ASPEN CARES ASSISTED LIVING LLC

A revisit survey was completed on 5/8/26 for all previous deficiencies cited on 3/26/26. The facility is in compliance with all deficiencies that were cited.

An administrative relicensure survey was completed on 3/26/26. Deficiencies were cited.

Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 12 current residents. Findings include:On 3/19/26 at 12:14 p.m., a 72-hour Continuation of Care policy and procedure was requested; however, the residence did not have one included in their emergency policies. On 3/26/26 at approximately 11:10 a.m., the administrator stated he was not aware of the regulation to have a 72-hour plan included in the residence's emergency policies. He acknowledged the need for the plan to be in place.

Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 12 current residents. Findings include:On 3/19/26 at approximately 12:15 p.m., the residence's emergency plan was requested. The residences emergency plan failed to include the following: A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids. On 3/26/26 at approximately 11:10 a.m., the administrator confirmed the emergency plan failed to include all required elements, and acknowledged the need to have them in place.

A revisit survey was completed on 1/28/25 for all previous deficiencies cited on 9/26/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 1/28/25 for all previous deficiencies cited on 9/26/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 1/28/25 for all previous deficiencies cited on 9/26/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 1/28/25 for all previous deficiencies cited on 9/26/24. The facility is in compliance with all deficiencies that were cited.

A relicensure survey was completed on 9/26/24. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data System (CAPS) requirements prior to hiring staff who provided care to the residents, for two of three sample staff (#1, house manager) affecting 12 current residents. Findings include:On 9/26/24 at 8:30 a.m., the personnel files including a Colorado Adult Protective Service Data System (CAPS) request for Staff #2 and the house manager were requested; however, no records were provided. b. Face sheets for Residents #1, #3, and #6 revealed their ages were as follows as of the date of the onsite visit: Resident #1 was 69 years old. Resident #3 was 39 years old. Resident #6 was 32 years old. 2. InterviewOn 9/26/24 at approximately 2:00 p.m., the owner stated he was aware of the requirement for a CAPS check to be conducted prior to the hire of a prospective employee. The owner stated Staff #2 and the house manager were hired under the previous owner and he was unaware the residence had no staff files for them, including a CAPS request.

ased on record review and interview, the residence failed to request, prior to hire, a name-based criminal history record check conducted through the Colorado Bureau of investigation (CBI) for each prospective staff member for two of three sample staff (#2, house manager) affecting 12 current residents. On 9/26/24 at 8:30 a.m., the personnel files including a name-based criminal history record check through the CBI for Staff #2 and the house manager were requested; however, no records were provided. On 9/26/24 at approximately 2:00 p.m., the owner stated he was aware of the requirement for the residence to complete a background check through the CBI prior to the hire of a prospective employee. The owner stated Staff #2 and the house manager were hired under the former administrator designee and owner and he was unaware the residence had no staff files including a name based criminal history record check. The owner stated he is unaware why the deficiency had not been corrected.

Based on record review and interview, the residence failed to ensure personnel files included documentation of training and orientation for two of three staff (#2 house manager), affecting 12 current residents. Findings include:On 9/26/24 at 8:30 a.m., the personnel files including documentation of staff orientation and training for Staff #2 and the house manager were requested; however, no records were provided. On 9/26/24 at approximately 2:00 p.m., The owner stated Staff #2 and the house manager were hired under the former owner and he was unaware the residence had no staff file including documentation of staff orientation and training.

Based on record review and interview, the residence failed to ensure there was 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 12 current residents. Findings include:Documented CPR certification for Staff #2 and the house manager revealed expiration date of 4/30/24. The staff schedule from 9/1/24 to 9/31/24 revealed the residence failed to ensure the following shifts had a staff member on site with current certification in CPR as follows:Staff #2 worked 7:00 a.m. to 10:00 p.m., on 9/22, 9/27, 9/29, and 10/4/24. Staff #2 worked from 5:00 p.m. to 10:00 p.m., on 9/23, 9/24, 9/30, 10/1/24. The house manager was scheduled for every night shift from 10:00 p.m. to 7:00 a.m. for the entire month of September 2024. On 9/26/24 at approximately 2:00 p.m., the owner stated he was unaware that Staff #2 and the house manager did not have current CPR certification from a nationally recognized organization. The administrator said he expected all staff to have current and valid CPR certifications.

Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 12 current residents. Findings include:On 10/1/24 at approximately 8:00 a.m., the residence's involuntary discharge grievance policy was requested but not provided. On 10/1/24 at 12:30 a.m., the administrator stated he was unaware of the regulation updated 1/1/24 requiring the residence to develop and implement an involuntary discharge grievance policy.

