be completed and distributed as soon as possible, and care staff will be informed. Monitoring plan to ensure deficiency remedied and will not reoccur: (1) During the record review conducted as above, existing care plans will be scanned and stored electronically in a master care plan folder, so they are available for reprint if necessary, and as a basis for updates. The original hard-copy form will be maintained in the resident’s primary chart in the Administration office, in a sheet protector labeled “DO NOT REMOVE FROM PRIMARY CHART.“ A copy will be maintained in each resident’s working House chart for ongoing reference. (2) The master care plan electronic folder will also include a spreadsheet tracking completion and dates of all care plans scanned. The ED or Admin Assistant will update the tracking spreadsheet as needed, and the ED will review compliance status monthly for at least 3 months, or until such review has documented compliance for a period of 90 days. Completion date NMT 30 days after issuance of deficiency list: 9/30/24
8/6/2024Licensure Complaint · ID 7WNS114 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO36713, was completed on 8/6/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0430Rpt Req-Occ RprtS/S A▼
Findings
Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of two sample residents (#1). Findings include:1. Reference and Residence Policya. According to the Health Facilities and Emergency Medical Services Division Occurrence Reporting Manual (2018), the residence was required to report "Any occurrence involving sexual ... abuse of a patient or resident, as described in section ...18-3-402, 18-3-403, 18-3-404, or 18-3-405 C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility." Section 25-1-124 (2)(d) C.R.S.b. The residence's Occurrence and Critical Incident Reporting policy, dated 7/1/23, read in part, "In accordance with Colorado regulations, reportable occurrences must be reported to the department by the next business day after the occurrence, or after the residence becomes aware of the occurrence ..."2. Resident #1 was admitted to the residence on 12/18/23 with diagnoses of delusions and paranoia. A review of the department's database on 8/6/24 revealed that the residence did not report any occurrences of sexual abuse. 3. Interview On 8/6/24 at 1:00 p.m., the administrator stated Resident #1 was admitted to the hospital on 6/30/24 for a deteriorating wound on her left toe, muscle weakness, and cognitive decline. She stated Resident #1's external service provider (ESP) was going to discharge Resident #1 back to the residence on 7/10/24; however, the resident stated she did not feel safe going back because she had been molested at the residence. The administrator stated she was notified by Resident #1's ESP about the allegations and conducted an internal investigation; however, she did not report it as an occurrence to the department because she was under the impression the ESP had already reported it to the department.
Plan of correction
The state did not require a plan of correction for this citation.
1140Res Care Srvs-Comp Res Asmnt ICPS/S A▼
Findings
Based on observation, record review and interview, the residence failed to ensure a comprehensive assessment was completed, documented in writing and kept in the resident's record, affecting one of two sample residents (#1). Finding include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences in part 12.6 requires that at the time a new resident moves in, the assisted living residence shall complete a comprehensive assessment that reflects information requested and received from the resident, the resident's representative if requested by the resident, and a practitioner. Information from the comprehensive assessment shall be used to establish an individualized care plan.b. The residence's Admission and Continued Stay policy, dated 7/1/23, read in part, "Prior to admission, the residence will complete a pre-admission assessment ... Updates of the individual assessments will be updated annually or upon evidence of significant change ..." 2. Resident #1 was admitted to the residence on 12/18/23. On 8/6/24, review of Resident #1's record revealed no evidence that the residence completed a comprehensive assessment at the time the resident moved in. 3. Interview On 8/6/24 at 2:00 p.m., the administrator stated the residence had completed an assessment for Resident #1; however, she could not locate the document. She stated the assessment should have been in the resident's file but could not explain why it was not there.
