SENECA HOUSE ASSISTED LIVING

A complaint revisit was completed on 7/7/26 for all previous deficiencies cited on 4/9/26. The residence is in compliance with all regulations surveyed

A complaint revisit was completed on 7/7/26 for all previous deficiencies cited on 4/9/26. The facility is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO42036 was completed on 4/9/26. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with occurrence reporting requirements required by state law, affecting 13 current residents. (Cross-reference U1322, U1410)Findings include:1. Record ReviewOn 1/9/26 at approximately 9:30 a.m., a record review showed that neither the administrator nor the administrator designee submitted an occurrence report for two physical altercations that occurred on 1/24/26, during which Former Resident #5 punched Resident #1 in the face, causing injury. A second physical altercation occurred on 1/25/26, Resident #1 punched Former Resident #5 in the face, causing injury that led to a hospital visit. 2. InterviewsOn 1/9/26 at 3:15 p.m., the administrator designee and the director of clinical services stated that they did not know what occurrence reporting was. The director of clinical services further stated that the administrator handled occurrence reporting and was aware of the two incidents that occurred on 1/24 & 1/25/26; however the administrator was unavailable to answer questions.

Based on interview and record review, the residence failed to ensure residents had the right to be free from physical abuse, affecting two of two sample residents (#1 and #5). (Cross-reference U430, U1410)Specifically, on 1/24/26 at 1:33 p.m., Former Resident #5 hit Resident #1 on the face, which caused a bruise on his eye. On 1/25/26 at 11:30 p.m., Resident #1 stepped into the common area and spoke loudly and cursed at Former Resident #5 and they started fighting. Former Resident #5 was punched in the face by Resident #1 and sustained a bruise on her left temple. Findings include:Resident #1 was admitted to the residence on 3/6/25 with diagnoses including schizoaffective disorder, bipolar and Parkinson's disease. Former Resident #5 was admitted to the residence on 10/9/25 with diagnoses including borderline personality disorder, depression, post-traumatic stress disorder, insomnia due to other mental disorder and opioid dependence. An incident report on 1/24/26 at 1:33 p.m., read Resident #1 got into an altercation and sustained a bruise on his face. A progress note for Former Resident #5 revealed on 1/24/26 Resident #1 had an altercation with Former Resident #5 because Resident #1 called her names and was following her around the house. A progress note for Resident #1 on 1/24/26 read he was being aggressive towards other residents and was provoking Former Resident #5 since the morning. An incident report on 1/25/26 at 11:30 p.m., read Resident #1 stepped into the common area and yelled curse words loudly where Former Resident #5 was. Resident #1 and Former Resident #5 got into an altercation. Former Resident #5 sustained a bruise from the altercation. An ambulance report for Former Resident #5, dated 1/25/26, read Former Resident #5 sustained a bruise on her left temple from an assault from another resident. An external court document for Resident #1, dated 2/25/26 read Resident #1 had a protection order that read Resident #1 "Shall refrain from contacting or directly or indirectly communicating with the victims or witnesses." Defendant was Resident #1. Protected party was Former Resident #5. The care plan for Resident #1 was last updated on 6/5/25. The care plan read he required no support with aggression management. The care plan for Former Resident #5 was last updated 10/8/25 and did not include any interventions for staff after she assaulted Resident #1 on 1/24/26. On 4/9/26 at 10:50 a.m., the administrator designee (AD) said on 1/24/26 Former Resident #5 hit Resident #1. She added the following day on 1/25/26 Resident #1 hit Former Resident #5 and she got a black eye. On 4/9/26 at approximately 3:15 p.m., the AD acknowledged Resident #1 and Former Resident #5 assaulted one another based on the incident reports. She added she expected residents to be free from abuse.

