BONAVENTURE OF COLORADO SPRINGS

A revisit survey was completed on 05/21/26 for all previous deficiencies cited on 03/03/26. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 4/8/26 for all previous deficiencies cited on 12/9/25. The facility is in compliance with all deficiencies that were cited.

An administrative relicensure survey was completed on 3/10/26. A deficiency was cited.

Based on record review and interview, the residence failed to have emergency policies that addressed all minimum requirements, affecting 47 current residents. Findings include: On 3/10/26 at 8:00 a.m., the residence's Emergency Preparedness policy and procedures were requested and received. However, the following item was not included in the policy as required: (I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. On 3/10/26 at 12:46 p.m., the administrator stated she was unable to locate written agreements with other health facilities in the event the residents had to be relocated. She stated that she had taken over the administrator role on 11/20/25 and was unsure if the previous administrator had completed written agreements with other health facilities.

A complaint revisit was completed on 2/9/26 for all previous deficiencies cited on 10/22/25. The residence is in compliance with all regulations surveyed.

Deficiency cited for occurrence event ID #2523U243006.

The facility failed to provide the final report for Physical Abuse occurrence event # 2523U243006. Findings Include:The facility submitted an initial Physical Abuse occurrence report on 7/3/25. The facility failed to provide the final report within the required timeframe. Department staff sent electronic messages regarding the late final report through the COHFI system on 7/24/25 and 9/9/25. On 7/24/25, the message was opened for review by a facility representative on 8/14/25 and marked as read by the same facility representative on 11/17/25. On 9/9/25, the message was opened for review by a facility representative on 9/9/25 and marked as read by the same facility representative on 11/17/25. On 9/16/25, a representative from the Occurrence section contacted the facility administrator via phone and left a voice mail requesting the completion and submission of the final report for this event. On 10/22/25, an external email was sent to facility representatives regarding the late final report. On 12/2/25, another external email was sent to facility representatives regarding the late final report. On 12/3/25, an administrative facility representative responded via email and indicated the final report would be completed and submitted. As of 12/9/25, the final report has not been submitted.

A licensure complaint, prompted by #CO41028 and #CO40860, was completed on 10/22/25. Deficiencies were cited.