Plan of correction · submitted by the facility
Description of how CSSH will correct the deficiency: (1) Executive Director (ED) will reconstruct the Pre-Admission Assessment for Resident #1 from memory and her notes if the original cannot be found, including a notation that it is a late reconstruction rather than original. (2) Resident charts will be audited for any other missing Pre-Admission Assessments for residents admitted within the last year. When possible, any missing Pre-Admission Assessment identified during the audit will be likewise reconstructed, if possible. Monitoring plan to ensure deficiency remedied and will not reoccur: All Pre-Admission Assessments will now be scanned as soon as completed and stored electronically for backup. The original hard-copy form will be maintained in the resident’s primary record in the Administration office, in a sheet protector labeled “DO NOT REMOVE FROM PRIMARY CHART.“ A copy will be maintained in each resident’s working House chart for ongoing reference. The electronic master folder will be reviewed monthly for at least 3 months, or until such review has documented compliance for a period of 90 days. Completion date NMT 30 days after issuance of deficiency list: 9/30/24
1150Res Care Srvs-Res CPS/S A▼
Findings
Based on interview and record review, the residence failed to maintain a documented care plan of current personal services needs and preferences along with staff tasks necessary to meet the needs of residents, affecting one (#1) of two sample residents whose care plans were reviewed. Findings include:1. Residence PolicyThe right to choice and personal involvement regarding care and services, including:The right to be informed and participate in decision making regarding your care and services, in coordination with family members who may have different opinions;The right to be informed about and formulate advance directives;The right to freedom of choice in selecting a health care service or provider; andThe right to expect the cooperation of the residence in achieving the maximum degree of benefit from services we provide you. If you have limited English proficiency or impairments that inhibit communication, residence will find a way to facilitate communication of care needs. 2. Record ReviewResident #1 was admitted to the residence on 12/18/23 with diagnoses of delusions and paranoia, a history of medical treatment noncompliance, and diabetes mellitus II.The resident record for Resident #1 contained a care plan created by the resident's external service provider. On 8/6/24 at 8:46 a.m., a care plan for Resident #1 was requested. However, the administrator was unable to provide the requested document. 3. InterviewOn 8/6/24 at 4:20 p.m., the administrator acknowledged the residence did not maintain a documented care plan of current personal services needs and preferences along with staff tasks necessary to meet Resident #1's needs. She added that the residence did not create a care plan specific to Resident #1's medical needs.
Plan of correction · submitted by the facility
Description of how CSSH will correct the deficiency: (1) Since Resident #1 no longer resides at the facility, a care plan cannot be reconstructed for her at this point. (2) The Executive Director (ED) and/or Admin Assistant will review all resident charts for current care plans, to identify any other missing Assessment & Care Plans (“care plans“). Once identified as missing, the care plan will be completed and distributed as soon as possible, and care staff will be informed. Monitoring plan to ensure deficiency remedied and will not reoccur: (1) During the record review conducted as above, existing care plans will be scanned and stored electronically in a master care plan folder, so they are available for reprint if necessary, and as a basis for updates. The original hard-copy form will be maintained in the resident’s primary chart in the Administration office, in a sheet protector labeled “DO NOT REMOVE FROM PRIMARY CHART.“ A copy will be maintained in each resident’s working House chart for ongoing reference. (2) The master care plan electronic folder will also include a spreadsheet tracking completion and dates of all care plans scanned. The ED or Admin Assistant will update the tracking spreadsheet as needed, and the ED will review compliance status monthly for at least 3 months, or until such review has documented compliance for a period of 90 days. Completion date NMT 30 days after issuance of deficiency list: 9/30/24
1320Res Rghts Rts/Rspn-Civ/Rel-Dig-RspctS/S A▼
Findings
Based on record review and interview, the residence failed to ensure the residents' right to be treated with dignity and respect, affecting one (#2) of two sample residents. Findings include:1 Residence PolicyThe residence's undated residence rights policy read in part, "The right to civil and religious liberties, including, the right to be treated with dignity and respect."2. Record ReviewResident #2 was admitted to the residence on 11/3/05 with diagnoses of schizophrenia, seizure disorder, hypothyroidism and depression. A functional assessment and assistance care document dated 9/29/23, indicated that the resident required assistance with activities of daily living (ADLs) such as dressing, grooming, and meals. The document also read, "staff need to remind Resident #2 to use (a) walker and to keep (the) walker close by (to) prevent falls." An investigation report, dated 6/14/24, revealed Resident #2 reported Staff #5 grabbed and hit her, which caused bruises. Resident #2 also reported that Staff #5 did not assist her with her ADLs and refused to provide her with assistance when she fell. 3. InterviewsOn 8/6/24 at 1:00 p.m., the administrator confirmed that the residence assessed Resident #2 when bruises were discovered on her arm; she added an investigation was conducted with Staff #5 which resulted in the residence's decision by to move Staff #5 to a different work location. On 8/6/24 at 12:07 p.m., Resident #2 said staff did not help her with her ADLs. She said Staff #5 always yelled at her, and did not assist her when she fell. Resident #2 added that Staff #5 grabbed her arm and caused bruises. On 8/6/24 at 1:00 p.m., Resident #3 said she disliked that Staff #5 always yelled at Resident #2. She said she was happy Staff #5 was moved to a different residence and was not allowed to return to work at theirs. On 8/6/24 at 4:15 p.m., Resident #9 said that some staff members treated him with respect but Staff #5 who was transferred from a different residence did not care about his needs. He added that Staff #5 never responded to his needs. On 8/6/24 at 4:15 p.m., Resident #10 said Staff #5 always talked down to him. He said, "expected the staff member to be his caregiver but the staff cared less about my needs."
