19
Inspections
17
Deficiencies
0
Actual Harm or Above
2
Occurrences
July 21, 2026
Last Inspection
S/S A/B Minimal potential
The most recent inspection of EDDIE'S HOUSE on record is dated July 21, 2026. Across 19 published inspections, state surveyors cited 17 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
Aragon, Alicia
Owner
TRIPLERRR LLC
Phone
(719) 560-9415
Payor Source
Medicaid, Private Pay
City
PUEBLO
ZIP
81004
Inspections & Citations
19 inspections · 17 deficiencies7/21/2026Licensure (Re-licensure) · ID 1SND11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 7/27/2026. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/4/2026Licensure Complaint · ID A7R4113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint survey, prompted by #CO42166 and #CO42171, was conducted on 5/11/26 with three deficiencies cited.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S A▼
Findings
Based on record review and interview, the residence failed to provide personal services sufficient to meet the needs of the resident, affecting one sample resident (#1) of 12 residents. Findings include:1. Record ReviewReview of a blank resident agreement, approved on April 2023, revealed language in pertinent part; "Through its certified staff, Provider will administer Resident ' s medications and Resident ' s medications, (unless there is a self administer order signed by a physician), will be stored in a locked, and properly labeled cabinet, if medications are not approved for self administration. All medications will be stored, administered and/or monitored in accordance with Colorado State laws."A record review for Resident #1 revealed an oxygen order reading,"Portable oxygen concentrator with oxygen mask for diagnosis of hypoxia, shortness of breath and cough." The order did not specify specific elements such as dose, liters per minute (LPM) and when to use. Additionally, the order expired on 11/6/25.2. InterviewsAn interview was conducted with the medication manager on 5/4/26 at 1:48 p.m. She said the order should have the dose and frequency indicated, and if the medication is expired. She added that it should have included more information than it had. A second interview was conducted on 5/5/26 at 8:58 a.m. with the medication manager. She said the order did not meet her or the agency's expectation of a complete order. She said the order did not look like other orders she had seen in the past. The medication manager said, "It does not meet my expectations. It doesn't look like other oxygen orders that I have seen". An interview with the administrator on 5/5/26 at 1:40 p.m. revealed the administrator was aware of what a correct medication order would include. The administrator acknowledged that the oxygen order was not appropriately written and that it had expired.
Plan of correction · submitted by the facility
Goals for CorrectionEnsure Compliance with Resident Care Regulations: All personal care services must meet the outlined requirements under 6 CCR 1011-1, ensuring a safe and supportive environment. Enhance Staff Training: Equip staff with the knowledge necessary to recognize and address incomplete or expired medical orders and to properly manage resident care. Establish a System for Monitoring Orders: Implement a regular review system for medication and treatment orders to ensure they meet resident needs consistently. Corrective ActionsReview and Update Medical Orders:Action: Conduct a comprehensive review of all residents' medical orders to ensure completeness and compliance with regulations. Specifically, the oxygen order for Resident #1 will be updated to include necessary details such as dosage, liters per minute (LPM), and usage instructions. Timeline: Complete review and update by May 15, 2026. Responsible Party: House Manager and Administrator. Staff Training:Action: Develop and conduct mandatory training sessions for all nursing and medication management staff on the requirements for complete medication orders, the importance of monitoring expiration dates, and the system for identifying and reporting resident concerns. Timeline: Initial training to be completed by May 20, 2026, with refresher training scheduled every six months. Responsible Party: Administrator in collaboration with the training coordinator. Implementation of Monitoring System:Action: Establish a systematic process for regularly reviewing and updating all medication and treatment orders. This system should include:A checklist for staff to verify the completeness of orders. A schedule for reviewing orders every 30 days to ensure they remain current and compliant with regulations. Timeline: Implementation of the system by May 25, 2026. Responsible Party: AdministratorDocumentation Protocol:Action: Review and revise documentation protocols to ensure that all staff members are aware of the procedures for handling expired orders and the steps required to obtain new orders promptly. Timeline: Complete revisions by May 30, 2026. Responsible Party: Administrator. Quality Assurance Measures:Action: Conduct monthly audits of medication orders and treatment plans to ensure compliance with 6 CCR 1011-1 and to identify any discrepancies or issues that need addressing. Timeline: Start audits by June 1, 2026, and report findings monthly. Responsible Party: AdministratorMonitoring and EvaluationMonthly Review: Monitor the effectiveness of the corrective actions through monthly evaluations and audits of medication orders and treatment plans (quality assurance). Monitoring is ongoing
