15
Inspections
26
Deficiencies
0
Actual Harm or Above
0
Occurrences
July 2, 2026
Last Inspection
S/S B Minimal potential
The most recent inspection of GOSHEN ASSISTED LIVING LLC on record is dated July 2, 2026. Across 15 published inspections, state surveyors cited 26 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Assisted Living Residence/Alternative Care Facility (Medicaid)
Administrator
ELSELL, ROJAI
Owner
GOSHEN ASSISTED LIVING LLC
Phone
(303) 810-8197
Payor Source
Medicaid, Private Pay
City
AURORA
ZIP
80012
Inspections & Citations
15 inspections · 26 deficiencies7/2/2026Revisit: Licensure Complaint · ID 1YW312No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 7/2/26 for all previous deficiencies cited on 4/22/26. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
7/2/2026Revisit: Licensure Complaint · ID 2MXY12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 7/2/26 for all previous deficiencies cited on 4/22/26. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
4/22/2026Licensure Complaint · ID 1YW3111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO41160 was completed on 4/22/26. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0910PA Req-Room/Board▼
Findings
Based on observation, record review, and interview, the facility (residence) failed to ensure room and board included basic toiletries, affecting eleven current members (residents). Findings include:1. Record ReviewRecord review of the resident agreement revealed the residence agreed to provide a safe and sanitary environment, room and board, personal services, protective oversight, and social care. 2. ObservationOn 4/22/26 at approximately 9:00 a.m., paper towels were not available for use in the common area bathroom located on the first floor, on the left side of the hallway between three bedrooms. The bathroom was in a shared area of the residence and was accessible to residents using the common areas. The bathroom also served as the primary shower bathroom for four of eleven residents. Paper towels were not available in the bathroom at the time of observation. The residence had three resident-accessible bathrooms: two bathrooms on the first floor and one bathroom in the basement. The second first-floor bathroom was located inside the main bedroom, and no concerns were observed in that bathroom. No concerns were observed in the basement bathroom. On 4/22/26 at approximately 10:00 a.m., staff placed a new paper towel roll in the dispenser; however, the dispenser did not function properly and did not dispense paper towels. On 4/22/26 at approximately 2:00 p.m., the surveyor observed the common bathroom again did not have accessible paper towels or a functioning hand drying device available for resident use. 3. InterviewOn 4/22/26 at 3:38 p.m., Staff #1 stated a part was missing from the paper towel dispenser, which prevented the paper towels from dispensing properly, therefore the residence did not have paper towels in the bathroom. On 4/22/26 at 2:00 p.m. the Administrator stated the hallway bathroom was used by residents in the common areas, staff, visitors and by residents assigned to nearby bedrooms. On 4/22/26 at 10:00 a.m. Resident #2 stated he uses the common bathroom daily.
Plan of correction · submitted by the facility
Response to POC Tag # 0910Issue Identified:The paper towel dispenser was properly loaded and functioning as intended for resident use. During use, a resident pulled excessively hard on the paper towel, causing the paper towel roll to become tilted and disconnected from the mounting bracket. Corrective Action:A house meeting was conducted with all residents and staff to review the incident and discuss the proper use of the automatic paper towel dispenser. Residents were instructed not to pull forcefully on the paper towels and to allow the dispenser to operate through its automatic dispensing function. In addition, staff training was conducted to ensure employees routinely inspect all paper towel dispensers to verify they are properly loaded, securely mounted, and functioning correctly. Monitoring Plan:Staff will monitor all paper towel dispensers and toilet paper dispensers to ensure they are properly stocked, securely installed, and functioning appropriately. These items will be reviewed during daily and weekly staff meetings. Addendum to the Monitoring Plan:A line item was added to the cleaning schedule requiring staff to verify that all dispensers are properly loaded and functioning during each bathroom cleaning. Monitoring will occur each time bathrooms are cleaned and restocked with appropriate supplies. Compliance checks will be performed daily, and findings will be reviewed and documented by the administrator during weekly staff meetings. Monitoring began immediately following the survey conducted on April 22 and will continue as part of the facility’s ongoing daily, weekly, and monthly cleaning and staff training processes.
4/22/2026Licensure Complaint · ID 2MXY111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO41158 was completed on 4/22/26. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
2680In Env-BR TP dspnsrS/S B▼
Findings
Based on observation and interview, the residence failed to ensure paper towels or hand drying devices were available at all times in the common bathroom affecting 11 current residents. 1. Record ReviewRecord review of the resident agreement revealed the residence (facility) agreed to provide a safe and sanitary environment, room and board, personal services, protective oversight, and social care. 2. ObservationOn 4/22/26 at approximately 9:00 a.m., paper towels were not available for use in the common area bathroom located on the first floor, on the left side of the hallway between three bedrooms. The bathroom was in a shared area of the residence and was accessible to residents using the common areas. The bathroom also served as the primary shower bathroom for four of eleven residents. Paper towels were not available in the bathroom at the time of observation. The residence had three resident-accessible bathrooms: two bathrooms on the first floor and one bathroom in the basement. The first floor bathroom near the common area did not have paper towels. On 4/22/26 at approximately 10:00 a.m., staff placed a new paper towel roll in the dispenser; however, the dispenser did not function properly and did not dispense paper towels. On 4/22/26 at approximately 2:00 p.m., the surveyor observed the common bathroom again did not have accessible paper towels or a functioning hand drying device available for resident use. 3. InterviewOn 4/22/26 at 3:38 p.m., Staff #1 stated a part was missing from the paper towel dispenser, which prevented the paper towels from dispensing properly, therefore the residence did not have paper towels in the bathroom. On 4/22/26 at 2:00 p.m. the administrator stated the hallway bathroom was used by residents in the common areas, staff, visitors and by residents assigned to nearby bedrooms. On 4/22/26 at 10:00 a.m. Resident #2 stated he uses the common bathroom daily.