Plan of correction · submitted by the facility
Description of how CSSH will correct the deficiency: ED further investigated reported staff failure to observe resident rights, by personally interviewing other residents as well. Two staff members were placed on administrative suspension pending completion of that investigation, and were subsequently terminated due to the results of that investigation as well as previous counseling. Staff #5 was verbally counseled as to providing assistance and responding to residents’ needs in accordance with their care plan or current observation, and regarding maintaining professional and respectful interactions with residents. No other staff members were reported by residents to have similar issues. Monitoring plan to ensure deficiency remedied and will not reoccur: Every two months, all residents will be asked to complete a satisfaction survey designed to identify any problems with staff treating them with dignity, respect and other resident rights, as well as staff not following through with residents’ care plans. Residents will be asked to indicate their House number if they choose, but not their name, in order to provide resident privacy while allowing the ED to target any further investigation or research indicated in response to the survey results. The Individual surveys will be reviewed by the Executive Director (ED), and the aggregate satisfaction data will be shared with the staff at All-Staff meetings. Potentially negative trends will result in refresher training for all staff, and targeted training for individual staff member(s) if indicated. After at least two consecutive surveys have been completed indicating residents are in fact being treated with dignity and respect, the monitoring frequency may be decreased but surveys will continue for another year to verify continued compliance. The ED will follow up on Staff 5’s counseling by observing and talking with residents under Staff #5’s care at least monthly. Should results of that or other investigation(s) or research identify repeated or egregious disrespect or failure of care on the part of a specific staff member, appropriate disciplinary action will be taken, up to and including termination. Completion date NMT 30 days after issuance of deficiency list: 9/30/24
3/22/2024Revisit: State Certification and State Certification Complaint (Combined) · ID 6YRQ12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 10/11/23. 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.
3/22/2024Revisit: Licensure and Licensure Complaint (Combined) · ID H3O612No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 10/11/23. 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.
10/10/2023State Certification and State Certification Complaint (Combined) · ID 6YRQ111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey with complaint #CO30402 was completed on 10/11/23. A deficiency was cited. The facility was comprised of four free-standing buildings (#2, #4, #6, #8).
Plan of correction
The state did not require a plan of correction for this citation.
0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼
Findings
Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting three of three sample residents (#1-#3). Findings include:1. Chapter VII regulations governing assisted living residents part 14.11, requires only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. Findings include:a. Residence PolicyThe residence's medication policy, dated 7/26/23, read in part that the residence did not administer any medications without a valid written order from a practitioner. All medication orders included the date, medication, strength, dosage, frequency, route and a valid written or electronic signature by a physician or other authorized provider.b. Resident #3 was admitted to the residence on 12/15/21. The September and October 2023 medication administration records (MARs) revealed the residence administered medications to Resident #3 as follows:Atorvastatin 10 mg at bedtime on 9/1-9/30 and 10/3-10/7/23Benztropine 1 mg twice daily on 9/1-9/30 and 10/4-10/7/23Miralax 17 gm at bedtime on 9/1, 9/14-9/16, 9/21, 9/27, 10/3, and 10/10/23Metamucil one packet daily on 9/1-9/13, 9/15-10/1, and 10/4/23However, the resident record for Resident #3 included no written pracititioner's orders for the above administered medications.c. Resident #1 was admitted to the residence on 6/2/23. The resident record for Resident #1 also did not include written practitioner's orders for all medications that were administered in September and October 2023.d. InterviewOn 10/11/23 at approximately 12:00 p.m., the administrator stated she did not know why the residence did not have written practitioner's orders for all medications administered to Residents #1 and #3 throughout September and October 2023. She stated she began as the administrator of the residence in late July 2023, and she stated that the former administrator should have ensured that the residence met this requirement. 2. Chapter VII regulations governing assisted living residents part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. Findings include:a. Residence PolicyThe residence's medication policy, dated 7/26/23, read in part that the residence maintained a medication administration record (MAR) for each resident for whom they were responsible for administering medications. Each MAR included a specific box designated for each administration time. Blocks were numbered for each day in the month, and staff were to initial the box when they administered the corresponding medication. If a resident refused a medication, was unavailable to receive a scheduled medication, or if the medication itself was unavailable, the QMAP circled their initials and documented the reason on the reverse side of the MAR. The administrator was responsible for ensuring appropriate and accurate documentation of medication administration.b. Resident #3 was admitted to the residence on 12/15/21. A written practitioner's order, dated 3/1/23, directed the residence to administer famotidine 20 mg twice daily. However, the September and October 2023 MARs revealed blank spaces for the administration of one of two daily doses of the medication on 9/11 and 10/10/23, for a total of two inaccurately documented doses. A