CARING SOULS ASSISTED LIVING AT TOLLGATE

A revisit survey was completed on 12/16/25 for all previous deficiencies cited on 8/20/25. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 12/16/25 for all previous deficiencies cited on 8/20/25. The facility is in compliance with all deficiencies that were cited.

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

A revisit survey was completed on 12/16/25 for all previous deficiencies cited on 8/20/25. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey with complaint revisit was completed on 8/20/25 for all previous deficiencies cited on 9/19/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25. Tags U664 and U1634 were not cited in the previous event; however, the deficiencies were included in the previous event's informational 999 tag.

Based on observation, record review, and interviews, the residence failed to have a quality management program (QMP) designed to improve client safety and well-being, affecting seven current residents. This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:On 8/19/25 at 8:30 a.m., the residence's QMP was requested from the administrator. On 8/19/25 at 11:00 a.m., a binder labeled "QMP" was provided; however, all of the pages in it were blank. On 8/20/25 at approximately 9:00 a.m., the administrator stated there had not been any QMP projects completed this year. Contrary to the previous statement, the administrator stated she had implemented a project to change to electronic documents. The administrator further stated the QMP projects were not documented since she did not believe they needed to be since "everything had been addressed as it came up." The administrator stated she believed the deficiency had been corrected. On 8/20/25 at approximately 9:40 a.m., the assistant administrator stated the QMP was not implemented as required since she did not believe the administrator understood how to implement a QMP. She further stated the administrator was filling out the pages in the binder as she was speaking to the surveyor, in an attempt to correct the deficiency onsite. On 8/20/25 at 9:43 a.m., the administrator was observed filling out the QMP binder that was previously blank.

Based on interviews and record review, the residence failed to ensure personnel files included the results of background checks and first aid and cardiopulmonary resuscitation (CPR) certifications for two of four sample staff members (#4, #5), affecting seven current residents. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 7.13, requires each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable;(E) Results of background checks and follow up, as applicable. 2. Record ReviewStaff #4 and #5's personnel files provided by the administrator on 8/19/25 at approximately 11:00 a.m., revealed they were hired on 9/22/21 and 9/26/21, respectively. However, the personnel files were missing the results of background checks and current CPR and first aid certifications. 3. InterviewsOn 8/20/25 at approximately 8:45 a.m., the assistant administrator (AA) stated Staff #4 and #5 provided care and services to residents when needed, and were also the owners. The AA stated she was unsure why the personnel files for Staff #4 and #5 did not contain results of background checks and current CPR and first aid certifications. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware of the requirement for personnel files to include results of background checks and CPR and first aid certifications; however, the documentation was misplaced when she had begun moving documents to upload electronically.

Based on observation, interview and record review, the residence failed to ensure there was at least one staff member on-site at all times who had current certification in first aid from a nationally recognized organization affecting seven current residents. This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. ObservationOn 8/19/25 from approximately 7:30 a.m. until 8:30 a.m., Staff #1 provided care and services to residents. No other direct care staff were present. 2. Record ReviewThe July 2025 staff schedule revealed Staff #1 and #3 were the only staff members that worked at the residence. Moreover, the August 2025 staff schedule revealed Staff #1 and #2 were the only staff members onsite as follows:Staff #1 worked 8:00 a.m. to 2:00 p.m. on 8/19 and 8/20/25, and 2:00 p.m. to 8:00 a.m. on 8/4-8/7 and 8/11-8/14, 8/18-8/20/25. Staff #2 worked 8:00 a.m. to 2:00 p.m. on 8/1, 8/2, 8/7-8/9, and 8/14-8/16/25. The personnel files for Staff #1 and #3, revealed their first aid certifications were not completed through a nationally recognized organization. 3. InterviewsOn 8/20/25 at 7:30 a.m., Staff #1 stated she resided at the residence, and was the only staff member onsite if another staff member was not scheduled to work. Staff #1 stated the certificates in the personnel files for herself and Staff #3 were the only current certifications they had. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware Staff #1 and #3's first certifications were not nationally recognized. The administrator stated Staff #1 and #3 were supposed to complete an in-person course that was nationally recognized; however, had not, which was why the deficiency had not been corrected.

