APPLEWOOD OUR HOUSE ASSISTED LIVING LLC — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

July 28, 2026

Last Inspection

S/S A/B Minimal potentialS/S E Potential for harm

The most recent inspection of APPLEWOOD OUR HOUSE ASSISTED LIVING LLC on record is dated July 28, 2026. Across 6 published inspections, state surveyors cited 16 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 (Licensed Only)

Administrator

Gaddis, Tiffany

Owner

APPLEWOOD OUR HOUSE ASSISTED LIVING LLC

Phone

(720) 398-9743

Payor Source

Private Pay

City

GOLDEN

ZIP

80401

Inspections & Citations

6 inspections · 16 deficiencies

7/28/2026Revisit: Licensure and Licensure Complaint (Combined) · ID Q1TI12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey and complaint revisit was completed on 7/28/26 for all previous deficiencies cited on 12/3/25. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

12/2/2025Licensure and Licensure Complaint (Combined) · ID Q1TI115 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey, with a complaint #CO41162, was completed on 12/3/2025. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0734Stf Req-First Aid 1 Stf Onsite CPRS/S E▼

Findings

Based on interview and record review, the residence failed to have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting eight current residents. Specifically, the residence did not ensure that a staff member with current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques was on duty for 33 shifts between November 1 and December 1, 2025, leaving those shifts without required coverage. This failure warranted an Immediate Jeopardy (IJ) determination because, during these weeks, residents were at risk of experiencing a medical emergency without any qualified staff available to initiate life-saving CPR or obstructed airway interventions. Due to the absence of staff with current CPR certification, the residence was unable to provide adequate coverage for these shifts, further increasing the likelihood of serious injury, harm, or death. The IJ was lifted on 12/2/25, after the residence implemented corrective actions ensuring that a CPR-certified staff member was present and on duty for all shifts. Findings include:1. Record ReviewOn 12/2/25 at approximately 11:35 a.m., the house manager provided a staff schedule from November 1 through December 2,2025. The schedule consistently did not have a CPR qualified staff member for overnight shifts, including upcoming overnight shifts specifically on 12/2/25. On 12/2/25 at approximately 9:36 a.m., a review of the resident roster revealed that three residents had "unknown" listed for their specified advance directives. With "unknown" documented, staff would not have known how to respond during an emergency, which could have resulted in the residents being treated as full code and the residents needing and receiving CPR.On 12/2/25 at approximately 12:30 p.m., a review of the staff schedule from November 1 through December 1, 2025 revealed that 33 shifts were not covered by a staff member certified in CPR. Of those 33 uncovered shifts, 30 occurred between 10:00 p.m. and 6:00 a.m. This lack of CPR-certified coverage placed residents at risk for serious harm in the event of a medical emergency, and a serious adverse outcome was likely as a result of the identified noncompliance. 2. InterviewsOn 12/2/25 at approximately 12:45 p.m., the administrator stated he was unaware that the overnight shift on 12/2/25 was not covered by a CPR qualified staff member. On 12/2/25 at approximately 1:30 p.m., the administrator acknowledged that the residence had assigned staff to shifts that were not covered by a staff member with current CPR certification. He stated that while the residence employed staff with CPR and obstructed airway certifications, those staff members were not scheduled for all upcoming shifts, leaving gaps in coverage. To address the immediate risk, the administrator pulled a CPR-certified staff member from a sister home and had a certified CPR instructor provide certification to another staff member that evening, 12/2/25. Following these actions, the residence ensured that all upcoming shifts would have at least one staff member with current CPR and obstructed airway certification on duty. The Immediate Jeopardy was lifted on 12/2/25, once the residence demonstrated that the staffing plan provided continuous coverage by qualified personnel. 3. Immediate Jeopardy RiskThe survey established that the above findings placed eight current residents at immediate jeopardy risk because the residence failed to comply with the requirement to have at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) and obstructed-airway techniques from a nationally recognized organization. The residence was directed to provide the department with written evidence that the risk has been removed. Part 8.7 of Chapter VII regulations required residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/2/25 at 3:48 p.m., the administrator submitted written evidence stating, in part, that the residence would implement systemic changes to ensure staff who were not CPR certified prior to or at new employee orientation would be scheduled for the next CPR class, which would occur on the first and third Thursdays of each month. He also stated that a CPR-qualified staff member would work the night shift for the next two nights. The administrator indicated that employee CPR status would be reviewed during weekly plan of correction PoC meetings until the PoC was cleared, after which monthly reviews would occur during QMP meetings. However, the written evidence did not contain an acceptable monitoring element, specifically who will be monitoring the schedule and the employee's CPR status. The administrator was directed to submit additional written evidence. On 12/2/25 at 4:01 p.m., the administrator submitted additional written evidence that read in part, CPR status of employees will be reviewed during weekly PoC meetings until PoC is cleared and then monthly reviews will be conducted during monthly QMP meetings. The house manager will monitor schedule and the HR Director will monitor CPR status of employees and new hires to schedule them for CPR class if needed to prevent recurrence of citation. On 12/2/25 at approximately 4:05 p.m., the plan of correction was accepted.

