Applewood Our House Assisted Living LLC

A relicensure survey, with a complaint #CO41162, was completed on 12/3/2025. Deficiencies were cited. Based on interview and record review the residence failed to ensure the administrator and qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration records affecting eight current residents. Findings include:1. Record reviewOn 12/3/25 at approximately 3:00 p.m., the house manager provided a document intended to audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records; however, the document was blank and not completed.2. InterviewOn 13/3/25 at 3:44 p.m., the administrator acknowledged t.. Based on interview and record review, the residence failed to have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting eight current residents. Specifically, the residence did not ensure that a staff member with current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques was on duty for 33 shifts between November 1 and December 1, 2025, leaving those shifts without required coverage. This failure warranted an Immediate Jeopardy (IJ) determination because, during these weeks, residents were at risk of e.. Based on record review and interview, the residence failed to develop written policies to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, including, but not limited to, a long-term power failure, affecting eight current residents.Findings include:1. Record ReviewOn 12/3/25 at 1:51 p.m., all emergency preparedness documents were requested. The residence was unable to provide emergency preparedness documents, which included written policies to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency.2. InterviewOn 12/3/25 at approximately 3:00 p.m., the .. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents and their room assignments, affecting eight current residents.Findings include:1. Record reviewOn 12/2/25 at 8:00 a.m., Staff #1 was asked to provide a resident roster. She provided the emergency preparedness book, which contained an outdated roster and overstated the total number of residents as nine instead of eight. The emergency preparedness book also lacked a diagram of the residence.2. InterviewOn 12/2/25 at 8:00a.m., Staff #1 stated that there were nine residents living in the residence, when in fact there were eight residents.On 12/3/25 at 3:36 a.m., t.. Based on record review and interview, the residence failed to reassess residents every six months for the need of a secure environment, affecting two out of three sample residents in the secure environment (#1,#3). Findings include:1. Record reviewResident #1 was admitted to the residence on 10/29/24 with a diagnosis of dementia and resided in a secured environment.On 12/3/25 at approximately 9:30 a.m., Resident #1 ' s record contained a care plan for Resident #1, dated 10/22/24. However, the record contained no additional evidence that the residence had re-assessed the resident every six months for the need for a secure environment.2. InterviewOn 12/3/25 at 3:52 p.m..

A revisit survey was completed on 9/24/25 for all previous deficiencies cited on 4/18/25. 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 revisit was completed on 4/18/25 for the previous deficiencies cited on 11/15/22. Deficiencies were 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' s orders associated with medication administration, affecting one of three sample residents (#12).This deficiency was cited previously during a state licensure survey on 1/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #12 was admitted to the residence on 7/11/24 with diagnoses including aortic valve regurgitation and gout. He received services from an external hospice provider.A written practitioner' s order, dated 3/1/25, directed the residence to administer tramadol 50 mg three times daily. However, the April 2025 medication administration record (MAR) revealed that the residence failed to administer one dose of the medication on 4/11/25. The MAR contained no documentation for the reason that staff did not administer the medication on 4/11/25.On 4/18/25, at 1:49 p.m., the house manager stated that the residence was out of stock for the bedtime dose of tramadol on 4/11/25. She stated that the resident had a new nurse and there was miscommunication between the nurse and the pharmacy, which caused a delay in delivery. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements for four of five sample staff, affecting 11 current residents.This deficiency was cited previously during a state licensure survey on 1/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 4/18/25 at approximately 11:00 a.m., CAPS checks for Staff #3-#5 and Former Staff #7 were requested but not provided.On 4/18/25 at 10:28 a.m., the administrator acknowledged that the HRD was responsible for obtaining and maintaining all staff records.On 4/18/25 at 10:28 a.m., the human resource director (HRD) stated she had been working on turning all staff documents into electronic files, but she was not done with the process and was unable to provide them. At 11:25 a.m., the HRD stated that the CAPS checks were saved on a hard drive off site and she would provide them electronically.The residence did not provide CAPS checks for any of the above staff.

A licensure complaint, prompted by #CO39862, was completed on 4/18/25. Deficiencies were cited. Based on interview and record review, the residence failed to re-assess a resident when the resident' s condition changed from baseline status, affecting one current resident (#11).Findings include:Resident #11 was admitted to the residence on 1/28/25 with diagnoses including dementia and conduct disorder, child onset type. Progress notes, date.. Based on observations and interview, the residence failed to ensure that residents in the secure environment had all the same resident rights as set forth in Part 13 of Chapter VII regulations, including the right to privacy and confidentiality, affecting one of three sample residents (#11).Findings include:1. ObservationsOn 4/18/25 at approxi.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting one of three sample residents (#12).Findings include:Resident #12 was admitted to the residence on 7/11/24 with diagnoses including aortic valve regurgitation and gout. He received servi.. Based on record review and interview, the residence failed to ensure that resident records included progress notes of out of the ordinary events or issues along with the actions taken by staff to address the residents' changing needs, affecting two of three sample residents (#11, #13).Findings include:On 4/18/25 at 7:32 a.m., Staff #6 stated that Res.. Based on record review and interview, the residence failed to ensure that residents had the right to be free from neglect, affecting 11 current residents. (Cross-reference B172, S630, S636)Findings include:A law enforcement report, dated 4/17/25, read in part that law enforcement arrived at the residence on 4/15/25 at 1:53 a.m. and found Forme.. Based on record review and interview, the residence failed to ensure that the enhanced care plan included a description of the resident' s behavioral expressions along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, affecting 1 current resident (#11).Findings in.. Based on record review and interview, the residence failed to have policies and procedures restricting on-site access by staff with drug or alcohol use that would adversely impact their ability to provide resident care and services, affecting 11 current residents. (Cross-reference S630, S1324)Findings include:The residence' s undated Reasonable Sus.. Based on record review and interview, the residence failed to have staff members who were physically and mentally able to adequately and safely perform all functions essential to resident care, affecting 11 current residents. (Cross-reference S636, S1324)Findings include:A law enforcement report, dated 4/17/25, read in part that law enfor.. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements for four of five sample staff, affecting 11 current residents.Findings include:On 4/18/25 at approximately 11:00 a.m., CAPS checks for Staff #3-#5 and Former Staff #7 were requested bu.. 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 7.14.29 All prescribed and PRN medications shall be listed and recorded on a medication admi..