Birch Assisted Living INC

A complaint revisit was completed on 12/17/25 for all previous deficiencies cited on 9/3/25. The residence/facility is in compliance with all regulations surveyed. 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 #CO41096 was completed on 12/17/25. Deficiencies were cited. Based on observation and interview the residence failed to monitor outdoor smoking areas whenever residents were present, affecting five of 14 sample residents (#20, #29, #31, #32 and #34)Findings include:On 12/16/25 at 8:10 a.m., the residence provided a list of residents who smoke cigarettes. On 12/16/25 at 8:45 a.m., resident #20, #34, and four unnamed residents were observed smoking in the smoking area; however, no staff were present.On 12/17/25 at 9:43.. Based on observation, interview and record review the residence failed to develop and implement a fall management program affecting 2 of 14 sample residents with falls (#3 and #13).Specifically, On 12/5/25, Resident #3 sustained one fall. The residence failed to update the care plan and implement fall interventions. Subsequently, the resident sustained a second fall on approximately 12/11/25 with continued pain until 12/13/25 and deep bruising to he.. Based on observation, interview, and record review, the residence failed to provide personal services and protective oversight for one of one (#8) resident affecting 43 current residents.Specifically, Resident #8 was last seen by the residence on 12/11/25. A progress noted dated 12/11/25 read in pertinent part, Resident #8 was seen smoking illicit drugs on premises, Resident #8 was verbally given a discharge notice by the residence. As of 12/16/25, the ad.. Based on observation, record review, and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary events. Additionally, the residence failed to ensure that staff members had documented, before the end of their shift, events or issues regarding a resident that they observed or reported to them, affecting three of 14 sample residents. (#3, #6, #8) Findings include.. Based on record review and interview, the residence failed to develop written policies to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, including, but not limited to, a long-term power failure, affecting 43 current residents.On 12/16/25 at 9:05 a.m., the residence' s 72-hour Continuation of Care policy and procedure was requested; however, the residence did not have one included in their .. Based on record review and interview, the residence failed to investigate an allegation of neglect and exploitation affecting two of two sample residents (#19 and #34).Findings include:1. Reference and Residence Policy:a. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The wri.. Based on record review and interviews the residence failed to identify the highest potential risk, hold, and document routine drills to facilitate staff and resident response to that risk, affecting 43 residents.Findings include: On 12/16/25 at 9:00 a.m., the residences risk assessment for the highest potential emergency risk and the documented drills for those risks were requested; however, the risk assessment that had been provided was dated for 2021, and no drills h.. Based on record review and interviews, the residence failed to respect the right to choice and personal involvement; The residence failed to provide a 30 days written notice of changes in services provided by the assisted living residence, including, but not limited to, involuntary change of room affecting 6 of 14 sample residents (#1,#9, #13, #20, #29, #34). Findings Include:1. Record ReviewResident #20 was admitted to the residence on 3/1/23.Resident #2..

A complaint revisit was completed on 12/17/25 for all previous deficiencies cited on 9/23/25. A deficiency was cited. Based on record review and interview, the residence failed to investigate an allegation of neglect and exploitation affecting two of two sample residents (#19 and #34).This deficiency was cited previously during a state licensure complaint on 9/23/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Reference and Residence Policy:a. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation;(C) The process for investigating such allegations;(D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted;(E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted;(F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and(G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review.b. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as 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: (G) Is blind as defined in Section 26-2-103(3), C.R.S.;c. Chapter II regulations g..

A complaint revisit was completed on 12/17/25 for all previous deficiencies cited on 3/6/25. Deficiencies were cited. Based on record review and interview, the facility (residence) failed to timely report, record and reviewing of Incidents affecting two of two sample members (residents) (#19 and #34).Findings include:1. Reference and Residence Policy:a. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation;(C) The process for investigating such allegations;(D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted;(E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted;(F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and(G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review.b. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as 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: (G) Is blind as defined in Section 26-2-103(3), C.R.S.;c. Chapter II regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal servi..

A relicensure survey with complaints revisit was completed on 12/17/25 for all previous deficiencies cited on 12/17/24.Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25. Based on observation, interview, and record review, the residence failed to provide personal services and protective oversight for one of one (#8) resident affecting 43 current residents.Specifically, Resident #8 was last seen by the residence on 12/11/25. A progress noted dated 12/11/25 read in pertinent part, Resident #8 was seen smoking illicit drugs on premises, Resident #8 was verbally given a discharge notice by the residence. As of 12/16/25, the administrator confirmed Resident #8 had not been discharged from the residence and was still a resident. However, the residence did not know where Resident #8 was, since 12/11/25. Resident #8 ' s medications and belongings were currently in the residence. The administrator believed Resident #8 had been arrested and was unaware of his location, and had not filed a missing person report. Resident #8 ' s primary practitioner stated Resident #8 could not make safe decisions on his own and outside of the residence. The practitioner further stated Resident #8 is an at risk adult. This failure created an immediate jeopardy risk of protective oversight to Resident #8 residing in the residence. On 12/17/25 the department directed the residence to provide written evidence that the risk had been removed.Findings include:1. ReferencesChapter VII governing assisted living residences, part 2.49, defined protective oversight as guid.. 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