Plan of correction · submitted by the facility

Problem: The facility failed to ensure that at least 1 person was trained in CPR and obstructed airway for 33 shifts. Solution: The HR Director will be retrained on the importance of direct care staff to be trained in CPR and obstructed airway during the orientation time. This training will be completed by December 30, 2025 and documented. To ensure compliance: The House Manager will review the staff schedule weekly on Monday and cross reference the schedule with the list of staff trained on CPR and obstructed airway to ensure all shifts have at least 1 staff member adequately trained for all shiftsThe Administrator will add this issue as an area of focus in the QMP review in monthly for 3 months.

0910Em Pr-Pol/Proc Res RstrS/S B▼

Findings

Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents and their room assignments, affecting eight current residents. Findings include:1. Record reviewOn 12/2/25 at 8:00 a.m., Staff #1 was asked to provide a resident roster. She provided the emergency preparedness book, which contained an outdated roster and overstated the total number of residents as nine instead of eight. The emergency preparedness book also lacked a diagram of the residence. 2. InterviewOn 12/2/25 at 8:00a.m., Staff #1 stated that there were nine residents living in the residence, when in fact there were eight residents. On 12/3/25 at 3:36 a.m., the administrator acknowledged that the residence did not have a readily available roster that included a facility diagram and stated that staff should always know how many residents are living in the residence.

Plan of correction · submitted by the facility

Problem: The facility failed to ensure the resident roster was readily available for all 8 residents. Solution: The House Manager will be trained on the importance of the resident roster by December 30th, 2025 including the requirement for a schematic map showing resident room numbers. The House Manager will update the resident roster when a resident moves in, moves out or is out of the facility such as a hospital stay or out with family. To ensure compliance: The Administrator will review the roster during visits to the home. The Administrator will also add this issue to one of the areas of focus in the QMP and will review it monthly during the QMP meetings. This will be reviewed for 90 days or longer if needed.

0914Em Pr-Pol/Proc 72 hrs EmS/S B▼

Findings

Based on record review and interview, the residence failed to develop written policies to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, including, but not limited to, a long-term power failure, affecting eight current residents. Findings include:1. Record ReviewOn 12/3/25 at 1:51 p.m., all emergency preparedness documents were requested. The residence was unable to provide emergency preparedness documents, which included written policies to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency. 2. InterviewOn 12/3/25 at approximately 3:00 p.m., the administrator stated that the residence did not have policies for a 72 hour plan.

Plan of correction · submitted by the facility

Problem: The Residence failed to develop a written policy for care for 72 hours for residents if needed:Solution: The facility will develop the written policy by December 30th and review it will staff at the January staff meeting. To ensure continued compliance, the Administrator will add this to the QMP and review the policy every month for 3 months to ensure it is accurate or there is a need to revise it. The written policy for care for 72 hours care for residents will be reviewed specifically noting where will each of the residents will go for 72 hours for an extended power outage or other evacuation issue. The evacuation plan will also be reviewed with staff with specifics such as transportation, who is packing resident belongings, who is responsible for medications and resident records, who is calling the legal responsible party and who is providing care at the alternate location. The Administrator will notify the Department within 48 hours of relocating the residents. Applewood Our House has 5 locations so residents will be moved to one of these homes.

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on interview and record review the residence failed to ensure the administrator and qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration records affecting eight current residents. Findings include:1. Record reviewOn 12/3/25 at approximately 3:00 p.m., the house manager provided a document intended to audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records; however, the document was blank and not completed. 2. InterviewOn 13/3/25 at 3:44 p.m., the administrator acknowledged that the residence had not completed medication audits per the regulation.

Plan of correction · submitted by the facility

Problem: The facility failed to provide evidence of Med. Cart Audits. Solution: The House Manager will do a Med Cart Audit monthly and the next one will be completed by Dec. 30th, 2025, and document the results. On a quarterly basis the House Manager and the Administrator jointly will do the Med Cart audit to include a sample of residents matching the medications, to the order to the MAR sheet. To ensure continued compliance, the Administrator will add Medication Management to include a Med. Cart audit to the QMP as required in Chapter 7 and review it monthly for 90 days and ongoing after that.

