Creekside Village Assisted Living LLC

A licensure complaint prompted by #CO36860, #CO39501, and change of ownership survey, was completed on 4/8/25. Deficiencies were cited. A change of ownership occurred on 9/1/24. Based on interview and record review, the residence failed to be responsible for the coordination of resident care services with known external service providers (ESPs), affecting two of two sample residents who required podiatry service (#5, #13). Findings include:Resident #5 was admitted to the residence on 12/28/22 with a diagnosis of cellulitis; bilateral lower extremities and peripheral edema.An external case management agency (ECMA) care plan, dated 1/17/25, read that Resident #5 required assistance with accessing and coordinating ESPs. The residence care plan, dated 3/28/24, read in part the residence assisted Resident #5 with clear explanations of all care activities pri.. Based on interview and record review, the residence failed to ensure that appealing substitutes of similar nutritional value were consistently available for residents, affecting 21 current residents. (Cross-reference S0722)Findings include:On 4/8/25, the residence posted a weekly menu with one alternative for each meal.On 4/8/25, during the onsite visit, Residents #2, #3, #9, #13, and #16 stated that during meal times, when the attached sister nursing facility (NF) failed to send the residence meal alternatives that met the residents' needs, the single staff member was unable to retrieve the alternatives. Residents #9 and #13 stated this impacted them as they had food allergies or the need f.. Based on interview and record review, the residence failed to have a sufficient number of staff to help residents needing or potentially needing assistance, affecting 21 current residents. (Cross-reference S2112)Findings include:The staffing schedule for March and April 2025 read in part that the following staff worked alone at the residence, providing care and services, serving meals, and conducting engagement activities:On Saturdays, from 6:00 a.m. to 6:00 p.m., Staff #1 worked.On Saturdays, from 6:00 a.m. to 6:00 p.m., Staff #4 worked.On Saturdays and Sundays, from 6:00 p.m. to 6:00 a.m., Staff #6 worked.On 4/8/25, during the onsite visit, Residents #2, #3, #9, #13, and #16 s.. Based on observation, record review, and interview, the residence failed to make a sanitary environment available, either directly or indirectly, through resident agreement, affecting 21 current residents.1. Reference and Resident AgreementChapter VII regulations governing assisted living residences, part 23.3, requires screens or other pest control measures shall be provided on all exterior openings. Residence doors, door screens, and window screens shall fit with sufficient tightness at their perimeters to exclude pests.The residence' s undated resident agreement read that the residence provided maintenance to promote a clean, safe, and comfortable environment.2. ObservationOn 4/8/2.. Based on record review and interview, the residence failed to contact the correct practitioner for clarification of unclear orders and failed to obtain new orders in writing, affecting one sample resident (#14).Findings include:Resident #14 was admitted to the residence on 9/30/24 with a diagnosis of neuropathy and was later diagnosed with cervical radiculopathy, inflammation, and muscle spasms.A written emergency department (ED) practitioner' s order, dated 3/29/25, directed the residence to administer methylprednisolone 4 mg tablets for six days with a quantity of 21 tablets. However, the practitioner' s order did not direct the frequency the residence was requir..

A relicensure revisit was completed on 4/8/25 for all previous deficiencies cited on 11/30/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25. Based on observation, interview, and record review, the residence failed to provide sufficient ventilation sufficient to meet the needs of the residents. affecting one sample resident (#12) and six non-sample residents (#6, #7, #13, #15-#17).This deficiency was cited previously during a state licensure survey on 11/30/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 4/8/25, during the onsite visit, Resident #12, #13, and #16 rooms were 78-81 degrees fahrenheit (F). On 4/8/25, during the onsite visit, Residents #5, #6, #13, #15-#17 stated that their rooms were uncomfortably warm to them at times. Resident #5 taped a heating vent to reduce the heat. Residents #9 and #15 stated their rooms were uncomfortably warm; however, they acquired window air conditioning units independent of the residence and the rooms were now comfortable. Residents #6, #13, and #16 expressed concern regarding the summer months since it was only spring and their rooms were already warm. Resident #6 added that his room had been over 86 degrees F in past summers and was very uncomfortable. Residents #5, #6, #9, #13, #15-#17 stated the residence did not provide air conditioning units to the residents. On 4/8/25 at 11:37 a.m., the maintenan.. Based on observation, record review, and interview, the residence failed to make a sanitary environment available, either directly or indirectly, through resident agreement, affecting 21 current residents.1. Reference and Resident AgreementChapter VII regulations governing assisted living residences, part 23.3, requires screens or other pest control measures shall be provided on all exterior openings. Residence doors, door screens, and window screens shall fit with sufficient tightness at their perimeters to exclude pests.The residence' s undated resident agreement read that the residence provided maintenance to promote a clean, safe, and comfortable environment.2. ObservationOn 4/8/25, during the onsite survey, the north exterior door had gaps at the top, and the bottom of the doorway, and the east exterior door had gaps along the bottom of the door to the external environment without a screen or sweep to prevent pests from entering the residence. 3. Record ReviewContracted pest control inspections, dated 1/8/25-3/28/25, read in part: On 1/8, 1/24, 2/5, 2/18, 3/14, and 3/28, the residence had structural concerns that caused pest problems. The north door did not properly close or seal and had more than a quarter of an inch gap between the door and doorframe. The inspection advised the residence to replace the door sweep to reduce the num..

