BLOSSOM VIEW ASSISTED LIVING

A relicensure survey with complaint #CO40482 was completed on 3/10/26. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure each personnel file included orientation and training, verification of active certifications, and documentation of initial and continuing dementia education for two of two sample staff (#1 #2), affecting 14 current residents. Findings Include:A review of the personnel files for Staff #1 and #2, hired 9/16/18 and 6/30/15, respectively, revealed that the files failed to contain all required documentation. The personnel file for Staff #2 failed to contain verification of her certification as a qualified medication administration person (QMAP), as well as documentation of initial orientation and training. Finally, both personnel files failed to include initial and continuing dementia training. On 3/10/26 at 3:30 p.m., the administrator acknowledged that Staff #2's personnel file did not contain evidence of orientation and training, QMAP verification, and training on dementia. She agreed that they should be in her file and added that Staff #2 was hired before she became the administrator on 1/3/21. She acknowledged that Staff #1's file additionally did not include evidence of dementia training. She confirmed that staff had been trained as required. On 3/10/26 at 3:35 p.m., Staff #2 stated that she had been provided with orientation and training when she had been hired on 6/30/15. Additionally, she added that she had completed her QMAP certification on 10/20/16. She also stated that she had been provided with training on dementia and related diagnoses and was unsure why there was not documentation of it.

Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises, affecting 14 current residents. Findings Include:On 3/10/26, the residence's emergency preparedness plan (EPP) was requested from the administrator via electronic communication at 7:58 a.m. and was provided by the administrator at approximately 8:30 a.m. Review of the EPP revealed that there was no risk assessment of all hazards and preparedness measures to address natural and human-caused crises. On 3/10/26 at 5:30 p.m., the administrator confirmed that the residence's EPP did not include a risk assessment of all hazards and preparedness measures. Additionally, she stated that she expected the residence's EPP to meet all requirements.

Based on record review and interview, the residence failed to develop written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following an emergency, affecting 14 current residents. Findings Include:Review of the residence's emergency preparedness plan (EPP) revealed that there were no written policies and procedures (P&P) to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency. On 3/10/26 at 5:30 p.m., the administrator confirmed that the residence's EPP did not include written P&Ps to ensure the continuation of necessary care to all residents for at least 72 hours immediately following an emergency. Additionally, she stated that she expected the residence's EPP to meet all requirements.

Based on records review and interviews, the residence failed to have emergency policies that addressed all required items, affecting 14 current residents. Findings Include:Review of the residence's emergency preparedness plan (EPP) revealed that it failed to include the following required items:(1) A pre-determined means of communicating with residents, families, staff, and other providers;(2) Assignment of specific tasks and responsibilities to the staff members on each shift, including the use of a triage system to assess the needs of the most vulnerable residents first;(3) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. On 3/10/26 at 5:30 p.m., the administrator confirmed that the residence's EPP did not include all required items. Additionally, she stated that she expected the residence's EPP to meet all requirements.

Based on record review and interview, the residence allowed a person to move in who had a history of conduct that had been disclosed that would pose a danger to the resident or others without reasonable therapeutic approaches to manage the conduct, affecting Former Resident #5 (FR#5). (Cross-reference U1064)Findings Include:An assessment completed by FR#5's case manager dated 12/9/24 and read in part: "[FR#5] reported major defects with behaviors due to chronic medical conditions, mood instability, paranoia, agitation, and impaired judgment caused by bipolar, PTSD, and Asperger's. [FR#5] reported that he struggled with impulse control and making good decisions. [FR#5] reported that he has a history of making poor decisions, which has caused him to struggle to maintain relationships, stable housing, and employment. [FR#5] talked about situations in which his "PTSD kicks in" and he becomes aggressive, describing a time 8-9 years ago that he beat up his neighbor because he believed his neighbor was a "bad guy". A review of FR#5's resident record revealed he was admitted to the residence on 3/12/25. There was no evidence of a pre- admission assessment completed by the residence, or an individualized care plan. On 3/10/26 at 5:31 p.m., the administrator acknowledged that FR#5 should not have been allowed to move into the residence. The administrator acknowledged they should have conducted a pre-admission assessment at the time of move-in for FR #5. She added that the residence was a "last resort" for FR#5 as he was staying in a hotel at the time they admitted him. Additionally, the administrator acknowledged that the assessment completed by the case manager on 12/9/24 indicated that FR#5 had a history of conduct that would pose a danger to himself or others. She agreed that because no assessment or care plan was created, the residence did not have reasonable therapeutic approaches to manage this conduct.

Based on records review and interviews, the residence failed to reassess Former Resident #5 (FR#5) and revise his care plan to identify the then-current needs and what services the residence would provide to meet those needs once he had demonstrated that he had become a danger to himself and others, affecting Former Resident #5 (FR#5). (Cross-reference U1020)Findings Include:A review of FR#5's resident record revealed he was admitted to the residence on 3/12/25. The record included progress notes dated from 5/1/25 to 6/15/25, demonstrating that FR#5 had intimidated the cats, caused property damage, threatened others, and caused harm to himself. Additionally, paranoid, manic, threatening, and intimidating behavior was described. A critical incident report (CIR) dated 6/18/25 read in part: "[The residence] has received multiple complaints from residents this morning that they are terrified to live in the same house as [FR#5]. They are afraid he is going to hurt or kill them due to his constant threats and harassment." The CIR indicated that FR#5 was subjected to "immediate eviction."Further review of FR#5's resident record revealed no evidence of reassessment and care plan revisions being completed by the residence for FR#5 after they had determined he had become a danger to himself and others. On 3/10/26 at 11:53 a.m., the administrator stated that FR#5 had been evicted on 6/14/25 due to his hostile and threatening behaviors towards staff and residents. She stated that when he was evicted, they provided him with $150 in cash and provided a three-night hotel stay. She added that just as he was leaving, he stole another former resident's liquor bottle and poured it out on the floor in front of the resident just to instigate, as well as threw the empty bottle at the van driver. The administrator also added that after he had been evicted, he continued to monitor and harass the residents from across the street. On 3/10/26 at 5:30 p.m., the administrator confirmed that she had determined FR#5 had become an immediate threat to the safety of other residents and needed to be immediately evicted from the residence. She confirmed that no reassessment or care plan revision was completed when she determined that he had become a danger to himself and others. She stated that she was not aware of this requirement and stated that she would expect this to be completed as required.