Based on interview and record review, the residence failed to thoroughly investigate allegations in accordance with the residence's written policy, affecting 13 current residents. (Cross-reference U430, U1322)Specifically, on 1/24/26 at 1:33 p.m., Former Resident #5 hit Resident #1 on the face, which caused a bruise on his eye. No interventions were implemented after the physical altercation, other than to keep Resident #1 and Former Resident #5 separated. The residence did not conduct a thorough investigation of the physical assault. On 1/25/26 at 11:30 p.m., Resident #1 was in the common area near Former Resident #5 and spoke loudly and cursed at Former Resident #5 and they started physically fighting. Former Resident #5 was punched in the face by Resident #1 and sustained a bruise on her left temple. The residence's only investigation, dated 1/25/26 did not indicate that either Resident #1 and Former Resident #5 sustained bruises as a result of the physical altercation. No witness statements were provided and the only intervention implemented was for Resident #1 and Former Resident #5 to remain separated. The interventions did not include how other residents would be safe in the house due to Former Resident #5's erratic behavior. On 3/11/26 Former Resident #5 entered Resident #4's room was "getting violent" as she demanded she have her blanket back. This scared Resident #4 so Staff #1 had to physically remove Former Resident #5 from Resident #4's room. Findings include:1. Residence PolicyThe residence's undated Investigation of Abuse, Neglect, Exploitation Allegations or Injuries of Unknown Origin policy referenced a different residence and not the name of the current residence. The policy read, in part, that there would be documentation of notifications made by staff. Additionally the policy read the administrator or designee would assess the resident, protect the resident, find facts that include interviewing residents, staff or witnesses. Specifically, "Documentation shall include Incident report, Written statements from staff and witnesses, Interview notes, medical assessments, Evidence collected (photos, records reviewed), Reports submitted to external agencies, Notifications made to the legal representative, Findings and conclusions of the investigation, Corrective actions taken (if applicable). All documentation must be dated and maintained in a secure file ... Retention of Investigation Reports A copy of the completed investigation report, including all supporting documentation and findings, shall be: Maintained by the assisted living residence, Stored in accordance with record retention policies"2. Record ReviewResident #1 was admitted to the residence on 3/6/25 with diagnoses including schizoaffective disorder, bipolar and Parkinson's disease. Former Resident #5 was admitted to the residence on 10/9/25 with diagnoses including borderline personality disorder, depression, post-traumatic stress disorder, insomnia due to other mental disorders and opioid dependence. An incident report on 1/24/26 at 1:33 p.m., read Resident #1 got into a physical altercation and sustained a bruise on his face. Progress notes for Resident #1 and Former Resident #5 revealed on 1/24/26 Resident #1 had an altercation with Resident #1 because Resident #1 called her names and was following her around the house. An incident report on 1/25/26 at 11:30 p.m., read Resident #1 stepped into the common area and yelled curse words loudly where Former Resident #5 was. Resident #1 and Former Resident #5 got into an altercation. Former Resident #5 sustained a bruise from the altercation. An ambulance report for Former Resident #5, dated 1/25/26 read she sustained a bruise on her left temple from an assault from another resident. On 4/9/26 at approximately 8:45 a.m., the residence's investigations of abuse since December 2025 were requested. At 11:39 a.m., the residence provided two incident reports with limited information. A second request was made for any investigation notes for the 1/24 and 1/25/26 incidents. At 12:20 p.m., the administrator provided a one page document, dated 1/25/26 and titled Investigation Report: Resident to Resident Altercation. The investigation report detailed a summary of what happened on 1/24 and 1/25/26 between Resident #1 and Former Resident #5 and only mentions one incident. The investigation read there were witnesses but it did not include detailed information that a thorough investigation was conducted for each separate event on 1/24 and 1/25/26, as each incident was separate as on 1/24/26 Resident #1 was physically assaulted and sustained a bruise and on 1/25/26 Former Resident #5 was physically assaulted and sustained a bruise. The only intervention that was implemented to protect other residents from both Resident #1 and Former Resident #5's erratic behaviors were to separate the two of them and "different meal times were offered to both parties for dining room space use. Staff to continue to monitor future interactions between (Resident #1) and (Former Resident #5), advocate for medication changes for both parties, if appropriate."The care plan for Resident #1 was last updated on 6/5/25. The care plan read he required no support with aggression management. The care plan for Former Resident #5 was last updated 10/8/25 and did not include any interventions for staff after she assaulted Resident #1 on 1/24/26. An incident report in Resident #4's record read "(Former Resident #5) went to request a blanket she had allegedly borrowed from (Resident #4). (Resident #4) claimed not to have the blanket. (Former Resident #5) got upset and tore napkins and paper products she had and threw it on the floor (sic) aggressively, scaring (Resident #4) ... Conclusion: The altercation between (Resident #4) and (Former Resident #5) seemed to be as a result of increasing aggressiveness from (Fromer Resident #5)."3. InterviewsOn 4/9/26 at 1:15 p.m., Resident #4 said on 3/11/26 Former Resident #5 walked into her room with Staff #1 and Former Resident #5 demanded her blanket back. When Resident #4 said she no longer had it Former Resident #5 got upset and was "getting violent" and ripped up some paper and threw it at Resident #4. She added she became scared when Former Resident #5 started going through her room to look for the blanket and that is when Staff #1 physically removed Former Resident #5 from the room and Resident #4 asked to lock her door to keep Former Resident #5 out of her room. On 4/9/26 at 1:50 p.m., Staff #1 said after Former Resident #5 hit Resident #1 in the face on 1/24/26 there were no interventions in place to protect other residents from Former Resident #5. She added, the administrator had not come to the residence on either 1/24 or 1/25/26 to conduct witness statements from staff, residents or families. On 4/9/26 at 1:55 p.m., Staff #2 said after the incident 1/24/26 when Former Resident #5 hit Resident #1 he added the intervention implemented was to ask what to do about Resident #1's behaviors and report his behavior to his practitioner. There was no direction or intervention about how to protect Former Resident #5 from other residents other than to keep Resident #1 and Former Resident #5 separated. On 4/9/26 at approximately 3:15 p.m., the administrator designee (AD) said when the physical altercations happened between Resident #1 and Former Resident #5 on 1/24 and 1/25/26 she was not present so the administrator was the one who carried out the investigations. The director of clinical services (DCS) said she expected interview notes to have been documented for each event. She added, the interventions were to keep them separated from each other. Neither the AD or the DSC responded when asked if a thorough investigation was conducted for both physical alterations on 1/24 and 1/25/26.