10 CCR 2505-10 8.7000 Home and Community-Based Services 8.7506.F 5. Environmental Standards C. Alternative Care Facilities shall maintain a comfortable temperature throughout the Alternative Care Facility and Member rooms, sufficient to accommodate the use and needs of the Members, never to fall outside the range of 68 degrees to 76 degrees Fahrenheit.G. Provide nutritious food/beverages that Members have access to at all times. Access to food/cooking of food per Chapter VII, Part 17.1-3. Based on record review, observation, and interview, the facility (residence) failed to maintain a comfortable temperature never to fall outside the range of 68 degrees F to 76 degrees F throughout the residence and member (resident) rooms. Further, the residence failed to provide access to food per.. 10 CCR 2505-10 8.7000 Home and Community-Based Services 8.7506.F Alternative Care Facility Provider Agency Requirements6. Staffing Requirements b. Staffing at an Alternative Care Facility shall meet the following standardsi. A minimum of 1 staff to 10 Members during the daytime.ii. A minimum of 1 staff to 16 Members during the nighttime.Based on record review and interview, the facility (residence) failed to ensure staffing requirements met minimum staffing ratios, affecting 21 current members (residents). (Cross-reference S0001)Findings include:The staffing schedule for March and April 2025 read in part that the following staff worked alone at the residence, providing care and services, serving meals, and conducting engagement activities:On Saturdays, from 6:00 a.m. to 6:.. A certification complaint, prompted by #CO36861, #CO39503, was completed on 4/8/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to have a care plan for each member (resident) that included the member' s service, care needs regarding coordination with other provider agencies, affecting two of two sample residents (#5, #13). Findings include:Resident #5 was admitted to the residence on 12/28/22 with a diagnosis of cellulitis; bilateral lower extremities and peripheral edema.An external case management agency (ECMA) care plan, dated 1/17/25, read that Resident #5 required assistance with accessing and coordinating ESPs. The residence care plan, dated 3/28/24, read in part the residence assisted Resident #5 with clear explanations of all care activities prior to and as they occur; however, the care plan did not specifically include residence support with servi.. Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of all medications due to the residence' s failure to contact the correct practitioner for clarification of unclear orders and failed to obtain new orders in writing, affecting one sample residents (#14).Findings include:Resident #14 was admitted to the residence on 9/30/24 with a diagnosis of neuropathy and was later diagnosed with cervical radiculopathy, inflammation, and muscle spasms.A written emergency department (ED) practitioner' s order, dated 3/29/25, directed the residence to administer methylprednisolone 4 mg tablets for six days with a quantity of 21 tablets. However, the practitioner' s order did not direct the frequency the residence was requir..

10 CCR 2505-10 8.7000 Home and Community-Based Services 8.7506.F 5. Environmental Standards C. Alternative Care Facilities shall maintain a comfortable temperature throughout the Alternative Care Facility and Member rooms, sufficient to accommodate the use and needs of the Members, never to fall outside the range of 68 degrees to 76 degrees Fahrenheit.G. Provide nutritious food/beverages that Members have access to at all times. Access to food/cooking of food per Chapter VII, Part 17.1-3. .Based on record review, observation, and interview, the facility (residence) failed to maintain a comfortable temperature never to fall outside the range of 68 degrees F to 76 degrees F throughout the residence and member (resident) rooms. Further, the residence failed to provide access to food per Chapter VII, Part 17.1-3, affecting 21 current residents. (Cross-reference S0002)Findings Include:1. Room Temperatures On 4/8/25, during the onsite visit, Resident #12, #13, and #16 rooms were 78 degrees F. On 4/8/25, during the onsite visit, Residents #5, #6, #13, #15-#17 stated that their rooms were uncomfortably warm to them at times. Resident #5 taped a heating vent to reduce the heat. Residents #9 and #15 stated their rooms were uncomfortably warm; however, they acquired window air conditioning units independent of the residence and the ro.. A recertification revisit was completed on 4/8/25 for all previous deficiencies cited on 11/30/23.Deficiencies were cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 2/15/25. Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of all medications due to the residence' s failure to contact the correct practitioner for clarification of unclear orders and failed to obtain new orders in writing, affecting one sample residents (#14).Findings include:Resident #14 was admitted to the residence on 9/30/24 with a diagnosis of neuropathy and was later diagnosed with cervical radiculopathy, inflammation, and muscle spasms.A written emergency department (ED) practitioner' s order, dated 3/29/25, directed the residence to administer methylprednisolone 4 mg tablets for six days with a quantity of 21 tablets. However, the practitioner' s order did not direct the frequency the residence was required to administer the medication to the resident. A residence electronic communication to the resident' s primary practitioner, dated 4/1/25, read in part that the residence sought clarification regarding the order. A progress note, dated 4/1/25, read in part that the residence contacted the resident' s primary practitioner and left a message regarding clarification of the methylprednisolone.On 4/8/25 at 11:27 a.m., Staff #4 stated she called and sent an electronic communication for clarification to the resident' s practitioner. On 4/8/25 at 11:50 a.m., a registered nurse..