3050Sec Env-Re AsS/S B▼

Findings

Based on record review and interview, the residence failed to reassess residents every six months for the need of a secure environment, affecting two out of three sample residents in the secure environment (#1,#3). Findings include:1. Record reviewResident #1 was admitted to the residence on 10/29/24 with a diagnosis of dementia and resided in a secured environment. On 12/3/25 at approximately 9:30 a.m., Resident #1 ' s record contained a care plan for Resident #1, dated 10/22/24. However, the record contained no additional evidence that the residence had re-assessed the resident every six months for the need for a secure environment. 2. InterviewOn 12/3/25 at 3:52 p.m., the administrator acknowledged that the residence had not been reassessing residents in the memory care unit every six months. Similar deficient practice was found for Resident #3.

Plan of correction · submitted by the facility

Problem: the facility failed to reassess residents every 6 months as required:Solution: The House Manager will be trained on resident reassessments by Dec. 30, 2025 with written documentation. To ensure continued compliance, the Administrator will add this to the QMP for 90 days and discuss this at the monthly QMP meetings. Addendum:The Resident will be reassessed every 6 months or upon change of baseline to address issue of care such as wander patterns, behaviors, safety issues, access to their room and issues with unwanted residents in their room, safety of personal items in their possession, staff oversight needed. The Administrator will review the move in date of each resident at the monthly QMP meeting along with any changes from baseline for each resident and update the enhanced care plan at that time. Meeting notes will be kept for each meeting documenting which residents care plan was assessed and updated. The Administrator will continue this process for 90 days and ongoing so that reassessment are done timely for each resident. Added: The residents 6 month re assessment will be completed by Feb. 6th with written documentation available then.

9/24/2025Revisit: Licensure (Re-licensure) · ID 3DTN13No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 9/24/25 for all previous deficiencies cited on 4/18/25. The facility is in compliance with all deficiencies that were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9/24/2025Revisit: Licensure Complaint · ID JOBJ12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 9/24/25 for all previous deficiencies cited on 4/18/25. The facility is in compliance with all deficiencies that were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

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

Plan of correction

The state did not require a plan of correction for this citation.

4/18/2025Revisit: Licensure (Re-licensure) · ID 3DTN122 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 4/18/25 for the previous deficiencies cited on 11/15/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25.

Plan of correction

The state did not require a plan of correction for this citation.

0172LicProc-IntlApp CAPSS/S B▼

Findings

Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements for four of five sample staff, affecting 11 current residents. This deficiency was cited previously during a state licensure survey on 1/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 4/18/25 at approximately 11:00 a.m., CAPS checks for Staff #3-#5 and Former Staff #7 were requested but not provided. On 4/18/25 at 10:28 a.m., the administrator acknowledged that the HRD was responsible for obtaining and maintaining all staff records. On 4/18/25 at 10:28 a.m., the human resource director (HRD) stated she had been working on turning all staff documents into electronic files, but she was not done with the process and was unable to provide them. At 11:25 a.m., the HRD stated that the CAPS checks were saved on a hard drive off site and she would provide them electronically. The residence did not provide CAPS checks for any of the above staff.

Plan of correction · submitted by the facility

All current associate files to be audited by Administrator or Designee no later than 6/15/2025 to ensure compliance. All files to be uploaded to confidential drive shared by Administrator and Human Resources Director. Newly hired associates CAPS check to be completed and uploaded to the confidential shared drive upon hire. Spot checks to be completed by Administrator or Designee weekly for 12 weeks. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting one of three sample residents (#12). This deficiency was cited previously during a state licensure survey on 1/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #12 was admitted to the residence on 7/11/24 with diagnoses including aortic valve regurgitation and gout. He received services from an external hospice provider. A written practitioner's order, dated 3/1/25, directed the residence to administer tramadol 50 mg three times daily. However, the April 2025 medication administration record (MAR) revealed that the residence failed to administer one dose of the medication on 4/11/25. The MAR contained no documentation for the reason that staff did not administer the medication on 4/11/25. On 4/18/25, at 1:49 p.m., the house manager stated that the residence was out of stock for the bedtime dose of tramadol on 4/11/25. She stated that the resident had a new nurse and there was miscommunication between the nurse and the pharmacy, which caused a delay in delivery.

