6
Inspections
11
Deficiencies
0
Actual Harm or Above
9
Occurrences
December 16, 2025
Last Inspection
S/S A/B/C Minimal potential
The most recent inspection of Bluegrass Homecare LLC on record is dated December 16, 2025. Across 6 published inspections, state surveyors cited 11 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
Aime, Ketsia
Owner
EAST SIDE ASSISTED LIVING LLC
Phone
(719) 391-4444
Payor Source
Medicaid, Private Pay
City
PUEBLO
ZIP
81001
Inspections & Citations
6 inspections · 11 deficiencies12/16/2025Licensure Complaint · ID BVFU11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO41276, was completed on 12/16/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/16/2025Licensure Complaint · ID P4W011No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO41269, was completed on 12/16/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Licensure and Licensure Complaint (Combined) · ID 1D2K118 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO39383, #CO39089, and #CO37690 was completed on 3/10/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0430Rpt Req-Occ RprtS/S B▼
Findings
Based on record review and interview the residence failed to comply with all occurrence reporting requirements by state law affecting one former resident (#8). Former Resident #8 was admitted to the residence on 8/1/24 with a diagnosis of human immunodeficiency virus, heart failure, and chronic pulmonary disease. A progress note dated 1/28/25 read that Former Resident #8 slapped another resident in the face and witnesses were present. A progress note dated 2/8/25 read that Former Resident #8 contacted law enforcement to inform them that he was assaulted in the dining room of the residence and that the staff member was aware of this incident. On 3/10/25 at approximately 12:30 p.m., the investigation and occurrence report for the incidents that occurred on 1/28/25 and 2/8/25 were requested. On 3/10/25 at approximately 2:40 p.m., the administrator stated that she was aware of the behavior issues with Former Resident #8 and that she was told that there was not an investigation done or occurrence report completed for the previous incidents on 1/28/25 and 2/8/25. On 3/10/25 at approximately 4:00 p.m., the HWD stated the incident that occurred with Former Resident #8 on 1/28/25 and 2/8/25 were not investigated and no occurrence report was started.
Plan of correction · submitted by the facility
AddendumInvestigations were done as 4/24/2025.1.- Occurrence Date: 01/28/2025 - Case ID: 25235KQX003 - the occurrence was reported as a Physical Abuse. 2.- Occurrence date: 02/08/2025 - Case ID: 25235KQX004 - the Occurrence was reported as Verbal Abuse. Addendum to Facility POCThe events that occurred involving former sample resident #8 on 1/28/2025 and 2/8/2025 have not yet been reported on the COHFI occurrence portal. The facility was mistakenly under the impression as a result of conversations with the surveyors that, since the resident no longer lived in the facility as of 2/20/2025, filing an occurrence report after the 3/10/2025 survey was not necessary. Both events will be reported on the portal no later than close of business 4/24/2025. The occurrence #s will be immediately relayed via a message from the facility under this survey. As noted in the citation text, full investigations of the events of 1/28/2025 and 2/8/2025 involving former sample resident #8 were not conducted at the time, and the facility did not address doing investigations in the POC as the facility was under the impression that since sample resident #8 was no longer living at the facility and occurrence reports had not been filed, no further investigation was required. Investigations have now been initiated. There were resident observation notes referenced in the citation information and at survey exit interview. These notes have been reviewed and an investigation of both events is currently in progress. All involved residents, witnesses, and staff members that could be identified have been/are being interviewed. Attempts are being made to contact former sample resident #8 for interview. Findings will be included in the occurrence report submittal and filed at the facility in accordance with the facility’s occurrence reporting policy. Reiterating what was included in the original POC, in order to ensure the safety of all residents following any abuse allegation, all facility employees have been in-serviced on the proper procedures to be followed regarding investigations of alleged abuse, the requirement to ensure all residents’ safety during the investigation process, and following proper reporting procedures of abuse allegations.(a) The facility administrator or designee will continually monitor/audit resident council meeting minutes, incident report logs, resident progress notes, shift to shift reports, grievance forms, and any other sources of information that may be identified to verify that any mention by a resident or staff member of a potential incident involving abuse has been fully investigated, documented, and reported to the proper entities. If something is identified as not investigated/reported as a result of these audits, the administrator or designee will immediately start the process and ensure safety measures are put into place for the affected resident/s.(b) Former sample resident #8 no longer lives at the facility, therefore no monitoring procedures can be put into place specific to him. Monitoring of all sources/materials referenced in (a) above will be done for all residents going forward.(c) Monitoring/Auditing of the identified sources/materials will happen on a daily/weekly/monthly basis, depending on how often the source/material is generated, i.e., council meeting minutes will be reviewed once/month following the monthly resident council meeting, shift to shift reports will be monitored daily after shift changes, grievance forms will be reviewed the same day the resident turns in the form, etc.(d) Monitoring/Audit findings will be documented on the Unaddressed Threats of Abuse Audit Form.(e) The monitoring/audit period will continue for 12 months.(f) The Unaddressed Threats of Abuse Audit Form will be reviewed monthly as a part of the facility’s QA process. If abuse allegations are identified that were not immediately addressed at the time of the allegation, a root cause analysis of the delay/s will be conducted during the QA process and facility staff will be retrained, procedures will be adjusted, and policies will be revised as needed. POC Actions:- In-service from to Director of Operations to Administrator to review all incidents to see if they are reportable.- In-service from Director of Operations to Administrator to conduct a full investigation on incidents to ensure safety of all residents.- In-service from Administrator to all staff that any incident or allegation of abuse is reported to the Administrator as soon as possible. Auditing Process:- Name: Unaddressed Threats of Abuse Audit Form- Who: The Director of Operations and Administrator- When: Monthly- What: Audit the resident council meeting, the QA, and incident report logs, to determine if there are unaddressed threats or allegations of abuse- Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
0632Prsnl-Ablty Prfrm Job Fn CmptS/S B▼
Findings
Based on observations and interviews the residence failed to select direct care staff that demonstrated competency to effectively provide care and services, affecting 27 current residents. On 3/10/25 at approximately 7:30 a.m., Staff #1 stated that she did not understand English and prompted the use of a translation program on her phone for the rest of the interview. On 3/10/25 at approximately 8:00 a.m., Staff #1 was observed checking on Resident #6. Resident #6 asked three to four times where her food was before Staff #1 understood the question and brought her the plate of food that was sitting on her dresser. On 3/10/25 at approximately 5:00 p.m., the administrator stated that she understood that Staff #1 did not speak English.