written practitioner's order, dated 1/4/23, directed the residence to administer haloperidol 5 mg twice daily. However, the September 2023 MAR revealed blank spaces for the administration of one of two daily doses of the medication on 9/4/23, for a total of one inaccurately documented dose.c. Resident #1 was admitted to the residence on 6/2/23. The September and October 2023 MARs revealed inaccurate documentation for the administration of Resident #1's medications for which there were written practitioner's orders.d. Resident #2 was admitted to the residence on 10/7/21. The September and October 2023 MARs revealed inaccurate documentation for the administration of Resident #2's medications for which there were written practitioner's orders.e. InterviewOn 10/11/23 at approximately 12:00 p.m., the administrator stated that she expected QMAPs to document whether they administered each resident's medication in the MAR. She acknowledged that QMAPs had left blanks spaces in the September and October 2023 MARs for Residents #1-#3. The administrator stated that QMAPs were required to document in the MAR when they were unable to administer medications to residents and to include an explanation for the missed medication, but they did not do so in the September and October 2023 MARs for Residents #1-#3.3. Chapter VII regulations governing assisted living residents part 14.31 requires the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence ' s Quality Management Program assessment and review. Findings include:On 10/10/23 at 1:16 p.m., documentation of medication audits from the previous two quarters were requested but not provided. On 10/11/23 at approximately 12:00 p.m., the administrator stated that the residence had no documentation of any medication audits completed by the former administrator. She stated she started as the administrator of the residence in late July 2023 and she was unable to explain why quarterly medication audits were not completed and documented. The administrator stated that she was sure medication errors could have been caught and corrected with quarterly medication audits.
Plan of correction · submitted by the facility
1. Description of how licensee will correct each identified deficiency:ED will reach out to any and all providers requesting written orders that the house does not have, for any medications being administered. ED will re-train/counsel ALL QMAP STAFF by November 17th 2023 on how to properly obtain and store medication orders, emphasizing that medication orders must be on site at all times for all meds being administered. All the training will be documented in All Staff meeting minutes, and attending staff will sign their attendance. 2. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur:ED will perform bi-weekly chart audits for 3 months in each house beginning on November 3rd 2023 to verify medication orders are on hand. Any missing orders will be immediately resolved by contacting the pharmacy or provider for a copy of the order(s). After the completion of 3 months' audits, with demonstrated compliance, chart audits will be done monthly in each house thereafter, for as long as the issue continues as a QMP focus element. All chart audits that have been completed will be reviewed and monitored through the QMP, which will confirm compliance or determine and document any additional corrective actions or monitoring schedule changes needed. Bi-weekly/monthly chart audits will be documented on the POC Medication/MAR Audit form and kept in the POC binder or the ED’s audit binder, as well as attached to the QMP minutes. 3. Completion date: Audits to start by 11/10, target date for 100% compliance will be 11/27/23.
9999Final observationsSurveyor note▼
Findings
THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.495.6(I)(2) 2. Staffing at a facility shall be no less than the following standards:a. A minimum of 1 staff to 10 participants during the daytime.b. A minimum of 1 staff to 16 participants during the nighttime.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
11 records4/24/2025Physical Abuse · ID 25230518003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/24/25, 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 prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed a verbal altercation turn into a physical altercation between Client (A) and (B). Client (A), the victim, sustained a laceration and bruising under their left eye. Client (A) was treated by the paramedics. Both clients gave a different point of view on what occurred. The clients were apologetic to each other. They will be redirected to stay away from each other and to get staff assistance if a concern arises in the future. The event was 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 9/29/2025 · released to the public 10/6/2025.
11/13/2024Missing Person · ID 24230518008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/13/24, 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 prevent a future recurrence. The healthcare entity reported a missing client. During the course of the investigation the healthcare entity conducted a search and interviewed staff. The police were notified. The facility was notified that the paramedics took the client to the hospital for an evaluation and determined no concerns. The client chose to stay out in the community for 72 hours without notifying the facility. The client now had a cell phone and was educated to communicate. The address where the client was found was also provided to the facility. The event was 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 3/13/2025 · released to the public 3/21/2025.
10/21/2024Misappropriation of Property · ID 24230518006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/24/24, 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 prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation, the healthcare entity conducted interviews. Client (A) stated they gave Client (B) money to buy items they did not receive. Client (A) alleged Client (B) stole his money. Client (B) denied the allegation. The facility could not determine if money was stolen due to conflicting statements and no other witnesses. 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 3/17/2025 · released to the public 3/25/2025.
