Care Group of Northglenn LLC

A revisit survey was completed on 3/31/26 for all previous deficiencies cited on 10/15/25. 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 3/31/26 for all previous deficiencies cited on 10/15/25. 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 3/31/26 for all previous deficiencies cited on 10/15/25. 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 licensure commplaint revisit was completed on 10/15/25 for the previous deficiency/deficiencies cited on 12/11/24. Deficiencies were cited.Tags S0816 was not cited in the previous event; however, the deficiencies were included in the previous event' s informational 9999 tag. The regulations governing Assisted Living Residences were revised. The new regulation 6 CCR 1011-1, Chapter 7 was implemented on 7/1/25. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy thatincluded all required elements, affecting 13 current residents.Findings include:A review of the residence' s discharge and grievance policies and the termination section of the resident agreement revealed that the residence did not include the following required parts of the involuntary discharge grievance policy: (1) The ability for any of the persons the assisted living residence must notify under Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), within 14 calendar days after the assisted living residence provides written notice of the involuntary discharge. (2) The ability for the resident, or other person allowed to file a grievance, to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (3) A requirement that no later than 5 busin.. Based on record review and interviews, the residence failed to ensure each resident' s care plan contained all of the required elements, affecting four of five sample residents (#6, #15,#17, and #16).This deficiency was cited previously during a state licensure survey on 12/11/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:Resident #6 was admitted to the residence on 7/17/17 with diagnosis of Schizophrenia.On 10/15/25 at 10:00 a.m., the administrator stated Resident #6 was alcohol dependent and it needed to be monitored daily. On 10/15/25, a review of Resident #6' s record showed no evidence the residence had completed a care plan at all.Evidence obtained during the onsite visit revealed similar deficient practice with Residents #15, #17 and #16.On 10/15/25 at approximately 2:00 p.m., the administrator stated she was unaware she was required to create care and update care plans. The administrator stat..

A relicensure survey with complaint #CO40024 was completed on 10/15/25. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure the administrator and qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration.. Based on observation and interview the residence failed to keep grounds maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction, affecting .. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 13 current residents.1. ReferenceThe Colorado Clean Indoor Air Act, s.. Based on observation, record review and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets, affecting 13 current residents. Findings include: The administrator provided a list of .. Based on observation, record review, and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring staff who provided care to the residents fo.. Based on record review and interview the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR), affecting 13 current residents.On 10/15/25 at appr.. Based on record review and interview, the residence failed to ensure that at the time of admission, the resident record contained a signed copy of the resident agreement in the resident record, affecting four of four sample reside.. Based on record review and interview, the residence failed to ensure that each personnel file contained all required elements for three of three sample staff (#1, #4 and #5), affecting 13 current residents.This deficiency was cited pre.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy thatincluded all required elements, affecting 13 current residents.Findings include:A review of the residence' s discha.. Based on record review and interview, the residence failed to have emergency policies addressing all required elements, affecting 13 current residents. Findings include:The residence' s emergency plan failed to include the follo.. Based on record review and interview, the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting 13 current resident.. Based on record review and interview, the residence failed to provide face sheets for its residents, affecting two of five sampled residents ( #17 and #16). Findings include:Resident #16 was admitted to the residence, date unknown p.. Based on record review and interviews, the residence failed to ensure each resident' s care plan contained all of the required elements, affecting four of five sample residents (#6, #15,#17, and #16).Findings include:Resident #6 was a.. Based on record review and interviews, the residence failed to ensure each resident' s comprehensive assessment was updated annually, affecting three of five sample residents (#6, #15 and #16).Findings include:Resident #15 was admit.. Based on records review and interview, the residence failed to have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications, affecting 15 current residents. (Cross r.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLYNo response is necessary This residence was advised it must review and maintain the following processes in accordance with existingprogram regulations found at..

