Aspen Leaf Assisted Living-Flagler Co

A revisit survey was completed on 4/15/26 for all previous deficiencies cited on 12/10/25. 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 revisit survey was completed on 4/15/26 for all previous deficiencies cited on 12/10/25. 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 recertification survey with complaint #CO40264, was completed on 12/10/25. A deficiency was cited. Based on record review and interview the facility (residence) failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting one of four sample members (residents) (#3). Findings include:1. Resident #3 was admitted to the residence on 8/23/24.The November 2025 electronic medication administration record (EMAR), read the following medications were being administered with no signed and dated practitioner' s orders on file: alive women' s multivitamin, citrical + vitamin D3, vitamin B-12 1000 mcg daily, and zithromax 250 mg for three days.The December 2025 EMAR, read the following medications were being administered with no signed and dated practitioner' s orders on file: alive women' s multivitamin, citrical + vitamin D3 and vitamin B-12 1000 mcg daily.2. InterviewOn 12/10/25 at 9:35 a.m., the administrator stated that herself and the community manager received medication orders from the practitioners; entered the order into the residence' s electronic system; sent the practitioner' s order to the pharmacy; and followed up with the pharmacy on the medication orders being filled and delivered to the residence. The administrator stated that she was responsible for ensuring that all practitioner' s orders were signed, dated, and in the resident' s records for all medications being admi.. 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 8.7000.8.7001.B.3.a.viii Individuals are able to smoke and vape nicotine products in a safe, designated outdoor area, unless prohibited by the restrictions on smoking near entryways set forth in the Colorado Clean Indoor Air Act, Section 25-14-204(1)(ff), C.R.S., or any law of the county, city, or other local government entity. 8.7408.A.10.a Provider Agency shall have a documented contingency plan for providing services if a Member' s caregiver or direct service provider are unavailable due to an emergency or unforeseen circumstances.8.7408.A.12.c. Each HCBS Provider Agency shall have written policies and procedures to address emergencies, unless otherwise specified within service regulations. 8.7506.F.2 a. In consultation with Members served, Alternative Care Facility Provider Agencies shall provide social and recreational engagement opportunities both within and outside the setting. i. Opportunities for social and recreational engagement shall take into consideration the individual interests and wishes of the Members. 8.7506.F.5.b Alternative Care Facilities shall provide an outdoor are..

A relicensure survey with complaint #CO40263, was completed on 12/10/25. Deficiencies were cited. A change of ownership occurred on 10/21/25. Based on observation and interview, the residence failed to ensure that opened or prepared refrigerated foods were date-marked with a "use by" or "discard by" date, affecting 11 current residents.Findings include:During an environmental tour on 12/9/25 at 7:55 a.m., the residence' s refrigerator revealed multiple unmarked containers of food.On 12/9/25 at 7:55 a.m., the community manager stated being unsure how staff were labeling when foods were opened or prepared, and acknowledged the containers in the refrigerator did not have a label that had the food name or a use-by or discard date. The community manager acknowledged that staff needed to create a label.On 12/10/25 at 9:43 a.m., the administrator acknowledged that, due to a lack of oversight, there had been no process in place for st.. Based on record review and interview, the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting one of four sample residents (#3). (Cross Reference U1604)Findings include:1. Resident #3 was admitted to the residence on 8/23/24.The November 2025 electronic medication administration record (EMAR), read the following medications were being administered with no signed and dated practitioner' s orders on file: alive women' s multivitamin, citrical + vitamin D3, vitamin B-12 1000 mcg daily, and zithromax 250 mg for three days.The December 2025 EMAR, read the following medications were being administered with no signed and dated practitioner' s orders on file: alive women' s multivitamin, citrical + vitamin D3 .. Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records on a quarterly basis, affecting 11 current residents. (Cross Reference U1530)Findings includeOn 12/9/25 at 7:52 a.m., documentation of the last two quarterly medication administration record audits was requested; however, was not provided.On 12/9/25 at 2:18 p.m., the community manager stated that she had completed the medication audits in May 2025 and June 2025, and the previous owner had two caregivers complete the medication audits.On 12/9/25 at 2:20 p.m., the.. 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. 10.6 Each assisted living residence' s emergency policies shall address, at a minimum, all of the following items:(A) Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the ..

A revisit survey was completed on 8/3/23 for all previous deficiencies cited on 2/1/23. The facility is in compliance with all deficiencies 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 relicensure survey was completed on 2/1/23. Deficiencies were cited. Based on observation and interview, the residence failed to place in a visible location the residence' s process to handle grievances or complaints, as well as contact information for required agencies, affecting 12 current residents. Findings include: On 2/1/23 at approximately 8:00 a.m., no grievance policy with contact information for the adult protection services, advocacy services of the area' s agency on aging, nor any state department contacts were visible within the residence. On 2/1/23 at 11:00 a.m., Staff #1 stated he had not seen the postings for the process for raising concerns and addressing grievances and complaints in a visible location since he began his employment with the residence in October of 2022.On 2/1/23 at 3:15 p.m., the administrator stated the residence had a grievance policy but confirmed it was not posted in a visible location on the day of survey. She added the only posted agency contact information was for the local ombudsman. She stated that "the residence had a couple of residents who liked to take.. Based on observation, interview and record review, the residence failed to ensure the name and contact information for the administrator was readily available to the residents and public, affecting 12 current residents. Findings include:1. References Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. 2. ObservationsOn 2/1/23 at approximately 7;30 a.m., no name and contact information for the administrator was visibly available where residents and/or the public could access the information. 3. InterviewOn 2/1/23 at 11:00 a.m., Staff #1 stated he had not seen the name and contact information of the administrator on a visible location since he began his employment with the residence in October of 2022.On 2/1/23 at 3:30 p.m., the administrator stated she had known it was required that her name and contact information be readily available to re.. 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 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.(A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI).12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (A) Providing fall management education and materials to residents and family members; (B) Detailing..