Plan of correction · submitted by the facility
Response to POC Tag # 2680Issue Identified:The paper towel dispenser was properly loaded and functioning as intended for resident use. During use, a resident pulled excessively hard on the paper towel, causing the paper towel roll to become tilted and disconnected from the mounting bracket. Corrective Action:A house meeting was conducted with all residents and staff to review the incident and discuss the proper use of the automatic paper towel dispenser. Residents were instructed not to pull forcefully on the paper towels and to allow the dispenser to operate through its automatic dispensing function. In addition, staff training was conducted to ensure employees routinely inspect all paper towel dispensers to verify they are properly loaded, securely mounted, and functioning correctly. Monitoring Plan:Staff will monitor all paper towel dispensers and toilet paper dispensers to ensure they are properly stocked, securely installed, and functioning appropriately. These items will be reviewed during daily and weekly staff meetings. Addendum to the Monitoring Plan:A line item was added to the cleaning schedule requiring staff to verify that all dispensers are properly loaded and functioning during each bathroom cleaning. Monitoring will occur each time bathrooms are cleaned and restocked with appropriate supplies. Compliance checks will be performed daily, and findings will be reviewed and documented by the administrator during weekly staff meetings. Monitoring began immediately following the survey conducted on April 22 and will continue as part of the facility’s ongoing daily, weekly, and monthly cleaning and staff training processes.
12/15/2025Revisit: State Certification and State Certification Complaint (Combined) · ID MIGZ12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/15/25 for all previous deficiencies cited on 8/7/25. 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.
12/15/2025Revisit: Licensure and Licensure Complaint (Combined) · ID TNGP12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/15/25 for all previous deficiencies cited on 8/7/25. 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.
8/7/2025State Certification and State Certification Complaint (Combined) · ID MIGZ114 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey with complaint #CO40323 was completed on 8/7/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0792PA Req-P/P-Med Admin▼
Findings
Based on observation and interview, the facility (residence) failed to store medications under proper conditions, affecting one of one sample member (resident) on refrigerated medications (#2). Findings include:1. ObservationsOn 8/7/25 at 8:07 a.m., an environmental tour revealed a "staff only" sign was on a door that led to the garage where there was a refrigerator filled with food which was also the medication refrigerator. The refrigerated medications included as follows:A box of Lantus 100 unit injectionsA box of risperidone 200 mg injectionsA clear bag with a single dose of Humulog 100 unit and Lantus 100 unit injections. However, the clear bag was not labeled with the resident's name or prescribing information. 2. InterviewsOn 8/7/25 at 8:07 a.m., the administrator stated Resident #2 was the only resident on refrigerated medications. The administrator further stated that food was also stored in the refrigerator that was used by staff to make resident meals. On 8/7/25 at approximately 1:30 p.m., the administrator stated he believed that refrigerated medications could be stored with food as long as they were not accessible to residents. The administrator further stated the medications in the plastic bag belonged in the boxes of injectable medication that had the prescribing information and resident name. On 8/7/25 at 2:00 p.m., Staff #1 stated Resident #2's refrigerated medications had been stored with food since he was admitted to the residence in June of 2024.
Plan of correction · submitted by the facility
Response to POC Tag # 0792We acknowledge the deficiency. Historically a secure medication box was in place and was being used until one of the staff members changed the code and locked the box and could not open it again. Corrective Action: a new and secure medication lock box has been put in place for refrigerated medications storage. Monitoring plan: review the med storage policy with the staff during the weekly staff meeting. Addendum to the Monitoring Plan: Added a line item / note to the MAR (Medication Administration Record) for all refrigerated medication must be stored in a secure box and isolated from the food and will be checked during the daily medication administration.monitoring will be conducted when each refrigerated meds are administered by the QMAP and recorded in the MAR. This will be checked daily and documented by the administrator during the weekly staff meeting. Monitoring started after the survey was conducted on August 7th and will continue as part of the MAR daily, weekly and monthly reconciliation process and QAPI process.