Plan of correction · submitted by the facility
Addendum to Facility POCTo prevent recurrence of this citation, sample employee #1 has been moved from a direct care worker position to strictly a housekeeping position where she no longer provides direct care to the residents. Her hours and duties are now such that she has minimal to no contact with residents. With her hours adjustment, sample employee #1now has daytime hours to pursue outside sources to improve her English skills.(a) A Comprehensive Testing Tool that includes English reading, writing, comprehension, and speaking has been developed and will be used to assess all sample employee #1’s, as well as going forward any other English as a second language employee’s, progress with English language improvement to ensure communications between residents and their care providers are clear and understandable. If sample employee #1 or any other employee that will be providing care to residents cannot pass the minimum testing requirements, they will not be placed in a position where they must communicate with residents until a marked and recorded improvement in their English speaking/understand skills is made.(b) Sample employee #1, as well as any other English as a second language employee or applicant will be subject to passing the minimum requirements of and showing progressive improvement in the Comprehensive Testing Tool.(c) The Administrator or an English-speaking designee will administer the comprehensive testing tool monthly.(d) Administration and employee English skills progress will be documented via the facility’s English Improvement Audit Tool.(e) The facility will continue monitoring the progress of sample employee #1and any other current English as a second language employee for the next 12 months, as well as administer the test to new English as a second language applicant on an on-going basis. If sample employee #1 or any other current applicable employee does not show continued monthly improvement of their various English skills, she/they will be removed from facility employment.(f) The English Improvement Tracking Tool will be reviewed monthly in the facility’s QA process to ensure employee required improvement is made. The Comprehensive Testing Tool will also be reviewed monthly in the facility’s QA process to make sure it continues to be an effective measure of skills. Improvements may be made to either tool as a result of these reviews to ensure the facility is adequately testing and tracking the skills necessary to ensure our staff can clearly and effectively communicate with all residents. POC Actions:- All direct care staff are trained and go thru an on-boarding process that includes testing to assure they have the ability to read, write, carry out directions, communicate with staff and residents, and demonstrate that they can safely and effectively provide the tasks as outlined in their job descriptions. The training includes Activated Insights, formerly Home Care Pulse, an orientation checklist with return demonstration, in-person QMAP training, etc. Staff #1 has completed and passed all of the above.- Staff who speak English as a second language are encouraged to improve their English through classess and use communication modalities. Auditing Process:Name: English Improvement Audit ToolWho: AdministratorWhen: MonthlyWhat: The audit tool will be a comprehensive test that will include reading, writing, and English comprehension to ensure that the above requirements are met. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
1146Res Care Srvs-Comp Res Asmnt Annl/Chng BslnS/S B▼
Findings
Based on record review and interview the residence failed to ensure the comprehensive assessment included behaviors, physical health and mental health, affecting three (#2, #3, #5) of eight sample residents. Findings include: 1. Resident #2 was admitted to the residence on 7/19/24 with diagnoses including type 2 diabetes, chronic pain, coronary artery disease, deep vein thrombosis, methamphetamine dependence, schizophrenia and bipolar disorders. The residence's most recent assessment for Resident #2, dated 10/4/24 was not updated after a change in condition. Additionally, it did not contain information regarding behavioral patterns, physical health, and mental health. A hospital discharge note, dated 11/18/24, indicated that Resident #2 was admitted to the hospital for suicidal ideations. The residence's progress notes and incident notes confirmed that Resident #2 was admitted to the hospital; however, the progress notes stated that the reason for hospital admission was due to epilepsy. A hospital discharge note, dated 1/2/25, read that Resident #2 was admitted to the hospital due to a fall. The residence progress notes and incident report confirmed that Residence #2 was admitted to the hospital due to a fall. On 3/10/25 at approximately 2:00 p.m., the administrator acknowledged that Resident #2's most recent assessment was incomplete and the residence should have updated Resident #2's assessment with the required information. 2. There was similar deficient practice for Resident #3 and #5.