Based on record review and interviews, the residence failed to provide protective oversight, affecting one of four residents (#2). (Cross-reference U1352)Findings include:1. Record ReviewResident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility. The care plan, with an effective date of 4/1/25, read, "(Resident #2) understood the call system. In the event the resident needed extra assistance, the resident would call for help ... (Resident #2) was not considered a fall risk; however, staff would monitor and report any and all falls to the wellness director/registered nurse ..."2. Interviews On 10/21/25 at 8:30 a.m., Resident #2 stated that she could not recall the exact date, but in August 2025, around 10:00 p.m., she had slipped out of bed onto the floor and was unable to get herself up. She stated that her call pendant had not been working properly for the past couple of weeks, but pressed it anyway. Resident #2 stated that staff usually responded right away; however, after about 10 minutes or so, she realized the pendant was not working and started yelling for help. She stated there was no response from staff, and ended up lying on the floor for over seven hours. Resident #2 stated it was around 5:00 a.m. when staff finally entered her room. On 10/21/25 at 2:20 p.m., Resident #2's family member stated that the resident's pendant had not been working properly prior to her fall on August 19th, 2025. She stated that the residence provided another pendant to Resident #2; however, that one was not working either. The family member stated that even though Resident #2 was extremely independent, she was surprised that the residence did not have staff complete periodic checks on Resident #2 until the pendant issue had been resolved. She further stated that if staff had done periodic checks, Resident #2 would have been found sooner and not been on the floor for over seven hours. On 10/21/25 at 3:30 p.m., the assistant executive director (AED) stated she was on vacation when Resident #2 had fallen and heard that her pendant was not working properly during that time. She stated that Resident #2 was independent and did not require safety checks; however, because the pendant was not working properly, the residence should have had a temporary plan until the issue had been resolved. On 10/22/25 at 9:38 a.m., Staff #1 stated that Resident #2's pendant had not been working properly prior to her on 8/19/25. She stated Resident #2's pendant would randomly go off without the resident pressing it and would reset itself, which was not supposed to happen. She stated that when working properly, staff placed a magnet over the pendant, which would reset it. Staff #1 stated management was aware that Resident #2's pendant was not working properly; however, staff were instructed to only check on the resident before and after their shifts because the resident was independent with all of her activities of daily living. She stated that when she arrived for her 10:00 p.m. to 6:00 a.m. shift on 8/19/25, she heard Resident #2's pendant going off. Staff #1 stated that the outgoing staff reported they had checked on Resident #2 and attempted to reset the pendant; however, they were unable to do so. Staff #1 stated at 10:00 p.m., she and former Staff #2 conducted their pre-shift check on Resident #2. She stated Resident #2's pendant was still going off, but the resident was safely in bed. Staff #1 stated at some point during the night, Resident #2's pendant randomly reset itself and did not go off again until around 5:00 a.m. the next morning. She stated she had a "bad feeling," and that was when she discovered Resident #2 on the floor. Staff #1 stated Resident #2 reported she had slipped out of bed right after Staff #1 and former Staff #2 had left her room the night before. On 10/22/25 at 12/30 p.m., former Staff #2 stated Resident #2's pendant had not been working properly for about a month before the resident fell on 8/19/25. She stated management were well aware the pendant was not working properly; however, they did not have a back up plan in case of an emergency. Former Staff #2 stated because Resident #2 did not require safety checks and was independent, staff were to only check on the resident before and after their shifts, even though the resident's pendant was faulty. She stated on 8/19/25, the outgoing staff reported that Resident #2's pendant had been going off and that they could not get it to reset. Former Staff #2 stated she and Staff #1 conducted their pre-shift check on Resident #2, who was safely in bed. She stated she and Staff #1 attempted to reset the resident's pendant, but they were unable to do so. Former Staff #2 stated the pendant kept going throughout the night, but then randomly reset itself at some point. She stated Resident #2's pendant went off again around 5:00 a.m., so she and Staff #1 decided to check on her; that was when they found her on the floor. Former Staff #2 stated Resident #2 reported she had slipped out of bed not long after Staff #1 and former Staff #2 had left her room. Additionally, she stated Resident #2 reported she had yelled for help; however, no one heard her and laid on the floor for a little over seven hours.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated whenever the resident's condition changed from baseline status, affecting one of four sample residents (#2). Findings include: 1. Record Review Resident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility. There was no evidence of an assessment completed by the residence in Resident #2's record after a change from baseline status. Record review revealed on 8/29/25, Resident #2 was seen by her external service provider for pain and swelling in her right knee after a fall at the residence. Additionally, on 9/15/25, Resident #2 was transported to the hospital for severe right leg pain. Upon return to the residence, the residence failed to complete an assessment after the resident's change in baseline status. 2. InterviewsOn 10/22/25 at 9:00 a.m., the administrator stated she had not taken over as administrator until 10/7/25, and was unaware that Resident #2 had been sent to the hospital on 9/15/25. She stated that the former resident care coordinator (RCC) or community nurse (CN) should have completed an assessment after Resident #2 returned from the hospital. On 10/22/25 at 9:45 a.m., the assistant executive director stated that the RCC or CN was responsible for updating comprehensive assessments after a change in baseline status. She stated she was unaware that an assessment had not been completed after Resident #2 had returned from the hospital.

Based on record review and interviews, the residence failed to contact the resident's representative whenever the resident experienced a significant change from baseline status, affecting one of four sample residents (#2). (Cross-reference U2230)Findings include: 1. Record Review Resident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility. A face sheet, undated, for Resident #2, indicated that legal representative #1 (LR#1) was "Emergency Contact 1", that legal representative #2 (LR#2) was "Emergency Contact 2", and that legal representative #3 (LR#3) was "Emergency Contact 3. On 10/21/25 at 7:30 a.m., progress notes and resident occurrence reports were requested; however, the residence was unable to provide the requested documentation. 2. Interviews On 10/21/25, at 2:00 p.m., and 2:20 p.m., interviews with Resident #2's LR#1 and LR#2 revealed that the residence failed to contact them after Resident #2 experienced a fall on 8/19/25. Both LR#1 and LR#2 stated they had found out about the fall after LR#3 had contacted them. LR#1 and LR#2 stated that Resident #2 called LR#3 and reported she had fallen the night before and was lying on the ground for over seven hours because her pendant was not working, and that no one could hear her yelling for help. On 10/21/25 at 3:30 p.m., the assistant executive director stated that staff were expected to notify management and the legal representatives when a change in baseline occurred with a resident. She stated she was on vacation when this incident occurred, so she could not explain why staff had not notified Resident #2's legal representatives after the fall. On 10/22/25 at 9:00 a.m., the administrator stated that staff were expected to notify management and legal representatives after a resident experienced a change in baseline status, like a fall. She stated she had not begun employment at the residence until 10/7/25 and was unaware that Resident #2 had a fall, as there was no documentation. Additionally, she was unaware that Resident #2's legal representatives had not been contacted.