1410Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S B▼
Findings
Based on interview and record review, the residence failed to investigate allegations of abuse in accordance with the residence's written policy, affecting 12 current residents. Findings include:1. Residence PolicyThe residence's policy,"Abuse: Neglect", undated, read specific in part, "The residence is to document all injuries of a known or unknown source." The policy further noted the following instructions for an investigation to occur, "Who- identify the resident (s) involved, staff observers or staff who may be involved or implicated. Review staff schedules to ascertain that all possible individuals that may have knowledge of the event are interviewed." However, the policy was missing the required elements: - Reporting requirements to the appropriate agencies such as the Adult Protection Services of the appropriate county Department of Social Services, and to the assisted living residence administrator;- A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; - A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; - A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and - A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. The administrator responded to an email request for all investigations of abuse and neglect on 5/4/26 at 11:51 a.m. noting, "Per policy, we have not had any grievances reported to owner or admin. There has been no abuse reported to the owner or admin for investigations to log."2. InterviewsThe house manager said law enforcement came to the residence on 4/4/26 due to allegations of a staff member not being able to care for residents because she was incapacitated. The house manager stated staff #2 was found on the sofa unable to respond and the house manager was notified by graveyard shift staff who came in to relieve staff #2. She stated the law enforcement officer did not seem concerned when he arrived and the residence did not investigate further into the potential neglect allegation. In a later interview , the house manager said if there was an allegation of abuse or neglect, the residence was required to investigate, however, she did not think there were any allegations. An interview with confidential individual #3 revealed a law enforcement officer had asked the house manager about her pushing a resident, and confidential individual #3 acknowledged that the house manager did not mention that part of the conversation when describing the officer's visit to the administrator, and that the house manager had not been truthful to the administrator regarding the details of why the police had been there. On 5/5/26 at 8:53 a.m., the house manager and the medication manager stated that law enforcement officers showed up to the residence on 4/4/26 due to reports of a staff member being under the influence of drugs and unable to care for residents. On 5/5/26 at 1:40 p.m., the administrator confirmed law enforcement was at the residence on 4/4/26 due to the allegation of caregiver neglect (a caregiver being incapacitated). The administrator said the residence did not conduct an investigation because there was no concern from law enforcement and the residence staff had not been aware of any allegations of abuse. The administrator said she had observed the residents on 4/4/26 and they all seemed ok so she believed it wasn't necessary. She stated she did not request a report because the house manager told her what had happened. An interview with the house manager was conducted on 5/5/26 at 8:58 a.m. She said the police were called about an issue with the staff and residents, but there was nothing that the police could pursue. The officer looked into the t.v. room and asked if everyone was okay, they said yes and he left. The house manager said she did not conduct an investigation because she did not know who was involved. She said "I didn't think anything happened. To investigate we have to know who is involved no names were given."On 5/5/26 at 12:00 the house manager was interviewed again and stated "if an allegation of abuse was made, I would need to investigate and would reach out to the administrator."
Plan of correction · submitted by the facility
Goals for CorrectionEnsure Continued Resident Satisfaction: Maintain an environment where all residents feel safe, respected, and valued. Enhance Staff Training: Equip staff with the necessary skills and knowledge to provide high-quality care. Establish Effective Feedback Mechanisms: Foster open communication between residents and staff to quickly address any concerns. Corrective ActionsOngoing Monitoring:Action: Implement a schedule for regular follow-up interviews with residents to monitor satisfaction and identify any new concerns. Timeline: Initiate follow-ups starting May 15, 2026, with subsequent interviews every three months. Responsible Party: House Manager. Staff Training:Action: Develop and conduct a comprehensive training program for staff focusing on resident care, communication skills, and recognizing signs of neglect or abuse. Timeline: Complete initial training by June 1, 2026, and schedule refresher courses every six months. Responsible Party: Administrator in collaboration with a training coordinator. Feedback Mechanism:Action: Establish a structured feedback