Plan of correction · submitted by the facility

Administrator or Designee will conduct training for all staff that are Qualified Medication Administration Personnel, on the importance of having ordered medication on-hand, so as to not interrupt resident services. Training to be completed by May 31, 2025. Training will be documented on an In-Service form, then uploaded into a Training file on our shared drive. A combination of two of the following:Medication Lead/Assistant Manager/House Manager/Administrator will conduct a weekly med cart and EMAR audit beginning June 13th to ensure there are plenty of medications in stock, ordered before they run out, and are readily available for administration. EMAR Spot checks to be completed by Administrator or Designee weekly for 12 weeks. EMAR spot check audits will be documented on a paper log in a binder located above the med cart. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

4/18/2025Licensure Complaint · ID JOBJ119 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO39862, was completed on 4/18/25. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0172LicProc-IntlApp CAPSS/S B▼

Findings

Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements for four of five sample staff, affecting 11 current residents. Findings include:On 4/18/25 at approximately 11:00 a.m., CAPS checks for Staff #3-#5 and Former Staff #7 were requested but not provided. On 4/18/25 at 10:28 a.m., the administrator acknowledged that the HRD was responsible for obtaining and maintaining all staff records. On 4/18/25 at 10:28 a.m., the human resource director (HRD) stated she had been working on turning all staff documents into electronic files, but she was not done with the process and was unable to provide them. At 11:25 a.m., the HRD stated that the CAPS checks were saved on a hard drive off site and she would provide them electronically. The residence did not provide CAPS checks for any of the above staff.

Plan of correction · submitted by the facility

0630Prsnl-Ablty Prfrm Job Fn Phys/MntlS/S B▼

Findings

Based on record review and interview, the residence failed to have staff members who were physically and mentally able to adequately and safely perform all functions essential to resident care, affecting 11 current residents. (Cross-reference S636, S1324)Findings include:A law enforcement report, dated 4/17/25, read in part that law enforcement arrived at the residence on 4/15/25 at 1:53 a.m. and found two females (one of whom was later identified as Former Staff #8), both unconscious and not breathing in one of the residence's bathrooms, due to overdose of illicit drugs. Former Staff #8 was transported to an emergency department and then was arrested and charged with 11 counts for abuse of at-risk adults. Former Staff #7 had reported that her friend was not responsive and CPR was in progress. Former Staff #7 stated that she herself "doesn't feel good and feels like she is to pass out." Former Staff #7 sat on the floor, vomited into a bucket, and "explained she was tingling, having a hard time breathing, and her chest was hurting." Former Staff #7 reported she consumed alcohol and marijuana prior to walking through the door of the residence. Law enforcement observed that the former staff sitting, standing, pacing and stated she was having a "panic attack." Former Staff #7 did not check on any residents during that time; "Due to her state of mind, Former Staff #7 was unable to provide proper care to the residents living at the house."On 4/18/25 at 8:23 a.m., the house manager confirmed that Former Staff #8 was unresponsive on the early morning of 4/15/25. She stated that Former Staff #7 was on site at the residence until she arrived at approximately 3:00 a.m. She acknowledged that she was unaware as to whether the former staff was able to adequately and safely provide care to residents. On 4/18/25 at 10:36 a.m., the administrator stated that the information provided in the law enforcement report revealed that neither staff who were on duty on 4/15/25 (Former Staff #7 and #8) were able to adequately and safely perform all functions essential to resident care.

Plan of correction · submitted by the facility

(Cross-reference S636, S1324)Administrator or Designee will conduct Reasonable Suspicion training with all associates annually during all staff meetings beginning June 2025. Administrator or Designee will also include Reasonable Suspicion training in the New Hire Orientation beginning June 2025. Staff training will be documented on an In-House Training form for current staff and all newly hired staff, then uploaded into a Training Folder on our Shared Drive. The Administrator or Designee will perform weekly spot checks of completed In-House Training Forms for all current and new staff, recorded in a log above the med cart, for 12 weeks. The Administrator, HR, or Designee will audit the Training Folder for these forms. Monitoring may be discontinued after three consecutive months if compliance expectations are met consistently. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance in training.

0636Prsnl-Ablty Prfrm Job Fnctns P/P AcS/S B▼

Findings

Based on record review and interview, the residence failed to have policies and procedures restricting on-site access by staff with drug or alcohol use that would adversely impact their ability to provide resident care and services, affecting 11 current residents. (Cross-reference S630, S1324)Findings include:The residence's undated Reasonable Suspicion Drug and Alcohol Testing policy read in part that reasonable suspicion was a belief based on observations made by an employee that a staff member may be under the influence of drugs or alcohol. The policy did not address restricting on-site access to these staff. A law enforcement report, dated 4/17/25, read in part that law enforcement arrived at the residence on 4/15/25 at 1:53 a.m. and found two females (one of whom was later identified as Former Staff #8), both unconscious and not breathing in one of the residence's bathrooms, due to overdose of illicit drugs. Former Staff #7 reported she consumed alcohol and marijuana prior to walking through the door of the residence. On 4/18/25 at 10:36 a.m., the administrator stated that Former Staff #7 clocked in for her shift on 4/14/25 at 10:01 p.m., and Former Staff #8 clocked in for her shift at 10:21 p.m. She acknowledged that any staff who suspected other staff of being under the influence of drugs or alcohol should have reported it. She acknowledged that the residence's policy addressed testing when there was reasonable suspicion, but no one limited on-site access to Former Staff #7 and #8 on 4/15/25.

