FAMILY CARE ASSISTED LIVING LLC

A revisit survey was completed on 3/23/26 for all previous deficiencies cited on 10/29/25. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 3/23/26 for all previous deficiencies cited on 10/29/25. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 3/23/26 for all previous deficiencies cited on 10/29/25. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 3/23/26 for all previous deficiencies cited on 10/29/25. The facility is in compliance with all deficiencies that were cited.

A recertification survey was completed on 10/29/25. Deficiencies were cited.

Based on record review and interview the facility (residence) failed to ensure a rights modification (RM) were supported by a specific need and justified in the person-centered support plan and not imposed across-the-board and may not be based on the convenience of the provider agency, affecting all current residents. (Cross reference B0172)Findings include:During the onsite visit on 10/28/25 Staff #2 came into the staff room, unlocked the cabinet and pulled out a kitchen knife. On 10/28/25 at 12:58 p.m., Staff #2 stated there were no residents with rights modifications. On 10/28/25 at 2:10 p.m., record review of the sampled residents' charts revealed the residence failed to complete a rights modification. On 10/28/25 at 6:08 p.m., the administrator stated that all residents are expected to inform the residence staff where they were going so that the residence staff could get to know their day-to-day habits and residents were also not allowed to have sharp objects in their rooms. He added that since several of the residents have mental health diagnoses they lock up the kitchen knives for the safety of all the residents.

Based on record review and interview, the facility (residence) failed to ensure a rights modification (RM) were documented in one of one sample member's (resident's) with a behavior care plan (#10). Findings include:1. Record reviewResident #10 was admitted into the residence on 1/31/22 with a diagnosis of schizoaffective disorder. A review of Resident #10's chart revealed a critical incident report form dated 9/27/25. The incident report read that Resident #10 went to the neighbor's house, and "pounded" on their door with a butter knife in his hands. It continued to read that Resident #10 was claiming that they (the neighbors) did something to his wife and "other nonsense." The incident report continued to read that the police were called, and Resident #10 needed to be sedated and was transported to an external medical facility. The residence's behavior plan dated 9/28/25, read that Resident #10 was not allowed to have sharp objects in his room, and was not able to leave the residence without informing staff. During the onsite visit on 10/28/25 at 3:45 p.m., Resident #10's case manager sent an email outlining the timeline of the behavior care plan and the rights modifications. The case manager's email outlined the following:On 9/29/25, the case manager received the behavior contract. On 10/1/25, the case manager emailed the administrator with the informed consent template document and explained that the department required the document to be used for rights modifications. On 10/1/25, the administrator responded to the case manager, stating that he was leaving the country from 10/1/25 to 10/19/25, and he would have to complete it upon his return. On 10/20/25, the administrator requested a fillable version of the rights modification to be sent, and it was provided by the case manager on 10/20/25. However, there was no documentation of an informed consent for rights modification, in Resident #10's record. 2. InterviewsOn 10/28/25 at 12:58 p.m., Staff #2 stated there were no residents with rights modifications. On 10/28/25 at 2:42 p.m., Resident #10's case manager confirmed that she informed the administrator that he needed to complete a rights modification and could not use the behavior care plan without one. On 10/28/25 at 6:08 p.m., contrary to the above case manager interview, the administrator stated he did not fill out a rights modification form and was unaware that he needed to fill one out until Resident #10's case manager informed him to do so.

included conducting quarterly fire drills at their physical facility for ten current members (residents). Findings Include:On 10/28/25 at 12:55 p.m., fire drills were requested. A review of the fire drill documentation for the previous four quarters revealed the residence had one documented fire drill, dated 1/3/25. On 10/28/25 at 1:23 p.m., Staff #3 stated he had taken over doing the fire drills and 'spaced' them, ensuring that they were completed for the past two quarters, and had only completed one drill in 2025. On 10/28/25 at 6:53 p.m., the administrator acknowledged the fire drills were not conducted quarterly and added that he expected staff to do fire drills every other month, but at the very minimum to be done four times a year. The administrator stated he was aware of the requirement and believed the drills were being completed by the staff.