Based on observations, records review, and interviews, the residence failed to ensure each resident's care plan prompted resident mobility, independence, and safety, as well as detail specific personal needs, the staff tasks necessary to meet those needs and identify all external service providers, affecting two of three sample residents who records were reviewed (#2, #3). Findings Include:A review of the record for Resident #2 revealed the most recent care plan was completed 7/1/25, and it did not include any mobility, independence, or safety information, along with the specific personal services needs and the staff tasks needed to meet those needs. Finally, no evidence of her physical therapy provider was found. An incident report dated 3/8/26 at 8:20 p.m. revealed that Resident #2 had an unwitnessed fall in her bedroom. Staff found the resident sitting up with her back against her bedframe. Staff identified a "2-inch goose egg bump on the right side of her forehead". Resident #2 reported that she had lost her footing while adjusting her oxygen concentrator and fell forward, and hit her head on the foodboard of the bed. On 3/10/26 at 8:45 a.m., the day of the onsite investigation, Resident #2 was observed walking with her four-wheeled walker with landry basket on the seat. She was walking slowly and appeared weak and timid in her stance. Her gait was short and shuffling. Additionally, there was a bandage around her head from a head injury due to a fall from the previous week. On 3/10/26 at 11:35 a.m., the administrator stated that Resident #2 just had another fall in the laundry room "just moments ago" during the onsite investigation. She explained that she had fallen while taking her laundry to the laundry room and she had hit her head and cut her wrist. The administrator explained that she and Staff #2 were able to assist her to a seated position on her walker with the resident's assistance. The administrator explained that Resident #2 had fallen out of bed back in December 2025 and had broken her hip. She stated that it was a series of increasingly worse falls in the months before. She then stated that the primary care practitioner reviewed and changed her prescriptions. Additionally, physical therapy, a new four-wheeled walker, and a stay at a local rehabilitation facility had prevented her from falling until the fall on 3/8/26. The administrator also added that she investigated the most recent fall and put her concentrator onto a table so that she did not have to bend to adjust it. She added that she had not predicted that she would have fallen trying to do the laundry. On 3/10/26 at approximately 12:00 p.m., Staff #1 acknowledged there were appropriate safety interventions in place for Resident #2. She stated that she was aware that Resident #2 was a fall risk. She added that she had fallen last week because she had bent over to adjust her oxygen concentrator and lost her balance. Staff #1 stated that the staff was directed to monitor her closely, especially at night, as that is when she falls the most. She added that she had been seeing PT to assist her with strengthening her gait and learning how to better utilize her new four-wheeled walker. Staff #1 stated that when she fell this last time, they rearranged her room to ensure she had more mobility access and moved her oxygen concentrator off the floor onto a table so that Resident #2 did not have to bend down to adjust the flow. Records review and interviews revealed similar deficient practice with Resident #3.

Based on record review and interviews, the residence failed to maintain a legible list of the names of the persons utilizing the medication administration record (MAR), as well as ensure each qualified medication administration person (QMAP) accurately documents medication administration events at the time each event is completed, affecting 14 current residents. Findings Include:A review of the list of the names of the persons utilizing the MAR, along with their signatures and initials, failed to include two of the six QMAPs who had utilized the February and March 2026 MARs. A review of the March 2026 MAR for Resident #1 revealed that the QMAPs failed to accurately document four medication administration events on 3/5/26 as follows, for the following ordered medications: risperidone 0.5 mg at 8:00 p.m., risperidone 1 mg at 8:00 p.m., blood glucose check at 8:00 p.m., and daily fiber 11.6 g at 8:00 a.m. On 3/10/26 at 5:14 p.m., the administrator confirmed that the two newest QMAPs had passed medications to all 14 current residents and marked the February and March 2026 MARs with their initials, but were not yet included on the list of names with their signatures. On 3/10/26 at 5:30 p.m., the administrator acknowledged that the four blank spaces on Resident #1's March 2026 MAR were not accurate documentation. She agreed that staff must accurately document each medication administration event in the MAR.

Based on observations and interviews, the residence failed to keep controlled substances in double-lock storage (DLS), affecting 14 current residents. Findings Include:Observations of the morning medication administration event at 8:10 a.m. revealed that Staff #1 had left the key to the medication cabinet in the cabinet while she went to the laundry room to assist a resident with the administration of medication, leaving four other residents alone by the unlocked medication cart with the medications for approximately two minutes. In an interview with Resident #4 on 3/10/26 at 8:30 a.m., she confirmed that staff often leave the medication cabinet unlocked when they go back to the laundry room for administration or to get refrigerated medications. Observations of the medication storage area on 3/10/26 at 11:10 a.m. revealed that the controlled substances were only locked behind one lock. Additional observations of the kitchen where the medications were stored revealed that the area is freely accessible to all residents and is not always monitored by staff. On 3/10/26 at 11:35 a.m., Staff #2 stated that the controlled substances are kept in the pantry in a small box that is supposed to be locked along with the pantry. On 3/10/26 at 5:30 p.m., the administrator stated that she agreed that this second box should have been locked, as well as the pantry. She agreed that staff have been directed to keep all the medications locked as required and to keep their keys in their pocket.