1710Ben/Svc Req-ACF-Inclusions▼
Findings
Based on interviews and record review, the facility (residence) failed to ensure an assessment was conducted prior to admission and at least annually, and documented the member (resident's) behavioral and social needs, affecting three of three residents who had a history of behaviors (#1-#3). (Cross reference B1770)Findings include:1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). An intake assessment dated 6/15/24, which was the residence's pre-admission assessment, was completed by the assistant administrator. The intake assessment read the resident was an elopement risk. An admission assessment dated 6/15/24, read on a scale of one to ten, the resident rated a four in combativeness toward others, and a five in wandering. However, there was no evidence the assessments addressed Resident #2's physical, behavioral or social needs. Moreover, there were no other assessments in the resident's record. On 8/7/25 at 7:50 a.m., Resident #2 stated approximately two days prior to the onsite investigation, he had left the residence and was unable to find his way back. Resident #3 stated "strangers" took him back to the residence. On 8/7/25 at 8:07 a.m., the administrator stated that Resident #2 would elope from the residence and be unable to find his way back home, and would also frequently refuse his medications. He further stated Resident #2 had engaged in a previous verbal altercation with Resident #5 and felt the residence was unable to meet his needs. On 8/7/25 at approximately 1:01 p.m., the administrator, who was also the administrator at Resident #2's former residence, stated Resident #2 was discharged from the residence since he had engaged in verbal altercations with other residents, wandered out of the residence and was unable to find his way back home, and was "out of control." The administrator stated he felt the resident required a secure environment. On 8/7/25 at approximately 1:30 p.m., acknowledged the residence's assessments did not include all the requirements. 2. Additionally, the residence failed to ensure a comprehensive pre-admission assessment was completed to include information on resident physical, behavioral and social needs for Residents #1 and #3.
Plan of correction · submitted by the facility
Response to POC 1710We acknowledge the deficiency..An assessment was conducted and placed in resident #2 folder. however, this resident has been refusing medications and any additional assessments or treatments. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. Also, this resident has major drinking and drugs problems that will affect his behavior and the facility have not been able to transfer this resident to an alternative facility. Corrective Action: all records for resident #1, #2 and #3 were reviewed for completeness and proper location. Monitoring plan:all residence supporting documents have been reviewed and will be reviewed with the staff during the weekly staff meeting. Addendum to the Monitoring Plan: A checklist and an interval schedule has been developed for all/each resident to: re-create, review, ensure and sign off on all required documents: Assessment prior to admission for behavioral and social needs. Annually schedule, conduct and document the re-assessment and care plan for behavioral, social needs and daily living. All residence records, supporting documents have been reviewed and will be scheduled to be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of residents requiring a re-assessment and signed off by the administrator during the weekly staff meeting. Monitoring and corrective action started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly audit process and QAPI process.
1770Ben/Svc Req-ACF-PA-PCSP▼
Findings
Based on interview and record review, the facility (residence) failed to ensure that each resident care plan included special health or behavioral management needs that support the member (resident) affecting affecting three of four sample residents (#1-#3). (Cross reference B1710)Findings include:1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). An intake assessment dated 6/15/24, completed by the assistant administrator (AA). The intake assessment read the resident was an elopement risk. An admission assessment dated 6/15/24, completed by the AA, The assessment read on a scale of one to ten, the resident rated a four in combativeness toward others, and a five in wandering. However, the most recent care plan dated 6/15/24, did not include any behavioral interventions related to the resident's combative behavior and elopement risk. On 8/7/25 at 7:50 a.m., Resident #2 stated approximately two days prior to the onsite investigation, he had left the residence and was unable to find his way back. Resident #3 stated "strangers" took him back to the residence. On 8/7/25 at 8:07 a.m., the administrator stated that Resident #2 would elope from the residence and be unable to find his way back home, and would also frequently refuse his medications. He further stated Resident #2 had engaged in a previous verbal altercation with Resident #5. On 8/7/25 at 8:39 a.m., Resident #5 stated Resident #2 yelled expletives toward him "a lot," with a more severe expletive verbalized two weeks prior to the onsite investigation. On 8/7/25 at 12:29 p.m., Staff #1 stated Resident #2 engaged in verbal altercations with other residents and would leave the residence without telling staff where he was going. Staff #1 stated Resident #2 yelled at Resident #5 on 7/30/25. Staff #1 further stated there were no behavioral interventions in place in the residence's care plan. On 8/7/25 at approximately 1:30 p.m., the administrator acknowledged Resident #2 had behaviors that required staff intervention. The administrator stated he was aware of the requirement for care plans to include specific personal services needs and staff tasks necessary to meet those needs; however, he was unaware the care plan did not include that information. 2. There was similar deficient practice for Residents #1 and #3.
Plan of correction · submitted by the facility
Response to POC 1770We acknowledge the deficiency. An assessment was conducted and placed in resident #2 folder. however, this resident has been refusing medications and any additional assessments or treatments. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. Also, this resident has major drinking and drugs problems that will affect his behavior and the facility have not been able to transfer this resident to an alternative facility. Corrective Action: all records for resident #1, #2 and #3 were reviewed for completeness and proper location. Addendum to the Monitoring Plan:A checklist and an interval schedule has been developed for all/each resident to: re-create, review, ensure and sign off on all required documents: Assessment prior to admission for behavioral and social needs. Annually schedule, conduct and document the re-assessment and care plan for behavioral, social needs and daily living. All residence records, supporting documents have been reviewed and will be scheduled to be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of residents requiring a re-assessment and signed off by the administrator during the weekly staff meeting. Monitoring and corrective action started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly audit process and QAPI process.