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 7.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident's representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence's visitation policy as required by Part 9.2, along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs. 18.8 Resident records shall contain, but not be limited to, the following items:(F) Documentation of on-going services provided by external service providers including, but not limited to, caregivers, essential caregivers, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and care providers

A certification complaint, prompted by #CO42037, was completed on 4/9/26. Deficiencies were cited.

Based on record review and interview, the (residence) failed to ensure members (resident) were free from physical abuse, affecting two of two sample residents (#1, #5). (Cross-reference B796)Findings include:Resident #1 was admitted to the residence on 3/6/25 with diagnoses including schizoaffective disorder, bipolar and Parkinson's disease. Former Resident #5 was admitted to the residence on 10/9/25 with diagnoses including borderline personality disorder, depression, post-traumatic stress disorder, insomnia due to other mental disorder and opioid dependence. An incident report on 1/24/26 at 1:33 p.m., read Resident #1 got into an altercation and sustained a bruise on his face. A progress note for Former Resident #5 revealed on 1/24/26 Resident #1 had an altercation with Former Resident #5 because Resident #1 called her names and was following her around the house. A progress note for Resident #1 on 1/24/26 read he was being aggressive towards other residents and was provoking Former Resident #5 since the morning. An incident report on 1/25/26 at 11:30 p.m., read Resident #1 stepped into the common area and yelled curse words loudly where Former Resident #5 was. Resident #1 and Former Resident #5 got into an altercation. Former Resident #5 sustained a bruise from the altercation. An ambulance report for Former Resident #5, dated 1/25/26, read Former Resident #5 sustained a bruise on her left temple from an assault from another resident. An external court document for Resident #1, dated 2/25/26 read Resident #1 had a protection order that read Resident #1 "Shall refrain from contacting or directly or indirectly communicating with the victims or witnesses." Defendant was Resident #1. Protected party was Former Resident #5. The care plan for Resident #1 was last updated on 6/5/25. The care plan read he required no support with aggression management. The care plan for Former Resident #5 was last updated 10/8/25 and did not include any interventions for staff after she assaulted Resident #1 on 1/24/26. On 4/9/26 at 10:50 a.m., the administrator designee (AD) said on 1/24/26 Former Resident #5 hit Resident #1. She added the following day on 1/25/26 Resident #1 hit Former Resident #5 and she got a black eye. On 4/9/26 at approximately 3:15 p.m., the AD acknowledged Resident #1 and Former Resident #5 assaulted one another based on the incident reports. She added she expected residents to be free from abuse.