Based on observations and interviews, the residence failed to maintain the grounds to protect residents from holes and other hazards, affecting 14 current residents. Findings Include:An environmental tour of the residence grounds on 3/10/26 at 7:30 a.m. revealed five areas around the paved patio and the gravel walking paths along the back courtyard that had a drop-off of one to three inches and two two-by-two-inch holes, all presenting tripping hazards. Observation of the grounds from 7:00 a.m. to 6:00 p.m. revealed that multiple residents, some with mobility limitations, utilized the courtyard frequently. On 3/10/26 at 5:30 p.m., the administrator agreed that the courtyard walking path and patio did have drop-offs and that those did present a falling hazard to residents. She agreed that the grounds needed to be better maintained.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter 7.7.2 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall obtain a check of the Colorado adult protective services data system pursuant to Section 26-3.1-111, C.R.S. Based on the results of the check, the assisted living residence shall ensure it follows its policy regarding the hiring or continued service of any staff member or volunteer, as required by Part 7.4.12.12 The assisted living residence shall notify the resident's representative whenever the resident experiences a significant change from baseline status. 12.26 Each assisted living residence shall place notices of planned resident engagement offerings in a central location readily accessible to residents, relatives, and the public. Copies shall be retained for at least six months. 13.6 Meetings shall be held at least quarterly with an opportunity for more frequent meetings if requested. 14.38 All medications shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff.

A recertification survey with complaint #CO40483 was completed on 3/10/26. Deficiencies were cited.

Based on records review and interviews, the facility (residence) failed to establish policies and procedures for contingency planning, affecting 14 current members(residents). Findings Include:The residence's emergency preparedness plan (EPP) was requested from the administrator via electronic communication at 7:58 a.m. and was provided by the administrator at approximately 8:30 a.m. Review of the EPP revealed that there was no risk assessment of all hazards and preparedness measures to address natural and human-caused crises. Further review of the residence's emergency preparedness plan (EPP) revealed that it failed to include the following required items:(1) A pre-determined means of communicating with residents, families, staff, and other providers;(2) Assignment of specific tasks and responsibilities to the staff members on each shift, including the use of a triage system to assess the needs of the most vulnerable residents first;(3) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. On 3/10/26 at 5:30 p.m., the administrator confirmed that the residence's EPP did not include a risk assessment of all hazards and preparedness measures. Additionally, she stated that she expected the residence's EPP to meet all requirements. Additionally, the administrator confirmed that the residence's EPP did not include all required items. Finally, she stated that she expected the residence's EPP to meet all requirements.

Based on records review and interviews, the Provider Agency (residence) failed to maintain records documenting the qualifications and training of employees (staff) for the two sample staff (#1, #2), affecting 14 current members (residents). Findings Include:A review of the personnel files for Staff #1 and #2, hired 9/16/18 and 6/30/15, respectively, revealed that the files failed to contain all required documentation. The personnel file for Staff #2 failed to contain verification of her certification as a qualified medication administration person (QMAP), as well as documentation of initial orientation and training. Finally, both personnel files failed to include initial and continuing dementia training. On 3/10/26 at 3:30 p.m., the administrator acknowledged that Staff #2's personnel file did not contain evidence of orientation and training, QMAP verification, and training on dementia. She agreed that they should be in her file and added that Staff #2 was hired before she became the administrator on 1/3/21. She acknowledged that Staff #1's file additionally did not include evidence of dementia training. She confirmed that staff had been trained as required. On 3/10/26 at 3:35 p.m., Staff #2 stated that she had been provided with orientation and training when she had been hired on 6/30/15. Additionally, she added that she had completed her QMAP certification on 10/20/16. She also stated that she had been provided with training on dementia and related diagnoses and was unsure why there was not documentation of it.

Based on record review and interviews, the facility (residence) failed to ensure qualified medication administration personnel (QMAP) record all medications administered, including the date, time, and amount of each medication administered, affecting one of five sample members (residents) (#1). Findings Include:A review of the list of the names of the persons utilizing the MAR, along with their signatures and initials, failed to include two of the six QMAPs who had utilized the February and March 2026 MARs. A review of the March 2026 MAR for Resident #1 revealed that the QMAPs failed to accurately document four medication administration events on 3/5/26 as follows, for the following ordered medications: risperidone 0.5 mg at 8:00 p.m., risperidone 1 mg at 8:00 p.m., blood glucose check at 8:00 p.m., and daily fiber 11.6 g at 8:00 a.m. On 3/10/26 at 5:14 p.m., the administrator confirmed that the two newest QMAPs had passed medications to all 14 current residents and marked the February and March 2026 MARs with their initials, but were not yet included on the list of names with their signatures. On 3/10/26 at 5:30 p.m., the administrator acknowledged that the four blank spaces on Resident #1's March 2026 MAR were not accurate documentation. She agreed that staff must accurately document each medication administration event in the MAR.

