Aspen Ridge Alzheimers Special Care Center

A licensure complaint, prompted by #CO40937 and #CO41356, was conducted on 1/7/26. Deficiencies were cited. Based on interviews and record review, the residence failed to thoroughly investigate allegations of abuse, affecting four of nine sample residents (#1, #2, #5 and #8). (Cross reference U0410,U0430, and U3062) Specifically, the residence failed to investigate allegations of abuse. On 11/9/25 an incident of resident-to-resident abuse between Resident #1 and Resident #5 occurred. Resident #1 pushed resident #5 to the ground, There was no investigation nor interventions put into place to prevent future incidents . On 1/2/26/26 Resident #1 striked Resident #8, causing a skin tear to Resident #8' s hand. There was an investigation for the incident on 1/26/26 however there were multiple elements missing in the investigation including an updated care plan or how they would protect the residents during .. Based on record review and interview, the residence failed to ensure an enhanced care plan was developed with input from the resident' s representative and detailed specific personal service needs and preferences, along with the staff tasks necessary to meet those needs, affecting two of nine sample Resident (#2 and #1). (Cross reference U0410) Specifically, Resident #2 fell 13 times in three months. Two of the falls resulted in injury and one with the resident hitting her head. On 12/4/25 Resident #2 was found on the floor with a skin tear to her right forearm which required basic first aid.On 12/11/25 Resident #2 was walking down the hallway when she fell and obtained a new skin tear to her right hand.On 12/29/25 Resident #2 fell while walking and hit her head on the cabinet. The care plan was not up.. Based on record review and interview, the residence failed to report an occurrence affecting two residents (#1 & #2) out of nine sample residents. (Cross-reference U0410 and U1410) Findings include:1. Reference a. Chapter II regulations governing assisted living residences, part 4.2.2, requires that the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (A) Any occurrence that results in the death of a client of the facility or agency and is required to be reported to the coroner pursuant to section 30-10-606, C.R.S., as arising from an unexplained cause or under suspicious circumstances.b. According to the Occurrence Reporting Manual, dated Ma.. Based on record review and interview, the residence failed to report suspected physical abuse to law enforcement (LE) within 24 hours of discovery pursuant to Colorado Revised Statutes (C.R.S.), affecting two of nine sample residents (#1 & #2). (Cross-reference U0430, U1410)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences: Part 2.8, defines an "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (F) Is mentally impaired.b. Chapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" means the non-accidental infliction of bodily injury, serious bodily injurt or death and confinement or restraint that is unreason..

A revisit survey was completed on 9/24/25 for all previous deficiencies cited on 7/15/25. 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 relicensure survey with complaint revisit was completed on 7/15/25 for all deficiencies cited on 5/23/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The Chapter VII regulations were implemented on 5/23/23 and the new Chapter VII regulations were 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 four sample residents (#4).This deficiency was cited previously during a state licensure survey 5/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #4 was admitted to the residence on 2/17/22, diagnoses included dementia. A written practitioner' s order, dated 11/23/23, directed the residence to administer two 325 mg acetaminophen tablets three times a day. However, the July 2025 medication administration record (MAR) revealed that the residence failed to administer two doses on 7/7 and three doses from 7/9 to 7/11/25. The MAR read the medication had not been given because it was not available. On 7/15/25 at 2:41 p.m., the health services director (HSD) said they had an order but the pharmacy needed a script from a practitioner to fill the order. The HSD said there was nothing preventing the residence from purchasing the medication until the pharmacy was able to deliver.On 7/15/25 at 4:30 p.m., the administrator said the deficiency was being cited again because the residence was continuing to work on a process with the pharmacy to avoid medication not being available.

A relicensure survey with complaint #CO038130 and CO40248 were completed on 7/15/25. Deficiencies were cited. Based on observation, interview and record review the residence failed to ensure resident care plans contained a description of of how residents would have continuous independent access to his or her individual room, along with the a plan to protect the resident from unwanted visitation by other residents, affecting four of four sample residents (#4 - #7) who resided in a secure environment (SE).Findings include:Resident #5 was admitted to the residence on 2/3/23, diagnosis included dementia.A care plan, dated 4/11/25, did not include a description of how the resident would have continuous independent access to her individual room.On 7/15/25 at 7:20 a.m, Staff #17 approached an unknown resident' s room, knocked on the door and used a key from her pocket to unlock the door. Staff #17 said all t.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting one of four sample residents (#4).This deficiency was cited previously during a state licensure survey 5/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #4 was admitted to the residence on 2/17/22, diagnoses included dementia. A written practitioner' s order, dated 11/23/23, directed the residence to administer two 325 mg acetaminophen tablets three times a day. However, the July 2025 medication administration record (MAR) revealed that the residence failed to administer two doses on 7/7 and three doses from .. Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment, affecting four of four sample residents (#4 - #7) who resided in a secure environment (SE).Findings include:Resident #4 was admitted to the residence on 2/17/22, diagnosis included dementia. The record for Resident #4 contained an initial practitioner' s evaluation, date unknown, for the placement in a secure environment. However, the record contained no further evidence that the residence included the attending practitioner to reassess the resident every 6 months for the continued need of a secure environment. On 7/15/25 at 4:30 p.m., the administrator said she did not know it was required to include the attending practitioner to assess 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 7.25.26 A secure environment shall meet the following criteria: Is independently accessible to residents without staff assistance for entrance or exit.