Plan of correction · submitted by the facility

(Cross-reference S630, S1324)Administrator or Designee will update the Reasonable Suspicion Policy to include restricting on-site access to staff believed to be under the influence of drugs or alcohol. Current Staff was educated on the updated Reasonable Suspicion policy on May 8, 2025 at the all-staff meeting. Training was documented on our In-House Training form and uploaded to our Training folder on our shared drive. Administrator or Designee will review the policy bi-annually, in June and December, to ensure it meets requirements. After 2 years of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued.

1324Res Rghts Rts/Rspn-Civ/Rel-NeglectS/S B▼

Findings

Based on record review and interview, the residence failed to ensure that residents had the right to be free from neglect, affecting 11 current residents. (Cross-reference B172, S630, S636)Findings include:A law enforcement report, dated 4/17/25, read in part that law enforcement arrived at the residence on 4/15/25 at 1:53 a.m. and found Former Staff #8 unconscious and not breathing in one of the residence's bathrooms, due to overdose of illicit drugs. Law enforcement observed that the former staff was sitting, standing, pacing and stated she was having a "panic attack." Former Staff #7 did not check on any residents during that time; "Due to her state of mind, Former Staff #7 was unable to provide proper care to the residents living at the house." Both Former Staff #7 and #8 were arrested and charged with 11 counts of at-risk adult abuse. On 4/18/25 at 10:36 a.m., the administrator stated that the residence's policy was for staff to complete safety checks on residents every two hours. She stated that because the law enforcement report read that Former Staff #8 was unresponsive and Former Staff #7 was not in the state of mind to provide care to residents, the residence failed to ensure the residents were free from neglect. The administrator acknowledged that all 11 residents were left unattended and unchecked from approximately 1:00 a.m. until approximately 3:00 a.m. on 4/15/25; she acknowledged that she considered it caretaker neglect. On 4/18/25 at 8:23 a.m., the house manager (HM) stated that on 4/15/25, Former Staff #8 was found at the residence unresponsive at approximately 1:00 a.m. She stated that Former Staff #7 was physically present at the residence with Staff #8 with no other staff present until 3:00 a.m., when the HM arrived to take over.

Plan of correction · submitted by the facility

(Cross-reference B172, S630, S636)Administrator or Designee will conduct training with all current staff, as well as all newly hired staff, on the importance of Safety Checks, not leaving residents unattended, and the definition of being in the right state of mind to ensure resident safety. Training will be documented on our In-House Training form and uploaded into our Shared Drive. Safety checks will be documented in our EMAR system, ECP.Spot checks to be completed by Administrator or Designee weekly for 12 weeks. The Administrator or Designee will weekly audit the EMAR system, specifically Safety Checks to ensure they are being completed and signed off on. Monitoring will be documented on a log that is kept in a binder located above the medication cart, the involved party will sign off on and date the log. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting one of three sample residents (#12). Findings include:Resident #12 was admitted to the residence on 7/11/24 with diagnoses including aortic valve regurgitation and gout. He received services from an external hospice provider. A written practitioner's order, dated 3/1/25, directed the residence to administer tramadol 50 mg three times daily. However, the April 2025 medication administration record (MAR) revealed that the residence failed to administer one dose of the medication on 4/11/25. The MAR contained no documentation for the reason that staff did not administer the medication on 4/11/25. On 4/18/25, at 1:49 p.m., the house manager stated that the residence was out of stock for the bedtime dose of tramadol on 4/11/25. She stated that the resident had a new nurse and there was miscommunication between the nurse and the pharmacy, which caused a delay in delivery.