Plan of correction · submitted by the facility
Addendum :Administrator or Designated supervisor will do daily review residents’ status to verify all Residents Status and occurrences for the day before and current day if residents went to hospital review the discharged paperwork. As administrator or Designated review daily status and occurences; will immediately review any changes and update immediately. The administrator will review and monitor daily to ensure that all residents status, occurrences were reviewed, updated and follow-up were done immediatelyThe monitoring plan:a. Administrator or designated person will do a daily check on recent hospitalizations and immediately review the discharged paperwork from the hospital, for any changes in resident(s) mental and physical health and Review Medications; follow up if needed.b.- Sample facility representative/Qmap on shift will communicate daily or as soon as a resident return to facility from hospital to Administrator or Designated supervisor of changes on resident Meds, physical and mental health. Any changes will be immediately recorded and updated on resident care plan, contact PCP for meds changesc.- The monitoring process will occur weekly by the administrator. Review and update resident Care plan for any mental or physical health changes, update Meds list if needed and Follow-up.d.- The facility administrator will do a daily review with Qmap and RCC; it will be documented on our daily meeting review and added to the weekly monitoring audit process.e.- This monitoring process will continue for 12 months.f.- The process will be reviewed on a monthly basis on our Quality Management Program/QA.POC Actions:- Resident #2 has been reassessed and changes in his care plan have been implemented.- Resident #3 has been reassessed and the changes in her care plan have been implemented.- Resident #5 has been reassessed and changes in his care plan have been implemented.- In-service from Director of Operations to Administrator and Resident Care Coordinator emphasizing updating care plans as resident changes in condition are identified. Auditing Process:Name: Resident Care Plan Audit ToolWho: AdministratorWhen: MonthlyWhat: Review all resident care plans on a monthly basis to ensure all changes in condition have been addressed in the care plan. Duration: Review in QA monthly, will be continued for 12 months for re-evaluation.
1522Med/Med Adm-Gen Rq Proper AdmS/S A▼
Findings
Based on observations and interviews, the residence failed to ensure that each resident received proper monitoring of medications, affecting one (#8) out of six sample residents. 1. Residence PolicyThe residence's medication management policy, dated 12/21/23, read in part: "The residence shall ensure that each resident receives proper administration and/or monitoring of medications."2. ObservationOn 3/10/25 from 7:15 a.m. to 8:15 a.m., Staff #2 was observed crushing medications for Resident #8. Staff #2 placed the crushed medications in a plastic cup filled with pureed fruit. Staff #2 placed the plastic cup with crushed medications on the table in front of Resident #8. Staff #2 walked out of the Resident #8's room and did not monitor Resident #8 to ensure her medications were properly administered. 3. InterviewsOn 3/10/25 at approximately 2:00 p.m., the administrator stated that she did not expect a qualified medication administration personnel (QMAP) to pass medication to a resident and walk away without ensuring the resident ingested all of their medication. She further stated that this was not how the residence trained their staff.
Plan of correction · submitted by the facility
Addendum(b) All residents in the facility will be included in the random, unannounced QMAP med pass observations which will be done by the Administrator or Designated. Addendum to Facility POCThe original POC identifies that resident #8 moved out of the facility on 2/20/2025, therefore the observation under this citation could not have been on resident #8 on 3/10/2025. As resident #8 no longer lives at the facility, a description of measures put into place specifically for the sample resident #8 cannot be done. Systemic measures put into place to keep all other residents with the potential to be affected by recurrence of this citation include random, unannounced Administrator or QMAP-certified designee observations of Sample Employee #2 as well as all QMAPs as they are passing meds to ensure proper medication administration policies and procedures are followed.(a) Random, unannounced Administrator or QMAP-certified designee observations of Sample Employee #2 as well as all QMAPs as they are passing meds to ensure proper medication administration policies and procedures are followed. Any improper procedures identified during the observations will be addressed and corrected immediately.(b) The census sample resident #8 no longer lives in the facility and cannot be included in the monitoring. All current residents being administered meds by the facility will be included in the random, unannounced QMAP med pass observations.(c) The random, unannounced observations will occur at least three times per week.(d) Monitoring/Observations will be documented on the QMAP Medication Monitoring Audit Tool.(e) The facility will be monitoring this citation for 12 months.(f) The QMAP Medication Monitoring Audit Tools will be reviewed during the monthly QA process for trends such as multiple process errors by the same QMAP or involving a specific resident, discovering the root cause of the errors, and correcting any systemic issues identified.#3 – An in-service was completed on 3/10/2025 from the Administrator to sample employee #2 and all QMAPs reiterating that all proper med pass procedures must be followed at all times, including watching the resident specifically take their meds before walking away from/turning their attention from that resident. The facility has been in compliance since that date, but the facility will continue to monitor and review for 12 months. POC Actions:Resident #8 was not in the facility on 3/10/2025. He moved out of this facility on 20 February 2025. Auditing Process:Name: QMAP Medication Monitoring Audit ToolWho: The Administrator or designeeWhen: WeeklyWhat: Random observations of QMAPs administering medications to ensure proper procedures are followed. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼
Findings
Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one (#3) of six sample residents. (Cross Reference S1600)Specifically, Resident #3 had diagnoses including schizoaffective disorder. On 2/15/25, Resident #3 was transported to the emergency department (ED) due to extreme pain in the lower abdomen. Resident #3 was discharged with a diagnosis of "severe fecal retention in the colon". A written practitioner's order, dated 2/15/25, directed the residence to administer, one time, a milk of magnesia and a sodium phosphates enema to Resident #3. However, the residence did not administer this medication on 2/15/25. As a result, on 2/15/25-2/18/25, the resident reported that she experienced pain and discomfort in her abdomen and lower back. Resident #3's external service provider (ESP) stated that not being administered milk of magnesia and the fleet enema had caused Resident #3's extreme pain and discomfort on the lower abdomen and back. Findings include:1. Residence PolicyThe residence's resident care services policy dated 3/1/25, read in part: "The assisted living facility shall be responsible for the coordination of residence care services with known external service providers."An incident report for Resident #3, dated 2/15/25 at 7:20 a.m., read Resident #3 was sent to the ED because she had extreme pain in her lower abdomen. A written practitioner's order, dated 2/15/25 at 10:30 a.m., directed the residence to administer, one time, a milk of magnesia and a sodium phosphates enema. However, the February 2025 MAR did not contain the prescribed medication. A progress note dated 2/15/25 at 4:45 p.m., Resident #3 stated that she had watery stools. An ESP note read that on 2/18/25, Resident #3 was triaged and was given Miralax due to Resident #3 expressing pain and discomfort due to severe fecal impaction. On 3/10/25 at 2:00 p.m., the resident care coordinator stated that the residence did not administer the prescribed orders because they did not have the milk of magnesia and sodium phosphates enema. He added that he did not follow up with the external service provider. The administrator stated she expected the residence to administer residents' medications as ordered.
Plan of correction · submitted by the facility
Addendum:What is the agency's plan to ensure all medications are administered and available, as ordered. After the daily check on recent hospitalizations and immediately review on the discharged paperwork from the hospital, for any changes in resident(s) mental and physical health and Review Medications, Administrator or designated will follow up immediately by calling Hospital, doctor and Pharmacy to ensure that the resident' medications are available as soon as possible and ready to be administered to resident as ordered. Sample resident #3 no longer resides at the facility, therefore no specific plan can be put in place regarding future meds orders. Administrator or Designated supervisor will do daily review residents’ status to verify all Residents Status and occurrences for the day before and current day if residents went to hospital review the discharged paperwork. As administrator or Designated review daily status and occurences; will immediately review any changes and update immediately. Staff have been in-service on 4/22/2025 for when there are any confusions about any changes on meds orders, discharged paperwork for new instructions to notify immediately the Administrator and will take the lead on calling or necessary follow-up. Administrator or Designated supervisor will do daily review residents’ status to verify all Residents Status and occurrences for the day before and current day if residents went to hospital review the discharged paperwork. As administrator or Designated review daily status and occurrences; will immediately review any changes and update immediately. Following Monitoring process:a) Administrator or designated person will do a daily check on recent hospitalizations and immediately review the discharged paperwork from the hospital, for any changes in resident(s) mental and physical health and Review Medications; follow up if needed.b) Sample facility representative/Qmap on shift will communicate daily or as soon as a resident return to facility from hospital to Administrator or Designated supervisor of changes on resident Meds, physical and mental health. Any changes will be immediately recorded and updated on resident care plan, contact PCP for meds changesc) The monitoring process will occur weekly by the administrator.d) Review and update resident Care plan for any mental or physical health changes, update Meds list if needed and Follow-up.e) The facility administrator will do a daily review with Qmap and RCC; it will be documented on our daily meeting review and added to the weekly monitoring audit process.f) This monitoring process will continue for 12 months. The process will be reviewed on a monthly basis on our Quality Management Program/QA.POC Actions:- There was no order for Milk of Magnesia and Sodium Phosphates enema received from the hospital in the discharge paperwork.- There is conflicting information between the hospital discharge paperwork and an InnovAge nurse note. The InnovAge note says they confirmed with the ED that the two medications were given to the patient to be taken at her residence, however, the resident did not arrive at the facility with the medications.- There is a progress note from the staff on duty upon the resident's return to the facility that indicates there was no new order for any medications, and that Tylenol has been administered at the ED. This contradicts what was observed in the InnovAge nurse notes.- Regarding events on 2/18/2025, the facility has no documentation from the resident’s ESP that the resident complained of any pain or discomfort or that she was given Miralax while with the ESP.- Resident #3 made no mention of any pain or discomfort at any time between 2/15/2025 at 9:30am beyond the end of February. The resident’s complaint of pain was only PRIOR to her ED visit.- In-Service from Director of Operations to Administrator and all staff to make sure there is a thorough review of resident discharge paperwork from an ED visit or hospital stay. If there are any discrepancies or questions, staff is to call the ED, the hospital, or the PCP for clarification. Auditing Process:Name: Return from ED/Hospital Discharge Orders Audit ToolWho: The administrator or designeeWhen: DailyWhat: There will be a thorough review of resident ED or hospitalization discharge paperwork to ensure that all instructions and orders are being implemented.- Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
1600Med/Med Adm-Rcrd Kpng MARS/S B▼
Findings
Based on record review and interview, the residence failed to ensure all prescribed and PRN (as needed) medications shall be listed and recorded on a medication administration record (MAR), affecting two (#3, #4) of six sample residents. (Cross-reference S1568)Findings include: 1. Residence PolicyThe residence's medication management policy, dated 12/21/23, read in part: "The residence shall ensure that each resident receives proper administration and/or monitoring of medications."2. Resident #3 was admitted to the residence on 6/1/24 with diagnoses including Schizoaffective disorder. A written practitioner's order, dated 2/15/25 at 10:30 a.m., directed the residence to administer, one time, a milk of magnesia and a sodium phosphates enema. However, the February 2025 MAR did not contain the prescribed medication. On 3/10/25 at 2:00 p.m., the resident care coordinator confirmed that the medication was not listed on the MAR and therefore was not administered. The administrator stated she expected all ordered medications to be listed in the MAR.Evidence revealed similar deficient practice for Residents #2 and #4.