system that includes:Regular surveys to assess resident satisfaction. Suggestion boxes placed in common areas to encourage anonymous feedback. Timeline: Implement by May 20, 2026. Responsible Party: House Manager. Regular Staff Meetings:Action: Conduct bi-weekly staff meetings to discuss resident feedback, care strategies, and areas for improvement. Encourage team collaboration and open discussions about resident needs. Timeline: Begin meetings on May 10, 2026. Responsible Party: House Manager. Enhance Reporting Procedures:Action: Review and improve existing reporting procedures for any resident concerns, ensuring that all staff members are aware of their responsibilities in reporting and addressing issues. Timeline: Complete review by May 30, 2026. Responsible Party: Administrator. Monitoring and EvaluationMonthly Review: Monitor the effectiveness of the corrective actions through monthly evaluations of resident feedback and staff performance. This process will be ongoing**********************************************************************************************************************************************Investigation Process for Allegations of AbuseImmediate Response:Safety First: Upon receiving a concern from a resident, immediate steps are taken to ensure their safety and well-being. Documentation: Staff must record the concern in detail, including the date, time, and nature of the allegation. Adherence to Policy:The agency follows a defined protocol, which includes:Reporting Requirements: Allegations must be reported to relevant authorities, such as adult protection services. Notification of Legal Representatives: The resident's legal representative is informed within 24 hours of learning about the allegation. Investigation Protocols: The facility's written policy outlines specific steps for conducting investigations. Investigation Steps:Data Collection: Identify and interview individuals involved (residents, staff, witnesses). Thorough Documentation: Capture all relevant details following the "who, what, when, where, how, and why" framework. Objective Analysis: Evaluate evidence, including medical records and incident reports, to determine the validity of the claims. Conclusion and Reporting:A summary is prepared to indicate whether the allegations were substantiated, along with any corrective actions taken. Documentation of the investigation is retained for review by regulatory bodies. Policy UpdatesThe facility recognized gaps in its policies and took the following steps to address them:Inclusion of Essential Elements: Updated definitions of abuse and neglect, clarified reporting protocols, and specified investigation procedures. Regulatory Compliance: Ensured that all policy updates align with state and federal regulations. Staff Training on Policy UpdatesStaff training on the revised policies was conducted. This training included:Specific instructions on the new definitions of abuse and neglect. Detailed procedures for responding to allegations, conducting investigations, and documentation requirements. Emphasis on protecting residents during investigations and understanding their rights.
2112Fd/Din Srvs-M/Dr/Sn M Incld/SubS/S B▼
Findings
Based on observation and interview, the residence failed to ensure meals were nutritionally balanced with sufficiently available nutritional options to satisfy resident appetites, affecting 12 current residents. Findings include:1. ObservationOn 5/4/26, at 5:13 p.m. the dinner consisted of macaroni noodles with ground meat mixed in, a slice of bread, and a serving of corn. Observations failed to reveal any fruit or additional vegetables as a substitute were offered. On 5/5/26, breakfast was listed on the menu as cereal with a side of fruit. At 8:46 a.m. observation revealed three boxed cereals on the countertop. Milk and a canister of sugar were observed on the counter. No fruit or vegetable was observed to be offered. On 5/5/26 at 10:40 a.m. the medication manager was unable to locate any fruit to serve to the residents, including what the menu indicated should have been served at breakfast. On 5/5/26 and 5/6/26, the choice of snacks in-between meals being provided were microwave popcorn or a "Cup of Noodle" instant soup. On 5/5/26 at 11:49 a.m., lunch consisted of the macaroni noodles with ground meat mixed in, and a slice of white bread. The macaroni and meat was similar to what was observed being served for dinner on 5/4/26, except peas and carrots were mixed in for the 5/5/26 lunch serving. 2. Record ReviewA resident agreement with a finalized date of April 2023, read in part, "Meals and Snacks: Three (3) nutritionally well-balanced meals per day are included in Resident ' s Basic Services Rate. Healthy snacks would be readily available."3. InterviewAn interview was conducted on 5/5/26 at 10:40 a.m. with the medication manager and the house manager. The medication manager said the residence had no fruit cups available. She said the only fruit available at that time was a single can of applesauce, however, there was no can opener available to open it. The house manager said she created the meal plans for the residence and the plans were created from the resident input only. The house manager said a healthy meal consisted of a protein, vegetable, a side of fruit and a starch. On 5/5/26 at 1:40 p.m. the administrator said a healthy meal included meat, vegetables and a starch.