Plan of correction · submitted by the facility

Administrator or Designee will conduct training for all staff that are Qualified Medication Administration Personnel, on the importance of having ordered medication on-hand, so as to not interrupt resident services. Training to be completed by May 31, 2025. Training to be documented on our In-House Training Form and uploaded to our Shared Drive. The Administrator or Designee will audit the medications weekly to confirm the proper number of medications are on hand and available for administration. Medications provided by the residents' preferred pharmacy are currently on-cycle and will be delivered monthly. Pharmacy will be notified when any PRN or off-cycle medications reach 7 doses to ensure there is no interruption in resident services. EMAR Spot checks to be completed by Administrator or Designee weekly for 12 weeks. EMAR audit checks will be documented on a log, located in a binder above the medication cart, the person conducting the audit will sign and date the log. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

2230HIR-Cntnt IncldS/S B▼

Findings

Based on record review and interview, the residence failed to ensure that resident records included progress notes of out of the ordinary events or issues along with the actions taken by staff to address the residents' changing needs, affecting two of three sample residents (#11, #13). Findings include:On 4/18/25 at 7:32 a.m., Staff #6 stated that Resident #11 was transported to the emergency department on 4/16/25 because he was displaying aggressive behavior: screaming, yelling, taking other residents' plates away while they were eating, and becoming physically aggressive. On 4/18/25 at 2:30 p.m., the house manager stated she had not yet completed a progress note with regard to the events that took place on 4/16/25 resulting in Resident #11's transport to the ED. She stated she was aware that staff were required to complete progress notes before the end of their shift, but she had a lot to write, and she was too exhausted to complete the progress note that day from handling several incidents in addition to this. On 4/18/25 at 2:30 p.m., the administrator stated that the staff required more training on documenting out of the ordinary events in progress notes so that there was more detailed information along with how the staff responded to or handled the event. Progress notes revealed no documentation of Resident #11's behavior on 4/16/25 nor the actions taken by staff to address his changing needs. Evidence obtained during the onsite investigation revealed the resident record additionally did not contain progress notes to include actions taken by staff to address Resident #13's changing needs.

Plan of correction · submitted by the facility

Administrator or Designee will conduct training on all current staff, as well as newly hired/on-coming staff on the importance of completing documentation in a timely manner. Staff, to include QMAP's, caregivers, and managers, will also be trained on charting progress notes on out of the ordinary events or issues along with the actions taken after the event/episode has been resolved. Actions taken to address a resident's changing needs will be documented on the residents Care Plan. Training to be documented on an In-House Training form and uploaded to the Shared Drive. All in-house staff have secure access to our EMAR system, ECP, and have the ability to enter progress notes. Progress Note spot checks to be completed by Administrator or Designee weekly for 12 weeks. Audits will be documented on a paper log, located in a binder above the medication cart, the auditing person will sign and date the log each time the audit is completed. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

3050Sec Env-Re AsS/S A▼

Findings

Based on interview and record review, the residence failed to re-assess a resident when the resident's condition changed from baseline status, affecting one current resident (#11). Findings include:Resident #11 was admitted to the residence on 1/28/25 with diagnoses including dementia and conduct disorder, child onset type. Progress notes, dated 3/6/25 to 4/15/25, revealed that Resident #11 had behavioral expressions to include yelling, cursing, threatening, intimidating, restlessness, pacing, physically abusing the house dog, slammed doors, punched doors, among other behavioral expressions. The resident record contained no documentation that the residence re-assessed Resident #11 after changes in his baseline status. On 2/18/25 at 12:38 p.m., a licensed medical social worker (LMSW) from a hospital stated that Resident #11 was transported to the emergency department for a psychiatric evaluation due to behavioral expressions that the residence was unable to manage. She stated that the hospital was unable to provide him psychiatric care because the resident had a diagnosis of dementia. The LCSW stated that a patient with dementia would be unable to participate in psychiatric treatment, so she notified the residence that the ED was discharging Resident #11 back to the residence. On 2/18/25 at 10:49 a.m., the administrator stated Resident #11 was transported to the ED because he was not at his behavioral baseline status. She stated Resident #11's practitioner recommended he be transported so that he could obtain a psychiatric evaluation because she was concerned for the safety of the resident and that of the other residents. The administrator stated that the LCSW telephoned her that the ED administered oral zyprexa and that he was "cleared" to return to the residence. She stated that the LCSW informed her that they did not complete a psychiatric observation, adding that it was not required because of Resident #11's dementia diagnosis. The administrator stated upon the LCSW's notification of the resident's change in baseline status and discharge, she did not re-assess the resident while he was in the hospital. She stated that she or the house manager could have completed a re-assessment, but she wanted to ensure that the resident received psychiatric care first.