Based on interview and record review, the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence, affecting one of four sample residents (#2). (Cross-reference U1110 and U2230)Specifically, Resident #2 had pressed her call light pendant on 8/19/25 after 10:00 p.m. The request for assistance had not been responded to until 8/20/25 at 5:00 a.m., when Staff #1 and former Staff #2 found the resident lying on the ground. The residence's delayed response caused the resident to experience discomfort and pain, including back pain. Within a week, her knees were swollen, and she experienced painful jerking movements and significant discomfort when lying down or sitting to sleep. The resident stated the pain was getting worse and could barely apply pressure on it when walking. On 9/15/25, Resident #2 stated her right knee was causing her severe discomfort, and she was sent to the hospital. Findings include: 1. Record ReviewResident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility. The Resident Agreement for Resident #2, signed and dated 9/12/2025, revealed that Resident #2 agreed to obtain an emergency pendant provided by the residence for use in health, life, and safety emergencies. The care plan, with an effective date of 4/1/25, read, "(Resident #2) understood the call system. In the event the resident needed extra assistance, the resident would call for help ... (Resident #2) was not considered a fall risk; however, staff would monitor and report any and all falls to the wellness director/registered nurse."An external service provider (ESP) note, dated 8/29/25, read in part: (Resident #2) injured her right knee during the fall and noticed swelling in her leg from the knee down ... (Resident #2) ambulates without pain; however, experiences painful jerking movements and significant discomfort when lying down or sitting to sleep ...A resident occurrence report, dated 9/15/25, read in part: (Resident #2) stated her right knee was causing her severe discomfort, and she wanted to go to the hospital. The resident stated the pain was getting worse and could barely apply pressure on it when walking ... Emergency medical services were contacted, and the resident was sent to the hospital. An ESP note, dated 9/17/25, read in part: (Resident #2) had ongoing knee pain which is worse at night. 2. Interviews On 10/21/25 at 8:30 a.m., Resident #2 stated that she could not recall the exact date, but in August 2025, around 10:00 p.m., she had slipped out of bed onto the floor and was unable to get herself up. She stated that her call pendant had not been working properly for the past couple of weeks, but pressed it anyway. Resident #2 stated that staff usually responded right away; however, after about 10 minutes or so, she realized the pendant was not working and started yelling for help. She stated there was no response from staff, and ended up lying on the floor for over seven hours. Resident #2 stated it was around 5:00 a.m. when staff finally entered her room. She stated at first, her back was a bit sore from lying on the ground for so long, but refused to be transported to the hospital. Resident #2 stated that approximately a week later, she noticed her right leg from her knee down was swollen and sore as a result of the fall, and had gone to her ESP to have it looked at. Additionally, she stated she ended up going to the hospital because the pain in her right leg and knee was unbearable, and she could not put pressure on it. On 10/21/25 at 2:20 p.m., Resident #2's family member stated that the resident's pendant had not been working properly prior to her fall on August 19th, 2025. She stated that the residence provided another pendant to Resident #2; however, that one was not working either. The family member stated that even though Resident #2 was extremely independent, she was surprised that the residence didnot have staff complete periodic checks on Resident #2 until the pendant issue had been resolved. She further stated that if staff had done periodic checks, Resident #2 would have been found sooner and not been on the floor for over seven hours. Resident #2's family member stated Resident #2 ended up going to the hospital because the pain had become so severe. On 10/21/25 at 3:30 p.m., the assistant executive director (AED) stated she was on vacation when Resident #2 had fallen and heard that her pendant was not working properly during that time. She stated that Resident #2 was independent and did not require safety checks; however, because the pendant was not working properly, the residence should have had a temporary plan until the issue had been resolved. On 10/22/25 at 9:38 a.m., Staff #1 stated that Resident #2's pendant had not been working properly prior to her on 8/19/25. She stated Resident #2's pendant would randomly go off without the resident pressing it and would reset itself, which was not supposed to happen. She stated that when working properly, staff placed a magnet over the pendant, which would reset it. Staff #1 stated management was aware that Resident #2's pendant was not working properly; however, staff were instructed to only check on the resident before and after their shifts because the resident was independent with all of her activities of daily living. She stated that when she arrived for her 10:00 p.m. to 6:00 a.m. shift on 8/19/25, she heard Resident #2's pendant going off. Staff #1 stated that the outgoing staff reported they had checked on Resident #2 and attempted to reset the pendant; however, they were unable to do so. Staff #1 stated at 10:00 p.m., she and former Staff #2 conducted their pre-shift check on Resident #2. She stated Resident #2's pendant was still going off, but the resident was safely in bed. Staff #1 stated at some point during the night, Resident #2's pendant randomly reset itself and did not go off again until around 5:00 a.m. the next morning. She stated she had a "bad feeling," and that was when she discovered Resident #2 on the floor. Staff #1 stated Resident #2 reported she had slipped out of bed right after Staff #1 and former Staff #2 had left her room the night before. On 10/22/25 at 12/30 p.m., former Staff #2 stated Resident #2's pendant had not been working properly for about a month before the resident fell on 8/19/25. She stated management was well aware the pendant was not working properly; however, they did not have a backup plan in case of an emergency. Former Staff #2 stated because Resident #2 did not require safety checks and was independent, staff were instructed by management to only check on the resident before and after their shifts, even though the resident's pendant was faulty. She stated on 8/19/25, the outgoing staff reported that Resident #2's pendant had been going off and that they could not get it to reset. Former Staff #2 stated she and Staff #1 conducted their pre-shift check on Resident #2, who was safely in bed. She stated she and Staff #1 attempted to reset the resident's pendant, but they were unable to do so. Former Staff #2 stated the pendant kept going throughout the night, but then randomly reset itself at some point. She stated Resident #2's pendant went off again around 5:00 a.m., so she and Staff #1 decided to check on her; that was when they found her on the floor. Former Staff #2 stated Resident #2 reported she had slipped out of bed not long after Staff #1 and former Staff #2 had left her room. Additionally, she stated Resident #2 reported she had yelled for help; however, no one heard her and laid on the floor for a little over seven hours.