Plan of correction · submitted by the facility
Goals for CorrectionEnsure Nutritional Compliance: All meals and snacks will meet nutritional standards as outlined in resident agreements. Enhance Meal Variety: Implement a diverse menu that includes a variety of fruits and vegetables. Improve Resident Satisfaction: Engage residents in meal planning to better meet their dietary preferences and needs. Corrective ActionsMenu Revision:Action: Revise weekly menu to include at least one serving of fruit and one serving of vegetables at each meal. Timeline: Complete by June 15, 2026. Responsible Party: House Manager and Administrator. Stocking of Nutritional Options:Action: Ensure that fresh fruits (e.g., apples, bananas, oranges) and vegetables are available daily. Timeline: Inventory and restock by June 14, 2026. Responsible Party: Kitchen Manager. Training for Staff:Action: Conduct training sessions for kitchen and caregiving staff on nutritional guidelines and meal preparation. Timeline: Schedule training by June 20, 2026. Responsible Party: Administrator. Implementation of Snack Options:Action: Introduce a variety of healthy snacks (e.g., yogurt, nuts, whole-grain options) alongside current offerings. Timeline: New snacks available by June 15, 2026. Responsible Party: House Manager and AdministratorResident Feedback Sessions:Action: Organize monthly meetings with residents to gather input on meal preferences and satisfaction. Timeline: First meeting scheduled by June 1, 2026. Responsible Party: House Manager. Inventory and Equipment Check:Action: Conduct an inventory of kitchen supplies, including can openers and utensils, to ensure all necessary tools are available for meal preparation. Timeline: Inventory completed by June 10, 2026. Responsible Party: Kitchen Manager. Monitoring and EvaluationMonthly Review: Conduct monthly reviews of meal offerings and resident satisfaction surveys until compliance is met. This action will be ongoing
5/4/2026Licensure Complaint · ID 0P8E112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO42170 and #CO42165, was completed on 5/11/26. Three deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0158Ind Rts-Adtl Crit-Prov Own/Ctrl-Res-Food▼
Findings
Based on observation and interview, the residence failed to ensure meals were nutritionally balanced with sufficiently available nutritional options to satisfy resident appetites, affecting 12 current residents. Findings include:1. ObservationOn 5/4/26, at 5:13 p.m. the dinner consisted of macaroni noodles with ground meat mixed in, a slice of bread, and a serving of corn. Observations failed to reveal any fruit or additional vegetables as a substitute were offered. On 5/5/26, breakfast was listed on the menu as cereal with a side of fruit. At 8:46 a.m. observation revealed three boxed cereals on the countertop. Milk and a canister of sugar were observed on the counter. No fruit or vegetable was observed to be offered. On 5/5/26 at 10:40 a.m. the medication manager was unable to locate any fruit to serve to the residents, including what the menu indicated should have been served at breakfast. On 5/5/26 and 5/6/26, the choice of snacks in-between meals being provided were microwave popcorn or a "Cup of Noodle" instant soup. On 5/5/26 at 11:49 a.m., lunch consisted of the macaroni noodles with ground meat mixed in, and a slice of white bread. The macaroni and meat was similar to what was observed being served for dinner on 5/4/26, except peas and carrots were mixed in for the 5/5/26 lunch serving. 2. Record ReviewA resident agreement with a finalized date of April 2023, read in part, "Meals and Snacks: Three (3) nutritionally well-balanced meals per day are included in Resident ' s Basic Services Rate. Healthy snacks would be readily available."3. InterviewAn interview was conducted on 5/5/26 at 10:40 a.m. with the medication manager and the house manager. The medication manager said the residence had no fruit cups available. She said the only fruit available at that time was a single can of applesauce, however, there was no can opener available to open it. The house manager said she created the meal plans for the residence and the plans were created from the resident input only. The house manager said a healthy meal consisted of a protein, vegetable, a side of fruit and a starch. On 5/5/26 at 1:40 p.m. the administrator said a healthy meal included meat, vegetables and a starch.