Plan of correction · submitted by the facility

Administrator or Designee will perform an assessment on any and all residents that are out of the facility when the treating facility is requesting that the resident return. Assessment findings will then be entered into the facilities EMAR system in the resident Progress Notes, regardless of whether or not the resident returns to the facility. If the resident will not be returning, the notes will reflect the reason behind this, if the resident is allowed to return, the Care Plan will be updated upon the residents' return, to reflect any changes to the care the resident will receive. CORRECTION for sample resident #11 assessment: Administrator, upon speaking with hospital personnel and hearing that the resident had been given a medication not currently on his Medication List, did not feel comfortable allowing the resident to return to the house at that time. Resident was transferred out of the ED and into a regular room. Administrator and one of the company's House Manager's did go and assess the resident after more than a week in the regular room. Administrator asked for and was given nurses notes and spoke to one of the hospital nurses. The notes stated that the resident was still having aggressive outbursts, screaming at night, pounding on walls, and he threw a walker at a hospital staff member. At this time, the Administrator does not believe the resident's needs can be met in our environment. All House Managers will be trained on the importance of assessing residents that have been sent out for a medical emergency and have been out of the house for longer than 3 days. Training to be documented on an In-House Training form and uploaded to our Shared Drive. Training to be completed by June 30, 2025. No sample of current resident assessments have been completed. Spot checks of the residents' EMAR, to include the Care Plan and Progress Notes for any resident that has been sent out to the hospital, to ensure notes were updated after the assessment was completed at the outside location, the notes will include whether or not the resident was able to return. The Administrator or Designee will monitor the EMAR weekly for 12 weeks, the responsible person will document on a paper Log, located in a binder above the medication cart, signing and dating each audit and any found concerns. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

3060Sec Env-Enhncd Rsdnt CP IncldS/S A▼

Findings

Based on record review and interview, the residence failed to ensure that the enhanced care plan included a description of the resident's behavioral expressions along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, affecting 1 current resident (#11). Findings include:Progress notes, dated 3/6/25 to 4/15/25, revealed that Resident #11 had behavioral expressions to include yelling, cursing, threatening, intimidating, restlessness, pacing, physically abused the residence dog, slammed doors, punched doors, among other behavioral expressions. An undated care plan revealed a section for the residence to address mental health, aggression, and combativeness. The residence failed to include a description of the resident's known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact. On 4/18/25 at 2:56 p.m., the house manager (HM) stated she was responsible for updating resident care plans after residents were admitted. She acknowledged that the care plan did not address any of Resident #11's known behavioral expressions, and she should have updated it but did not. On 4/18/25 at 2:56, the administrator stated that the residence should have addressed Resident #11's known behavioral expressions in the care plan, adding that after admission, it was the responsibility of the HM to do so.

Plan of correction · submitted by the facility

Administrator or Designee will conduct training with all house managers upon hiring and then bi-annually, in February and July, on the importance of updating Care Plans, not just regarding the physical needs, but the emotional and behavioral needs and expressions of each resident. CORRECTION for sample Resident #11: Behaviors, watch for anxious body language such as fidgeting, clenching his jaw or fist, trembling or pacing. If resident appears to be getting anxious, offer to take him for a walk outside of the house - not the courtyard, take the dog with you. The dog gives him something to focus on beside his anxiety. Take him to his room and help him set up his record player, ask is he needs more paint or canvases. Music and painting redirect him to something more productive. If redirecting isn't working, call his PCP and ask her to assess for a PRN medication to help lower his anxiety/anger. Other resident Care Plans are being audited with the new House Manager and the Administrator to ensure they are not being affected. Care Plans will be reviewed every 6 months or when a change in condition happens, ie: return from hospital or rehab, admittance to Hospice, when there is a deterioration or improvement in physical or emotional needs. Spot Checks to be completed by Administrator or Designee weekly for 12 weeks. When performing Care Plan spot checks, the Administrator or Designee will look for ways the resident has been successfully redirected in the past, consistent triggers, as well as which staff member has the best rapport with the resident and has a calming effect with them. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will be documented on a paper Log in a binder, located above the medication cart. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

3120Sec Env-Res RghtsS/S A▼

Findings

Based on observations and interview, the residence failed to ensure that residents in the secure environment had all the same resident rights as set forth in Part 13 of Chapter VII regulations, including the right to privacy and confidentiality, affecting one of three sample residents (#11). Findings include:1. ObservationsOn 4/18/25 at approximately 8:35 a.m., the HM revealed three video recordings of Resident #11's behavioral expressions. Two recordings were on the residence's cell phone, one recording was on the HM's personal cell phone 2. InterviewsOn 4/18/25 at 7:48 a.m., the house manager (HM) stated that Resident #11 had a diagnosis of conduct disorder, and since his admission to the residence on 1/28/25, his behavioral expressions had been increasing. She stated "I can show you videos and videos of (Resident #11), adding that the resident's practitioner requested that they record the behaviors and send them to her. The HM stated she only video recorded the resident in the common spaces of the residence; she stated he was always clothed and she did not video record him in his room so she did not "invade his privacy in any way."On 4/18 /25at 11:04 a.m., the administrator stated that she did not instruct staff to record residents. She stated that the HM told her that the practitioner requested that she do it. The administrator stated that it was especially a violation of the resident's privacy when staff kept recordings on their personal cell phones because there is no way to know who else is seeing it. She acknowledged that when the practitioner requested the video recordings, the staff should have advocated for the resident's right to privacy in their home.