A relicensure survey revisit was completed on 10/15/25 for the previous deficiencies cited on 12/11/24. Deficiencies were cited. Tags S0816 was not cited in the previous event; however, the deficiencies were included in the previous event' s informational 9999 tag. The regulations governing Assisted Living Residences were revised. The new regulation 6 CCR 1011-1, Chapter 7 was implemented on 7/1/25. Based on record review and interview, the residence failed to ensure that each personnel file contained all required elements for three of three sample staff (#1, #4 and #5), affecting 13 current residents.This deficiency was cited previously during a state licensure survey 12/11/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:The residence' s staff roster indicated Staff #1, and #4 and #5 were hired on 7/10/22, 1/22/25 and 6/8/25 respectively.A review of the personnel file for Staff #1 revealed it did not contain a description of the employee duti.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy thatincluded all required elements, affecting 13 current residents.Findings include:A review of the residence' s discharge and grievance policies and the termination section of the resident agreement revealed that the residence did not include the following required parts of the involuntary discharge grievance policy: (1) The ability for any of the persons the assisted living residence must notify under Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), within 14 calen.. Based on record review and interviews, the residence failed to ensure each resident' s care plan contained all of the required elements, affecting four of five sample residents (#6, #15,#17, and #16).This deficiency was cited previously during a state licensure survey on 12/11/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:Resident #6 was admitted to the residence on 7/17/17 with diagnosis of Schizophrenia.On 10/15/25 at 10:00 a.m., the administrator stated Resident #6 was alcohol dependent and it needed to be monitored daily. On 10/15/25, a review of Resident #.. Based on records review and interview, the residence failed to have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications, affecting 15 current residents. (Cross reference U1604)This deficiency was cited previously during a state licensure survey 12/11/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:On 10/15/25 at 9:00 a.m., the policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and expired medications were requested but not provided.On 10/15/25 .. 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 #CO38630, was completed on 12/11/24. Deficiencies were cited. Based on record review and interview, the residence failed to ensure that it had trained staff available to evaluate residents who had fallen or were otherwise unable to independently get off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders, affecting 15 current residents.Findings include:The residence' s undated lift assistance policy read in part: Staff should not attempt to change the position or.. Based on record review and interview, the residence failed to have a policy that required documentation of the action taken by staff and ongoing efforts to prevent a reoccurrence of resident falls in the future, affecting one of six sample residents (#5).Findings include:Resident #5 was admitted to the residence on 8/1/23 with diagnoses of substance use disorder, anxiety, glaucoma, and diabetes mellitus type two.An incident report, dated 12/4/24 at 3:00 a.m., read in .. Based on record review and interview, the residence failed to make available protective oversight sufficient to meet the needs of the residents, affecting one of six sample residents (#14). (Cross-reference B536)Specifically, Resident #14 eloped from the residence on two occasions in the span of two hours. The first elopement resulted in the resident being returned to the residence by emergency medical services (EMS). The second elopement resulted in the residen.. Based on record review and interviews, the residence failed to ensure each resident care plan contained all of the required elements, affecting six of six sample residents (#5, #6, #12-#15).Findings include:Resident #5 was admitted to the residence on 8/1/23 with diagnoses of substance use disorder, anxiety, glaucoma, and diabetes mellitus type two.On 12/11/24, a review of Resident #5' s record showed no evidence the residence completed a care plan at all.Ev.. Based on records review and interview the residence failed to report to the Department that the residence could not locate a resident after a search of the residence, the grounds, and the surrounding area, and that the resident' s health, safety, or welfare were at risk affecting one of six sample residents (#14). (Cross-reference S1110)Findings include:Resident #14 was admitted to the residence on 12/7/24 with a diagnosis of dementia with behavioral disturb.. Based on records review and interviews the residence failed to complete a comprehensive assessment at the time of move-in affecting two of six sample residents (#13, #14).Findings include:Resident #13 was admitted to the residence on 8/19/24 with unknown diagnoses.On 12/11/24, a review of Resident #13' s record revealed no evidence that the residence completed a comprehensive assessment at the time of admission.Resident #14 was admitted to the residen.. 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..