Bonaventure of Castle Rock

A revisit survey was completed on 2/24/26 for all previous deficiencies cited on 10/21/25. 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 complaint revisit was completed on 10/22/25 for all previous deficiencies cited on 12/16/24. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of four sample residents whose medications were reviewed (#7, #10 and #11).This deficiency was cited previously during a complaint revisit on 12/16/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings Include:1. Residence PolicyThe residence medication administration policy dated 6/1/23, read in pertinent part, that the residence would be responsible for processing all medications and treatment orders to promote and facilitate delivery of the medication/treatment. 2. Record ReviewResident #11 was admitted to the residence on 6/20/25 with a diagnosis including dementia, general weakness, and heart disease. A written practitioner' s order, dated 10/4/25, directed the residence to administer four grams of cholestyramine twice daily. However, the October 2025 medication administration record (MAR) for Resident #11 read that the medication was unavailable on 10/4, 10/5, 10/7, 10/9, and 10/17/25, for a total of 10 missed doses and five days. The October 2025 MAR revealed additional deficient practice where the residence failed to follow the practitioner' s orders for:Dimethicone Cholecalciferol AtorvastatinFerrous SulfateBudesonide3. InterviewOn 10/21/25 at 3:20 p.m., the administrator acknowledged that staff did not administer medications to Resident #11 because the medications were not available. The administrator stated that they did not correct the deficiency because the residence relied solely on the pharmacy to deliver the medications. 4. Evidence revealed similar deficient practice for Residents #7 and #10.

A licensure complaint, prompted by #CO39231, was completed on 10/22/2025. A deficiency was cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of four sample residents whose medications were reviewed (#7, #10 and #11).Findings include:1. Residence PolicyThe residence medication administration policy dated 6/1/23, read in pertinent part, that the residence would be responsible for processing all medications and treatment orders to promote and facilitate delivery of the medication/treatment. 2. Record ReviewResident #11 was admitted to the residence on 6/20/25 with a diagnosis including dementia, general weakness, and heart disease. A written practitioner' s order, dated 10/4/25, directed the residence to administer four grams of cholestyramine twice daily. However, the October 2025 medication administration record (MAR) for Resident #11 read that the medication was unavailable on 10/4, 10/5, 10/7, 10/9, and 10/17/25, for a total of 10 missed doses and five days. The October 2025 MAR revealed additional deficient practice where the residence failed to follow the practitioner' s orders for:Dimethicone Cholecalciferol AtorvastatinFerrous SulfateBudesonide3. InterviewOn 10/21/25 at 3:20 p.m., the administrator acknowledged that staff did not administer medications to Resident #11 because the m.. 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 7.25.22 The assisted living residence shall meet the requirements of Part 13.10 regarding the internal grievance and complaint resolution process. In addition, the assisted living residence shall hold regular meetings to allow residents, their family members, friends, and representatives to provide mutual support and share concerns and/or recommendations about the care and services within each separate secure environment. (A) Such meetings shall be held at least quarterly, at a place and time that reasonably accommodates participation; and (B) The assisted living residence shall provide adequate advance notice of the meeting and ensure that details regarding any meeting are readily available in a common area within the secure environment.

A revisit survey was completed on 4/2/25 for all previous deficiencies cited on 7/19/24. 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 licensure complaint, prompted by #CO38281 and #CO38626, was completed on 12/16/24. Deficiencies were cited. Based on observation and interview, the residence failed to make available a physically safe and sanitary environment, either directly or indirectly through a resident agreement, affecting nine residents in the secure environment (SE). Findings include:1. ObservationsOn 12/16/24 at approximately 7:30 a.m., a food hot box blocked the SE courtyard door. At 8:00 a.m., the food hot box was still in the same location and staff had not removed it from that location. The courtyard was the only outdoor area accessible to SE residents. The food hot box created an obstacle for residents who might attempt to access the courtyard and posed a safety risk, as it obstructed the exit.On 12/16/24 at approximately 7:30 a.m., the sidewalk in the SE courtyard was covered in snow which caused a slippery surface. Other areas around the residence were clear of snow.On 12/16/24 at 2:48 p.m., the carpet in Resident #2' s room had visible feces stains around the apartment.2. InterviewsOn 12/16/24 at approximately 7:30 a.m., the memory care director stated staff normally kept the hot box in the space that blocked the door.On 12/16/24 at approximately 9:40 a.m., the maintenance director stated the residence had a contract with a local snow removal company to clear snow at the residence. However, because the SE courtyard was locked, the company missed doing a full snow removal. He stated.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of six current residents (#3). Findings Include:Resident #3 was admitted to the residence on 5/28/24.A written practitioner' s order, dated 11/4/24, directed the residence to administer morphine 5 mg two times daily for pain. However, the November 2024 medication administration record (MAR) read the residence failed to administer the medication on the evening of 11/15/24 because the medication was not available . On 12/16/24 at approximately 4:00 p.m., the administrator said she expected the residence to administer medications according to the practitioner' s orders and to have all medications readily available.

A relicensure and complaint revisit was completed on 7/19/24 for all previous deficiencies cited on 1/23/24. Deficiencies were cited. Based on observation and interview the residence failed to ensure there was a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR) in a visible location and readily available at all times affecting 48 current residents. This deficiency was cited previously during a state licensure survey 1/23/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. ObservationOn 7/18/24 at approximately 7:15 a.m. and 11:30 a.m., an environmental tour revealed no evidence of a visible list of staff with current first aid and CPR certifications.2. InterviewOn 7/18/24 at 10:06 a.m., the administrator acknowledged that the residence required a C.. 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 event or issue that affects a resident' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident' s changing needs. Additionally, the residence failed to ensure staff members documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they observed or was reported to them, affecting one of three sample residents (#2). Findings Include:1. Observation On 7/18/24 at 7:35 a.m., Resident #2 was administered medications. Resident #2 had an abrasion on the right side of her face on her cheekbone. 2. Rec.. Based on record review and interview the residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records affecting three of three current residents (#1, #2, #7).This deficiency was cited previously during a state licensure survey 1/23/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 7/18/24 at 9:26 a.m.. and 10:56 a.m, quarterly medication audits were requested from the administrator. However, no documentation was provided. On 7/19/24 at 9:36 a.m., the administrator acknowledged the residence failed to complete medication audits as require.. 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 7.7.13 "Each personnel file shall include, but not be limited to, written documentation regarding the following items: (C) Orientation and training, including first aid and CPR certification, if applicable (1)The residence shall maintain documentation of each employee ' s completion of initial dementia training and continuing education. Such records shall be available for inspection by representatives of the Department. "25.15 "Within sixty (60) days, the assisted living residence shall provide each staff member a minimum of six (6) hours of ge..