Plan of correction · submitted by the facility
Goals for CorrectionEnsure Nutritional Compliance: All meals and snacks will meet nutritional standards as outlined in resident agreements. Enhance Meal Variety: Implement a diverse menu that includes a variety of fruits and vegetables. Improve Resident Satisfaction: Engage residents in meal planning to better meet their dietary preferences and needs. Corrective ActionsMenu Revision:Action: Revise weekly menu to include at least one serving of fruit and one serving of vegetables at each meal. Timeline: Complete by June 15, 2026. Responsible Party: House Manager and Administrator. Stocking of Nutritional Options:Action: Ensure that fresh fruits (e.g., apples, bananas, oranges) and vegetables are available daily. Timeline: Inventory and restock by June 14, 2026. Responsible Party: Kitchen Manager. Training for Staff:Action: Conduct training sessions for kitchen and caregiving staff on nutritional guidelines and meal preparation. Timeline: Schedule training by June 20, 2026. Responsible Party: Administrator. Implementation of Snack Options:Action: Introduce a variety of healthy snacks (e.g., yogurt, nuts, whole-grain options) alongside current offerings. Timeline: New snacks available by June 15, 2026. Responsible Party: House Manager and AdministratorResident Feedback Sessions:Action: Organize monthly meetings with residents to gather input on meal preferences and satisfaction. Timeline: First meeting scheduled by June 1, 2026. Responsible Party: House Manager. Inventory and Equipment Check:Action: Conduct an inventory of kitchen supplies, including can openers and utensils, to ensure all necessary tools are available for meal preparation. Timeline: Inventory completed by June 10, 2026. Responsible Party: Kitchen Manager. Monitoring and EvaluationMonthly Review: Conduct monthly reviews of meal offerings and resident satisfaction surveys until compliance is met (quality assurance). This action will be ongoing
0796PA Req-P/P-MANE▼
Findings
Based on interview and record review, the residence failed to investigate allegations of abuse in accordance with the residence's written policy, affecting 12 current residents. Findings include:1. Residence PolicyThe residence's policy,"Abuse: Neglect", undated, read specific in part, "The residence is to document all injuries of a known or unknown source." The policy further noted the following instructions for an investigation to occur, "Who- identify the resident (s) involved, staff observers or staff who may be involved or implicated. Review staff schedules to ascertain that all possible individuals that may have knowledge of the event are interviewed." However, the policy was missing the required elements: - Reporting requirements to the appropriate agencies such as the Adult Protection Services of the appropriate county Department of Social Services, and to the assisted living residence administrator;- A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; - A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; - A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and - A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. The administrator responded to an email request for all investigations of abuse and neglect on 5/4/26 at 11:51 a.m. noting, "Per policy, we have not had any grievances reported to owner or admin. There has been no abuse reported to the owner or admin for investigations to log."2. InterviewsThe house manager said law enforcement came to the residence on 4/4/26 due to allegations of a staff member not being able to care for residents because she was incapacitated. The house manager stated staff #2 was found on the sofa unable to respond and the house manager was notified by graveyard shift staff who came in to relieve staff #2. She stated the law enforcement officer did not seem concerned when he arrived and the residence did not investigate further into the potential neglect allegation. In a later interview , the house manager said if there was an allegation of abuse or neglect, the residence was required to investigate, however, she did not think there were any allegations. An interview with confidential individual #3 revealed a law enforcement officer had asked the house manager about her pushing a resident, and confidential individual #3 acknowledged that the house manager did not mention that part of the conversation when describing the officer's visit to the administrator, and that the house manager had not been truthful to the administrator regarding the details of why the police had been there. On 5/5/26 at 8:53 a.m., the house manager and the medication manager stated that law enforcement officers showed up to the residence on 4/4/26 due to reports of a staff member being under the influence of drugs and unable to care for residents. On 5/5/26 at 1:40 p.m., the administrator confirmed law enforcement was at the residence on 4/4/26 due to the allegation of caregiver neglect (a caregiver being incapacitated). The administrator said the residence did not conduct an investigation because there was no concern from law enforcement and the residence staff had not been aware of any allegations of abuse. The administrator said she had observed the residents on 4/4/26 and they all seemed ok so she believed it wasn't necessary. She stated she did not request a report because the house manager told her what had happened. An interview with the house manager was conducted on 5/5/26 at 8:58 a.m. She said the police were called about an issue with the staff and residents, but there was nothing that the police could pursue. The officer looked into the t.v. room and asked if everyone was okay, they said yes and he left. The house manager said she did not conduct an investigation because she did not know who was involved. She said "I didn't think anything happened. To investigate we have to know who is involved no names were given."On 5/5/26 at 12:00 the house manager was interviewed again and stated "if an allegation of abuse was made, I would need to investigate and would reach out to the administrator."