Based on record review and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary occurrences and ensure that staff members had documented, before the end of their shift, events or issues regarding a resident that they observed or reported to them, affecting one of four sample residents (#2). (Cross-reference U1162)Findings include: 1. Record ReviewResident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility. The record review for Resident #2 revealed that the record did not contain progress notes as follows:An external service provider (ESP) note, dated 8/29/25, read in part: (Resident #2) injured her right knee during the fall and noticed swelling in her leg from the knee down ... (Resident #2) ambulates without pain; however, experiences painful jerking movements and significant discomfort when lying down or sitting to sleep ...A resident occurrence report, dated 9/15/25, read in part: (Resident #2) stated her right knee was causing her severe discomfort and she wanted to go to the hospital. The resident stated the pain was getting worse and could barely apply pressure on it when walking ... Emergency medical services were contacted and the resident was sent to the hospital ... An ESP note, dated 9/17/25, read in part: (Resident #2) had ongoing knee pain which is worse at night. 2. Interviews On 10/21/25 at 8:30 a.m., Resident #2 stated that she could not recall the exact date, but in August 2025, around 10:00 p.m., she had slipped out of bed onto the floor and was unable to get herself up. She stated that her call pendant had not been working properly for the past couple of weeks, but pressed it anyway. Resident #2 stated that staff usually responded right away; however, after about 10 minutes or so, she realized the pendant was not working and started yelling for help. She stated there was no response from staff, and ended up lying on the floor for over seven hours. Resident #2 stated it was around 5:00 a.m. when staff finally entered her room. She stated at first, her back was a bit sore from lying on the ground for so long, but refused to be transported to the hospital. Resident #2 stated that approximately a week later, she noticed her right leg from her knee down was swollen and sore as a result of the fall, and had gone to her ESP to have it looked at. Additionally, she stated she ended up going to the hospital because the pain in her right leg and knee was unbearable, and she could not put pressure on it. On 10/21/22 at 3:30 p.m., the assistant executive director (AED) stated that she was unaware that there were no progress notes for Resident #2 regarding her fall on 8/19/25 and the pain she was experiencing afterwards. She stated that staff were expected to document any incidents that occurred with a resident. The AED could not explain why there were no progress notes for Resident #2.

A relicensure survey and complaint revisit was completed on 10/22/25 for the previous deficiency cited on 7/7/25. The residence is in compliance with all regulations surveyed. The deficiency cited for Event PGT112 was cited prior to the regulation revision that was implemented on 7/1/25.