Based on record review and interview, the residence failed to have readily available a roster of current residents along with a residence diagram showing room locations and the emergency contacts for each resident, affecting 12 current residents. Findings include:On 9/26/24 at 7:30 a.m., the residence's resident roster for emergency preparedness was requested. On 9/26/24 at 7:54 a.m., the residence's resident roster was provided. However, the resident roster did not include Resident #10's personal information including the resident's name, room number and emergency contact. The resident roster also failed to include a diagram of the residence that showed room locations or the emergency contact information for each resident. On 9/26/24 at approximately 2:00 p.m., the administrator stated that he did not update the resident roster because he was unaware it was out of date. He stated Resident #10 was admitted right when he took over and assumed the house manager updated the roster. The administrator stated he was unaware as to why the deficiency had not been corrected since the last survey.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting two of three sample residents (#1 and #6). Findings include:1. Resident #6 was admitted to the residence on 9/15/24. A written practitioner's order, dated 1/31/24, directed the residence to administer quetiapine fumarate 200 mg nightly. However, the September 2024 medication administration record (MAR) read that the residence failed to administer the medication from 9/19/24-9/26/24 for a total of seven missed doses due to the medication being removed from the MAR. 2. InterviewsOn 9/26/24 at 7:31 a.m., Resident #6 stated the residence had not administered quetiapine fumarate since 9/19/24. She stated the house manager told her the medication was removed from the MAR and he was unable to administer the medication to her. Resident #6 stated she had an increase in irritability and was unsure why the staff removed the medication from the MAR.On 9/26/24 at 2:12 p.m., the administrator said the medication had been duplicated on the MAR and in an attempt to correct this error, the pharmacy removed the medication from the MAR. The administrator confirmed staff had not administered the medication since 9/19/24. He stated he expected medications to be administered to the residents as ordered by their practitioners. 3. Record review and interview revealed similar deficient practice for Resident #1.

Based on interview and record review the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting 12 current residents. Findings include:On 9/26/24 at 8:30 a.m. the last two quarterly medication audits were requested from the administrator. However, no documentation was provided. On 9/26/24 at approximately 2:00 p.m., the owner stated he was unaware of the requirement to perform and document quarterly medication administration audits. He stated he had no documentation that medication audits were completed from the former administrator. He stated he was unaware why the deficiency had not been corrected since the previous survey.

A recertification survey was completed on 9/26/24. Deficiencies were cited.

Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting 12 current members (residents). Findings include:1. Chapter VII regulations governing assisted living residents part 14.21, requires the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. a. Resident #6 was admitted to the residence on 9/15/24. A written practitioner's order, dated 1/31/24, directed the residence to administer quetiapine fumarate 200 mg nightly. However, the September 2024 medication administration record (MAR) read that the residence failed to administer the medication from 9/19/24-9/26/24 for a total of seven missed doses due to the medication being removed from the MAR. b. InterviewsOn 9/26/24 at 7:31 a.m., Resident #6 stated the residence had not administered quetiapine fumarate since 9/19/24. She stated the house manager told her the medication was removed from the MAR and he was unable to administer the medication to her. Resident #6 stated she had an increase in irritability and was unsure why the staff removed the medication from the MAR.On 9/26/24 at 2:12 p.m., the administrator said the medication had been duplicated on the MAR and in an attempt to correct this error, the pharmacy removed the medication from the MAR. The administrator confirmed staff had not administered the medication since 9/19/24. He stated he expected medications to be administered to the residents as ordered by their practitioners.c. Record Review and interview revealed similar deficient practice for Resident #1.2. Chapter VII regulations governing assisted living residents part 14.31, requires the assisted living residence to be responsible for The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence ' s Quality Management Program assessment and review. On 9/26/24 at 8:30 a.m. the last two quarterly medication audits were requested from the administrator. However, no documentation was provided. On 9/26/24 at approximately 2:00 p.m., the owner stated he was unaware of the requirement to perform and document quarterly medication administration audits. He stated he had no documentation that medication audits were completed from the former administrator. He stated he was unaware why the deficiency had not been corrected since the previous survey.