Based on interview and record review, the facility (residence) failed to thoroughly investigate allegations of abuse in accordance with the residence's written policy, affecting 13 current members (residents). Findings include:1. Residence PolicyThe residence's undated Investigation of Abuse, Neglect, Exploitation Allegations or Injuries of Unknown Origin policy referenced a different residence and not the name of the current residence. The policy read, in part, that there would be documentation of notifications made by staff. Additionally the policy read the administrator or designee would assess the resident, protect the resident, find facts that include interviewing residents, staff or witnesses. Specifically, "Documentation shall include Incident report, Written statements from staff and witnesses, Interview notes, medical assessments, Evidence collected (photos, records reviewed), Reports submitted to external agencies, Notifications made to the legal representative, Findings and conclusions of the investigation, Corrective actions taken (if applicable). All documentation must be dated and maintained in a secure file ... Retention of Investigation Reports A copy of the completed investigation report, including all supporting documentation and findings, shall be: Maintained by the assisted living residence, Stored in accordance with record retention policies"2. Record ReviewResident #1 was admitted to the residence on 3/6/25 with diagnoses including schizoaffective disorder, bipolar and Parkinson's disease. Former Resident #5 was admitted to the residence on 10/9/25 with diagnoses including borderline personality disorder, depression, post-traumatic stress disorder, insomnia due to other mental disorders and opioid dependence. An incident report on 1/24/26 at 1:33 p.m., read Resident #1 got into a physical altercation and sustained a bruise on his face. Progress notes for Resident #1 and Former Resident #5 revealed on 1/24/26 Resident #1 had an altercation with Resident #1 because Resident #1 called her names and was following her around the house. An incident report on 1/25/26 at 11:30 p.m., read Resident #1 stepped into the common area and yelled curse words loudly where Former Resident #5 was. Resident #1 and Former Resident #5 got into an altercation. Former Resident #5 sustained a bruise from the altercation. An ambulance report for Former Resident #5, dated 1/25/26 read she sustained a bruise on her left temple from an assault from another resident. On 4/9/26 at approximately 8:45 a.m., the residence's investigations of abuse since December 2025 were requested. At 11:39 a.m., the residence provided two incident reports with limited information. A second request was made for any investigation notes for the 1/24 and 1/25/26 incidents. At 12:20 p.m., the administrator provided a one page document, dated 1/25/26 and titled Investigation Report: Resident to Resident Altercation. The investigation report detailed a summary of what happened on 1/24 and 1/25/26 between Resident #1 and Former Resident #5 and only mentions one incident. The investigation read there were witnesses but it did not include detailed information that a thorough investigation was conducted for each separate event on 1/24 and 1/25/26, as each incident was separate as on 1/24/26 Resident #1 was physically assaulted and sustained a bruise and on 1/25/26 Former Resident #5 was physically assaulted and sustained a bruise. The only intervention that was implemented to protect other residents from both Resident #1 and Former Resident #5's erratic behaviors were to separate the two of them and "different meal times were offered to both parties for dining room space use. Staff to continue to monitor future interactions between (Resident #1) and (Former Resident #5), advocate for medication changes for both parties, if appropriate."The care plan for Resident #1 was last updated on 6/5/25. The care plan read he required no support with aggression management. The care plan for Former Resident #5 was last updated 10/8/25 and did not include any interventions for staff after she assaulted Resident #1 on 1/24/26. An incident report in Resident #4's record read "(Former Resident #5) went to request a blanket she had allegedly borrowed from (Resident #4). (Resident #4) claimed not to have the blanket. (Former Resident #5) got upset and tore napkins and paper products she had and threw it on the floor (sic) aggressively, scaring (Resident #4) ... Conclusion: The altercation between (Resident #4) and (Former Resident #5) seemed to be as a result of increasing aggressiveness from (Fromer Resident #5)."3. InterviewsOn 4/9/26 at 1:15 p.m., Resident #4 said on 3/11/26 Former Resident #5 walked into her room with Staff #1 and Former Resident #5 demanded her blanket back. When Resident #4 said she no longer had it Former Resident #5 got upset and was "getting violent" and ripped up some paper and threw it at Resident #4. She added she became scared when Former Resident #5 started going through her room to look for the blanket and that is when Staff #1 physically removed Former Resident #5 from the room and Resident #4 asked to lock her door to keep Former Resident #5 out of her room. On 4/9/26 at 1:50 p.m., Staff #1 said after Former Resident #5 hit Resident #1 in the face on 1/24/26 there were no interventions in place to protect other residents from Former Resident #5. She added, the administrator had not come to the residence on either 1/24 or 1/25/26 to conduct witness statements from staff, residents or families. On 4/9/26 at 1:55 p.m., Staff #2 said after the incident 1/24/26 when Former Resident #5 hit Resident #1 he added the intervention implemented was to ask what to do about Resident #1's behaviors and report his behavior to his practitioner. There was no direction or intervention about how to protect Former Resident #5 from other residents other than to keep Resident #1 and Former Resident #5 separated. On 4/9/26 at approximately 3:15 p.m., the administrator designee (AD) said when the physical altercations happened between Resident #1 and Former Resident #5 on 1/24 and 1/25/26 she was not present so the administrator was the one who carried out the investigations. The director of clinical services (DCS) said she expected interview notes to have been documented for each event. She added, the interventions were to keep them separated from each other. Neither the AD or the DSC responded when asked if a thorough investigation was conducted for both physical alterations on 1/24 and 1/25/26.