Based on observations, records review, and interviews, the Alternative Care Facility (residence) failed to implement Rights Modifications in compliance with Section 8.7001. B.4 before restricting the right to unrestricted access to all common areas as indicated by Section 8.7001. B.3.a.vii, affecting one (#1) of four current sample Members (residents). Findings Include:1. References a. Section 8.7000 regulations governing alternative care facilities, Part 8.7001. B.3.a.vii, requires the individual to have unrestricted access to all common areas, including areas such as the bathroom, kitchen, dining area, and comfortable seating in shared areas.b. Section 8.7000 regulations governing alternative care facilities, Part 8.7001. B.4, requires that any modification of an individual's rights must be supported by a specific assessed need and justified in the Person-Centered Support Plan, pursuant to the process set out in Sections 8.7001. B.4.c and 8.7001. B.4.d below. Rights Modifications may not be imposed across-the-board and may not be based on the convenience of the Provider Agency/its independent Contractor. The Provider Agency/its independent Contractor must ensure that a Rights Modification does not infringe on the rights of individuals not subject to the modification. Wherever possible, Rights Modifications should be avoided or minimized, consistent with the concept of dignity of risk. The process set out in Sections 8.7001. B.4.c-d below applies to all Rights Modifications. For a Rights Modification to be implemented, the following information must be documented in the individual's Person-Centered Support Plan, and any Provider Agency/its independent Contractor implementing the Rights Modification must maintain a copy of the documentation: The right to be modified. The specific and individualized assessed need for the Rights Modification. The positive interventions and supports used before any Rights Modification, as well as the plan going forward for the Provider Agency/its independent Contractor to support the individual in learning skills so that the modification becomes unnecessary. The less intrusive methods of meeting the need were tried but did not work. A clear description of the Rights Modification that is directly proportionate to the specific assessed need. The rights of an individual receiving services may be modified only in a manner that will promote the least restriction on the individual ' s rights and in accordance with rules herein. A plan for regular collection of data to measure the ongoing effectiveness of and need for the Rights Modification, including specification of the positive behaviors and objective results that the individual can achieve to demonstrate that the Rights Modification is no longer needed. An established timeline for periodic reviews of the data collected under the preceding paragraph. The Rights Modification must be reviewed and updated as necessary upon reassessment of functional need at least every 12 months, and sooner if the individual's circumstances or needs change significantly, the individual requests a review/revision, or another authority requires a review/revision. The Informed Consent of the individual (or, if authorized, their Guardian or other Legally Authorized Representative) agrees to the Rights Modification, as documented on a completed and signed Department-prescribed form. To be completed, the form must be filled out using Plain Language, addressed directly to the individual, and it must address only one Rights Modification. Informed Consent may not be requested or granted for a Rights Modification extending beyond the 12-month or shorter period as set out in Section 8.7001. B.4.c.vii. An assurance that interventions and supports will cause no harm to the individual, including documentation of the implications of the modification for the individual's everyday life and the ways the modification is paired with additional supports or other approaches to prevent harm or discomfort and to mitigate any effects of the modification. Alternatives to consenting to the Rights Modification, along with their most significant likely consequences. An assurance that the individual will not be subject to retaliation or prejudice in their receipt of appropriate services and supports for declining to consent or withdrawing their consent to the Rights Modification. Additional Rights Modification process requirements: Before obtaining Informed Consent, the Case Manager must offer the individual the opportunity to have an advocate, who is identified and selected by the individual, present at the time that Informed Consent is obtained. The Case Manager must offer to assist the individual, if desired, in identifying an independent advocate who is not involved with providing services or supports to the individual. These offers and the individual's response must be documented by the Case Manager. Any Provider Agencies that desire or expect to be involved in implementing a Rights Modification may supply to the Case Manager information required to be documented under this Section 8.7001. B.4, except for documentation of Informed Consent and the offers and responses relating to an advocate, which may be obtained and documented only by the Case Manager. The individual determines whether any information supplied by the Provider Agency is satisfactory before the Case Manager enters it into their Person-Centered Support Plan. When a Rights Modification is proposed, it is reviewed by the individual, their Guardian or other Legally Authorized Representative, and the rest of the individual ' s Member Identified Team, and, if consented to, it is documented in the Person-Centered Support Plan. When a right has been modified, the continuing need for such modification shall be reviewed by the individual's Member-Identified Team, as led by the individual or their Guardian or other Legally Authorized Representative, at a frequency decided by the team, but at least every six months. Such a review shall include the original reason for modification, current circumstances, success or failure of programmatic intervention, and the need for continued modification. Restoration of affected rights shall occur as soon as circumstances justify. If the review indicates that changes are needed to the Rights Modification, the Case Manager shall obtain a new signature on an updated Department-prescribed Informed Consent form. If the review indicates that no changes are needed, then the original signature is still valid for the remaining period (up to six months). At the time a right is modified, such action, if subject to Human Rights Committee review, shall be referred to the Human Rights Committee for review and recommendation. Such review shall include an opportunity for the individual or Member who is affected, Parent of a minor, Guardian, or other Legally Authorized Representative, after being given reasonable notice of the meeting, to present relevant information to the Human Rights Committee. Use of Restraints If Restraints are used with an individual at an HCBS Setting, their use must: Be based on an assessed need after all less restrictive interventions have been exhausted; Be documented in the individual's Person-Centered Support Plan as a modification of the generally applicable rights protected under Section 8.7001. B.2, consistent with the Rights Modification process in this Section 8.7001. B.4; and Be compliant with any applicable waiver. Prone Restraints are prohibited in all circumstances. Nothing in this Subsection 8.7001. B.4.e permits the use of any Restraint that is precluded by other authorities. If Restrictive or Controlled Egress Measures are used at an HCBS Setting, they must: Be implemented on an individualized (not setting-wide) basis; Make accommodations for individuals in the same setting who are not at risk of unsafe wandering or exit-seeking behaviors; Be documented in the individual's Person-Centered Support Plan as a modification of the generally applicable rights protected under Section 8.7001. B.2, consistent with the Rights Modification process in this Section 8.7001. B.4, with the documentation including: An Assessment of the individual's unsafe wandering or exit-seeking behaviors (and the underlying conditions, diseases, or disorders relating to such behaviors) and the need for safety measures; Options that were explored before any modifications occurred to the Person-Centered Support Plan; The individual's understanding of the setting's safety features, including any Restrictive or Controlled Egress Measures; The individual's choices regarding measures to prevent unsafe wandering or exit-seeking; The individual's (or, if authorized, their Guardian's or other Legally Authorized Representative's) consent to restrictive- or controlled-egress goals for care; The individual's preferences for engagement within the setting's community and within the broader community; and The opportunities, services, supports, and environmental design that will enable the individual to participate in desired activities and support their mobility; and Not be developed or used for non-person-centered purposes, such as punishment or staff/Contractor convenience. If there is a serious risk to anyone's health or safety, a Rights Modification may be implemented or continued for a short time without meeting all the requirements of this Section 8.7001. B.4, so long as the Provider Agency/its independent Contractor immediately (a) implements staffing and other measures to deescalate the situation and (b) reaches out to the Case Manager to set up a meeting as soon as possible, and in no event past the end of the third business day following the date on which the risk arises. At the meeting, the individual can grant or deny their Informed Consent to the Rights Modification. The Rights Modification may not be continued past the conclusion of this meeting or the end of the third business day, whichever comes first, unless all the requirements of this Section 8.7001. B.4 have been met. When a Provider Agency proposes a Rights Modification and supplies to the Case Manager the unsigned Informed Consent form with all of the information required to be documented under this Section 8.7001. B.4, except for documentation that may be obtained only by the Case Manager, the Case Manager shall arrange for a meeting with the individual to discuss the proposal and facilitate the individual's decision regarding whether to grant or deny their Informed Consent. Except when the timeline in Section 8.7001. B.4.g applies, the Case Manager shall arrange for this meeting to occur by the end of the tenth business day following the date on which they received from the Provider Agency all of the required information. The individual may elect to make a final decision during or after this meeting. If the individual does not inform their Case Manager of their decision by the end of the fifth business day following the date of the meeting, they are deemed not to have consented. 2. Record Review and ObservationA review of the care plan for Resident #1, dated 7/1/25, failed to include any evidence of drug diversion behaviors. The entire "Behavior Problems" section was blank. A progress note for Resident #1 dated 1/12/26 read in part: "We (residence staff) watch her carefully, taking medications. Then she has to wait 20 minutes in the dining room." Additionally, progress notes dated 3/2/26 and 3/7/26 revealed that the staff was still monitoring her after each medication administration event (MAE). On 3/3/26 at 7:29 a.m., a list of all residents who have active rights modifications was requested from the administrator via electronic communication and was not received. Observations of the MAE at 7:30 a.m. revealed Resident #1 asking Staff #2 what time she could leave the dining room. 3. Interviews On 3/10/26 at 8:00 a.m., Staff #2 stated she was directed to have Resident #1 remain in line-of-sight (LOS) for 20 minutesafter every MAE. Staff #2 stated that Resident #1 had been caught "cheeking" her medications, and this was the intervention to prevent her from continuing. On 3/10/26 approximately 9:00 a.m., the administrator stated that she did not have any residents with current rights modifications. Resident #4 stated in an interview on 3/10/26 at 8:30 a.m. that the staff made Resident #1 sit in the kitchen after she took her medications. On 3/10/26 at approximately 10:45 a.m. Resident #1 stated that she loved living at the residence, and she had no problem with any of the procedures or approaches of the staff. On 3/10/26 at 12:45 p.m., Resident #1's case manager (R#1CM) stated she was unaware of the residence staff requiring Resident #1 to remain in LOS after each MAE. She agreed that this would be a rights modification and would need to follow the requirements. R#1CM also stated that the residence did not inform her of Resident #1 "cheeking" any medications, and would have expected to have been informed. On 3/10/26 at 3:00 p.m., the administrator stated that she had become aware of Resident #1 "cheeking" her medication for the first time, three weeks before the onsite investigation. She added that the very next day, she found another instance. After learning about this new behavior, she consulted with Resident #1's primary care practitioner (PCP) and psychiatrist, who provided orders to have Resident #1 stay in LOS for 20 minutes following each MAE.