1780Ben/Svc Req-ACF-PA-Env Standards▼
Findings
Based on observations, record review and interview, the facility (residence) failed to maintain a home-like quality and feel for members (residents) at all times, affecting 12 current residents. Findings include:The residence's undated resident agreement read in part: "(The residence) agrees to make available... a physically safe and sanitary environment."On 8/7/25 from approximately 7:30 a.m. to 2:00 p.m., an environmental tour of the residence revealed the following:The residence grounds were covered in cigarette butts. The downstairs common area bathroom had a hole of approximately one foot, in the drywall above the shower. Additionally, the shower wall had six missing tiles that exposed concrete underneath, making it difficult to clean and sanitize. On 8/7/25 at 1:30 p.m., the administrator acknowledged the requirement to maintain a safe and sanitary environment. The administrator stated he had been having a difficult time finding someone to make repairs and residents continued to throw cigarette butts in the yard despite previous meetings about it.
Plan of correction · submitted by the facility
Response to POC Tag # 1780We acknowledge the deficiency. We have repeatedly notified all the residents and specifically the smokers in the house not to throw cigaret buts on the ground between the rocks and they did not listen. Signs were posted on the walls and have spoken to each individual and they promised not throw cigarette butts and they still did so! Smoking policy was reviewed and discussed during the house meeting in addition the smoking policy clearly states that smoking is only allowed in the designated smoking area and cigarettes butts to be disposed in the special containers. This issue has been a challenge to all of us and will be discussed during the house meeting. As for the missing tiles in the shower that was caused by one of the residents that punched the tiles and also waiting for the contractor to return and replace the tiles. As far as the hole in the bathroom ceiling we had a water leak the contractor opened the ceiling to repair the leak and stated that he need to repair another part before he closed the ceiling. Corrective action: all mentioned issues have been addressed and were repaired (Pictures will be provided for a desk revisit)Addendum to the Monitoring Plan:Smoking agreement was presented and signed by all smokers to ensure that they will not smoke and jeopardize or put the facility at risk.smoking area signed have been posted and house meeting is being held to discuss and address all house rules and smoking issues. A maintenance checklist and a maintenance schedule have been developed to review, ensure and sign off on all required maintenance and preventive maintenance schedule and needs. All facility maintenance records documents have been reviewed and will be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of maintenance items / issues requiring immediate attention. Monitoring, corrective action and repairs started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly review and audit process and QAPI process.
9999Final ObservationsSurveyor note▼
Findings
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 8.7000.8.7414 Medication AdministrationA. Provider Agencies shall provide sufficient support to Members in the use of prescription and non- prescription medications. Members shall be presumed capable of self-administration unless they are determined otherwise. The type and level of medication administration support provided shall be determined by the results of an assessment performed by a qualified person. Medications shall be administered only by persons authorized in accordance with 6 C.C.R. 1011-1, Chapter VII and XXIV.8.7001B Resident Agreementa. Provider-Owned or -Controlled Residential Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001. B.4: i. The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the State, county, city, or other designated entity. For settings in which landlord/tenant laws do not apply, a lease, residency agreement, or other form of written agreement must be in place for each individual, and the document must provide protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord/tenant law.
Plan of correction
The state did not require a plan of correction for this citation.
8/7/2025Licensure and Licensure Complaint (Combined) · ID TNGP119 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO40322 was completed on 8/7/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1010Res Ad/D/C-MoveIn CritS/S B▼
Findings
Based on record review and interview, the residence failed to complete a comprehensive pre-admission assessment of residents and ensure those persons' needs can be met fully by the existing staff, affecting three of three residents who had a history of behaviors (#1-#3). (Cross reference U1150, U1142 and U2230)Findings include: 1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). An intake assessment dated 6/15/24, which was the residence's pre-admission assessment, was completed by the assistant administrator. The intake assessment read the resident was an elopement risk. However, there was no evidence the assessment included the resident's mental and social needs. On 8/7/25 at 7:50 a.m., Resident #2 stated approximately two days prior to the onsite investigation, he had left the residence and was unable to find his way back. Resident #3 stated "strangers" took him back to the residence. On 8/7/25 at 8:07 a.m., the administrator stated that Resident #2 would elope from the residence and be unable to find his way back home, and would also frequently refuse his medications. He further stated Resident #2 had engaged in a previous verbal altercation with Resident #5 and felt the residence was unable to meet his needs. On 8/7/25 at approximately 1:01 p.m., the administrator, who was also the administrator at Resident #2's former residence, stated Resident #2 was discharged from the residence since he had engaged in verbal altercations with other residents, wandered out of the residence and was unable to find his way back home, and was "out of control." The administrator stated he felt the resident required a secure environment. 2. Additionally, the residence failed to ensure a comprehensive pre-admission assessment was completed to include information on resident mental and social needs for Residents #1 and #3.