An administrative relicensure survey was completed on 3/5/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40388, was completed on 1/20/26. No deficiencies were cited.

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 VII.21.2 The assisted living residence grounds shall be maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction.

A certification complaint, prompted by #CO40390, was completed on 1/20/26. No deficiencies were cited.

A revisit survey was completed on 2/25/25 for previous deficiencies cited on 12/30/24. The agency is in compliance with all regulations surveyed.

A revisit survey was completed on 2/25/25 for previous deficiencies cited on 12/30/24. The agency is in compliance with all regulations surveyed.

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 recertification survey with complaint #CO36111 was completed on 12/30/24. Deficiencies were cited.

Based on interview and record review, the facility's (residence) lease agreement failed to specify the rent or room and board charges associated with the services, affecting three sample residents (#1-#3). Findings include:The record for Resident #1 revealed the resident agreement was signed on 9/13/24. However, there was no room, board or rent amount listed. The record for Resident #2 revealed the resident agreement was signed on 3/24/23 with a monthly rent of $5850. However, the administrator acknowledged Resident #2's family was paying less than the agreed upon amount. The record for Resident #3 revealed the resident agreement was signed on 12/1/22. However, there was no room, board or rent amount listed. On 12/30/24 at approximately 2:30 p.m., the administrator acknowledged he had not listed the room/board/rent amount for Resident #1. The administrator also acknowledged that Resident #2's agreement needed to reflect the current amount the family was paying. The administrator added he probably should have added/updated the rent/room/board amount for Resident #3.

Based on observation and interview, the facility (residence) failed to store medications under proper conditions with regard to safety, affecting 13 current members (residents). Findings include:Throughout the onsite visit on 12/30/24 from 7:45 a.m. to 4:00 p.m., one of two refrigerators in the residence located in the kitchen was unlocked and accessible to residents. The refrigerator contained 10 pre-filled syringes of Resident #2's lorazepam 2 mg/ml. Staff #1 directed the surveyor to the unlocked refrigerator containing resident food and beverages when he was asked where Resident #2's narcotics were stored. On 12/30/24 at approximately 2:30 p.m., the administrator said he expected the residence to store Resident #2's refrigerated medication in a locked refrigerator and not with resident food. He added he was unsure how long the medication was in the unlocked refrigerator.