Based on observation, record reviews and interviews, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting seven current residents. This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. ObservationOn 8/19/25 from approximately 7:30 a.m. until 8:30 a.m., Staff #1 provided care and services to residents. No other direct care staff were present. 2. Record ReviewThe July 2025 staff schedule revealed Staff #1 and #3 were the only staff members that worked at the residence. Moreover, the August 2025 staff schedule revealed Staff #1 and #2 were the only staff members onsite as follows:Staff #1 worked 8:00 a.m. to 2:00 p.m. on 8/19 and 8/20/25, and 2:00 p.m. to 8:00 a.m. on 8/4-8/7 and 8/11-8/14, 8/18-8/20/25. Staff #2 worked 8:00 a.m. to 2:00 p.m. on 8/1, 8/2, 8/7-8/9, and 8/14-8/16/25. The personnel files for Staff #1 and #3, revealed their CPR certifications were not completed through a nationally recognized organization. 3. InterviewsOn 8/20/25 at 7:30 a.m., Staff #1 stated she resided at the residence, and was the only staff member onsite if another staff member was not scheduled to work. Staff #1 stated the certificates in the personnel files for herself and Staff #3 were the only current certifications they had. She further stated the CPR course herself and Staff #3 took, was completed online within a few hours and did not have an in-person skills component. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware Staff #1 and #3's CPR certifications were completed online through an organization that was not nationally recognized. The administrator stated Staff #1 and #3 were supposed to complete an in-person course; however, had not, which was why the deficiency had not been corrected.

Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed for administration were labeled or marked with residents' full names, affecting three of five sample residents (#1, #7 and #9). This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:On 8/19/25 at 8:15 a.m., a medication cart audit revealed Acetaminophen 500 mg was not labeled with Resident #1's full name. A written practitioner's order in Resident #1's record, dated 6/18/25, directed the residence to administer acetaminophen 500 mg three times daily. On 8/19/25 at 8:19 a.m., Staff #1 stated she did not believe OTC medications were required to include full names since they were supplied by residents. On 8/20/25 at approximately 9:00 a.m., the administrator stated all qualified medication administration persons (QMAPs) were trained and responsible for labeling OTC medications with resident first and last names. She further stated she was unaware why there were OTC medications that were not labeled as required. The administrator stated the deficiency had previously been corrected, and was unaware why it was not corrected the day of the onsite investigation. There was similar deficient practice related to failing to label OTC medications with residents' full names, for Resident #7 and #9.

Based on record reviews and interviews, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting one sample resident (#8) for whom the residence administers controlled substances. Findings include:1. Record ReviewResident #8 was admitted to the residence on 4/17/23 with a diagnosis of bipolar depression. A practitioner's order for Resident #8 dated 5/23/25, directed the residence to administer methadone 290 mg once daily. Review of the July and August 2025 controlled count record revealed qualified medication administration persons (QMAPs) failed to jointly sign documentation regarding the results of the count at the time it occurred, on 7/1-7/3, 7/7-7/11, 7/13-7/17, 7/20, 7/22-7/25 and 7/27-8/17/25. 2. InterviewsOn 8/19/25 at 1:00 p.m., Staff #1 stated she had forgotten to jointly sign documentation each time herself and another staff member counted Resident #8's methadone. On 8/20/25 at approximately 9:00 a.m., the administrator stated she expected qualified medication administration persons (QMAPs), to jointly count and sign documentation regarding the results of the count at the time it occurred as they were trained.

