4
Inspections
2
Deficiencies
0
Actual Harm or Above
0
Occurrences
February 12, 2024
Last Inspection
S/S B Minimal potential

The most recent inspection of ASSURED SENIOR LIVING 30 on record is dated February 12, 2024. Across 4 published inspections, state surveyors cited 2 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
Anderson, Lisa
Owner
L & M SERENITY LLC
Phone
(303) 814-2688
Payor Source
Private Pay
City
LAKEWOOD
ZIP
80215

Inspections & Citations

4 inspections · 2 deficiencies
2/12/2024Revisit: State Certification (Re-certification) · ID G2MT12No deficiencies
0000Initial CommentsSurveyor note
Findings
A revisit survey was completed on 2/12/24 for all previous deficiencies cited on 11/7/23. 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.
2/12/2024Revisit: CHOW and Licensure (Re-licensure) (Combined) · ID G6HO12No deficiencies
0000Initial CommentsSurveyor note
Findings
A revisit survey was completed on 2/12/24 for all previous deficiencies cited on 11/7/23. 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.
11/7/2023State Certification (Re-certification) · ID G2MT111 deficiency
0000Initial CommentsSurveyor note
Findings
A recertification survey was completed on 11/7/23. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0643Acf -Prov Role/Resp-Svc Req Engmt/ActS/S B
Findings
Based on record review and interview, the facility (residence) failed to encourage and assist participants' (residents') participation in engagement opportunities and activities within the community and the wider community, when appropriate, affecting all seven current residents. Findings include:1. Residence Policya. The residence's undated resident agreement read in part, the residence was integrated in and supported full access to the greater community.b. The residence's resident rights policy, dated 2023, read in part, the right to personal and community engagement including, and the right to participate in activities outside the assisted living residence. 2. Record ReviewMinutes from a resident council meeting under the heading of activities, dated 10/18/23, read in part that the residents requested outdoor drives. 3. ObservationOn 11/7/23, throughout the onsite visit, a large activity schedule for November 2023 was posted in the residence's common dining room. The schedule included no community-centered activities. 4. InterviewsOn 11/7/23 at 10:26 a.m., the administrator stated that the residence had offered no community-centered activities since 7/1/23. She stated the residence had two buses but they were unable to hire a driver with an acceptable driving record. On 11/7/23 at approximately 10:30 a.m., Resident #4 stated that the residence had not offered any community-centered activities since 7/1/23 because they did not have a driver. He stated the only community activity he did was to walk around the neighborhood approximately one-half mile from the residence. He stated he would participate in community activities (including shopping and eating in restaurants) if the residence scheduled it. On 11/7/23 at 11:45 a.m., Resident #1 stated that the residence did not offer going out into the community but if they did she would love to go for a drive in the mountains. On 11/7/23 at 11:45 a.m., Resident #2 stated that the residence did not offer going out into the community because there was no bus driver or transportation, but if they did she would love to go out into the community. On 11/7/23 at 11:45 a.m., Resident #3 stated that the residence did not offer going out into the community but if they did, she would like to go out to eat, shop, or for a ride in the mountains. On 11/7/23 at 11:45 a.m., Resident #5 stated he tended to stay on or near the residence's property, adding that he did not recall when the last community-centered event was offered to the residents.
Plan of correction · submitted by the facility
Tag 0643; Reg Set ID ACFQ1. Starting December 2023, public service endeavors, community events (such as concerts, exhibits, and plays) and community organized group engagement (such as senior citizen groups, sports leagues, and service clubs) and attendance at the place of worship of the residents’ choice will be included on monthly activity calendars for residents to attend. Transportation options will also be listed on the activities calendar for residents to reference to make arrangements independently or with the assistance of family or staff. 2. This will be reviewed and monitored by the ED monthly upon approving printing of monthly calendar. 3. This will be monitored on the monthly calendar for 2 months. 4. Correction Statement:The activities calendar will list local, community centered activities available for residents to enjoy outside of their home. 5. Examples of types of activities included on calendar:(Activities calendar attached)Church Sundays:Glory of God Lutheran Church- 12200 W. 38th Ave. Our Lady Of Fatima Catholic Church- 10530 W. 20th Ave. Fairmount Bible Church-15100 W 48th AveGlory of God Lutheran Church- 12200 W. 38th Ave. Lunch Suggestions:Go to the Olive GardenGo to Wild Basil Thai for lunchGo to McDonald's for LunchGo Amici's Italian RestaurantGo to Wendy's for lunchGo to Applebee's for lunchCommunity activities:Go to WalmartGo to Regal Cinemas for a movieGo to Belmar Shopping CenterGo to Bear Creek Plaza ShoppingCenter-3234 S. WadsworthGo to Shop @ Edgewater Public MarketGo to the Alamo Draft HouseCinema-4255 W. Colfax Ave