A relicensure survey was completed on 11/30/23. Deficiencies were cited. Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of one sample residents who experienced side effects due to medication being out of stock (#4). (Cross-reference Q1510)Specifically, Resident #4 was admitted to the residence on 11/1/23 without all her medications in stock. The resident missed doses of her antipsychotic medication clozapine, and antidepressant medications which included hydroxyzine and trintellix. As a result of the residence' s failure to administer the above medications as ordered, Resident #4 experienced severe headaches, incre.. Based on observation and interview, the residence failed to ensure fire resistant waste disposal containers were in the designated outdoor smoking area, affecting seven out of seven residents (#2, #7-#12), who were identified as smokers. Findings include:On 11/30/23 at 7:26 a.m., an environmental tour of the residence' s outdoor designated smoking area revealed a metal coffee can, planting pot, painted paint can, and fabric lined wicker basket located on top of the metal patio furniture; each was filled with cigarette butts, dirt and ashes. On 11/30/23 at 7:26 a.m., Resident #7 and Resident #2 were in the outdoor designated smoking area. Resident #7 used the wicker basket to extinguish his cigar.. Based on observation, record review and interview, the residence failed to provide a physically safe and sanitary environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 23 current residents.Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.34, defines "Personal Services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to:(A) An environment that is sanitary and safe from physical harm.b. According to the Colorado Department of Public Health a.. Based on observations and interviews the residence failed to provide sufficient ventilation sufficient to meet the needs of the residents affecting one of one sample residents who did not have a thermostat in their room (#12). Findings include:1. ObservationsOn 11/30/23 at 7:43 a.m., a portable A/C unit was observed in Resident #1' s room pointed at her, and she was observed with sweat dripping off her forehead. A thermometer revealed the temperature in Resident #1' s room was 80.8 degrees Fahrenheit. On 11/30/23 at 2:39 p.m., the hallway thermostat outside Resident #1' s room was set to 90 degrees Fahrenheit. 2. InterviewsOn 11/30/23 at 7:43 a.m., Resident #1' s family me.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event is completed for each resident, and failed to document accurate information in the medication administration record (MAR), including any medication omissions, refusals, and resident reported responses to medications, affecting one of one sample residents who experienced a pattern of documentation issues (#4). (Cross-reference Q1468)Findings include:1. Residence PolicyThe residence' s Medication Administration Policy, dated October 2019, read in part: "miss..

A recertification survey was completed on 11/30/23. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting one of one sample participants who experienced side effects due to medications being out of stock as well as inaccurate medication administration record (MAR) documentation (#4). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence comply with authorized practitioner' s orders associated with medication administration except for those medications which a resident self-administers.Specifically, Resident #4 was admitted to the residence on 11/1/23 without all her medications in stock. The resident missed doses of her antipsychotic medication clozapine, and antidepressant medications which included hydroxyzine and trintellix. As a result of the residence' s failure to administer the above medications as ordered, Resident #4 experienced severe headaches, increased anxiety and increased blood pressure. Findings include:A. References and Residence policyAccording to the National Library of Medicine: "sudden discontinuation of the antipsychotic medication known as clozapine, can contribute to withdrawal .. Based on observations and interviews the facility (residence) failed to provide sufficient ventilation sufficient to meet the needs of the residents affecting one of one sample participants (residents) who did not have a thermostat in their room (#12). Findings include:1. ObservationsOn 11/30/23 at 7:43 a.m., a portable A/C unit was observed in Resident #1' s room pointed at her, and she was observed with sweat dripping off her forehead. A thermometer revealed the temperature in Resident #1' s room was 80.8 degrees Fahrenheit. On 11/30/23 at 2:39 p.m., the hallway thermostat outside Resident #1' s room was set to 90 degrees Fahrenheit. 2. InterviewsOn 11/30/23 at 7:43 a.m., Resident #1' s family member stated Resident #1 had difficulty communicating since she previously had a stroke, so he stayed with her frequently. Resident #1' s family member stated the resident would frequently overheat and he was hot himself when he visited, so he provided her with a portable A/C unit to cool her off. Resident #1' s family member further stated only certain resident rooms had personal thermostats, and the temperature of her room was controlled by what the thermostats to the sides and outside her room were set too, which he could not change himself. On 11/30/23 at 12:58 p.m., Staff #4 stated thermostats were in every third resident' s room. She stated the thermostats in the hallwa..