A relicensure survey was completed on 8/20/25. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with occurrence report requirements required by state law, affecting seven current residents. (Cross reference U1410)Findings include:Review of Resident #9's record revealed a written statement dated 5/28/25, which read that Resident #8 acted "belligerent, abusive in manners (and) raised (his) fists." The statement further read Resident #8 verbalized to Resident #9, "I am going to kill you." Resident #9 further wrote, "I am seeking immediate relief from such abuse ... this situation started on Friday morning of 9/1/23 when (Resident #8) first came up behind (Resident #9) with a knife in hand and dropped the knife accidentally and said ... you're on(e) lucky dude. Two more incidents practically identical occurred this year."A progress note in Resident #9's record, dated 5/28/25, read Resident #9 called law enforcement after an argument with Resident #8. Staff #1 reported to the administrator Resident #9's allegations. On 8/19/25 at 11:50 a.m., the AA stated she completed the investigation on 5/28/25. On 8/19/25 at 12:38 a.m., a department representative stated there were no occurrences reported related to the abuse allegation on 5/28/25, as required. On 8/20/25 at approximately 8:45 a.m., the assistant administrator (AA), stated an occurrence report should be completed whenever there was an allegation made of abuse. She further stated she had not reported an occurrence for the allegation of abuse on 5/28/25, since she believed because law enforcement was involved she was not required to report. On 8/20/25 at approximately 9:00 a.m., the administrator stated both herself and the AA were responsible for making occurrence reports, and stated a report should be made whenever there was an allegation of abuse. The administrator stated she did not think an occurrence report should have been made for the allegation on 5/28/25, since the resident's paranoid behavior was an "everyday occurrence." The administrator further stated Resident #9 had not made any allegations of abuse other than on 5/28/25. The administrator stated the requirement to report all allegations of abuse to the department must have "fell through the cracks."

Based on observation, record review, and interviews, the residence failed to have a quality management program (QMP) designed to improve client safety and well-being, affecting seven current residents. On 8/19/25 at 8:30 a.m., the residence's QMP was requested from the administrator. On 8/19/25 at 11:00 a.m., a binder labeled "QMP" was provided; however, all of the pages in it were blank. On 8/20/25 at approximately 9:00 a.m., the administrator stated there had not been any QMP projects completed this year. Contrary to the previous statement, the administrator stated she had implemented a project to change to electronic documents. The administrator further stated the QMP projects were not documented since she did not believe they needed to be since "everything had been addressed as it came up." On 8/20/25 at approximately 9:40 a.m., the assistant administrator stated the QMP was not implemented as required since she did not believe the administrator understood how to implement a QMP. She further stated the administrator was filling out the pages in the binder as she was speaking to the surveyor, in an attempt to correct the deficiency onsite. On 8/20/25 at 9:43 a.m., the administrator was observed filling out the QMP binder that was previously blank.

Based on interviews and record review, the residence failed to ensure that each staff member met the dementia training requirements in 7.9 (B), affecting seven current residents. Findings include:Personnel files for Staff #1 and #3-#5 provided by the administrator, revealed no evidence that each staff member had completed the initial four hour dementia training. Review of resident records revealed Resident #1 had a diagnosis of dementia. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware of the requirement for initial four hour dementia training; however, it had not yet been completed for Staff #1 and #3-#5.

Based on interviews and record review, the residence failed to ensure personnel files included the results of background checks and first aid and cardiopulmonary resuscitation (CPR) certifications for two of four sample staff members (#4, #5), affecting seven current residents. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 7.13, requires each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable;(E) Results of background checks and follow up, as applicable. 2. Record ReviewStaff #4 and #5's personnel files provided by the administrator on 8/19/25 at approximately 11:00 a.m., revealed they were hired on 9/22/21 and 9/26/21, respectively. However, the personnel files were missing the results of background checks and current CPR and first aid certifications. 3. InterviewsOn 8/20/25 at approximately 8:45 a.m., the assistant administrator (AA) stated Staff #4 and #5 provided care and services to residents when needed, and were also the owners. The AA stated she was unsure why the personnel files for Staff #4 and #5 did not contain results of background checks and current CPR and first aid certifications. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware of the requirement for personnel files to include results of background checks and CPR and first aid certifications; however, the documentation was misplaced when she had begun moving documents to upload electronically.