Plan of correction · submitted by the facility
POC Actions:- The Director of Operations in-serviced Administrator and RCC, Administrator in-serviced QMAP staff, on the proper procedures for recording all prescribed and PRN medications on the Medication Administration Record (MAR), including one-time orders.- A full audit of all current resident MARs will be conducted to ensure all active and one-time medication orders are accurately listed and documented per policy and regulation. Any discrepancies will be corrected immediately.- The residence’s medication management policy will be reviewed and revised as necessary to emphasize the requirement for documenting all prescribed medications, including single-dose orders, on the MAR.Auditing Process:Name: MAR Compliance AuditWho: The Administrator or designeeWhen: WeeklyWhat: Review of all newly written and one-time medication orders to ensure they are properly documented on the MAR, with verification of administration, initials/signatures, and resident response or documentation of refusal/omission if applicable. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
2512Ext Env HazS/S B▼
Findings
Based on observations and interviews the residence failed to have a maintained ground to protect residents from slopes and other hazards, affecting 27 current residents. On 3/10/25 at approximately 2:00 p.m. two two-inch raised edges of the sidewalk in the back courtyard were observed. The raised edges were discovered when the surveyor tripped over them. On 3/10/25 at approximately 5:00 p.m. the director of operations acknowledged that the residence was aware of the edges and acknowledged that they could be a hazard for the elderly.
Plan of correction · submitted by the facility
POC Actions:- In-services from Director of Operations to Administrator and RCC, and Administrator to staff, regardin the importance of reporting any ground hazards immediately to maintenance was completed.- The identified raised sidewalk edge has been ground down to an appropriate level, no longer causing a trip hazard.- A full inspection of all outdoor walking areas was conducted to identify and correct any additional hazards. Auditing Process:Name: Environmental/Grounds AuditWho: The administrator or designeeWhen: WeeklyWhat: Inspection of facility grounds to identify uneven surfaces, slopes, holes, or other hazards. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
2930Waste Dspsl-RefuseS/S B▼
Findings
Based on observation and interview the residence did not dispose of rubbage properly, affecting 27 current residents. On 3/10/25 at approximately 2:00 p.m. glass was observed scattered and broken around the dumpster. Additionally, a full garbage bag sat outside of the front entrance of the residence from 2:00 p.m. until the survey was completed at approximately 5:00 p.m. Lastly, large boards, a wooden ladder and garbage was scattered throughout the back courtyard of the building. On 3/10/25 at approximately 5:00 p.m. the director of operations stated that a resident who liked to keep busy would place things like the garbage bag, wood boards and ladder around. She stated the glass needed to be picked up.
Plan of correction · submitted by the facility
POC Actions:- An in-service from the Director of Operations to the Administrator, and the Administrator to all staff, was given to re-educate expectations regarding collection, storage, and disposal of all garbage and rubbish.- A daily walk-through inspection will be conducted to ensure the outdoor refuse storage area, front entrance, and back courtyard to ensure all garbage and refuse is properly disposed of.- The administrator or designee will conduct a weekly environmental/grounds audit as verification that the daily walk-through inspections are catching everything.- A request has been submitted to the facility’s disposal company for a locking system to be placed on the dumpster to lock out additional trash being placed in our dumpster from the apartment complex next door which has been causing the dumpster to overflow.- The resident identified as moving objects around the premises has been redirected, and staff has been monitoring his behaviors to ensure compliance. Auditing Process:Name: Environmental/Grounds AuditWho: The administrator or designeeWhen: WeeklyWhat: Inspection of all refuse storage areas, front entrance, and back courtyard to verify cleanliness, proper use of waste containers, and absence of scattered garbage and rubbish. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
3/10/2025State Certification and State Certification Complaint (Combined) · ID 62L8113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey with complaint #CO39382 and #CO37688 was completed on 3/10/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0001Survey Details▼
Findings
8.7506.f. 6 Each Alternative Care Facility Provider Agency will divide the 24-hour day into two 12hour blocks which will be considered daytime and nighttime. The designation of daytime and nighttime hours shall be permanently documented in the Alternative Care Facilities policy and disclosed in the written Member agreements. In determining appropriate staffing levels, the Alternative Care Facility Provider Agency shall adjust staffing ratios based on the individual acuity and needs of the Members in the Alternative Care Facility. At a minimum, staffing must be sufficient in number to provide the services described in the Provider Care Plan, considering the Member's needs, level of assistance, and risks of accidents. A staff person may have multiple functions, as long as they meet the definition of Direct Care Worker at Section 8.7402. F Staff counted in the staff-to-Member ratio are those who are trained and able to provide direct services to Members. Staffing at an Alternative Care Facility shall meet the following standards i. A minimum of 1 staff to 10 Members during the daytime. ii. A minimum of 1 staff to 16 Members during the nighttime. Based on record review and interview the facility (residence) failed to have the appropriate number of staff to resident ratio, affecting 27 current members (residents). Findings include:A resident roster, undated, read that the number of current residents was 27. A staff schedule for dates 3/10/25 through 3/16/25 showed that between the hours of 6:00 a.m. to 6:00 p.m. only two staff members were scheduled to work. Additionally, just one staff member was to work between the hours of 8:00 a.m. to 4:30 p.m. This left a combined three and a half hours in which the residence did not meet the staffing requirements of one staff to every 10 residents. On 3/10/26 at approximately 5:00 p.m. the administrator acknowledged that she understood the staffing requirements. The administrator stated that she did not meet the staffing ratios as required.