Plan of correction · submitted by the facility
Response to POC 1010We acknowledge the deficiency. An assessment was conducted and placed in resident #2 folder. however, this resident has been refusing medications and any additional assessments or treatments. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. Also, this resident has major drinking and drugs problems that will affect his behavior and the facility have not been able to transfer this resident to an alternative facility. Corrective Action: all records for resident #1, #2 and #3 were reviewed for completeness and proper location. Monitoring plan:all residence supporting documents have been reviewed and will be reviewed with the staff during the weekly staff meeting. Addendum to the Monitoring Plan: A checklist and an interval schedule has been developed for all/each resident to: re-create, review, ensure and sign off on all required documents: Assessment prior to admission for behavioral and social needs. Annually schedule, conduct and document the re-assessment and care plan for behavioral, social needs and daily living. All residence records, supporting documents have been reviewed and will be scheduled to be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of residents requiring a re-assessment and signed off by the administrator during the weekly staff meeting. Monitoring and corrective action started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly audit process and QAPI process.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation, record review and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 12 current residents. Findings include:The residence's undated resident agreement read in part: "(The residence) agrees to make available... a physically safe and sanitary environment."On 8/7/25 from approximately 7:30 a.m. to 2:00 p.m., an environmental tour of the residence revealed the following:The residence grounds were covered in cigarette butts. The downstairs common area bathroom had a hole of approximately one foot, in the drywall above the shower. Additionally, the shower wall had six missing tiles that exposed concrete underneath, making it difficult to clean and sanitize. On 8/7/25 at 1:30 p.m., the administrator acknowledged the requirement to maintain a safe and sanitary environment. The administrator stated he had been having a difficult time finding someone to make repairs and residents continued to throw cigarette butts in the yard despite previous meetings about it.
Plan of correction · submitted by the facility
Response to POC Tag # 1110We acknowledge the deficiency. We have repeatedly notified all the smokers residents in the house not to throw cigarette buts on ground and between the rocks and they did not listen. Signs were posted on the walls and have spoken to each individual and they promised not throw cigarette butts and they still did so! Smoking policy clearly states that smoking is only allowed in the designated smoking area and cigarettes butts to be disposed in the special containers. As far as the hole in the bathroom ceiling we had a water leak the contractor opened the ceiling to repair the leak and stated that he need to repair another part before he closed the ceiling. As for the missing tiles in the shower that was caused by one of the residents that punched the tiles and also waiting for the contractor to return and replace the tiles. Corrective action: Writes ups were given to all violators and they agreed not to smoke outside the designated area again.all mentioned issues have been addressed and are being repaired as we speak (Pictures will be provided for a desk revisit) This issue has been a challenge to all and will be discussed during the house meeting. Monitoring plan: review all the above topics with the staff during the weekly staff meeting. We have repeatedly notified all the residents and specifically the smokers in the house not to throw cigaret buts on the ground between the rocks and they did not listen. Signs were posted on the walls and have spoken to each individual and they promised not throw cigarette butts and they still did so! Smoking policy was reviewed and discussed during the house meeting in addition the smoking policy clearly states that smoking is only allowed in the designated smoking area and cigarettes butts to be disposed in the special containers. This issue has been a challenge to all of us and will be discussed during the house meeting. As for the missing tiles in the shower that was caused by one of the residents that punched the tiles and also waiting for the contractor to return and replace the tiles. As far as the hole in the bathroom ceiling we had a water leak the contractor opened the ceiling to repair the leak and stated that he need to repair another part before he closed the ceiling. Corrective action: all mentioned issues have been addressed and were repaired (Pictures will be provided for a desk revisit)Addendum to the Monitoring Plan:Smoking agreement was presented and signed by all smokers to ensure that they will not smoke and jeopardize or put the facility at risk.smoking area signed have been posted and house meeting is being held to discuss and address all house rules and smoking issues. A maintenance checklist and a maintenance schedule have been developed to review, ensure and sign off on all required maintenance and preventive maintenance schedule and needs. All facility maintenance records documents have been reviewed and will be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of maintenance items / issues requiring immediate attention. Monitoring, corrective action and repairs started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly review and audit process and QAPI process.
1142Res Care Srvs-Comp Res Asmnt IncldS/S B▼
Findings
Based on interview and record reviews the residence failed to complete a comprehensive assessment that included all required information, affecting three of four sample residents (#1-#3). (Cross reference U1110, U1150 and U2230)Findings include:Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). An admission assessment dated 6/15/24, read on a scale of one to ten, the resident rated a four in combativeness toward others, and a five in wandering. However, the assessment did not include the types of physical, mental, or social support required, routines and interests, food and dining preferences and reactions to the environment and others that may occur at certain times or in certain circumstances. There were no other assessments in the resident's record. There was similar deficient practice for Residents #1 and #3. On 8/7/25 at approximately 1:30 p.m., the administrator stated he was aware of the requirement of what needed to be included in the comprehensive assessment and would make updates.