Based on record review, observation, and interview, the facility (residence) failed to ensure there was at least one staff member for every 10 participants (residents) during the daytime hours, affecting 12 current participants. Findings include:1. Record ReviewOn 9/26/24, a review of the department's database revealed the residence had not requested any staffing waivers. A resident roster, provided by the administrator and dated September 2024, read the residence had 12 current residents. The September 2024 staff schedule revealed only one staff member worked from 6:00 a.m. to 6:00 p.m. 3. InterviewOn 9/26/24 at approximately 2:30 p.m., the owner stated when he took over the business, the residence scheduled only one staff member during the day, which was sufficient. He stated that he had every intent on having the correct staffing ratios. The owner added that most of the residents had a low acuity of care.

A licensure revisit was completed on 9/26/24 for all previous deficiencies cited on 10/12/22 . Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on record review and interview, the residence failed to request, prior to hire, a name-based criminal history record check conducted through the Colorado Bureau of investigation (CBI) for each prospective staff member for two of three sample staff (#2, house manager) affecting 12 current residents. This deficiency was cited previously during a state licensure survey on 10/12/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. 1. Record ReviewOn 9/26/24 at 8:30 a.m., the personnel files including a name-based criminal history record check through the CBI for Staff #2 and the house manager were requested; however, no records were provided. 2. InterviewOn 9/26/24 at approximately 2:00 p.m., the owner stated he was aware of the requirement for the residence to complete a background check through the CBI prior to the hire of a prospective employee. The owner stated Staff #2 and the house manager were hired under the former owner and he was unaware the residence had no staff files including a name based criminal history record check. The owner stated he is unaware why the deficiency had not been corrected.

Based on record review and interview, the residence failed to have readily available a roster of current residents along with a residence diagram showing room locations and the emergency contacts for each resident, affecting 12 current residents. This deficiency was cited previously during a state licensure survey on 10/12/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 9/26/24 at 7:30 a.m., the residence's resident roster for emergency preparedness was requested. On 9/26/24 at 7:54 a.m., the residence's resident roster was provided. However, the resident roster did not include Resident #10's personal information including the resident's name, room number and emergency contact. The resident roster also failed to include a diagram of the residence that showed room locations or the emergency contact information for each resident. On 9/26/24 at approximately 2:00 p.m., the administrator stated that he did not update the resident roster because he was unaware it was out of date. He stated Resident #10 was admitted right when he took over and assumed the house manager updated the roster. The administrator stated he was unaware as to why the deficiency had not been corrected since the last survey.

Based on interview and record review the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting 12 current residents. This deficiency was cited previously during a state licensure survey on 10/12/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 9/26/24 at 8:30 a.m. the last two quarterly medication audits were requested from the administrator. However, no documentation was provided. On 9/26/24 at approximately 2:00 p.m., the owner stated he was unaware of the requirement to perform and document quarterly medication administration audits. He stated he had no documentation that medication audits were completed from the former administrator. He stated he was unaware why the deficiency had not been corrected since the previous survey.

A recertification revisit was completed on 9/26/24 for the previous deficiency cited on 10/12/22. A deficiency was cited. The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 11/15/23.

Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting 12 current members (residents). This deficiency was cited previously during a state licensure survey on 10/12/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residents part 14.21, requires the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. a. Resident #6 was admitted to the residence on 9/15/24. A written practitioner's order, dated 1/31/24, directed the residence to administer quetiapine fumarate 200 mg nightly. However, the September 2024 medication administration record (MAR) read that the residence failed to administer the medication from 9/19/24-9/26/24 for a total of seven missed doses due to the medication being removed from the MAR. b. InterviewsOn 9/26/24 at 7:31 a.m., Resident #6 stated the residence had not administered quetiapine fumarate since 9/19/24. She stated the house manager told her the medication was removed from the MAR and he was unable to administer the medication to her. Resident #6 stated she had an increase in irritability and was unsure why the staff removed the medication from the MAR.On 9/26/24 at 2:12 p.m., the administrator said the medication had been duplicated on the MAR and in an attempt to correct this error, the pharmacy removed the medication from the MAR. The administrator confirmed staff had not administered the medication since 9/19/24. He stated he expected medications to be administered to the residents as ordered by their practitioners.c. Record Review and interview revealed similar deficient practice for Resident #1.2. Chapter VII regulations governing assisted living residents part 14.31, requires the assisted living residence to be responsible for The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence ' s Quality Management Program assessment and review. On 9/26/24 at 8:30 a.m. the last two quarterly medication audits were requested from the administrator. However, no documentation was provided. On 9/26/24 at approximately 2:00 p.m., the owner stated he was unaware of the requirement to perform and document quarterly medication administration audits. He stated he had no documentation that medication audits were completed from the former administrator. He stated he was unaware why the deficiency had not been corrected since the previous survey.