Based on observations, records review, and interviews, the Provider (residence) failed to document in each Member's (resident's) Provider Care Plan (care plan) all required information, affecting the three current sample residents whose records were reviewed (#1-#3). Findings Include:A review of the record for Resident #2 revealed the most recent care plan was completed 7/1/25, and it did not include any mobility, independence, or safety information, along with the specific personal services needs and the staff tasks needed to meet those needs. Finally, no evidence of her physical therapy provider was found. An incident report dated 3/8/26 at 8:20 p.m. revealed that Resident #2 had an unwitnessed fall in her bedroom. Staff found the resident sitting up with her back against her bedframe. Staff identified a "2-inch goose egg bump on the right side of her forehead". Resident #2 reported that she had lost her footing while adjusting her oxygen concentrator and fell forward, and hit her head on the foodboard of the bed. On 3/10/26 at 8:45 a.m., the day of the onsite investigation, Resident #2 was observed walking with her four-wheeled walker with landry basket on the seat. She was walking slowly and appeared weak and timid in her stance. Her gait was short and shuffling. Additionally, there was a bandage around her head from a head injury due to a fall from the previous week. On 3/10/26 at 11:35 a.m., the administrator stated that Resident #2 just had another fall in the laundry room just moments ago. She explained that she had fallen while taking her laundry to the laundry room and she had hit her head and cut her wrist. The administrator explained that she and Staff #2 were able to assist her to a seated position on her walker with the resident's assistance. The administrator explained that Resident #2 had fallen out of bed back in December 2025 and had broken her hip. She stated that it was a series of increasingly worse falls in the months before. She then stated that the primary care practitioner reviewed and changed her prescriptions. Additionally, physical therapy, a new four-wheeled walker, and a stay at a local rehabilitation facility had prevented her from falling until the fall on 3/8/26. The administrator also added that she investigated the most recent fall and put her concentrator onto a table so that she did not have to bend to adjust it. She added that she had not predicted that she would have fallen trying to do the laundry. On 3/10/26 at approximately 12:00 p.m., Staff #1 acknowledged there were appropriate safety interventions in place for Resident #2. She stated that she was aware that Resident #2 was a fall risk. She added that she had fallen last week because she had bent over to adjust her oxygen concentrator and lost her balance. Staff #1 stated that the staff was directed to monitor her closely, especially at night, as that is when she falls the most. She added that she had been seeing PT to assist her with strengthening her gait and learning how to better utilize her new four-wheeled walker. Staff #1 stated that when she fell this last time, they rearranged her room to ensure she had more mobility access and moved her oxygen concentrator off the floor onto a table so that Resident #2 did not have to bend down to adjust the flow. Records review and interviews revealed similar deficient practice with Residents #1 and #3.