Plan of correction · submitted by the facility
Investigation Summary: No substantiated claims of neglect were found after interviews with fourteen residents. However, actions for continued oversight and improvements have been identified. Goals for CorrectionEnsure Continued Resident Satisfaction: Maintain an environment where all residents feel safe, respected, and valued. Enhance Staff Training: Equip staff with the necessary skills and knowledge to provide high-quality care. Establish Effective Feedback Mechanisms: Foster open communication between residents and staff to quickly address any concerns. Corrective ActionsOngoing Monitoring:Action: Implement a schedule for regular follow-up interviews with residents to monitor satisfaction and identify any new concerns. Timeline: Initiate follow-ups starting May 15, 2026, with subsequent interviews every three months. Responsible Party: House Manager. Staff Training:Action: Develop and conduct a comprehensive training program for staff focusing on resident care, communication skills, and recognizing signs of neglect or abuse. Timeline: Complete initial training by June 1, 2026, and schedule refresher courses every six months. Responsible Party: Administrator in collaboration with a training coordinator. Feedback Mechanism:Action: Establish a structured feedback system that includes:Regular surveys to assess resident satisfaction. Suggestion boxes placed in common areas to encourage anonymous feedback. Timeline: Implement by May 20, 2026. Responsible Party: House Manager. Regular Staff Meetings:Action: Conduct bi-weekly staff meetings to discuss resident feedback, care strategies, and areas for improvement. Encourage team collaboration and open discussions about resident needs. Timeline: Begin meetings on May 10, 2026. Responsible Party: House Manager. Enhance Reporting Procedures:Action: Review and improve existing reporting procedures for any resident concerns, ensuring that all staff members are aware of their responsibilities in reporting and addressing issues. Timeline: Complete review by May 30, 2026. Responsible Party: Administrator. Monitoring and EvaluationMonthly Review: Monitor the effectiveness of the corrective actions through monthly evaluations of resident feedback and staff performance. This process will be ongoing. This training was conducted 5/12/2025.*********How will the facility investigate allegations of abuse if resident responses indicate concerns? How does the agency plan to follow its policy? How did the facility update its policy missing the necessary elements? When did staff receiving training on these policy updates?Response:All these elements are in our current policy, and I quote as I pulled the wording directly from the regulation and cited it:Requirements:(E) It is required that a resident shall be protected from potential future abuse and neglect while the investigation is being conducted,(F) It is required that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action, and(G) It is required that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. Is the injury “suspicious” because of ANY of the following?The extent of the injuryThe location of the injury (the injury is in an areanot vulnerable to trauma)The number of injuries observed at one point.in timeThe incidence of injuries over a periodDEFINITIONS -13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with section 5 and its written policy which shall include, but not be limited to, the following: (A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services and to the assisted living residence administrator,(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation,(C) The process for investigating such allegations, CODE OF COLORADO REGULATIONS 6 CCR 1011-1 Chapter 7 Health Facilities and Emergency Medical Services Division 41(D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted,(E) A requirement that the resident shall be protected from potential future abuse and neglect while the investigation is being conducted,(F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action, and(G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. Serious Bodily Injury: Section 2011 (19)(A) of the Affordable Care Act provides that “serious bodily injury” is defined as an injury with:extreme physical pain.with the possibility of loss or impairment of a bodily member, mental faculty, or organ.a risk of death; orthat may require surgery, hospitalization, or rehabilitation. When in doubt about whether an injury qualifies as “serious bodily injury” report using the earlier timeline. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Thisincluded deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Physical Abuse: Hitting, slapping, pinching, and kicking. Also includes controlling behavior through corporal punishment. From 483.13(b)(c)Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. From 483.13 (b)(c). Misappropriation of resident property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without the resident’s consent. From Administrative Rules of COLORADO (ARSD). All Others:any death resulting from other than natural causes originating on facility property such as accidents, abuse, negligence, or suicide.any missing resident– individual away from facility without staff knowledge of department or exit time and destination.any fire with structural damage or where injury or death occurs.any partial or complete evacuation of the facility resulting from natural disaster; orany loss of utilities, such as electricity, natural gas, telephone, emergency generator, fire alarm, sprinklers, and other critical equipment necessary for the operation of the facility for more than 24 hours. CONDUCTING AND DOCUMENTING AN INVESTIGATION -When conducting and documenting an investigation, focus on the “problem.” Clearly identify it, stay on message, say it clearly, and keep it simple. Use simple terminology whenever possible. Answer the following:Who – identify resident(s) involved (please use names not initials or numbers), staff observers or staff who may be involved or[+] implicated ([+]please provide Date of hire, Social Security Number, Date of birth, Address, and Phone contact information, Licensure or Certification