A relicensure survey was completed on 10/29/25. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure at least one staff member was responsible for the onsite management of the facility's infection prevention and control program, and had completed the required training, affecting 10 current residents. Findings include: On 10/28/25 at approximately 11:29 a.m., the infection control person (ICP) certification was requested; however, the residence was unable to provide the documentation. On 10/28/25 at approximately 4:45 p.m., the administrator stated she was unaware of the Chapter II 12.2.2 regulation requiring the residence to assign at least one staff member as the ICP for the residence.

Based on interviews and record review, the residence failed to ensure that each staff member met the dementia training requirements in 7.9 (B), affecting ten current residents. Findings include:Personnel files for Staff #1 and #3-#5, which were provided by the administrator, revealed no evidence that each staff member had completed the initial four-hour dementia training. On 10/28/25 at approximately 4:54 p.m., the administrator stated she was not aware of the requirement for initial four-hour dementia training, and stated he, "focused more on getting staff trained on mental health needs," since the residents at the residence had mental health concerns.

Based on record review and interview, the residence failed to have a visitation policy that complied with Section 25-27-104.3, C.R.S., affecting ten current residents. Findings include:On 10/28/25 at approximately 11:29 a.m., the residence's visitation policy was requested; however, the policy provided failed to include the required elements. On 10/28/25 at approximately 4:45 p.m., the administrator acknowledged he was not aware of the requirement for a visitation policy that met the requirements of Chapter VII, Regulation 9.2 (A-H). The administrator acknowledged the policy provided did not include all of the required elements.

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting ten current residents. Findings include:On 10/28/25 at approximately 11:29 a.m., the residence's visitation policy was requested; however, the policy provided failed to include the required elements. On 10/28/25 at approximately 4:45 p.m., the administrator acknowledged he was not aware of the requirement for a visitation policy that met the requirements of Chapter VII, Regulation 9.3 (A-I). The administrator acknowledged the policy provided did not include all of the required elements.

Based on record review and interview, the residence failed to hold routine drills to facilitate staff and resident response to that risk, fire drills, for ten current residents. Findings Include:On 10/28/25 at 12:55 p.m., fire drills were requested. A review of the fire drill documentation for the previous four quarters revealed the residence had one documented fire drill, dated 1/3/25. On 10/28/25 at 1:23 p.m., Staff #3 stated he had taken over doing the fire drills and 'spaced' them, ensuring that they were completed for the past two quarters, and had only completed one drill in 2025. On 10/28/25 at 6:53 p.m., the administrator acknowledged the fire drills were not conducted quarterly and added that he expected staff to do fire drills every other month, but at the very minimum to be done four times a year. The administrator stated he was aware of the requirement and believed the drills were being completed by the staff.

Based on record review and interview, the facility failed to report staff influenza vaccination information to the Colorado Department of Public Health and Environment (CDPHE) as required by regulation, affecting ten current residents. Findings include:On 10/28/25 at approximately 11:29 a.m., the residence's influenza policy was requested; however, the policy provided was missing the required elements. On 10/28/25 at approximately 4:45 p.m., the administrator stated he was unable to update the policy after the earlier conversation that walked him through the required elements. He repeated that they had a policy in place; however, it was missing several of the required elements; including for when staff were to be vaccinated, defined procedures of how to prevent the spread between unvaccinated staff to residents, how long the records were to be saved onsite, who would report the vaccination status to the state health department, and who was who was in charge of coordinating vaccination clinics.

Based on interview and record review, the residence failed to conduct quarterly medication audits of medication administration records, controlled substance lists and medication error reports and medication disposal records, affecting ten current residents. Findings Include:On 10/28/25 at 12:55 p.m., during the onsite visit, the last three quarterly medication audits were requested from the administrator. However, the previous three medication audits were not provided. On 10/28/25 at approximately 5:00 p.m., the administrator acknowledged that there were no medication audits for 2025, and stated he expected Staff #1 to complete the medication audits every three months. He also stated he was unaware he was required to sign off on the audits.