Plan of correction · submitted by the facility
Response to POC 1142We acknowledge the deficiencyAn assessment was conducted and placed in resident #2 folder. however, this resident has been refusing medications and any additional assessments or treatments. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. Also, this resident has major drinking and drugs problems that will affect his behavior and the facility have not been able to transfer this resident to an alternative facility. Corrective Action: all records for resident #1, #2 and #3 were reviewed for completeness and proper location. Monitoring plan:all residence supporting documents have been reviewed and will be reviewed with the staff during the weekly staff meeting. Addendum to the Monitoring Plan:A checklist and an interval schedule has been developed for all/each resident to: re-create, review, ensure and sign off on all required documents: Assessment prior to admission for behavioral and social needs. Annually schedule, conduct and document the re-assessment and care plan for behavioral, social needs and daily living. All residence records, supporting documents have been reviewed and will be scheduled to be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of residents requiring a re-assessment and signed off by the administrator during the weekly staff meeting. Monitoring and corrective action started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly audit process and QAPI process.
1150Res Care Srvs-Res CPS/S B▼
Findings
Based on interviews and record review, the residence failed to ensure each resident care plan promoted resident safety and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting three of four sample residents (#1-#3). (Cross reference U1010, U1142 and U2230)Findings include:1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). An intake assessment dated 6/15/24 was completed by the assistant administrator (AA). The intake assessment read the resident was an elopement risk. An admission assessment dated 6/15/24, completed by the AA, The assessment read on a scale of one to ten, the resident rated a four in combativeness toward others, and a five in wandering. However, the most recent care plan, dated 6/15/24, did not include any behavioral interventions related to the resident's combative behavior and elopement risk. On 8/7/25 at 7:50 a.m., Resident #2 stated approximately two days prior to the onsite investigation, he had left the residence and was unable to find his way back. Resident #3 stated "strangers" took him back to the residence. On 8/7/25 at 8:07 a.m., the administrator stated that Resident #2 would elope from the residence and be unable to find his way back home, and would also frequently refuse his medications. He further stated Resident #2 had engaged in a previous verbal altercation with Resident #5. On 8/7/25 at 8:39 a.m., Resident #5 stated Resident #2 yelled expletives toward him "a lot," with a more severe expletive verbalized two weeks prior to the onsite investigation. On 8/7/25 at 12:29 p.m., Staff #1 stated Resident #2 engaged in verbal altercations with other residents and would leave the residence without telling staff where he was going. Staff #1 stated Resident #2 yelled at Resident #5 on 7/30/25. Staff #1 further stated there were no behavioral interventions in place in the residence's care plan. On 8/7/25 at approximately 1:30 p.m., the administrator acknowledged Resident #2 had behaviors that required staff intervention. The administrator stated he was aware of the requirement for care plans to include specific personal services needs and staff tasks necessary to meet those needs; however, he was unaware the care plan did not include that information. 2. There was similar deficient practice for Residents #1 and #3.
Plan of correction · submitted by the facility
Response to POC 1150We acknowledge the deficiency. Resident #3 was brought in as a respite for couple of day. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. An assessment was conducted and placed in resident #2 folder. however, this resident has been refusing medications and any additional assessments or treatments. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. Also, this resident has major problems that will affect his behavior and the facility have not been able to transfer this resident to an alternative facility. Corrective Action: all records for resident #1, #2, #3 and #5 were reviewed for completeness and proper location. Monitoring plan:all residence supporting documents have been reviewed and will be reviewed with the staff during the weekly staff meeting. Addendum to the Monitoring Plan: A checklist and an interval schedule has been developed for all/each resident to: re-create, review, ensure and sign off on all required documents: Assessment prior to admission for behavioral and social needs. Annually schedule, conduct and document the re-assessment and care plan for behavioral, social needs and daily living. All residence records, supporting documents have been reviewed and will be scheduled to be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of residents requiring a re-assessment and signed off by the administrator during the weekly staff meeting. Monitoring and corrective action started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly audit process and QAPI process.
1394Res Rghts-Res Mtgs Wrt MinS/S B▼
Findings
Based on interview and record review the residence failed to ensure written minutes of resident meetings were maintained and readily available for review, affecting 12 current residents. Findings include:On 8/7/25 at 7:57 a.m., meeting minutes for the last three resident council meetings were requested. Meeting minutes were requested again at 12:37 p.m. As of 2:00 p.m., the time of exit, no resident meeting minutes were provided. On 8/7/25 at 11:21 a.m., the administrator stated he would be unable to provide resident meetings until after the onsite investigation, since they were written on his phone. The administrator had his phone on his person at the time of the survey. On 8/7/25 at 1:30 p.m., the administrator stated he was aware resident meetings were required to be readily available; however, he believed the notes on his phone were sufficient.
Plan of correction · submitted by the facility
Response to POC 1394Meeting minutes were provided to the state surveyor via email and she acknowledged receipt. I have an email response from the surveyor dated August 7th 2025 stating that she will review the documents. Corrective Action: all house meeting will be printed and posted at the facility on monthly basis. Monitoring plan:all house meeting records will be printed and posted and will be reviewed with the staff during the weekly staff meeting. Addendum to the Monitoring Plan: House meetings were being held and will continue to be held on monthly basis and will be posted on the bulletin board in the common area. Additional house meeting will be scheduled at time if we feel there has been issue or topics or urgent announcement to be discussed. An interval house meeting schedule and an agenda have been developed to discuss: announcements, events, celebrations, Birthdays, new residents, holidays, parties, activities issues, review open issues from the last house meeting, challenges for the month and Q&A.Meeting notes were provided electronically to the surveyor before departing from the facility in August 7th. Monitoring and corrective all house meeting records will be printed and posted and will be reviewed with the staff during the weekly staff meeting and will continue as part of the monthly meetings process and QAPI process.