Plan of correction · submitted by the facility
POC Actions:- Immediate corrective action was taken to ensure appropriate staffing coverage to the referenced 3/10-16/2025 schedule.- In-service to Administrator and RCC to first review and compare the facility PPD requirements against the regulation staffing requirements each week prior to developing the work schedule to be sure the facility meets at least the minimum staff to resident ratio at all times.- The administrator or designee will refer to the current PPD and regulation requirements when scheduling coverage for a call off. Auditing Process:Name: Staffing Compliance AuditWho: The administrator or designeeWhen: Weekly prior to the next week’s schedule being finalizedWhat: This audit will review weekly staff schedules to ensure staffing ratios of 1:10 during daytime and 1:16 during nighttime are consistently met and confirm that all staff counted toward the ratio meet the Direct Care Worker definition and are appropriately trained. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
0796PA Req-P/P-MANE▼
Findings
Based on record review and interview the facility (residence) failed to comply with all policies and procedures for the monitoring of incident reports and verbal and written reports regarding Mistreatment, Abuse, Neglect, or Exploitation (MANE) affecting one of six sample members (residents) (Former Resident #8). Former Resident #8 was admitted to the residence on 8/1/24 with a diagnosis of human immunodeficiency virus, heart failure, and chronic pulmonary disease. A progress note dated 1/28/25 read that Former Resident #8 slapped another resident in the face and witnesses were present. A progress note dated 2/8/25 read that Former Resident #8 contacted law enforcement to inform them that he was assaulted in the dining room of the residence and that the staff member was aware of this incident. On 3/10/25 at approximately 12:30 p.m. the investigation and occurrence report for the incidents that occurred on 1/28/25 and 2/8/25 were requested. On 3/10/25 at approximately 2:40 p.m., the administrator stated that she was aware of the behavior issues with Former Resident #8 and that she was told that there was not an investigation done or occurrence report completed for the previous incidents on 1/28/25 and 2/8/25. On 3/10/25 at approximately 4:00 p.m., the HWD stated that the incident that occurred with Former Resident #8 on 1/28/25 and 2/8/25 were not investigated and no occurrence report was started.
Plan of correction · submitted by the facility
POC Actions:- In-service from Director of Operations to Administrator and RCC about the importance of investigating all abuse allegations and the urgency of advising all entities of the allegation, i.e., state report, police, APS, family/POA, providers, etc. Once the allegation is reported, the investigation needs to happen immediately to determine if a potential victim is at risk of further abuse. Interviews of witnesses will be obtained and reviewed. Anyone who presents as a threat should be removed immediately from the environment.- In-service from Director of Operations to Administrator and all staff reviewing company Resident Rights Policy.- In-service from Administrator to all staff with re-training on MANE, including immediate reporting requirements, proper documentation and completion of incident reports, and procedures for initiating and completing MANE investigations.- Residents will be advised in council meetings to also use grievance/concern forms to report any suspected allegations or threats of abuse. Auditing Process:Name: Unaddressed Threats of Abuse Audit ToolWho: The Administrator or DesigneeWhen: MonthlyWhat: Audit the resident council meeting, the QA, and incident report logs, to determine if there are unaddressed threats or allegations of abuseDuration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼
Findings
Based on observation, interview, and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting four (#2, #3 ,#4, and #8) of eight sample residents. Specifically, Resident #3 had diagnoses including schizoaffective disorder. On 2/15/25, Resident #3 was transported to the emergency department (ED) due to extreme pain in the lower abdomen. Resident #3 was discharged with a diagnosis of "severe fecal retention in the colon". A written practitioner's order, dated 2/15/25, directed the residence to administer, one time, a milk of magnesia and a sodium phosphates enema to Resident #3. However, the residence did not administer this medication on 2/15/25. As a result, on 2/15/25-2/18/25, the resident reported that she experienced pain and discomfort in her abdomen and lower back. Resident #3's external service provider (ESP) stated that not being administered milk of magnesia and the fleet enema had caused Resident #3's extreme pain and discomfort on the lower abdomen and back. Findings include:1. Chapter VII regulations, governing assisted living residence, part 14.21, read in part: "The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers." a. Residence PolicyThe residence's resident care services policy dated 3/1/25, read in part: "The assisted living facility shall be responsible for the coordination of residence care services with known external service providers."b. Record ReviewAn incident report for Resident #3, dated 2/15/25 at 7:20 a.m., read Resident #3 was sent to the (emergency department) ED because she had extreme pain in her lower abdomen. A written practitioner's order, dated 2/15/25 at 10:30 a.m., directed the residence to administer, one time, a milk of magnesia and a sodium phosphates enema. However, the February 2025 MAR did not contain the prescribed medication. A progress note dated 2/15/25 at 4:45 p.m., Resident #3 stated that she had watery stools. An ESP note read that on 2/18/25, Resident #3 was triaged and was given Miralax due to Resident #3 expressing pain and discomfort due to severe fecal impaction. c. InterviewOn 3/10/25 at 2:00 p.m., the resident care coordinator stated that the residence did not administer the prescribed orders because they did not have the medications in stock. He added that he did not follow up with the external service provider. The administrator stated she expected the residence to administer residents' medications as ordered. 