Assisted Living at Pueblo LLC

A recertification survey with complaint #CO40144 was completed on 1/13/26. A deficiency was cited. Based on observation, record review and interview, the facility (residence) failed to maintain a home-like quality and feel for members (residents) at all times, affecting one of 9 sample residents (#19).Findings include:The residence' s undated resident agreement read in part: "(The residence) agrees to make available... a physically safe and sanitary environment."On 1/13/26 at 9:40 a.m., during an on-site environmental tour, the following was observed: Resident #19' s room had a strong smell of urine. On 1/13/26 at 4:40 p.m., the administrator confirmed that Resident #19' s room had a strong smell of urine, and it was unsanitary. 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 CCR 2505-10 8.7000. 8.7001.B.2.a.vii Each individual is afforded the opportunity to:vii. Each individual is afforded the opportunity to:1) Lead the development of, and grant informed consent to, any provider-specific treatment, care, supports, or service plan;2) Have freedom of religion and the ability to participate in religious or spiritual activities, ceremonies, and communities;3) Live and receive services in a clean, safe environment;4) Be free to express their opinions and have those included when any decisions are being made affecting their life;5) Be free from physical abuse and inhumane treatment;6) Be protected from all forms of sexual exploitation;7) Access necessary medical care which is adequate and appropriate to their condition;8) Exercise personal choice in areas including personal style; and9) Accept or decline services and supports of their own free will and on the basis of informed choice.8.7001.B Individual Rights under the Home and Community-Based Services (HCBS) Settings Final Rule3. Additional Criteria for HCBS Settingsa. Provider-Owned or -Controlled Residential Settings must ..

A relicensure survey with complaint #CO40143 was completed on 1/13/26. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to maintain a physically safe and sanitary environment, affecting one of 9 sample residents (#19).Findings include:The residence' s undated resident agreement read in part: "(The residence) agrees to make available... a physically safe and sanitary environment."On 1/13/26 at 9:40 a.m., during an on-site environmental tour, the following was observed: Resident #19' s room had a strong smell of urine. On 1/13/26 at 4:40 p.m., the administrator confirmed that Resident #19' s room had a strong smell of urine, and it was unsanitary. 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 52 current residents.Findings include:On 1/13/26 at 7:45 a.m., the most current resident roster was requested from the residence. Staff #4 provided a roster which did not include emergency contact information, resident room numbers, and a diagram of the residence. A date at the bottom of the roster read it was updated on 1/8/26.On 1/13/26 at 8:10 a.m., a resident roster was requested the second time; however, the Administrator Designee provided an emergency roster which did not include resident room numbers. On 1/13/26 at 3:40 p.m, a resident roster was requested the third time; however, the administrator provided the same emergency roster as the administrator designee, which did not include resident room numbers. On 1/13/26 at 4:40 p.m., the administrator acknowledged the deficiency, and stated that the roster should have include.. 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 7.9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interfere..

A second initial relicensure survey revisit was completed on 1/13/26 for the previous deficiencies cited on 11/30/22. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25. 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 52 current residents.This deficiency was cited previously during a state licensure survey 11/30/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:On 1/13/26 at 7:45 a.m., the most current resident roster was requested from the residence. Staff #4 provided a roster which did not include emergency contact information, resident room numbers, and a diagram of the residence. A date at the bottom of the roster read it was updated on 1/8/26.On 1/13/26 at 8:10 a.m., a resident roster was requested the second time; however, the Administrator Designee provided an emergency roster which did not include resident room numbers. On 1/13/26 at 3:40 p.m, a resident roster was requested the third time; however, the administrator provided the same emergency roster as the administrator designee, which did not include resident room numbers. On 1/13/26 at 4:40 p.m., the administrator acknowledged the deficiency, and stated that the roster should have included resident room numbers. She further stated that the residence had not maintained compliance because an unknown staff member removed the resident room information during roster updates.