1636Med/Med Adm-Med Strge RefridgeS/S B▼
Findings
Based on observations and interviews, the residence failed to ensure all refrigerated medications were clearly labeled with the resident's name and prescribing information, and were stored in a refrigerator that did not contain food, affecting one of one sample residents on refrigerated medications (#2). Findings include:1. ObservationsOn 8/7/25 at 8:07 a.m., an environmental tour revealed a "staff only" sign was on a door that led to the garage, where there was a refrigerator filled with food which was also the medication refrigerator. The refrigerated medications included as follows:A box of Lantus 100 unit injectionsA box of risperidone 200 mg injectionsA clear bag with a single dose of Humulog 100 unit and Lantus 100 unit injections. However, the clear bag was not labeled with the resident's name or prescribing information. 2. InterviewsOn 8/7/25 at 8:07 a.m., the administrator stated Resident #2 was the only resident on refrigerated medications. The administrator further stated that food was also stored in the refrigerator that was used by staff to make resident meals. On 8/7/25 at approximately 1:30 p.m., the administrator stated he believed that refrigerated medications could be stored with food as long as they were not accessible to residents. The administrator further stated the medications in the plastic bag belonged in the boxes of injectable medication that had the prescribing information and the resident's name. On 8/7/25 at 2:00 p.m., Staff #1 stated Resident #2's refrigerated medications had been stored with food since he was admitted to the residence in June of 2024.
Plan of correction · submitted by the facility
Response to POC Tag # 1636We acknowledge the deficiency. Historically a secure medication box was in place and was being used until one of the staff members changed the code and locked the box and could not open it again. Corrective Action: a new and secure medication lock box has been put in place for refrigerated medications storage. Monitoring plan: review the med storage policy with the staff during the weekly staff meeting. Addendum to the Monitoring Plan: Added a note to the MAR (Medication Administration Record) that all refrigerated medication must be stored in a secure box and isolated from the food and will be checked during the medication administration.monitoring will be conducted each refrigerated meds are administered by the QMAP and recorded in the MAR. This will be checked and documented by the administrator during the weekly staff meeting. Monitoring started after the survey was conducted on August 7th and will continue as part of the MAR daily, weekly and monthly reconciliation process and QAPI process.
2230HIR-Cntnt IncldS/S B▼
Findings
Based on interviews and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issues affecting three of four sample residents (#1-#3). (Cross reference U1010, U1142 and U1150). Findings include:1. Resident #2 was admitted to the residence on 6/15/24 with diagnoses including paranoid schizophrenia, bi-polar disorder and post traumatic stress disorder (PTSD). Progress notes of all out of the ordinary events affecting Resident #2 were requested; however, there was no documentation in progress notes of the following:On 8/7/25 at 7:50 a.m., Resident #2 stated approximately two days prior to the onsite investigation, he had left the residence and was unable to find his way back. Resident #3 stated "strangers" took him back to the residence. On 8/7/25 at 8:07 a.m., the administrator stated that Resident #2 would elope from the residence and be unable to find his way back home. He further stated Resident #2 had engaged in a previous verbal altercation with Resident #5 over the television. On 8/7/25 at 8:39 a.m., Resident #5 stated Resident #2 yelled expletives toward him "a lot," with a more severe expletive verbalized two weeks prior to the onsite investigation. On 8/7/25 at 11:21 a.m., the administrator stated he documented through pictures and notes on his phone incidents he was made aware of. The assistant administrator added that the documentation of out of the ordinary behaviors is "eviction notices."On 8/7/25 at 12:29 p.m., Staff #1 stated Resident #2 had verbal altercations with other residents and would leave the residence without telling staff where he was going. Staff #1 stated Resident #2 yelled at Resident #5 on 7/30/25. Staff #1 further stated she was trained to inform the administrator of out of the ordinary events and did not document them unless related to medication refusals. On 8/7/25 at approximately 1:30 p.m., the administrator stated he thought making notes on his phone and pictures of incidents were sufficient. He was unaware residence staff needed to document in the progress notes in the resident record out of the ordinary events. 2. There was similar deficient practice for Residents #1 and #3.