2. Chapter VII regulations, governing assisted living residence, part 14.7, read in part: "The assisted living residence shall ensure that each resident receives proper administration and/or monitoring of medications."Based on observations and interviews, the residence failed to ensure that each resident received proper monitoring of medications, affecting one (#8) out of six sample residents. a. Residence PolicyThe residence's medication management policy, dated 12/21/23, read in part: "The residence shall ensure that each resident receives proper administration and/or monitoring of medications."b. ObservationOn 3/10/25 from 7:15 a.m. to 8:15 a.m., Staff #2 was observed crushing medications for Resident #8. Staff #2 placed the crushed medications in a plastic cup filled with pureed fruit. Staff #2 placed the plastic cup with crushed medications on the table in front of Resident #8. Staff #2 walked out of the Resident #8's room and did not monitor Resident #8 to ensure her medications were properly administered. c. InterviewsOn 3/10/25 at approximately 2:00 p.m., the administrator stated that she did not expect a qualified medication administration personnel (QMAP) to pass medication to a resident and walk away without ensuring the resident ingested all of their medication. She further stated that this was not how the residence trained their staff. 3. Chapter VII regulations, governing assisted living residence, part 14.29, read in part:"All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner."Based on record review and interview, the residence failed to ensure all prescribed and PRN (as needed) medications shall be listed and recorded on a medication administration record (MAR), affecting two (#3, #4) of six sample residents. a. Residence PolicyThe residence's medication management policy, dated 12/21/23, read in part: "The residence shall ensure that each resident receives proper administration and/or monitoring of medications."b. Resident #3 was admitted to the residence on 6/1/24 with diagnoses including schizoaffective disorder. A written practitioner's order, dated 2/15/25 at 10:30 a.m., directed the residence to administer, one time, a milk of magnesia and a sodium phosphates enema. However, the February 2025 MAR did not contain the prescribed medication. On 3/10/25 at 2:00 p.m., the resident care coordinator confirmed that the medication was not listed on the MAR and therefore was not administered. stated that the residence did not administer the prescribed orders. The administrator stated she expected the residence to administer residents' medications as ordered. Evidence revealed similar deficient practice for Residents #2 and #4.
Plan of correction · submitted by the facility
POC Actions:1.- There was no order for Milk of Magnesia and Sodium Phosphates enema received from the hospital in the discharge paperwork.- There is conflicting information between the hospital discharge paperwork and an ESP nurse note. The InnovAge note says they confirmed with the ED that the two medications were given to the patient to be taken at her residence, however, the resident did not arrive at the facility with the medications.- There is a progress note from the staff on duty upon the resident's return to the facility that indicates there was no new order for any medications, and that Tylenol has been administered at the ED. This contradicts what was observed in the ESP nurse notes.- Regarding events on 2/18/2025, the facility has no documentation from the resident’s ESP that the resident complained of any pain or discomfort or that she was given Miralax while with the ESP.- Resident #3 made no mention of any pain or discomfort at any time between 2/15/2025 at 9:30am and beyond the end of February. The resident’s complaint of pain was only PRIOR to her ED visit.- In-Service from Director of Operations to Administrator and all staff to make sure there is a thorough review of resident discharge paperwork from an ED visit or hospital stay. If there are any discrepancies or questions, staff is to call the ED, the hospital, or the PCP for clarification. Auditing Process:Name: Return from ED/Hospital Discharge Orders Audit ToolWho: The administrator or designeeWhen: DailyWhat: There will be a thorough review of resident ED or hospitalization discharge paperwork to ensure that all instructions and orders are being implemented. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation. 2.-Resident #8 was not in the facility on 3/10/2025. He moved out of this facility on 20 February 2025. Auditing Process:Name: QMAP Medication Monitoring Audit ToolWho: The Administrator or designeeWhen: WeeklyWhat: Random observations of QMAPs administering medications to ensure proper procedures are followed. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation. 3.- The Director of Operations in-serviced Administrator and RCC, Administrator in-serviced QMAP staff, on the proper procedures for recording all prescribed and PRN medications on the Medication Administration Record (MAR), including one-time orders.- A full audit of all current resident MARs will be conducted to ensure all active and one-time medication orders are accurately listed and documented per policy and regulation. Any discrepancies will be corrected immediately.- The residence’s medication management policy will be reviewed and revised as necessary to emphasize the requirement for documenting all prescribed medications, including single-dose orders, on the MAR.Auditing Process:Name: MAR Compliance AuditWho: The Administrator or designeeWhen: WeeklyWhat: Review of all newly written and one-time medication orders to ensure they are properly documented on the MAR, with verification of administration, initials/signatures, and resident response or documentation of refusal/omission if applicable. Duration: Reviewed in QA monthly, will be continued for 12 months for re-evaluation.