8/11/2024Misappropriation of Property · ID 24230518003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/11/24, 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 prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted interviews, and reviewed documentation, and provided transportation to a bank for the client moving forward. 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 not submitted within the required timeframe.
Publication
Sent to facility 2/6/2025 · released to the public 2/13/2025.
6/27/2024Sexual Abuse · ID 24230518004Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/28/24, 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 prevent a future recurrence. The healthcare entity reported sexual abuse of a client. During the course of the investigation the healthcare entity conducted interviews, and reviewed documentation. The client had been sent out to the hospital and then to rehabilitation for other concerns related to delusions and paranoia. The client stated while at the rehabilitation center they were molested at this facility. No additional information was provided. It is unclear if the client was assessed at the hospital or rehabilitation center. The police were notified. No findings of abuse and no assailant were identified. Staff were educated on timely reporting. The client did not return to 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 not submitted within the required timeframe.
Publication
Sent to facility 4/2/2025 · released to the public 4/9/2025.
6/14/2024Physical Abuse · ID 24230518002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/14/24, 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 prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured Clients (A) and the alleged assailant (staff member 1) were separated before the police were notified. The client alleged staff member (1) hit them in the arm. Client (A) had a small yellowish bruise to their arm. The client later retracted their allegation and stated they must have fallen out of bed. Staff member (1) denied the allegation. No further concerns from other clients or staff members. Staff member (1) will not work with the client and twice a week the client's skin will be assessed. 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 3/12/2025 · released to the public 3/19/2025.
2/13/2024Verbal Abuse · ID 24230518001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 2/13/24, a female resident (A) alleged staff member (1) attempted to take a video or photo of her while she was in the bathroom and send it to someone. Resident (A) stated staff member (1) was talking on the phone and pointing the phone towards her. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, and ombudsman. Staff member (1) was asked to leave the facility during the investigation. Staff member (1) denied being on the phone or taking any photos. Other staff members were able to corroborate staff member (1)’s statement. The facility investigation concluded the allegation was not substantiated. To help prevent a recurrence, staff member (1) will not work with resident (A) alone. Resident (A) was provided reassurances in order for her to feel safe.
DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 11/26/2024 · released to the public 12/3/2024.
10/3/2023Physical Abuse · ID 23230518007Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 10/3/23, staff member (1) witnessed a male resident (B) in his 60s angrily shove another male resident (A) in his 90s in the chest causing resident (A) to fall backwards. Resident (A) hit his head on the bedside table. Resident (A) sustained multiple skin tears and was diagnosed with a fractured lumbar four vertebrae at the hospital.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, families/guardians, ombudsman, Adult Protective Services and physician. Resident (B) was escorted to his room where he sat with management until the police arrived. The police arrested resident (B) and he was taken to jail. Resident (B) denied touching resident (A). However the altercation was witnessed. Resident (A) stated resident (B) pushed him causing him to fall backwards. The facility investigation concluded the altercation was witnessed and the allegation of abuse was substantiated. To help prevent a recurrence, resident (B) was given an immediate discharge from the facility. Staff were educated on how to react to specific behaviors from residents diagnosed with agitation. Resident (A) was offered a different home and declined.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency.
The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 9/13/2024 · released to the public 9/15/2024.
9/27/2023Missing Person · ID 23230518006Reported on time: No▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 9/25/23, a male resident (A) in his 70s went out on a pass for his birthday to have dinner with his friends. Resident (A) did not return as expected. A search was conducted on 9/26/23 and his whereabouts were unknown.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, Adult Protective Services, and physician. Other residents were accounted for and stated not to worry about resident (A) because he did this before. Resident (A) returned to the facility on 9/28/23 in the evening and stated he forgot to call the facility. Resident (A) stated he was tired and hungry. The facility will have resident (A) assessed by his physician. The facility investigation concluded resident (A) did not return when he was supposed to and he could not be reached. To help prevent a recurrence, resident (A) was reminded of the facility rules, needing to sign in and out and to communicate with the facility.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency.
The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 8/30/2024 · released to the public 9/3/2024.
4/2/2023Missing Person · ID 23230518003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 04/02/23 a male resident, in his 70s, signed out of the facility saying he was going out "for a bit". He did not return. The resident was not considered to be at risk.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police and ombudsman. The resident had a history of homelessness and substance abuse. The facility learned the resident had gone to Las Vegas. He could not be located and was subsequently discharged.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 9/26/2023 · released to the public 9/26/2023.