Caring Souls Assisted Living at Tollgate

A revisit survey was completed on 12/16/25 for all previous deficiencies cited on 8/20/25. 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 12/16/25 for all previous deficiencies cited on 8/20/25. 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 8/20/25. Deficiencies were cited. Based on interview and record review, the residence failed to thoroughly investigate allegations of abuse or report alligations of abuse to the appropriate agencies in accordance with the residence' s written policy, affecting seven cu.. Based on interviews and record review, the residence failed to ensure personnel files included the results of background checks and first aid and cardiopulmonary resuscitation (CPR) certifications for two of four sample staff m.. Based on interviews and record review, the residence failed to ensure that each staff member met the dementia training requirements in 7.9 (B), affecting seven current residents. Findings include:Personnel files for Staff #1 and #.. Based on observation, interview and record review, the residence failed to ensure there was at least one staff member on-site at all times who had current certification in first aid from a nationally recognized organization affecting seve.. Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed for administration were labeled or marked with residents' full names, affecting three of five s.. Based on observation, record review, and interviews, the residence failed to have a quality management program (QMP) designed to improve client safety and well-being, affecting seven current residents. On 8/19/25 at 8:30 a.m., .. Based on observation, record reviews and interviews, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques fro.. Based on record review and interview, the residence failed to comply with occurrence report requirements required by state law, affecting seven current residents. (Cross reference U1410)Findings include:Review of Resident #9' s reco.. 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., affecting seven current residents.Findings include:On 8/19/25 at 8:30 a... Based on record review and interview, the residence failed to have an visitation policy that complied with Section 25-27-104.3, C.R.S., affecting seven current residents.Findings include:On 8/19/25 at 8:30 a.m., the residence' s visit.. Based on record reviews and interviews, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurr.. 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 a..

Based on observation, record review, and interviews, the residence failed to have a quality management program (QMP) designed to improve client safety and well-being, affecting seven current residents. This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:On 8/19/25 at 8:30 a.m., the residence' s QMP was requested from the administrator. On 8/19/25 at 11:00 a... A relicensure survey with complaint revisit was completed on 8/20/25 for all previous deficiencies cited on 9/19/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.Tags U664 and U1634 were not cited in the previous event; however, the deficiencies were included in the previous event' s informational 999 tag. Based on interviews and record review, the residence failed to ensure personnel files included the results of background checks and first aid and cardiopulmonary resuscitation (CPR) certifications for two of four sample staff members (#4, #5), affecting seven current residents. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 7.13, requires 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.. Based on observation, interview and record review, the residence failed to ensure there was at least one staff member on-site at all times who had current certification in first aid from a nationally recognized organization affecting seven current residents. This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ObservationOn 8/19/25 from approximately 7:30 a.m. until 8:30.. Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed for administration were labeled or marked with residents' full names, affecting three of five sample residents (#1, #7 and #9). This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:On 8/19/25 at 8:15 a.m., a medication cart audit reve.. Based on observation, record reviews and interviews, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting seven current residents.This deficiency was cited previously during a relicensure survey with complaint, on 9/19/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ObservationO.. Based on record reviews and interviews, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting one sample resident (#8) for whom the residence administers controlled substances.Findings include:1. Record ReviewResident #8 was admitted to the residence on 4/17/23 with a diagnosis of bipolar depression.A practitioner' s order for Resident #8 dated 5/23/25, directed the residence to administer methadone 29..

A recertification survey was completed on 8/20/25. A deficiency was cited. Based on interviews and record review, the facility (residence) failed to maintain a personnel record for each employee that contained results of background checks for two of four sample staff members (#4, #5), affecting seven current members (residents). Findings include:1. Record ReviewStaff #4 and #5' s personnel files provided by the administrator on 8/19/25 at approximately 11:00 a.m., revealed they were hired on 9/22/21 and 9/26/21, respectively. However, the personnel files were missing the results of background checks. 2. InterviewsOn 8/20/25 at approximately 8:45 a.m., the assistant administrator (AA) stated Staff #4 and #5 provided care and services to residents when needed, and were also the owners. The AA stated she was unsure why the personnel files for Staff #4 and #5 did not contain results of background checks. On 8/20/25 at approximately 9:00 a.m., the administrator stated she was aware of the requirement for personnel files to include results of background checks; however, the documentation was misplaced when she had begun moving documents to upload electronically. 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 8.7000.8.7506.C Alternative Care Facility Inclusions1. Member Eligibilitya. Members enrolled in the HCBS Elderly, Blind and Disabled (EBD) and the HCBS Community Mental Health Supports (CMHS) Waivers to are eligible to receive services in an Alternative Care Facility.i. Potential Members shall be assessed, at a minimum, by a team that includes the Member and/or Guardian or other Legally Authorized Representative, the Alternative Care Facility administrator or appointed representative, and Case Management Agency Case Manager to determined that the Alternative Care Facility is an appropriate community setting that will meet the Member' s choice and need for independence and community integration. If one of the parties listed above is not available, input or information must be obtained from each party prior to making an admission determination. The team may also include Family Members, Accountable Care Collaborative or Mental Health Center Case Managers, and any other interested parties as approved by the Member.1) An assessment shall be conducted prior to admission, annually, whenever there is a significant cha..