Plan of correction · submitted by the facility
Response to POC 2230We acknowledge the deficiency. Resident #3 was brought in as a respite for couple of day. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. An assessment was conducted and placed in resident #2 folder. however, this resident has been refusing medications and any additional assessments or treatments. All the issues that were mentioned by surveyor have documents and were added to the resident file for review. Also, this resident has major problems that will affect his behavior and the facility have not been able to transfer this resident to an alternative facility. Corrective Action: all records for resident #1, #2 and #3 were reviewed for completeness and proper location. Monitoring plan:all residence supporting documents have been reviewed and will be reviewed with the staff during the weekly staff meeting. Addendum to the Monitoring Plan: A checklist and an interval schedule has been developed for all/each resident to: re-create, review, ensure and sign off on all required documents: Assessment prior to admission for behavioral and social needs. Annually schedule, conduct and document the re-assessment and care plan for behavioral, social needs and daily living. All residence records, supporting documents have been reviewed and will be scheduled to be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of residents requiring a re-assessment and signed off by the administrator during the weekly staff meeting. Monitoring and corrective action started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly audit process and QAPI process.
2516Ex Env MntnedS/S B▼
Findings
Based on observation and interview, the residence failed to keep the residence handrails in good repair, affecting 12 current residents. Findings include:On 8/7/25 from approximately 7:30 a.m. to 2:00 p.m., an environmental tour of the residence revealed the handrails on the ramp at the front of the residence had peeling paint and splintering wood. On 8/7/25 at approximately 1:30 p.m., the administrator acknowledged the requirement to keep handrails in good repair. The administrator stated he had been having a difficult time finding someone to make repairs.
Plan of correction · submitted by the facility
Response to POC Tag # 2516We acknowledge the deficiency. The handrails has been maintained/painted repeatedly throughout the year. We have spoken to the contractor to repaint it and they suggested different type of paint. Corrective action: all mentioned issues have been addressed and are being repaired as we speak (Pictures will be provided for a desk revisit). Monitoring plan: review all the above topics with the staff during the weekly staff meeting. Addendum to the Monitoring Plan:A maintenance checklist and a maintenance schedule have been developed to review, ensure and sign off on all required maintenance and preventive maintenance schedule and needs. All facility maintenance records documents have been reviewed and will be reviewed with the staff during the weekly, monthly, quarterly staff meetings to determine the list of maintenance items / issues requiring immediate attention. Monitoring, corrective action and repairs started after the survey was conducted on August 7th and will continue as part of the daily, weekly and monthly review and audit process and QAPI process.
2680In Env-BR TP dspnsrS/S B▼
Findings
Based on observation and interviews, the residence failed to provide paper towels or hand drying devices in each common bathroom, affecting 12 current residents. Findings include:On 8/7/25 from approximately 7:30 a.m. to 2:00 p.m., an environmental tour revealed all three common area bathrooms at the residence failed to make available paper towels or any other hand drying devices. On 8/7/25 at 7:33 a.m., Resident #4 stated there was a hand towel in the bathrooms; however, it had been gone for about a week prior to the onsite investigation. Resident #4 stated he had been drying his hands on his clothes. On 8/7/25 at 8:39 a.m., Resident #5 stated he believed there were no paper towels or other hand drying devices for approximately a month prior to the onsite investigation. Resident #5 stated he dried his hands by "shaking them off."On 8/7/25 at 8:52 a.m., Resident #1 stated there had been no hand drying devices or paper towels for as long as he could remember. He further stated he dried his hands on his clothes. On 8/7/25 at 11:16 a.m., Staff #1 stated the residence did not use paper towels. She stated she provided fabric towels for handwashing; however, she was washing them. On 8/7/25 at approximately 1:30 p.m., the administrator acknowledged he was aware of the requirement for there to be paper towels or hand drying devices in each common bathroom. The administrator stated if there weren't paper towels, it was because residents took them.
Plan of correction · submitted by the facility
Response to POC Tag # 2680We acknowledge the deficiency. Corrective action: Paper towel dispensers have been installed to prevent the residents from taking the full roles of paper towels and hide it their roomMonitoring plan: paper towels dispensers will be checked daily by the staff! also, discussed with the residence during the house meeting to remind the staff to refill the dispensers when they are out. Addendum to the Monitoring Plan: Added line items/notes to the cleaning schedule to check and initial that paper towels, toilet papers and other cleaning supplies are sufficient for the entire day at each of the bathrooms in the house.monitoring will be conducted during the cleaning process each day and at the change of each shift. administered will check and sign off that each bathroom has been cleaned and supplies are replenished every day. This will be checked and documented by the administrator during the weekly, monthly and quarterly staff meeting. Monitoring started after the survey was conducted on August 7th and will continue as part of the daily cleaning process and QAPI process.
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 7.7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items: (C) Orientation and training, including, but not limited to the following, as applicable: (1) First aid and CPR certification. 11.3 At the time the resident moves in, the assisted living residence shall ensure that the resident and/or the resident ' s legal representative has received a copy of the written resident agreement and agreed to the terms set forth therein. The assisted living residence shall ensure that the agreement is signed and dated by both parties. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.21 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.
Plan of correction
The state did not require a plan of correction for this citation.
1/30/2024Revisit: CHOW and Licensure (Re-licensure) (Combined) · ID 9RMS12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/30/24 for all previous deficiencies cited on 2/15/23. 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.
1/30/2024Revisit: State Certification (Re-certification) · ID OQ5K12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/30/24 for all previous deficiencies cited on 2/15/23. 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.
Reportable Occurrences
0 recordsNo reportable occurrences
The state has not published occurrence summaries for this facility.