Bonaventure of Colorado Springs

Deficiency cited for occurrence event ID #2523U243006. The facility failed to provide the final report for Physical Abuse occurrence event # 2523U243006. Findings Include:The facility submitted an initial Physical Abuse occurrence report on 7/3/25. The facility failed to provide the final report within the required timeframe. Department staff sent electronic messages regarding the late final report through the COHFI system on 7/24/25 and 9/9/25. On 7/24/25, the message was opened for review by a facility representative on 8/14/25 and marked as read by the same facility representative on 11/17/25. On 9/9/25, the message was opened for review by a facility representative on 9/9/25 and marked as read by the same facility representative on 11/17/25. On 9/16/25, a representative from the Occurrence section contacted the facility administrator via phone and left a voice mail requesting the completion and submission of the final report for this event. On 10/22/25, an external email was sent to facility representatives regarding the late final report. On 12/2/25, another external email was sent to facility representatives regarding the late final report. On 12/3/25, an administrative facility representative responded via email and indicated the final report would be completed and submitted. As of 12/9/25, the final report has not been submitted.

A licensure complaint, prompted by #CO41028 and #CO40860, was completed on 10/22/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence, affecting one of four sample residents (#2). (Cross-reference U1110 and U2230)Specifically, Resident #2 had pressed her call light pendant on 8/19/25 after 10:00 p.m. The request for assistance had not been responded to until 8/20/25 at 5:00 a.m., when Staff #1 and former Staff #2 found the resident lying on the ground. The residence' s delayed response caused the resident to experience discomfort and pain, including back pain. Within a week, her knees were swollen, and she experienced painful jerkin.. Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated whenever the resident' s condition changed from baseline status, affecting one of four sample residents (#2). Findings include: 1. Record Review Resident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility.There was no evidence of an assessment completed by the residence in Resident #2' s record after a change from baseline status. Record review revealed on 8/29/25, Resident #2 was seen by her external service provider for pain and swelling in her right knee after a fall at the residence.Additionally, on 9/15/25, Resident #2 was transporte.. Based on record review and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary occurrences and 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 one of four sample residents (#2). (Cross-reference U1162)Findings include: 1. Record ReviewResident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility.The record review for Resident #2 revealed that the record did not contain progress notes as follows:An external service provider (ESP) note, dated 8/2.. Based on record review and interviews, the residence failed to contact the resident' s representative whenever the resident experienced a significant change from baseline status, affecting one of four sample residents (#2). (Cross-reference U2230)Findings include: 1. Record Review Resident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility.A face sheet, undated, for Resident #2, indicated that legal representative #1 (LR#1) was "Emergency Contact 1", that legal representative #2 (LR#2) was "Emergency Contact 2", and that legal representative #3 (LR#3) was "Emergency Contact 3.On 10/21/25 at 7:30 a.m., progress notes and resident occurrenc.. Based on record review and interviews, the residence failed to provide protective oversight, affecting one of four residents (#2). (Cross-reference U1352)Findings include:1. Record ReviewResident #2 was admitted to the residence on 6/30/24 with a diagnosis of limited mobility.The care plan, with an effective date of 4/1/25, read, "(Resident #2) understood the call system. In the event the resident needed extra assistance, the resident would call for help ... (Resident #2) was not considered a fall risk; however, staff would monitor and report any and all falls to the wellness director/registered nurse ..."2. Interviews On 10/21/25 at 8:30 a.m., Resident #2 stated that she could not recall the..

A relicensure survey with complaint revisit was completed on 7/7/25 for the previous deficiencies cited on 3/19/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25. Based on record review and interview the residence failed to comply with authorized practitioner ordersassociated with medication administration affecting one of 10 sample residents (#9).This deficiency was cited previously during a state licensure survey 3/19/25. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement.Findings Include:1. Record ReviewResident #9 was admitted to the residence on 8/10/20 with a diagnosis of weakness and cognitive communicationdeficit. A practitioner' s order dated 2/28/22 prescribed tramadol HCL one tablet twice daily for joint pain.A practitioner' s order dated 5/21/25 prescribed ferrous gluconate 324 mg tablets one tablet twice daily for ironDeficiency.The May medication administration record (MAR) read that Resident #9 missed her dose of tramadol on May 13thand 14th due to the medication not available. The June MAR read that Resident #9 missed her dose of ferrous gluconate on 6/4-/6/7/25 and 6/22-6/27/25 dueto medication not available. 2. InterviewsOn 7/7/25 at approximately 1:30 p.m., the community nurse stated that to ensure residents' medication was filledthe residence had a three check system where the qualified medication administration personnel (QMAP) wouldrequest the medication, the assisted living dir.. 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 existingprogram 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:(A) A description of the employee or volunteer duties; (B)Date of hire or acceptance of volunteer service and date duties commenced; (C) Orientation and training, including, but not limited to the following, as applicable: (1) First aid and CPR certification, (2) Proof of portable training(s) accepted by the assisted living residence, including documentation of the acceptance conditions at Part 7.9(D) being met. (D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable; (E) Results of background checks and follow up, as applicable; and (F) Tuberculin test results or proof of a portable test compliant with Part 7.7, if applicable. (G) Documentation of initial dementia training and continuing education for direct-care staff members: (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 re..

A relicensure survey with complaint #CO39516 was completed on 3/19/25. Deficiencies were cited. Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting two of two sample residents (#5 and #10) with medication issues. Findings include:1. Resident #10 was admitted to the residence on 2/6/19 with diagnoses that included legal blindness, multiple sclerosis, and major depressive disorder. a. Methylphenidate (Ritalin) A written practitioner' s order, dated 2/20/24, directed the residence to administer Ritalin 20 mg by mouth every morning and 10 mg by mouth twice daily at 12:00 p.m. and at 3:00 p.m. Although the March 2025 medication administration record (MAR) for Resident #10 read the medication was administered according to the practitioner' s orders, an internal investigation, dated 3/11/25, revealed the residence failed to administer the morning and afternoon doses on 3/12/25.b. Acetaminophen (Codeine number three) A written practitioner' s order, dated 2/28/22, directed the residence to administer codeine 30 mg four times daily. Although the March 2025 MAR for Resident #10 read that the medication was administered according to the practitioner' s orders, an internal investigation, dated 3/11/25, revealed that the residence failed to administer one dose of codeine on 3/11/25.On 3/19/25 at 9:33 a.m., Staff #1 revealed that she had failed to administer Residen.. Based on observation and interview, the residence failed to prohibit a qualified medication administration person (QMAP) from pre-pouring medication, affecting three of six sample residents (#5, #7, #8). Findings include: On 3/18/24, at approximately 7:55 a.m., Staff #1 went into the medication room and returned with a medication cup containing medication for Resident #5. She then went to Resident #5' s room and administered the medication to him. On 3/18/25 at 8:17 a.m., Staff #1 returned to the medication room and grabbed a cup containing medications. It was labeled with Resident #7 ' s room number. She then went to Resident #7' s room and administered the medication.On 3/18/25 at 8:29 a.m., Staff #1 returned to the medication room and grabbed a a small blue container that contained the medication for Resident #8: two medication cups filled with medication tablets, an inhaler, leg pain gel medication, and nose lubrication gel. She then went to Resident #8' s room and administered the medications.On 3/18/25 at 8:49 a.m., Staff #1 stated she "was trained that medication could be ' popped' early as long as it was within the hour that the dosage was scheduled to be administered." On 3/19/25 at 9:48 a.m., the health and wellness director (HWD) stated that the staff had been trained to pre-pour medications during the "heavy med pass;" ..