Assisted Living at Greeley, LLC

A relicensure survey was completed on 10/1/25. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to thoroughly investigate all allegations of abuse of a resident, affecting one sample resident (#1) and 14 other current residents. (Cross-reference T0410, T0430).Specifically, Resident #1 reported allegations of sexual abuse by Resident #4 on 6/23/25. The residence failed to follow its policy and conduct a thorough investigation that included how the residence protected residents from abuse during the investigations. Resident #1 expressed feeling threatened and harassed by Resident #4. Subsequently, Resident #1 reported sexual abuse and harassment by Resident #5 on 7/17, 7/30, and 9/16/25, and the residence again failed to thoroughly investigate the allegation and did not protect the resident, as the residence failed to move.. Based on record review and interview, the residence failed to comply with occurrence reporting requirements, affecting one of five sample residents (#1) who alleged abuse. (Cross-reference S0410, S1410).Findings include:1. References and Policiesa. 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: (D) Any occurrence involving physical, sexual, or verbal abuse of a client, by another client, an employee of the licensee or a visitor to the facility or agency. b. Chapter VII regulations governing assisted living residences, part 2.1, defines"Abuse" mea.. Based on record review and interview, the residence failed to ensure each care plan was developed with input from the resident' s representative and detailed specific personal service needed and preferences, along with the staff tasks necessary to meet those needs, affecting one of five sample residents (#1). Findings include:References and Residential Policy a. Chapter VII regulations governing assisted living residences, part 12.10 requires each resident care plan to include: (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs.b. The resident' s Procedure for Suspected or Verified Physical Abuse, dated 8/1/14, read in part, "all actions and interventions must be recorded in the appropriate resident records, in the appropriate care plan(s), .. 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 one of five sample residents (#1). (Cross-reference U0430, U1410)Findings include:1. References and Policiesa. 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 subjection to sexual conduct or contact that is classified as a crime.c. C.R.S. Section 18-6.5-108, read in part, staff of any care facility w..

A certification survey was completed on 10/1/25. Deficiencies were cited. Based on observation, interview, and record review, the facility (residence) failed to thoroughly investigate all allegations of abuse of a resident, affecting one sample member (resident) (#1) and 14 other current residents. Specifically, Resident #1 reported allegations of sexual abuse by Resident #4 on 6/23/25. The residence failed to follow its policy and conduct a thorough investigation that included how the residence protected residents from abuse during the investigations. Resident #1 expressed feeling threatened and harassed by Resident #4. Subsequently, Resident #1 reported sexual abuse and harassment by Resident #5 on 7/17, 7/30, and 9/16/25, and the residence again failed to thoroughly investigate the allegation and did not protect the resident, as the residence failed to move.. Based on record review and interview the facility (residence) failed to report critical incidents to the (HCBS)member' s (resident) case management agency case manager within 24 hours of the alleged incidents.Findings Include:1. References and Resident Policies Colorado Code of Rules (CCR) 10 2505-10 8.7000 governing assisted living residences, part 8.7411 (B), require a provider agency submit a verbal or written report for all Critical Incidents, as defined at Section 8.7201.L.5, to the home and community based services (HCBS) Member ' s Case Management Agency Case Manager within 24 hours of discovery of the actual or alleged incident. The report must include: Name of person reporting; name of member who was involved in the incident; member ' s medicaid identific.. Based on record review and interview, the facility (residence) failed to ensure each care plan was developed with input from the members (resident' s) representative and detailed specific personal service needed and preferences, along with the staff tasks necessary to meet those needs, affecting one of five sample residents (#1). Findings include:References and Residential Policy a. Chapter VII regulations governing assisted living residences, part 12.10 requires each resident care plan to include: (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs.b. The resident' s Procedure for Suspected or Verified Physical Abuse, dated 8/1/14, read in part, "all actions and interventions must be recorded in the appropriate resident records, in the appr.. Based on record review, and interview the facility (residence) failed to provide victim support for any allegations ofmistreatment, abuse, neglect and exploitation (MANE), affecting one of five sample members (residents) (#1).Findings Include:1. ReferenceColorado Code of Rules (CCR) 10 2505-10 8.7000 governing assisted living residences, part 8.7411 (F), requiresthat provider agencies provide victim support for any allegations of MANE.2. Record Reviewa. Resident #1 was admitted to the residence on 8/23/23 with a diagnosis including schizophrenia and post-traumatic stress disorder (PTSD). Resident #4 was admitted to the residence on 1/25/24 with a diagnosis including schizophrenia, bipolar, and emotional dysregulation disorders (EDD). Resident #5 was admitted to the resid..

A revisit survey was completed on 7/18/23 for all previous deficiencies cited on 11/14/22. 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