A relicensure survey with complaint revisit was completed on 7/7/25 for the previous deficiencies cited on 3/19/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25.

Based on record review and interview the residence failed to comply with authorized practitioner ordersassociated with medication administration affecting one of 10 sample residents (#9). This deficiency was cited previously during a state licensure survey 3/19/25. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement. Findings Include:1. Record ReviewResident #9 was admitted to the residence on 8/10/20 with a diagnosis of weakness and cognitive communicationdeficit. A practitioner's order dated 2/28/22 prescribed tramadol HCL one tablet twice daily for joint pain. A practitioner's order dated 5/21/25 prescribed ferrous gluconate 324 mg tablets one tablet twice daily for ironDeficiency. The May medication administration record (MAR) read that Resident #9 missed her dose of tramadol on May 13thand 14th due to the medication not available. The June MAR read that Resident #9 missed her dose of ferrous gluconate on 6/4-/6/7/25 and 6/22-6/27/25 dueto medication not available. 2. InterviewsOn 7/7/25 at approximately 1:30 p.m., the community nurse stated that to ensure residents' medication was filledthe residence had a three check system where the qualified medication administration personnel (QMAP) wouldrequest the medication, the assisted living director would verify the medication and then herself, the communitynurse, would ensure the proper medication was ordered and ordered promptly. She stated that forcommon medications she expected a 48 hour wait for medication refills. On 7/7/25 at approximately 2:15 p.m., the administrator stated that she considered a medication to bemissed due to being out of stock a failure to comply with practitioners' orders, because if there was an issue fillingthe medication an alternative method needed to be found.

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 existingprogram 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:(A) A description of the employee or volunteer duties; (B)Date of hire or acceptance of volunteer service and date duties commenced; (C) Orientation and training, including, but not limited to the following, as applicable: (1) First aid and CPR certification, (2) Proof of portable training(s) accepted by the assisted living residence, including documentation of the acceptance conditions at Part 7.9(D) being met. (D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable; (E) Results of background checks and follow up, as applicable; and (F) Tuberculin test results or proof of a portable test compliant with Part 7.7, if applicable. (G) Documentation of initial dementia training and continuing education for direct-care staff members: (1) The residence shall maintain documentation of each employee ' s completion of initial dementia training and continuing education. Such records shall be available for inspection by representatives of the Department.(2) Completion shall be demonstrated by a certificate, attendance roster, or other documentation. (3) Documentation shall include the number of hours of training, the date on which it was received, and the name of the instructor and/or training entity. (4) Documentation of the satisfactory completion of an equivalent training as defined in sub-part 7.9(B)(2)(b) and as required in the criteria for an exception discussed in sub-part 7.9(B)(4), shall include the information required in this sub-part 7.13 (G)(2) and (3). (5) After the completion of training and upon request, such documentation shall be provided to the staff member for the purpose of employment at another covered facility. For the purpose of dementia training documentation, covered facilities shall include assisted living residences, nursing care facilities, and adult day care facilities as defined in Section 25.5-6-303(1), C.R.S.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (I) Masking or deceiving administration of medication including, but not limited to, concealing in food or liquid. 18.4 At the time of admission, the resident record shall contain, at a minimum, the following items: (A) face sheet18.8 Resident records shall contain, but not be limited to, the following items: (A) face sheet18.9 The face sheet shall be updated at least annually and contain the following information: Resident ' s full name, including maiden name, if applicable; Resident ' s sex, date of birth, and marital status; Resident ' s most recent former address; Resident ' s medical insurance information and Medicaid number, if applicable; Date of admission and readmission, if applicable; Name, contact information, and mailing address, if available, for family members, legal representatives, and/or other persons to be notified specifically in case of emergency; Name, contact information, and mailing address, if available, for the legal representative and all relatives or other persons the resident and/or legal representative specifically designates to receive a notice of discharge in accordance with Part 11.16; Name, address, and contact information for resident ' s practitioner and case manager, if applicable; Resident ' s primary spoken language and any issues with oral communication; Indication of resident ' s religious preference, if any; Resident ' s current diagnoses; and Notation of resident ' s allergies, if any.

A complaint revisit was completed on 3/19/25 for all previous deficiencies on 8/18/22. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event DLP311 were cited prior to the regulation revision that was implemented on 3/17/25.

A complaint revisit was completed on 3/19/25 for the previous deficiency on 8/18/22. The residence is in compliance with all regulations surveyed. The deficiency cited for Event GSXC12 was cited prior to the regulation revision that was implemented on 3/17/25.