Based on observations, records review, and interviews, the Alternative Care Facility (residence) failed to comply with Environmental Standards as outlined in Section 8.7506. F.5 subsections (b), (d), and (e) affecting 14 current Members (residents). Findings Include:Observations of the residence at 7:13 a.m. revealed the residence's activity calendar was dated July 2025. An environmental tour of the residence grounds at 7:30 a.m. revealed five areas around the paved patio and the gravel walking paths along the back courtyard that had a drop-off of one to three inches and two two-by-two-inch holes, all presenting tripping hazards. Observation of the grounds from 7:00 a.m. to 6:00 p.m. revealed that multiple residents, some with mobility limitations, utilized the courtyard frequently. Review of the residence's emergency preparedness plan (EPP) revealed that there were no written policies and procedures (P&P) to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency. During an interview with the administrator on 3/10/26 at 7:15 a.m., she acknowledged that the posted activity calendar is out of date and needs to be updated. She added that residents do get regular activities and outings to the community; however, the information is usually provided verbally. On 3/10/26 at 5:30 p.m., the administrator confirmed that the residence's EPP did not include written P&Ps to ensure the continuation of necessary care to all residents for at least 72 hours immediately following an emergency. Additionally, she stated that she expected the residence's EPP to meet all requirements. Additionally, the administrator agreed that the courtyard walking path and patio did have drop-offs and that those did present a falling hazard to residents. She agreed that the grounds needed to be better maintained.

Based on observations, records review, and interviews, the Alternative Care Facility (residence) failed to comply with 6 C.C.R. 10.11-1 Chapter 7, Part 11.2(H) and 11.13(B) when admitting and providing 30 days' notice of discharge to Former Member (Resident) #5 (FR#5). Findings Include:1. Referencesa. Chapter 7 regulations governing assisted living residences, Part 11.2(H), requires that an assisted living residence shall not allow to move in any person who has a history of conduct that has been disclosed to the assisted living residence that would pose a danger to the resident or others, unless the ALR reasonably believes that the conduct can be managed through therapeutic approaches.b. Chapter 7 regulations governing assisted living residences, Part 11.13(B), requires that where a resident has demonstrated that he or she has become a danger to self or others, the assisted living residence shall promptly implement the following process pending discharge. Reassess the resident to be discharged and revise his or her care plan to identify the resident ' s current needs and what services the assisted living residence will provide to meet those needs. 2. Record ReviewA review of FR#5's resident record revealed he was admitted to the residence on 3/12/25. The record included progress notes dated from 5/1/25 to 6/15/25, demonstrating that FR#5 had intimidated the cats, caused property damage, threatened others, and caused harm to himself. Additionally, paranoid, manic, threatening, and intimidating behavior was described. A critical incident report (CIR) dated 6/18/25 read in part: "[The residence] has received multiple complaints from residents this morning that they are terrified to live in the same house as [FR#5]. They are afraid he is going to hurt or kill them due to his constant threats and harassment." The CIR indicated that FR#5 was subjected to "immediate eviction."Further review of FR#5's resident record revealed no evidence of reassessment and care plan revisions being completed by the residence for FR#5 after they had determined he had become a danger to himself and others. 3. Interviews On 3/10/26 at 11:53 a.m., the administrator stated that FR#5 had been evicted on 6/14/25 due to his hostile and threatening behaviors towards staff and residents. She stated that when he was evicted, they provided him with $150 in cash and provided a three-night hotel stay. She added that just as he was leaving, he stole another former resident's liquor bottle and poured it out on the floor in front of the resident just to instigate, as well as threw the empty bottle at the van driver. The administrator also added that after he had been evicted, he continued to monitor and harass the residents from across the street. On 3/10/26 at 5:30 p.m., the administrator confirmed that she had determined FR#5 had become an immediate threat to the safety of other residents and needed to be immediately evicted from the residence. She confirmed that no reassessment or care plan revision was completed when she determined that he had become a danger to himself and others. She stated that she was not aware of this requirement and stated that she would expect this to be completed as required.