11/7/2023CHOW and Licensure (Re-licensure) (Combined) · ID G6HO111 deficiency
0000Initial CommentsSurveyor note
Findings
A relicensure survey was completed on 11/7/23. A deficiency was cited. A change of ownership occurred on 8/3/23.
Plan of correction
The state did not require a plan of correction for this citation.
1222Res Care Srvs-Res Enggmnt Crd w/Local/OrgsS/S B
Findings
Based on record review and interview, the residence failed to coordinate with local agencies and organizations to promote participation in community centered activities affecting seven current residents. Findings include:1. Residence Policya. The residence's undated resident agreement read in part, the residence was integrated in and supported full access to the greater community.b. The residence's resident rights policy, dated 2023, read in part, the right to personal and community engagement including, and the right to participate in activities outside the assisted living residence. 2. Record ReviewMinutes from a resident council meeting under the heading of activities, dated 10/18/23, read in part that the residents requested outdoor drives. 3. ObservationOn 11/7/23, throughout the onsite visit, a large activity schedule for November 2023 was posted in the residence's common dining room. The schedule included no community-centered activities. 4. InterviewsOn 11/7/23 at 10:26 a.m., the administrator stated that the residence had offered no community-centered activities since 7/1/23. She stated the residence had two buses but they were unable to hire a driver with an acceptable driving record. On 11/7/23 at approximately 10:30 a.m., Resident #4 stated that the residence had not offered any community-centered activities since 7/1/23 because they did not have a driver. He stated the only community activity he did was to walk around the neighborhood approximately one-half mile from the residence. He stated he would participate in community activities (including shopping and eating in restaurants) if the residence scheduled it. On 11/7/23 at 11:45 a.m., Resident #1 stated that the residence did not offer going out into the community but if they did she would love to go for a drive in the mountains. On 11/7/23 at 11:45 a.m., Resident #2 stated that the residence did not offer going out into the community because there was no bus driver or transportation, but if they did she would love to go out into the community. On 11/7/23 at 11:45 a.m., Resident #3 stated that the residence did not offer going out into the community but if they did, she would like to go out to eat, shop, or for a ride in the mountains. On 11/7/23 at 11:45 a.m., Resident #5 stated he tended to stay on or near the residence's property, adding that he did not recall when the last community-centered event was offered to the residents.
Plan of correction · submitted by the facility
Tag 1222; Reg Set ID OONO1. Activities Director and ED will continue to collaborate with volunteers, local agencies and organizations. Starting December 2023, public service endeavors, community events (such as concerts, exhibits, and plays) and community organized group engagement (such as senior citizen groups, sports leagues, and service clubs) and attendance at the place of worship of the residents’ choice will be included on monthly activity calendars for residents to attend. Transportation options will also be listed on the activities calendar for residents to reference to make arrangements independently or with the assistance of family or staff. 2. This will be reviewed and monitored by the ED monthly upon approving printing of monthly calendar. 3. This will be monitored on the monthly calendar for 2 months. 4. Correction Statement:The activities calendar will list local, community centered activities available for residents to enjoy outside of their home. 5. Examples of types of activities included on calendar:(Activities calendar attached)Church Sundays:Glory of God Lutheran Church- 12200 W. 38th Ave. Our Lady Of Fatima Catholic Church- 10530 W. 20th Ave. Fairmount Bible Church-15100 W 48th AveGlory of God Lutheran Church- 12200 W. 38th Ave. Lunch Suggestions:Go to the Olive GardenGo to Wild Basil Thai for lunchGo to McDonald's for LunchGo Amici's Italian RestaurantGo to Wendy's for lunchGo to Applebee's for lunchCommunity activities:Go to WalmartGo to Regal Cinemas for a movieGo to Belmar Shopping CenterGo to Bear Creek Plaza ShoppingCenter-3234 S. WadsworthGo to Shop @ Edgewater Public MarketGo to the Alamo Draft HouseCinema-4255 W. Colfax Ave
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 7.22.4 Designated areas where smoking is allowed shall be equipped with fire resistant wastebaskets. Resident rooms occupied by smokers, even when house rules prohibit smoking in resident rooms, shall have fire resistant wastebaskets. 22.30 The assisted living residence shall prohibit smoking in areas where oxygen is stored and/or used and shall post a conspicuous "No Smoking" sign in those areas.
Plan of correction
The state did not require a plan of correction for this citation.

Reportable Occurrences

0 records
No reportable occurrences
The state has not published occurrence summaries for this facility.