Brighton Co Cares Wellspring

A revisit survey was completed on 4/15/26 for all previous deficiencies cited on 12/04/25. 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 revisit survey was completed on 4/15/26 for all previous deficiencies cited on 12/04/25. 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 relicensure survey was completed on 12/4/25. Deficiencies were cited. A change of ownership occurred on 12/18/24. Based on document review and interviews, the facility failed to report influenza vaccination rates to the Colorado Department of Public Health and Environment (CDPHE) for the 2024 to 2025 influenza season, affecting five current residents. (Cross-reference B0290)Findings include:1. Residence PolicyThe Employee Health Policy, Part VI, read in part, staff are encouraged to maintain influenza and Coronavirus Disease (COVID-19) vaccinations. Proof of vaccination accepted. Declination acknowledged. Additional requirements may apply during outbreaks.2. Record ReviewThe resi.. Based on record review and interview, the residence failed to have a roster of current residents readily available, affecting five current residents. (Cross reference B0290)Findings include: On 12/2/25 at 7:30 a.m., a current resident roster was requested from the residence. Staff #1 provided an emergency binder, which only included residents' pictures, medication administration records, and their medications. However, it did not include their room assignments or emergency contact information, along with a facility diagram showing room locations, as required. O.. Based on record review and interview, the residence failed to have an Involuntary Discharge Grievance policy that complied with Section 25-27-104.3, C.R.S. E, F and I, affecting five current residents. (Cross-reference B0290)Findings include:On 12/2/25 at 7:55 a.m., the residence' s Involuntary Discharge and Grievance policy was requested from the administrator.On 12/2/25 at 11:42 a.m., the administrator provided the policy; however, the policy failed to include required elements of Chapter 7 Regulation 9.3 (E (2 and 3), F, and I (1-3).On 12/2/25 at approximately 11:50 a.m., t.. Based on record review and interviews, the residence failed to provide, upon request, access to individual resident records, personnel files, as well as policies and procedures that met regulatory requirements required by the Department for regulatory oversight, affecting five current residents. (Cross-reference B0910, U0816, B1224 and U2320)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 12.8, require that the comprehensive assessment shall be documented in writing and kept in the resident' s health information reco.. Based on records review and interviews, the residence failed to follow written procedures that addressed the transmission of communicable diseases, affecting five current residents. (Cross-reference B0290)Findings include:1. Reference and Residence Policya. CDPHE mitigation and outbreak guidelines for assisted living residences defines an influenza outbreak as at least one resident with a positive influenza test and at least one resident with onset of undiagnosed respiratory illnessoccurring within a seven-day period.b. The residence ' s Vaccination & Infectious .. 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 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administratio..

A recertification survey was completed on 12/4/25. Deficiences were cited. Based on observations, record review, and interviews, the facility (residence) failed to provide, upon request, access to the requested documents, affecting five current members (residents).Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 12.8, require that the comprehensive assessment shall be documented in writing and kept in the resident' s health information record.b. Chapter VII regulations governing assisted living residences, part 18.8, require that resident records shall contain, but not be limited to, the following items:(A) Face Sheet;(C) Individualized resident care plan;(D) Progress notes which shall include information on resident status and well-being, as well as 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.(E) Medication Administration Record; (F) Documentation of ongoing services .. Based on record review and interview, the facility (residence) failed to have an Involuntary Discharge Grievance policy that complied with Section 25-27-104.3, C.R.S. E, F and I, affecting five current members (residents). Findings include:On 12/2/25 at 7:55 a.m., the residence' s Involuntary Discharge and Grievance policy was requested from the administrator.On 12/2/25 at 11:42 a.m., the administrator provided the policy; however, the policy failed to include required elements of Chapter 7 Regulation 9.3 (E (2 and 3), F, and I (1-3 ).On 12/2/25 at approximately 11:50 a.m., the administrator acknowledged that the policy was not complete and compliant with the regulation. 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 10 CCR 2505-10 8.7000.8.7414 Medication AdministrationA. Provider Agencies shall provide sufficient support to Members in the use of prescription and non- prescription medications. Members shall be presumed capable of self-administration unless they are determined otherwise. The type and level of medication administration support provided shall be determined by the results of an assessment performed by a qualified person. Medications shall be administered only by persons authorized in accordance with 6 C.C.R. 1011-1, Chapter VII and XXIV.

A revisit survey was completed on 8/3/23 for all previous deficiencies cited on 12/12/22. 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

A revisit survey was completed on 8/3/23 for all previous deficiencies cited on 12/12/22. 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