Divine Care Homes LLC

A change of ownership survey was completed on 12/10/25. No deficiencies were cited.A change of ownership occurred on 1/9/25. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1 Chapters 2 and 7.2.3.6 Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in Section 26-3.1-111, C.R.S.5.3 An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR 1011-1, Chapter 2, Part 4.2. (A) An assisted living residence shall investigate an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations. (1) Documentation regarding the investigation, including the appropriate measures to be instituted, shall be made available to the Department, upon request. (B) An assisted living residence shall submit its final investigation report to the Department within five business days after the initial report of the occurrence. (C) Nothing in this Part 5.3 shall be construed to limit or modify any statutory or common law right, privilege, confidentiality, or immunity.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: (A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 ho..

A licensure complaint, prompted by #CO38740 and #CO38780, was completed on 12/24/24. Deficiencies were cited. Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting one current resident (#1) and one former resident (#2). Findings include: 1. Former Resident #2 was admitted to the residence on 5/6/24.a. Levetiracetam A .. Based on interview and record review, the residence failed to ensure each resident care plan identified all external service providers and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting one former resident (#2).Findings include:1. Residence PolicyThe residence' s Resident Ag.. Based on interview and record review, the residence failed to ensure the resident rights to be free from neglect affecting one former resident (#2). (Cross-reference S0540, S0760, S0762, S1122, S1130, S1150, S1410, S2230)Specifically, Former Resident #2 was admitted to the residence on 5/6/24 with a small red spot on his coccyx .. Based on interview and record review, the residence failed to have documentation of on-going services provided by external service providers and progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s condition, along with the.. Based on interview, and record review, the residence failed to ensure that each staff member received initial orientation, affecting six current residents and one former resident (#2). Findings include:Record review The staff schedule provided for the month of December 2024 read Staff #2 started working at the residence starting 12/5/2024.. Based on observation, record review, and interview the residence failed to ensure each staff member received training of their specific duties and responsibilities prior to providing any care services to a resident, affecting six current residents and one former resident (#2). Findings include:1. Observations On 12/24/24 at 8:00 a.m., Staff #2 was obse.. Based on record review and interview the residence failed to refrain from caring for a stage three to four bed sore, affecting one former resident (#2). Findings include: A progress note dated 11/18/24 read in part, a staff member had changed Former Resident #2' s dressing of their wound located on his coccyx area. On 12/23/24 at approximately 8:00.. Based on record review and interview, the residence failed to ensure written agreements with external hospice providers included required elements/provisions, affecting one former resident (#2) receiving external agency hospice services. Findings include:On 12/23/24 at approximately 3:50 p.m., the administrator provided the residence' .. Based on record review and interview, the residence failed to obtain a practitioner' s assessment when a resident experienced a significant change in their baseline status, affecting one former resident (#2). (Cross-reference S2230, S1324). Findings include:Former Resident #2 was admitted to the residence on 5/6/24. A face sheet, provided by the..

A relicensure survey with complaint #CO36923 was completed on 11/5/24. Deficiencies were cited. Based on interview and record review, the residence failed to comply with authorized practitioner' s orders associated with medication administration for three of three sample residents (#1-#3). (Cross-reference B290)Findings include:1.. Based on interview and record review, the residence failed to ensure medication administration records (MARs) conta.. Based on interview and record review, the residence failed to ensure personnel files for current employees were onsite and readily available for department review, for three of three sample staff (#1-#3), affecting seven current r.. Based on interview and record review, the residence failed to ensure personnel files included results of background c.. Based on interview and record review, the residence failed to ensure there was at least one staff member onsite at all times certified in first aid affecting seven current residents. (Cross-reference B290)Findings include:A review of staff.. Based on observation and interview, the residence failed to have a weekly menu available for resident and public vie.. Based on observation and interview, the residence failed to provide toilet paper and paper towels in each common bathroom, affecting seven current residents.Finding include:On 11/5/24 at approximately 9:00 a.m., an environment.. Based on observation, interview, and record review, the residence failed to appoint a qualified designee to satisfact.. Based on observation, record review and interview, the current licensee failed to notify the Department and the pros.. Based on observation, record review, and interview, the residence failed to ensure the administrator managed the day-to-day delivery of services, ensured adequate training and supervision of all personnel, completed all reports an.. Based on observation, record review, and interview, the residence failed to notify the department of a change in the.. Based on record review and interview, the residence failed to comply with Colorado Adult Protective Services (CAPS) Data System prior to hiring staff who provided direct care to at-risk residents for one of three sample staff (#3), affe.. Based on record review and interview, the residence failed to ensure that only medications ordered by an authorized.. 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. (Cross-reference S540)Findings include:.. Based on record review and interview, the residence failed to meet the required elements and have written policies .. Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting seven current residents. (Cross-reference B172, B200, B262, S540, S542, S66.. Based on record review and interview, the residence failed to retain in employee' s personnel files, who were qualifie..