information, Any previous disciplinary action, Date of termination if applicable) , family or other visitors. Review staff schedules to ascertain that all possible individuals that may have knowledge of the event are interviewed. What – describe the event, use all senses, be objective. See/Sight – pallor, sweating, deformities, bruises, edema, redness, body fluid color, pupil reaction. Feel – dampness, localized heat, localized coldness, pulses. Hear – complaints of pain, moaning, breathing pattern, heart sounds, blood pressure. Smell – fruity odors, fecal or urine odors, foul smelling drainage, alcohol breath. When – document the time. Accuracy is critical. If taking information from the electronic medical record (EMR) ensure, when entries are made later, staff record the actual time of the occurrence as the EMR system time stamps the entry time. Where – document the location, be as descriptive as possible. How – description of how the event may have occurred with the acquired information from those interviewed if there were no witnesses and/or the individual is not a good historian. Do review the resident’s BIMs score. Why – other particulars such as care plan not followed, staff not available, resident contributing factors, etc. These are areas that may be fruit for litigation, but also a great opportunity for review of the system and education. Conclusion – This is a summary statement that indicates an allegation or suspicion of abuse/neglect was either substantiated or not substantiated. Termination of an employee or having them terminate themselves does not automatically indicate whether the provider was able to substantiate an allegation; for example– With completion of internal investigation, we were able to substantiate the allegation that (name) made inappropriate advances toward (name), it was our administrative decision to terminate (name’s) employment and the Board of Nursing was notified; the provider made changes to a policy/procedure; education/re-education was provided to staff; care plans were reviewed/revised as necessary; a plausible explanation was gained for how an injury of unknown source occurred, personal property was found or restitution was made. In the event reporting of other reportable events, these are times where a staff “debriefing” needed and is an opportunity to evaluate system.processes and provide a learning/education opportunity.************************************************************************************************************************************************************The facility has established a comprehensive process for investigating allegations of abuse when resident concerns arise. Here is a detailed breakdown of how these investigations will be conducted, adherence to agency policy, and the updates to existing procedures:Investigation Process for Allegations of AbuseInitial Response to Concerns:Immediate Action: If a resident express concerns about potential abuse, staff must ensure the resident's safety and provide necessary support. Documentation: All concerns must be documented promptly to maintain an accurate record. Policy Adherence:The facility follows specific regulatory requirements, including:Reporting to appropriate agencies (e.g., adult protection services). Notifying the resident's legal representative within 24 hours of the allegation. Conducting a thorough investigation as per the established policy. Investigation Steps:Gather Information: Identify individuals involved (residents, staff, witnesses) and gather relevant details. Interview Process: Conduct interviews with all parties involved, ensuring a non-biased approach. Objective Documentation: Document the findings clearly, focusing on who, what, when, where, how, and why aspects of the incident. Analysis of Evidence: Review medical records, incident reports, and any other relevant documentation. Conclusion of Investigation:Summarize findings in a clear statement indicating whether the allegations were substantiated and outline any corrective actions taken. Ensure that the findings are retained within the facility for review by relevant departments. Policy UpdatesThe facility updated its policies to include essential elements that align with regulatory requirements. This included:Enhanced definitions of abuse and neglect. Clarification of reporting protocols and investigation processes. Procedures for protecting residents during investigations. Staff Training on Policy UpdatesStaff received training on the updated policies. This training focused on:Understanding the definitions and implications of abuse and neglect. The steps to take when allegations arise, including documentation and reporting. The importance of protecting residents during the investigation process.
12/5/2025Revisit: Licensure Complaint · ID DJ8312No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/5/25 for all previous deficiencies cited on 7/23/25. 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.
12/5/2025Revisit: Licensure Complaint · ID ET0N12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/5/25 for all previous deficiencies cited on 7/23/25. 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.
7/22/2025Revisit: Licensure and Licensure Complaint (Combined) · ID 5U0C12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A Relicensure Survey and Complaint Revisit was completed on 7/23/25 for all previous deficiency cited on 9/3/24. The residence is in compliance with all regulations surveyed.
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.
7/22/2025Licensure Complaint · ID DJ83111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO38635, was completed on 7/23/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0290LicProc-DeptOvrst-Srvy/Inspct Ensr Cmply-POCS/S A▼
Findings
Based on record review and interview, the residence failed to provide, upon request, copies of the resident records requested by the department affecting 1 former sample resident (#4). Findings Include:On 7/22/25 at approximately 12:30 p.m., Resident #4's records were requested. On 7/22/25 at approximately 1:00 p.m., the administrator stated that Resident #4's records were unavailable because the file room was inaccessible due to construction in the facility's basement.
