Aspens at Fort Collins

A complaint revisit was completed on 10/22/24 for all previous deficiencies cited on 8/24/23. A deficiency was cited.The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. Based on observation and interview, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting 47 current residents. This deficiency was cited previously during a complaint revisit on 8/24/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 10/22/24 at approximately 8:00 a.m., an environmental tour of the common courtyard revealed the following:The courtyard was located in the central part of the building and was accessible to all residents. There was a cement walkway approximately three feet wide in the courtyard that led from one exit of the building to another exit on the opposite side of the courtyard. There were several ledges on the sides of the walkway that dropped approximately three to five inches from the walkway to a rock garden. On 10/23/24 at approximately 2:00 p.m., the acting administrator (AA) acknowledged the environment in the courtyard was unsafe. She said that a contractor was coming to make the repairs in the courtyard. The AA said she had been the administrator since October 2024 and was unsure why the residence did not fix it prior.

A relicensure survey with complaints #CO36970, #CO37365, and #CO37873 was completed on 10/22/24. Deficiencies were cited. Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting 47 current residents. Findings include:On 10/22/24 at 8:00 a.m., quarterly medication audits were requested from the acting administrator (AA).On 10/22/24 at 9:00 a.m., the medication cart audits from August 2024 to October 2024 were provided by the AA; however, the medication cart audits had been completed and signed by a qualified medication administration person (QMAP). The medication cart audits revealed no evidence that audits were completed by the administrator and the QMAP supervisor as required per state regulations. On 10/22/24 at 3:30 p.m., the AA stated she was aware that the residence was required to conduct quarterly medication audits; however, she was not aware that the administrator was required to participate in the audits. Based on observation and interview, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting 47 current residents. Findings include:On 10/22/24 at approximately 8:00 a.m., an environmental tour of the common courtyard revealed the following:The courtyard was located in the central part of the building and was accessible to all residents. There was a cement walkway approximately three feet wide in the courtyard that led from one exit of the building to another exit on the opposite side of the courtyard. There were several ledges on the sides of the walkway that dropped approximately three to five inches from the walkway to a rock garden. On 10/23/24 at approximately 2:00 p.m., the acting administrator (AA) acknowledged the environment in the courtyard was unsafe. She said that a contractor was coming to make the repairs in the courtyard. The AA said she had been the acting administrator since October 2024 and was unsure why the residence did not fix it prior. Based on observation, record review, and interview the licensee failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting 47 current residents.Findings include: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. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1.On 10/22/24 at 8:00 a.m., the acting administrator (AA) introduced herself as the current administrator. On 10/22/24, the department' s database revealed that the AA was not listed as the administrator of record. On 10/22/24 at 8:00 a.m., the AA stated she began employment and took over the role of administrator on 10/8/24. She stated that the corporate office was responsible for submitting the application to the department and was unsure whether they had done so. On 10/22/24..

A complaint revisit was completed on 10/22/24 for all previous deficiencies cited on 5/4/22. A deficiency was cited.The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting 47 current residents. This deficiency was cited previously during a complaint revisit on 5/4/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 10/22/24 at 8:00 a.m., quarterly medication audits were requested from the acting administrator (AA).On 10/22/24 at 9:00 a.m., the medication cart audits from August 2024 to October 2024 were provided by the AA; however, the medication cart audits had been completed and signed by a qualified medication administration person (QMAP). The medication cart audits revealed no evidence that audits were completed by the administrator and the QMAP supervisor as required per state regulations. On 10/22/24 at 3:30 p.m., the AA stated she was aware that the residence was required to conduct quarterly medication audits; however, she was not aware that the administrator was required to participate in the audits.