Based on observation, interview and record review, the residence failed to ensure there was at least one staff member on-site at all times who had current certification in first aid from a nationally recognized organization affecting seven current residents. Findings include:1. ObservationOn 8/19/25 from approximately 7:30 a.m. until 8:30 a.m., Staff #1 provided care and services to residents. No other direct care staff were present. 2. Record ReviewThe July 2025 staff schedule revealed Staff #1 and #3 were the only staff members that worked at the residence. Moreover, the August 2025 staff schedule revealed Staff #1 and #2 were the only staff members onsite as follows:Staff #1 worked 8:00 a.m. to 2:00 p.m. on 8/19 and 8/20/25, and 2:00 p.m. to 8:00 a.m. on 8/4-8/7 and 8/11-8/14, 8/18-8/20/25. Staff #2 worked 8:00 a.m. to 2:00 p.m. on 8/1, 8/2, 8/7-8/9, and 8/14-8/16/25. The personnel files for Staff #1 and #3, revealed their first aid certifications were not completed through a nationally recognized organization. 3. InterviewsOn 8/20/25 at 7:30 a.m., Staff #1 stated she resided at the residence, and was the only staff member onsite if another staff member was not scheduled to work. Staff #1 stated the certificates in the personnel files for herself and Staff #3 were the only current certifications they had. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware Staff #1 and #3's first certifications were not nationally recognized. The administrator stated Staff #1 and #3 were supposed to complete an in-person course that was nationally recognized; however, had not.

Based on observation, record reviews and interviews, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting seven current residents. Findings include:1. ObservationOn 8/19/25 from approximately 7:30 a.m. until 8:30 a.m., Staff #1 provided care and services to residents. No other direct care staff were present. 2. Record ReviewThe July 2025 staff schedule revealed Staff #1 and #3 were the only staff members that worked at the residence. Moreover, the August 2025 staff schedule revealed Staff #1 and #2 were the only staff members onsite as follows:Staff #1 worked 8:00 a.m. to 2:00 p.m. on 8/19 and 8/20/25, and 2:00 p.m. to 8:00 a.m. on 8/4-8/7 and 8/11-8/14, 8/18-8/20/25. Staff #2 worked 8:00 a.m. to 2:00 p.m. on 8/1, 8/2, 8/7-8/9, and 8/14-8/16/25. The personnel files for Staff #1 and #3, revealed their CPR certifications were not completed through a nationally recognized organization. 3. InterviewsOn 8/20/25 at 7:30 a.m., Staff #1 stated she resided at the residence, and was the only staff member onsite if another staff member was not scheduled to work. Staff #1 stated the certificates in the personnel files for herself and Staff #3 were the only current certifications they had. She further stated the CPR course herself and Staff #3 took, was completed online within a few hours and did not have an in-person skills component. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware Staff #1 and #3's CPR certifications were completed online through an organization that was not nationally recognized. The administrator stated Staff #1 and #3 were supposed to complete an in-person course; however, had not.

Based on record review and interview, the residence failed to have an visitation policy that complied with Section 25-27-104.3, C.R.S., affecting seven current residents. Findings include:On 8/19/25 at 8:30 a.m., the residence's visitation policy was requested and was not provided. On 8/19/25 at 1:20 p.m., the assistant administrator stated there was no visitation policy because the residence had fallen behind in ensuring they were up-to-date with regulatory policies. On 8/20/15 at approximately 9:00 a.m., the administrator acknowledged she was aware of the requirement for a visitation policy that met the requirements of Chapter VII, Regulation 9.2 (A-H).; however, stated the policy had not yet been created.

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting seven current residents. Findings include:On 8/19/25 at 8:30 a.m., the residence's involuntary discharge grievance policy was requested and was not provided. On 8/19/25 at 1:20 p.m., the assistant administrator stated there was no involuntary discharge grievance policy because the residence had fallen behind in ensuring they were up-to-date with regulatory policies. On 8/20/15 at approximately 9:00 a.m., the administrator acknowledged she was aware of the requirement for an involuntary discharge grievance policy that met the requirements of Chapter VII, Regulation 9.3 (A-I).; however, stated the policy had not yet been created.