Plan of correction · submitted by the facility
Former residents #4 historical files were temporary inaccessible because of construction. All active residents files were available. The construction project has been completed, contractors materials/equipment have been removed, and access to resident filesIn the future the files archived will be kept accessible if these files are needed for review. Construction projects will be better directed so that their materials do not obstruct access to our archived files. In the future archived files will be kept accessible in our EMAR system so that these files can be accessed via our computers. Monitoring plan record:The residence will provide better direct construction projects to better locate their construction matters as to NOT block staff access to our archived files.(a) The facility will review and mark off areas that will not cause an obstruction to our archived files.(b) Access to these areas be monitored daily during the construction project until completion of the project.(c) This QMP will continue during active construction projects. There are no active construction projects.(d) This action will continue as a monitoring practice within our operations. The construction storage areas will be reviewed as apart of this monitoring during an active construction project. Access will be monitored daily during an active construction project. We will take a log of any construction obstructions on a log during an active construction project. This will be monitored until 1/1/2026. This action will continue as a monitoring practice within our operations.
7/22/2025Licensure Complaint · ID ET0N111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO38636, was completed on 7/23/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0740PA Req-Cert/DeCert/Term-Decertification▼
Findings
Based on record review and interview the facility failed to provide, upon request, copies of the member's records requested by the department affecting 1 former sample member (#4). Findings Include:On 7/22/25 at approximately 12:30 p.m., Member #4's records were requested. On 7/22/25 at approximately 1:00 p.m., the administrator stated that Member #4 records were unavailable because the file room was inaccessible due to construction in the facility's basement.
Plan of correction · submitted by the facility
Former residents #4 historical files were temporary inaccessible because of construction. All active residents files were available. The construction project has been completed, contractors materials/equipment have been removed, and access to resident filesIn the future the files archived will be kept accessible if these files are needed for review. Construction projects will be better directed so that their materials do not obstruct access to our archived files. In the future archived files will be kept accessible in our EMAR system so that these files can be accessed via our computers. Monitoring plan record:The residence will provide better direct construction projects to better locate their construction matters as to NOT block staff access to our archived files.(a) The facility will review and mark off areas that will not cause an obstruction to our archived files.(b) Access to these areas be monitored daily during the construction project until completion of the project.(c) This QMP will continue during active construction projects. There are no active construction projects.(d) This action will continue as a monitoring practice within our operations. The construction storage areas will be reviewed as apart of this monitoring during an active construction project. Access will be monitored daily during an active construction project. We will take a log of any construction obstructions on a log during an active construction project. This will be monitored until 1/1/2026. This action will continue as a monitoring practice within our operations
7/22/2025Revisit: State Certification and State Certification Complaint (Combined) · ID QECS12No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A Recertification Survey and Complaint Revisit was completed on 7/23/25 for all previous deficiency cited on 9/3/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9/3/2024Revisit: Licensure Complaint · ID LM2Z12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 9/3/24, for all previous deficiencies cited on 12/14/22 The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
2 records8/23/2023Sexual Abuse · ID 23230662002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 8/23/23, three male residents (A, B, and C) alleged another male resident (D) touched their buttock area without consent.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, families, ombudsman and physician. Residents (A), (B), and (C) all stated they felt safe and refused an assessment. Resident (D) admitted to the incident. The facility investigation substantiated an allegation of inappropriate touching. Management issued a discharge notice to resident (D) and staff assisted him to look for an alternate placement. Resident (D) was seen by his physician for any medication adjustments. Staff have been made aware of the actions to be taken to monitor resident (D)’s behavior until he moved out.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility 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 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 7/25/2024 · released to the public 8/1/2024.
3/8/2023Physical Abuse · ID 23230662001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 3/7/22 a female resident (A) in her 40s physically assaulted staff members. The police were called a few times and stated they could not remove resident (A) from the facility. The facility contacted the crisis center who also did not remove resident (A) from the facility. During this time, a male resident (B) in his 50s came forward to report that resident (A) had placed her hands around his neck and told him to move. This happened two days prior.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, Adult Protective Services and ombudsman. The police had been called a number of times to the facility as staff had to barricade themselves because of being physically assaulted by resident (A). It was revealed that other residents were fearful of resident (A) and did not come forward to report and were being bullied. Resident (A) denied the allegations even though there were several witnesses. Resident (A) reportedly fled the facility and had not returned. The facility investigation concluded resident (A) is a threat to herself and others, and a restraining order was implemented. To help prevent a recurrence all staff and other residents have been notified of the restraining order in place and to notify management if resident (A) is near the facility. A meeting was held with the remaining residents to ensure they felt safe and were encouraged to report safety concerns to staff as needed for support
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 10/5/2023 · released to the public 10/12/2023.