A revisit survey was completed on 2/8/24 for all previous deficiencies cited on 3/22/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 2/8/24 for all previous deficiencies cited on 3/22/23. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure revisit was completed on 3/22/23 for all previous deficiencies cited on 7/16/20. The residence is in compliance with all regulations surveyed.

A recertification survey was completed on 3/22/23. Deficiencies were cited.

Based on observation, interview, and record review, the facility (residence) failed to observe participant's (resident's) right to privacy affecting six participants (#7, #13, #14, #15, #17, #18). Findings include: 1. Residence Policy The residence's Resident Rights policy, dated 12/5/19, read in part: "The right to privacy."2. Observation On 3/22/23 an environmental tour of the residence revealed the following residents shared a room, though none of the rooms had any provision for privacy: Resident #7 and #13Resident #14 and #15Resident #17 and #18 3. Interviews On 3/21/23 at approximately 10:20 a.m., Resident #14 stated he wished he had more privacy in the room he shared with Resident #15. He stated he would liked to have had a privacy curtain or some type of divider. Resident #14 stated there was a private room that had opened up recently and had asked the administrator to be transferred. He added he had been placed on the waiting list for the private room, but had not heard back yet on if he had been approved. On 3/22/23 at approximately 1:24 p.m., the administrator stated the residence had four shared rooms; rooms A-D. She stated from what she remembered there were no privacy curtains in the shared rooms. The administrator stated she thought as long as the residents were the same gender it was not needed. She acknowledged the residents in the four shared rooms did not have privacy. The administrator stated all the rooms had locks on doors. She further stated that usually the other roommate left the room when the other one wanted privacy. On 3/22/23 at 1:44 p.m., Resident #15 stated he shared a room with another resident and would love to have privacy within the bedroom. However, he stated he was not aware privacy within his bedroom was an option. On 3/22/23 at approximately 1:44 p.m., Resident #10 stated he shared a bedroom with another resident and there was no privacy unless his roommate was not in his room. On 3/21/23 at approximately 1:45 p.m., Resident #17 stated she had lived at the residence for about two months. She stated she wished she had a single room or had something in her current room for privacy.

Based on observation and interview, the facility failed to maintain a home-like quality feel to participants during medication administration, affecting five participants (#4, #6-#7, #11-#12). Findings include: 1. Observation On 3/21/23 at approximately 8:00 a.m., medication administration had taken place in the kitchen/dining room. Participants #4, #6, #7, #11, and #12 were seated at the dining table, and were then called up one by one to the kitchen counter for their medications. 2. InterviewOn 3/21/23 at approximately 1:24 p.m. the administrator stated staff always called up the participants for their medications, especially during the breakfast pass because it was easiest. She said, "It was not necessarily home-like I guess." The administrator stated staff asked participants where they wanted to receive their medications and all said they wanted them in the kitchen. She stated that was something the facility had always done.

Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting 15 current participants (residents). Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.31, requires that 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. The residence's Medication Administration policy, dated 1/11/19, read in part: "All medication documentation will be reviewed by the supervisor/administrator ..."On 3/22/23 at approximately 7:30 a.m., the residence's quarterly audits of the medication administration records, controlled substances list, medication error reports, and medication disposal records. However, no such audits were provided. On 3/22/23 at approximately 9:06 a.m., the administrator stated she conducted medication audits; however, the audits were not documented.

A relicensure survey was completed on 3/22/23. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring one of three sample staff (#5) who provided direct care to at-risk residents, affecting 15 current residents. Findings include:1. Referencesa. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, "... individuals receiving care and services from persons employed in programs or facilities... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult."b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S. (F) Is mentally impaired as defined in Section 24-34-501(1.3)(b)(II), C.R.S.; 2. The personnel file for Staff #5 read the date of hire was 6/24/19 and she worked as a qualified medication administration personnel. On 3/22/23 at approximately 12:00 p.m., the personnel file for Staff #5 was provided, however, the file did not include a CAPS check. Staff #4 worked six times in March 2023 two weeks as follows: 3/3-3/5 and 3/10-3/13/23. On 3/22/23 at 1:24 p.m., the administrator confirmed she had not performed a CAPS check prior to hire for Staff #5. Additionally, she stated she was not aware that CAPS checks were required for staff.

Based on record review and interview, the residence failed to have a quality management program (QMP) that improved client safety and well-being, affecting 15 current residents. Findings include:On 3/22/23 at 7:20 a.m., the residence's QMP was requested. On 3/22/23 at approximately 9:00 a.m., the administrator provided a QMP binder that included a QMP policy, dated 9/3/15, that read in part, the residence would maintain a QMP.On 3/22/23 at 1:24 p.m., the administrator stated the residence had a QMP binder, however, she was not aware of what was required to be included in the QMP. She confirmed that she had not had a QMP in place that improved client safety and well-being.

Based on observation, interview, and record review, the residence failed to observe resident's right to privacy affecting six residents (#7, #13, #14, #15, #17 and #18)). Findings include: 1. Residence Policy The residence's Resident Rights policy, dated 12/5/19, read in part: "The right to privacy."2. Observation On 3/22/23 an environmental tour of the residence revealed the following residents shared a room, though none of the rooms had any provision for privacy: Resident #7 and #13Resident #14 and #15Resident #17 and #18 3. Interviews On 3/22/23 at approximately 10:20 a.m., Resident #14 stated he wished he had more privacy in the room he shared with Resident #15. He stated he would liked to have had a privacy curtain or some type of divider. Resident #14 stated there was a private room that had opened up recently and had asked the administrator to be transferred. He added he had been placed on the waiting list for the private room, but had not heard back yet on if he had been approved. On 3/22/23 at approximately 1:24 p.m., the administrator stated the residence had four shared rooms; rooms A-D. She stated from what she remembered there were no privacy curtains in the shared rooms. The administrator stated she thought as long as the residents were the same gender it was not needed. She acknowledged the residents in the four shared rooms did not have privacy. The administrator stated all the rooms had locks on doors. She further stated that usually the other roommate left the room when the other one wanted privacy. The administrator stated this had not been voiced to her by any of the residents who shared rooms. On 3/22/23 at approximately 1:45 p.m., Resident #17 stated she had lived at the residence for about two months. She stated she wished she had a single room or had something in her current room for privacy.