A licensure complaint, prompted by #CO34050 and #CO34904, was completed on 3/19/24. Deficiencies were cited. Based on record review and interview the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting two of three sample residents (#5, #6) and one former resident (#8).Findings include:1. Residence PolicyThe residence' s Medication Errors policy, dated 3/10/23, read in part, "Medication assistance and/or administration will be provided to residents in a manner that is safe and consistently free of errors ... The community will document and will be responsible to ensure that medications are administered without errors ... Examples of medication errors include ... a missed dose of medication ... "2. Resident #6 was admitted to the residence on 3/14/24 with diagnoses including fractured ribs and humeral fracture.a. Acetaminophen A written practitioner' s order, dated 3/15/24, directed the residence to administer acetaminophen 325 mg two table.. Based on record review and interview, the residence failed to ensure that no medication was administered by a qualified medication administration person (QMAP) on a pro re nata (PRN) or "as needed" basis, affecting one of three sample residents (#5) and one former resident (#8).Findings include:1. Resident #5 was admitted to the residence on 5/23/23 with diagnoses including dementia.A written practitioner' s order, dated 2/12/24, directed the residence to administer quetiapine 25 mg as needed for behavioral disturbance.The March 2024 medication administration record for Resident #5 read on 3/15/24 Resident #5 was administered quetiapine 25 mg at 8:53 p.m., "Per (health services director, HSD)."2. Evidence obtained during the onsite visit revealed the residence additionally failed to ensure that no medication was administered by a QMAP on a PRN basis for Former Resident #8. 3. InterviewsOn 3/19 at 10:22 a.m.. Staff #17 said Resident #5 was unable to request or understand the need for one of her as needed medications... Based on record review, and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one of three sample residents (#7).Findings include:1. Residence PolicyThe residence' s Abuse, Neglect, Misappropriation and Injuries of Unknown Sources policy, dated 8/1/21 read in part, "An injury should be classified as an injury of an unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. The injury is suspicious because of the extent of the injury, the location of the injury ...the number of injuries observed at any particular point in time, or the incidence of injuries over time ... Interview and obtain a statement from any persons allegedly involved, including the affected resident, the complainant, the accused perpetrator, any witnesses and any other persons who may have firsthand knowledge o..

A relicensure survey with complaint #CO32003 was completed on 5/23/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure at least one staff member was onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 39 current residents. Specifically, the residence failed to have at least .. Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting two of four sample residents (#1, #4). (Cross-reference Q1514)Specifically, the residence failed to administer metoprolol tartrate and lisinopril (medic.. Based on observation, record review and interview, the residence failed to establish a fall management program that included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting one sample resident (#2). Specifically, Resident #2 was admitted to the re.. Based on record review and interview, the administrator failed to be responsible for establishing and maintaining an infectious disease mitigation, vaccine and treatment plan; and, assigning at least one staff member responsible for the site management of the residence' s Infection Prevention and Control Program and training, affecting 39 current resid.. Based on record review and interview, the residence failed to ensure each personnel file included written documentation of training for three of three sample staff (#1-#3), affecting 39 current residents. (Cross-reference Q2978) Findings include: 1. ReferenceChapter VII regulations governing assisted living residences, part 7.8, re.. Based on record review and interview, the residence failed to ensure each staff was provided with training and education within 60 days on providing care and services to residents with dementia/cognitive impairment, that included all required topics for two of three sample staff (#1, #3), affecting 39 current residents. (Cross-reference Q.. Based on record review and interview, the residence failed to ensure staff preparing or serving food completed recognized food safety training and maintained evidence of completion onsite, affecting 39 current residents. Findings include: The residence' s staff list read Staff #1 was a qualified medication administration personnel (QMAP) and a car.. 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, controlled substance list, medication error reports, and medication disposal records, quarterly, affecting 39 .. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents with emergency contact information along with a residence diagram, affecting 39 current residents.Findings include: On 5/23/23 at 8:17 a.m., the residence' s roster was requested from the administrator. The residence' s provi.. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, for three of three sample staff (#1-#3), affecting 39 current residents. Findings include:1. References a. Chapter VII regulations g.. 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 7.12.9 The comprehensive assessment shall be updated for each resident ..