Based on record review and interviews the residence failed to require staff members who prepared food tocomplete food safety training and maintain evidence of completion on site, affecting ten current residents. Findings Include:On 10/28/2025 at approximately 10:00 a.m., the staff files for Staff #1- Staff #3 were reviewed. None of the staff filesincluded food safety training recognized by food safety experts or agencies. On 10/28/2025 at approximately 1:23 p.m., Staff #3 stated that he did not have her food safety training; everything he learned was from his mom, who used to work at the residence. Staff #2 stated that she had one and had never given it to this residence, but had it at another facility where she worked. Staff #2 continued to state that she did not believe her daughter, Staff #1, had her food handling trainer either. On 10/28/2025 at approximately 6:15 p.m., the administrator stated that he was not aware that staff membersrequired food safety training.

A relicensure survey revisit was completed on 10/29/25 for all previous deficiencies cited on 10/26/22. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25. Tag U1568 was not cited in the previous event; however, the deficiency was included in the previous event's informational 999 tag.

Based on record review and interview the residence failed to comply with authorized practitioners orders associated with medication administration for two of four sample residents (#4 and #10). This deficiency was cited previously during a state licensure complaint 10/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings Include:1. Resident #4 was admitted to the residence on 4/1/06 with a diagnosis of type two diabetes and paranoid schizophrenia. On 10/28/25 at approximately 8:33 a.m., Staff #3 stated that Resident #4 was out of oxybutynin chloride and buspirone. On 10/28/25 at approximately 2:38 p.m., medication orders for Resident #4 were requested. A practitioner's order dated 6/23/25 directed the residence to administer 5 mg of oxybutynin chloride one tablet by mouth once daily. On 10/28/25 at 1:47 p.m., a review of Resident #4's medication administration record (MAR) read that the residence failed to administer oxybutynin chloride in accordance with practitioner's orders, from 10/18/25 to 10/26/25. A practitioner's order dated 2/3/25 read that the residence was to administer 10mg of buspirone, one tablette twice a day. On 10/28/25 at 1:47 p.m., a review of Resident #4's MAR read the residence failed to administer buspirone in accordance with the practitioner's orders on 10/17/25.2. Similar deficient practice was found for Resident #10. On 10/28/25 at approximately 5:38 p.m., the administrator acknowledged that Resident #4 had missed the two medications. The administrator acknowledged the residence failed to administer medications to Resident #4 in accordance with the practitioner's orders. The administrator further stated the deficiency had not been corrected due to issues obtaining a discontinue order from the external facilities, and wanted to add ordering medications to their medication audits.

A recertification survey revisit was completed on 10/29/25 for the previous deficiency cited on 10/26/22. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 9/30/25.

Based on record review and interview the facility (residence) failed to ensure orders were maintained in the record for members (residents) who received assistance with medication administration for two of four sample residents (#4 and #10). This deficiency was cited previously during a state recertification complaint 10/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings Include:1. Resident #4 was admitted to the residence on 4/1/06 with a diagnosis of type two diabetes and paranoid schizophrenia. On 10/28/25 at approximately 8:33 a.m., Staff #3 stated that Resident #4 was out of oxybutynin chloride and buspirone. On 10/28/25 at approximately 2:38 p.m., medication orders for Resident #4 were requested. A practitioner's order dated 6/23/25 directed the residence to administer 5 mg of oxybutynin chloride one tablet by mouth once daily. On 10/28/25 at 1:47 p.m., a review of Resident #4's medication administration record (MAR) read that the residence failed to administer oxybutynin chloride in accordance with practitioner's orders, from 10/18/25 to 10/26/25. A practitioner's order dated 2/3/25 read that the residence was to administer 10mg of buspirone, one tablette twice a day. On 10/28/25 at 1:47 p.m., a review of Resident #4's MAR read the residence failed to administer buspirone in accordance with the practitioner's orders on 10/17/25.2. Similar deficient practice was found for Resident #10. On 10/28/25 at approximately 5:38 p.m., the administrator acknowledged that Resident #4 had missed the two medications. The administrator acknowledged the residence failed to administer medications to Resident #4 in accordance with the practitioner's orders. The administrator further stated the deficiency had not been corrected due to issues obtaining a discontinue order from the external facilities, and wanted to add ordering medications to their medication audits.