Based on observation, interview and record review revealed the residence failed to ensure house rules listed all possible actions which may be taken by the assisted living resident if any rule is knowingly violated by a resident and ensure the house rules addressed consumption of alcohol, affecting 15 current residents. Findings include:1. Residence policyThe residence's House Rules policy, dated 3/4/20, read in part, residents were not allowed use of controlled substances in the facility, however, there was nothing included regarding the consumption of alcohol. 2. ObservationsOn 3/22/23 the residence's House Rules, dated 3/4/20, was posted on a bulletin board in the living room area. However, the house rules did not list the actions which may be taken by the assisted living residents if any rule is violated. 3. InterviewsOn 3/22/23 at 1:24 p.m., the administrator stated she was not aware that the residence's rule on alcohol consumption was not listed in the house rules. She also stated the actions which may be taken by the assisted living residence if any rule was violated was in the resident agreement and not in the house rules as required. On 3/22/23 at 1:44 p.m., Resident #15 stated he was not aware of the actions which may be taken by the assisted living residents if any rule is violated or what the residence's rule was regarding alcohol consumption. On 3/22/23 at approximately 1:44 p.m., Resident #10 stated he was not aware of the actions which may be taken by the assisted living residents if any rule is violated or what the residence's rule was regarding alcohol consumption. On 3/22/23 at approximately 1:44 p.m., Resident #12 stated she was not aware of the actions which may be taken by the assisted living residents if any rule is violated or what the residence's rule was regarding alcohol consumption. On 3/22/23 at 1:50 p.m., Resident #14 stated he was not aware of the actions which may be taken by the assisted living residents if any rule is violated or what the residence's rule was regarding alcohol consumption.

Based on observation, record review and interview, the residence failed to ensure the process for raising and addressing grievances and complaints was placed in a visible on-site location along with the full contact information for the Colorado Department of Public Health and Environment, affecting 15 current residents. Findings include:1. Residence policyThe residence's Resident Grievance Policy, dated 12/5/19, read in part, the residents could contact The Adult Protection Services of the appropriate county Department of Social Services, and the advocacy services of the area's agency on aging. However, it did not include The Colorado Department of Public Health and Environment. 2. ObservationOn 3/22/23 from 7:30 to 1:53 p.m., the residence did not have the process for raising and addressing grievances and complaints placed in a visible on-site location. On 3/22/23 at 1:53 p.m., the administrator posted the grievance policy, dated 12/5/19, however, it did not include the full contact information for the Colorado Department of Public Health and Environment as required. 3. InterviewOn 3/22/23 at 1:24 p.m., the administrator stated she was not aware the grievance policy was not posted. She stated it was normally posted on the bulletin board in the living room area. She stated she was aware it was required to be placed in a visible location for the residents. On 3/22/23 at 1:44 p.m., Resident #15 stated he was not aware if the grievance policy was placed in a visible location. On 3/22/23 at approximately 1:44 p.m., Resident #10 stated he was not aware if the grievance policy was placed in a visible location. On 3/22/23 at approximately 1:44 p.m., Resident #12 stated she was not aware if the grievance policy was placed in a visible location. On 3/22/23 at 1:50 p.m., Resident #14 stated he was not aware if the grievance policy was placed in a visible location. During a second interview on 3/22/23 at 2:10 p.m., the administrator stated she was not aware the contact information for Colorado Department of Public Health and Environment was not included on the posting as required.

Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records, controlled substances list, medication error reports, and medication disposal records, quarterly, affecting 15 current residents. Findings include: The residence's Medication Administration policy, dated 1/11/19, read in part: "All medication documentation will be reviewed by the supervisor/administrator ..."On 3/22/23 at approximately 7:30 a.m., the residence's quarterly audits of the medication administration records, controlled substances list, medication error reports, and medication disposal records were requested. However, no such audits were provided. On 3/22/23 at approximately 9:06 a.m., the administrator stated she conducted medication audits; however, the audits were not documented.

Based on observation and interview, the residence failed to ensure designated smoking areas and resident rooms occupied by smokers had fire resistant wastebaskets, affecting nine residents (#1, #3, #4, #12-#15, #17, #18). Findings include: An environmental tour of the rooms for Residents #1, #3, #4, #12-#15, #17, and #18 revealed the rooms did not contain fire resistant wastebaskets as required by regulationOn 3/22/23 at approximately 1:24 p.m., the administrator confirmed Residents #1, #3, #4, #12-#15, #17, and #18 were all smokers. She stated she was unaware that the residence was required to have fire resistant wastebaskets in the rooms of residents who smoked. The administrator stated she had ordered some fire resistant wastebaskets online; however, did not know the status of arrival.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.6.8 The administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (J) Complying with all applicable federal, state, and local laws concerning licensure and certification; and 9.1 The assisted living residence shall develop and at least annually review, all policies and procedures. At a minimum, the assisted living residence shall have policies and procedures that address the following items: Fall Management18.9 The face sheet shall be updated at least annually and contain the following information:(E) Date of admission and readmission, if applicable;(J) Resident's current diagnoses