Plan of correction · submitted by the facility

Administrator or Designee will conduct training with all current staff members, as well as newly hired/on-coming staff members regarding the importance of resident privacy and the company policy on using personal recording devices to take photographs or videos of the residents. Training was documented on an In-House Training form and uploaded to our Shared Drive. Spot checks of newly hired staff's training of the company policy to be completed by Administrator or Designee weekly for 12 weeks concerning the training of staff. Administrator or Designee will randomly ask staff our policy on using personal devices to take photos or videos of residents. Staff will be asked to keep their personal devices in their locker or pocket at all times, unless they are on break and outside of an area where residents are located. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be discontinued. Monitoring will be documented on a paper Log in a binder above the medication cart. Monitoring will not be discontinued until the facility completes three consecutive months of monitoring that demonstrates sustained compliance.

9999Final ObservationsSurveyor note▼

Findings

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 7.14.29 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.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications. 25.26 A secure environment shall meet the following criteria:(F) There shall be a secure outdoor area that is available for resident use year-round that:(2) Is independently accessible to residents without staff assistance for entrance or exit.

Plan of correction

The state did not require a plan of correction for this citation.

Reportable Occurrences

6 records

12/1/2025Physical Abuse · ID 2523D173007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/1/25, 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 physical abuse of a client. Reportedly, client (B) pushed client (A), causing them to bump their head. During the course of the investigation, the healthcare entity seperated the clients prior to notifying law enforcement, conducted interviews, and assessed the client. Client (A) did not sustain any visible injuries. Client (B) could not recall why they pushed client (B). Client (B) moved out of the home 5 days after the event per a pre-planned move and education provided to staff. The event was substantiated. Client (B) was involved in previous occurrence events, please see the following case IDs for additional information: 2523D173004, 2523D173005, 2523D173006, and 2523D173007. 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 3/4/2026 · released to the public 3/11/2026.

11/29/2025Physical Abuse · ID 2523D173006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/29/25, 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 physical abuse of a client. Client (B) entered client (A)’s room to request access to the house pet, the two clients then hit and kicked each other. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, and conducted interviews. Neither client sustained visible injuries. Staff did not report the event to management when it occurred, and received re-education regarding reporting timelines. Client (A) moved to a different home within the facility, and client (B) received an evaluation for hospice services. The event was substantiated. Client (A) has been identified in two other occurrence events, please see case IDs 2523D173004 and 2523D173005 for additional information. 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 3/4/2026 · released to the public 3/11/2026.

11/24/2025Physical Abuse · ID 2523D173005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/24/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) hit client (A) on the hand causing a bruise. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, started increased monitoring, and assessed the client. The physical altercation was the result of an argument over the house pet. Client (B)’s power of attorney decided to move the client out of the facility on the day of the event without discussing the event further with management. Client (A)’s power of attorney decided to move them to another home within the facility. The event was substantiated. This is the second report of a client to client altercation involving these two clients. Please refer to case ID#2523D173004 for further information. 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 3/4/2026 · released to the public 3/11/2026.

11/17/2025Physical Abuse · ID 2523D173004Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/21/25, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) hit client (A) on the arm causing a bruise. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, and assessed the clients. Client (B) did not recall the event and denied hitting anyone. Staff reported the event started over an argument about the house pet. The facility determined staff did not report the allegation to management when it occurred. The facility started increased safety monitoring for both clients to ensure safety and keep them separated and educated staff regarding abuse reporting. 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 not submitted within the required timeframe.

Publication

Sent to facility 3/4/2026 · released to the public 3/11/2026.

5/22/2025Physical Abuse · ID 2523D173003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/22/25, 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. Client (C) was physically aggressive with staff and pushed Client (A) and (B). Client (C) injured themselves twice during these altercations. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Neither Client (A) or (B) had injuries but were tearful and expressed fear. Client (C) was sent to the hospital for evaluation and treatment of negative behaviors. Client (C) was later discharged from the facility on 6/17/25 after not returning. 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 11/24/2025.

4/15/2025Neglect · ID 2523D173002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/17/25, the healthcare entity investigated a reportable event of neglect. 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 4/18/25, Event ID JOBJ11. 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 submitted within the required timeframe.

Publication

Sent to facility 11/19/2025 · released to the public 11/26/2025.