1/3/2024Licensure (Re-licensure) · ID 3TYI11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An initial licensure survey was completed on 1/3/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/3/2024Initial State Certification (Medicaid) · ID PZZM11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An initial certification survey was completed on 1/3/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
9 records3/15/2026Physical Abuse · ID 26235KQX001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) and (B) had a verbal altercation that escalated to a physical altercation. Client (A) sustained an injury. During the course of the investigation, the healthcare entity separated both clients, contacted police, and conducted interviews. Staff assessed client (A)'s injuries. Both clients confirmed a physical altercation. Staff reported only witnessing the verbal altercation. Police issued a citation to client (B) for the injury client (A) sustained from them. The facility implemented a behavior plan for client (B) and educated them on the house rules, resident rights, and grievance procedures. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/6/2026 · released to the public 5/13/2026.
11/25/2025Missing Person · ID 25235KQX009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/26/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. At-risk Client (A) reported to staff they were leaving the facility with friends, but did not return that night. The next morning, staff were unable to locate Client (A). During the course of the investigation, the healthcare entity completed a search of the grounds, notified law enforcement, and conducted interviews. The facility confirmed the presence of all remaining clients and increased communication between staff regarding client whereabouts. All attempts to locate and contact the client were unsuccessful. Client (A) returned to the facility themselves the following day after missing for more than eight hours. The facility reviewed Client (A)’s plan of care and updated their records with new contact information. Client (A) was educated and agreed to frequently check in with staff when away from the facility. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 1/21/2026 · released to the public 1/28/2026.
5/21/2025Physical Abuse · ID 25235KQX005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/21/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (C) threw cold coffee on Client (A). Client (B) decided to interject themselves into Client (C) and (A)’s altercation which then Client (A) pushed Client (B) after being threatened. The clients were monitored more frequently. Client (C) due to declined cognition will be moved to a higher level of care. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 11/13/2025 · released to the public 11/25/2025.
2/8/2025Physical Abuse · ID 25235KQX004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/23/25, the healthcare entity investigated a reportable event of physical abuse. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 3/10/25, 1D2K11. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 7/30/2025 · released to the public 8/6/2025.
1/28/2025Physical Abuse · ID 25235KQX003Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/23/25, the healthcare entity investigated a reportable event of physical abuse. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 3/10/25, Event ID 1D2K11. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 7/23/2025 · released to the public 7/30/2025.
10/19/2024Physical Abuse · ID 24235KQX005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/19/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (A) and (B) in a verbal altercation. Client (A) stated Client (B) hit them in the arm. Client (A)’s arm was red. Client (B) had a history of being aggressive towards staff. The staff educated both clients to stay away from each other. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/2/2025 · released to the public 6/10/2025.
7/30/2024Physical Abuse · ID 24235KQX003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/30/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (A) hit Client (B) in the head because they were not listening after a verbal altercation. Client (A) was in tears. The clients were placed in separate rooms. Staff will mediate between the clients as they are husband and wife. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/25/2025 · released to the public 5/5/2025.
6/13/2024Physical Abuse · ID 24235KQX002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/14/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (A) and (B) in a verbal altercation before a physical altercation. Both clients were punching each other with closed fists. No visible injuries. The clients state they worked it out and are now friends. Staff will keep the clients separated and monitor for behaviors. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/26/2025 · released to the public 4/3/2025.
3/9/2024Diverted Drugs · ID 24235KQX001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 3/7/24 after resident (A) was seen by her pain physician she received and filled a new script for Oxycodone 10 mg (milligram) to take every 4-6 hours as needed. The prescription was for 180 pills; however when she turned them in to qualified medication administration person (QMAP) (1) there were 150 pills on 3/9/24. Drug diversion suspected by resident (A). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Resident (A) stated maybe the pharmacy miscounted the medication. Resident (A)’s roommate (resident B) was interviewed and they stated resident (A) had given them one tablet on 3/9/24. Resident (B) stated they new resident (A) took some tablets before turning them into staff and provided a written statement. No apparent injuries for either residents. Resident (B) was assessed by the paramedics and refused any further medical treatment. The facility investigation concluded resident (A) diverted medications before turning them into staff. To help prevent a recurrence, resident (A) signed a pharmacy agreement acknowledging all medications will be ordered and delivered right to the staff. Resident (A) will no longer pick up medications. This information was added to resident (A)’s plan of care, the staff will manage her medications.
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 12/2/2024 · released to the public 12/9/2024.