Applewood Our House Assisted Living Facilities II LLC

A revisit survey was completed on 3/25/26 for all previous deficiencies cited on 11/3/25. The facility is in compliance with all deficiencies that were cited. 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 licensure complaint, prompted by #CO41080, was completed on 11/3/25. Deficiencies were cited. Based on observation and interview the residence failed to ensure a readily available contact for the administrator or qualified designee was posted in the residence, affecting 14 current residents. 1. Observation On 11/3/25, during an onsite survey, the residence failed to ensure the name and contact information for the administrator or qualified designee on duty were readily available to the residents and public. 2. Interviews On 11/3/25 at 12:05 p.m., a family member of Resident #2 stated that she was unaware of who the current administrator was or if there had been a pos.. Based on record review and interview the residence failed to ensure that competency testing shall be performed to demonstrate that the individuals trained have a comprehensive, evidence-based understanding of the regulations and topics affecting 14 current residents (Cross-reference U540 and U510) Findings include:1. ReferenceThe residence' s job description for the administrator or designee read in part, that the designee was to provide oversight of all resident care, including assessments and care planning. Conduct comprehensive nursing assessments for new re.. Based on record review and interview, the residence failed to ensure that the appointed administrator is of good, moral, and responsible character, the assisted living residence shall request a fingerprint-based criminal history record check with notification of future arrests prior to hire, affecting 14 current residents. (Cross reference U534 and U0662)On 11/3/25, at 11:46 a.m., the administrator of record' s fingerprint-based criminal history record check was requested.On 11/3/25, at approximately 12:45 p.m., a second request for the administrator of record' s histor.. Based on record review and interview, the residence failed to have the personnel files readily available onsite for department review, affecting 14 current residents. (Cross reference U0510)Findings include: On 11/3/25, at 11:46 a.m., the residence personnel files were requested; however, it was not available on site. On 11/3/25, at approximately 12:45 p.m., a second request for the administrator of record' s personnel file was submitted. On 11/3/25 at 3:30 p.m., the administrator of record' s file was not provided. On 11/3/25 at 1:28 p.m., the administrato.. Based on record review, observation, and interview, the residence failed to ensure day-to-day services were provided per the residents agreement, including failure to complete comprehensive assessments or update care plans after baseline changes, affecting four sample residents (#1-#4). (Cross-reference U534)Findings include: 1. Record Review a. A resignation letter dated September 15, 2025, on company letterhead read in part that the previous administrator had given 30 days' notice. B .A letter located in an emergency binder dated 10/15/25, read in p.. 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 7.10.1 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.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the foll..

A revisit survey was completed on 5/29/25 for all previous deficiencies cited on 3/11/25. The facility is in compliance with all deficiencies that were cited. 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 licensure survey and complaint revisit was completed on 3/11/25 for all previous deficiencies cited on 12/30/24. A deficiency was cited. Based on record review and interview, the residence failed to meet the required elements and have written policies and procedures regarding an involuntary discharge grievance policy, affecting 14 current residents.This deficiency was cited previously during a state licensure survey and complaint on 12/30/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Residence PolicyThe residence' s Personnel Policy, dated January 2025, read in part: "The administrator is designated by Applewood Our house to receive involuntary discharge grievance notices. Residents are can submit a grievance either orally or in writing 14 days after the resident have been issued discharge notice ..."Record ReviewOn 3/11/25 at 10:00 a.m., the residence' s involuntary discharge grievance policy was requested, however, it lacked some of the required elements of Chapter 7, Regulation 9.3 (A-I).InterviewOn 3/11/25 at 12:10 p.m., the administrator stated that the residence did work on updating the policy in January of 2025 with an outside provider and thought the updated policy had all the required elements but acknowledged components were missing. 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

12.2.2 (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility' s Infection Prevention and Control Program and training. This individual shall be responsible for the following: Based o.. A relicensure survey with complaint #CO31771 was completed on 12/30/24. Deficiencies were cited. Based on observation and interview the residence failed to provide a physically safe and sanitary environment to reduce the risk of potential hazards, affecting 16 current residents.Findings include:On 12/30/24 at 8:23 a.m., Staff .. Based on observation and interview, the residence failed to ensure residents had independent access to drinks at all times, affecting 16 current residents residing in the secure environment.Findings Include:1. ObservationsDuring an on.. Based on observation and record review the residence failed to ensure that residents have freedom of movement to common areas and resident personal spaces, affecting 16 current residents.Findings include:During an onsite visit on .. Based on observation, record review and interview, the residence failed to ensure resident care plans contained a description of how the resident will have continuous independent access to his or her individual room, along with the.. Based on observation, record review, and interview, the residence failed to maintain a fall management program which included detailing in each resident' s care plan the individualized approaches necessary to address fall risks, aff.. Based on record review and interview the residence failed to meet the required elements and have written policies and procedures regarding an involuntary discharge grievance policy, affecting 16 current residents.On 12/30/24 at 9:.. Based on record review and interview the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting 16 current resident.. Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire(s), gas explosio.. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 16 current residents.Findings include:On 12/.. Based on record review and interview, the residence failed to identify the highest potential risk, hold, and document routine drills to facilitate staff and resident response to that risk, affecting 16 current residents.Findings include:On .. Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records list, controlled substance list, medication error reports and .. 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 regul..

A complaint revisit was completed on 12/30/24 for all previous deficiencies cited on 12/20/22. A deficiency was cited. Based on observation, record review and interview, the residence failed to ensure resident care plans contained a description of how the resident will have continuous independent access to his or her individual room, along with the residence' s plan to protect the resident from unwanted visitation by other residents, identification of the type and level of staff oversight, monitoring, and/or accompaniment that the residence deems necessary to meet the needs of the resident within the secure environment and secure outdoor area, and documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their possession for self-care, and how those items are stored to prevent unauthorized access by other residents affecting three of three sample residents (#5, #6, #7). (Cross-reference S2960).This deficiency was cited previously during a state licensure survey and complaint on 12/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. ObservationDuring an onsite visit on 12/30/24 from 7:15 a.m. to 5:30 p.m., the secure environment had locked bedroom and bathroom doors that required staff to unlock with a key to enter. The bathrooms contained resident' s personal hygiene items in individual baskets on a shelf. Additionally, residents of the residence wandered throughout the residence and attempted to enter other resident' s rooms without permission.2. Record ReviewResident #7 was admitted to the residence on 11/19/24 with a diagnosis of dementia.An updated care plan revealed no documentation describing Resident #7 continued independent access to their room or unwanted visitation by other residents, the type and level of oversight, monitoring, and accompaniment both within and outside the secure environment, and documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their possession for self-ca..