Based on interview and record review, the residence failed to thoroughly investigate allegations of abuse or report alligations of abuse to the appropriate agencies in accordance with the residence's written policy, affecting seven current residents. (Cross reference U430)Findings include:1. Residence PolicyThe residence's undated Investigations of Abuse and Neglect Allegations policy, read in part that the residence was required to report allegations to the appropriate agencies such as adult protective services (APS) and a copy of the report will be retained by the facility and available for Department review. 2. Record Reviewa. Resident #9 was admitted to the residence on 6/1/23, with a diagnosis of paranoid personality disorder. Review of Resident #9's record revealed a written statement dated 5/28/25, which read that Resident #8 acted "belligerent, abusive in manners (and) raised (his) fists." The statement further read Resident #8 verbalized to Resident #9, "I am going to kill you." Resident #9 further wrote, "I am seeking immediate relief from such abuse ... this situation started on Friday morning of 9/1/23 when (Resident #8) first came up behind (Resident #9) with a knife in hand and dropped the knife accidentally and he said ... you're on(e) lucky dude. Two more incidents practically identical occurred this year."A progress note in Resident #9's record, dated 5/28/25, read Resident #9 called law enforcement after an argument with Resident #8. Staff #1 reported to the administrator Resident #9's allegations.b. Resident #8 was admitted to the residence on 4/17/23. A written statement in Resident #8's record, dated 5/28/25, read Resident #9 was in the residence kitchen going through his "things" and an argument ensued and they called each other names. Resident #8 wrote that he never had threatened to "kill" Resident #9. c. InvestigationOn 8/19/25 at 10:00 a.m., an investigation of the allegations of abuse made by Resident #9 on 5/28/25 were requested; however, was unable to be provided until after the investigation ended on 8/19/25, since it was not retained onsite for department review. On 8/20/25 the assistant administrator (AA) provided documentation of the investigation dated 5/28/25 which read in part: Resident #9 stated on 5/28/25, that the residence needed to "get rid" of Resident #8 since he came out of his room yelling and cursing, and said he was going to "kill" Resident #9. The practitioner and law enforcement were notified by Resident #9 prior to the investigation. Resident #9 and Resident #8 both made written statements that were part of the investigation. The investigation further read law enforcement was unable to make a report due to the conflicting statements from Resident #8 and #9. Both residents were verbally warned and informed if there was any more conflict, they would need to find alternate housing. Resident #9 was offered assistance finding placement at a new home or moving to a room on a separate level from Resident #8; however, he refused both offers. The investigation read that two hour monitoring would be put in place for each resident and they were directed to stay away from one another. However, there was no evidence in the investigation that the residence notified APS of the abuse allegations. 3. InterviewsOn 8/19/25 at 8:10 a.m., Resident #9 stated earlier in the year, Resident #8 had threatened to kill him, so he called law enforcement. Resident #9 stated he did not remember when the verbal incident occurred; however, did not want to be around Resident #8 and felt his statement was abusive. Resident #9 further stated a couple of years prior to the onsite investigation Resident #9 pulled out a knife and dropped it when in the kitchen, and told Resident #8 He was "one lucky guy." Resident #9 stated he had paranoia and a history of post traumatic stress, and was fearful of Resident #8; however, no other incidents had occurred after the threat earlier in the year, since both residents kept their distance from one another. On 8/19/25 at 11:50 a.m., the AA stated she completed the investigation on 5/28/25; however, the investigation was retained at her place of residence. The AA stated she would be unable to provide the investigation until the evening of 8/19/25, due to residing far away. On 8/20/25 at 8:43 a.m., the AA stated APS was not made aware of the allegation made on 5/28/25, since law enforcement did not make a report. She further stated law enforcement were the ones who notified APS of any alleged abuse. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware of the requirement for APS to be notified of all allegations of abuse and for there to be a copy of the investigation findings retained by the residence for review. The administrator acknowledged the copy of the investigation was not retained onsite and residence staff did not notify APS of the incident on 5/28/25, as required.

Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed for administration were labeled or marked with residents' full names, affecting three of five sample residents (#1, #7 and #9). Findings include:On 8/19/25 at 8:15 a.m., a medication cart audit revealed Acetaminophen 500 mg was not labeled with Resident #1's full name. A written practitioner's order in Resident #1's record, dated 6/18/25, directed the residence to administer acetaminophen 500 mg three times daily. On 8/19/25 at 8:19 a.m., Staff #1 stated she did not believe OTC medications were required to include full names since they were supplied by residents. On 8/20/25 at approximately 9:00 a.m., the administrator stated all qualified medication administration persons (QMAPs) were trained and responsible for labeling OTC medications with resident first and last names. She further stated she was unaware why there were OTC medications that were not labeled as required. There was similar deficient practice related to failing to label OTC medications with residents' full names, for Resident #7 and #9.

Based on record reviews and interviews, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting one sample resident (#8) for whom the residence administers controlled substances. Findings include:1. Record ReviewResident #8 was admitted to the residence on 4/17/23 with a diagnosis of bipolar depression. A practitioner's order for Resident #8 dated 5/23/25, directed the residence to administer methadone 290 mg once daily. Review of the July and August 2025 controlled count record revealed qualified medication administration persons (QMAPs) failed to jointly sign documentation regarding the results of the count at the time it occurred, on 7/1-7/3, 7/7-7/11, 7/13-7/17, 7/20, 7/22-7/25 and 7/27-8/17/25. 2. InterviewsOn 8/19/25 at 1:00 p.m., Staff #1 stated she had forgotten to jointly sign documentation each time herself and another staff member counted Resident #8's methadone. On 8/20/25 at approximately 9:00 a.m., the administrator stated she expected qualified medication administration persons (QMAPs), to jointly count and sign documentation regarding the results of the count at the time it occurred as they were trained.

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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident ' s condition changes from baseline status. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (H) Pre-pouring of medication18.3 Each assisted living residence shall implement a policy and procedure for an effective information management system that is either paper-based or electronic. If the ALR maintains both paper-based and electronic records, there shall be a method for integration of those records that allows effective continuity of care. Processes shall include effective management for capturing reporting, processing, storing and retrieving care/service data and information.

A recertification survey was completed on 8/20/25. A deficiency was cited.

Based on interviews and record review, the facility (residence) failed to maintain a personnel record for each employee that contained results of background checks for two of four sample staff members (#4, #5), affecting seven current members (residents). Findings include:1. Record ReviewStaff #4 and #5's personnel files provided by the administrator on 8/19/25 at approximately 11:00 a.m., revealed they were hired on 9/22/21 and 9/26/21, respectively. However, the personnel files were missing the results of background checks. 2. InterviewsOn 8/20/25 at approximately 8:45 a.m., the assistant administrator (AA) stated Staff #4 and #5 provided care and services to residents when needed, and were also the owners. The AA stated she was unsure why the personnel files for Staff #4 and #5 did not contain results of background checks. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware of the requirement for personnel files to include results of background checks; however, the documentation was misplaced when she had begun moving documents to upload electronically.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.7000.8.7506. C Alternative Care Facility Inclusions 1. Member Eligibilitya. Members enrolled in the HCBS Elderly, Blind and Disabled (EBD) and the HCBS Community Mental Health Supports (CMHS) Waivers to are eligible to receive services in an Alternative Care Facility.i. Potential Members shall be assessed, at a minimum, by a team that includes the Member and/or Guardian or other Legally Authorized Representative, the Alternative Care Facility administrator or appointed representative, and Case Management Agency Case Manager to determined that the Alternative Care Facility is an appropriate community setting that will meet the Member's choice and need for independence and community integration. If one of the parties listed above is not available, input or information must be obtained from each party prior to making an admission determination. The team may also include Family Members, Accountable Care Collaborative or Mental Health Center Case Managers, and any other interested parties as approved by the Member. 1) An assessment shall be conducted prior to admission, annually, whenever there is a significant change in physical, cognitive, or behavioral needs, or as requested by the Member. The annual assessment must be completed by the team described in Sections 8.7506. C.1.a.i.

A recertification survey with complaint revisit was completed on 8/20/25 for the previous deficiencies cited on 9/19/22. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event ONDM11 were cited prior to the regulation revision that was implemented 2/15/25.