Fremont Home Care, INC

A recertification survey was completed on 1/6/26. Deficiencies were cited. Based on observation, record review, and interviews, the facility (residence) failed to comply with the restrictions on smoking near entryways outlined in the Colorado Clean Indoor Air Act (CCIAA), affecting 15 current members (residents).Findings include:An environmental tour of the residence on 1/6/26 at 8:00 a.m., revealed that one designated smoking area was attached to the main building, near the back entrance. The enclosed area was less than 5 feet from the entrance of the residence.Observation of the enclosed designated smoking area on 1/6/26 at 10:07 a.m., revealed two residents smoking within three to five feet. On 1/6/26 at 9:00 a.m., the administrator confirmed.. Based on record review and interview the facility (residence) failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to members (residents), affecting four of four sample residents (#1-#4).Findings include:1. Resident #1 was admitted to the residence on 6/23/10.The November and December 2025 and January 2026 medication administration records (MARs), read the following medications listed were being administered with no signed and dated practitioners' orders on file: omeprazole, ibuprofen, clozapine, aspirin, iloperidone, Jardiance, clonazepam, metformin, atorvastatin, glipizide and hydroxyzine. 2. InterviewsOn 1/6.. Based on record review and interview, the facility (residence) failed to conduct and document fire drills at least quarterly in the physical facility, affecting 15 current members (residents).Findings include:On 1/6/26 at 8:30 a.m., emergency drill documentation was requested. However, the most recent documented drill occurred in July 2025.On 1/6/26 at 11:30 a.m., the administrator stated the last drill was conducted in August 2025, but was not documented, and acknowledged that drills failed to meet regulatory requirements. Based on record review and interview, the facility (residence) failed to have policies and procedures to ensure the continuation of care to all members (residents) for 72 hours following any emergency, including, but not limited to, a long-term power failure, affecting 15 current residents.Findings include:On 1/6/26 at approximately 10:30 a.m., the written policy to ensure the continuation of care necessary for all residents for at least 72 hours was requested. However, no policy was provided. On 1/6/26 at 11:30 a.m., the administrator said she had a plan, but had not developed or written out the policy to ensure the necessary care for at least 72 hours. The administrator stated she .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The service agency was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10.8.7001.B Individual Rights under the Home and Community-Based Services (HCBS) Settings Final Rule8.7410 Rendering services according to the Person-Centered Support PlanA. Provider Agencies shall provide all Provider Agencies identified in the Person-Centered Support Plan (PCSP) a copy of the PCSP. Provider Agencies shall maintain this plan on file and ensure it is accessible to all staff who need it.B. Provider Agencies shall ..

A relicensure survey was completed on 1/6/26. Deficiencies were cited. Based on observations and interviews, the residence failed to comply with the Colorado Clean Indoor Air Act (CCIAA) by permitting smoking within 15 feet of the residence entryway, affecting 15 current residents.Findings include:An environmental tour of the residence on 1/6/26 at 8:00 a.m., revealed that one designated smoking area was attached to the main building, near the back entrance. The enclosed area was less than 5 feet from the entrance of the residence.Observation of the enclosed designated smoking area on 1/6/26 at 10:07 a.m., revealed two residents smoking within three to five feet. On 1/6/26 at 9:00 a.m., the administrator confirmed that the enclosed designated.. Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting four of four sample residents (#1-#4).Findings include:1. Resident #1 was admitted to the residence on 6/23/10.The November and December 2025 and January 2026 medication administration records (MARs), read the following medications listed were being administered with no signed and dated practitioners' orders on file: omeprazole, ibuprofen, clozapine, aspirin, iloperidone, Jardiance, clonazepam, metformin, atorvastatin, glipizide and hydroxyzine. 2. InterviewsOn 1/6/26 at 11:28 a.m., the administ.. Based on record review and interview, the residence failed to develop written policies to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, including, but not limited to, a long-term power failure, affecting 15 current residents.Findings include:On 1/6/26 at approximately 10:30 a.m., the written policy to ensure the continuation of care necessary for all residents for at least 72 hours was requested. However, no policy was provided. On 1/6/26 at 11:30 a.m., the administrator said she had a plan, but had not developed or written out the policy to ensure the necessary care for at least 72 hours. The administrator stated she .. Based on record review and interview, the residence failed to maintain written documentation of routine emergency drills, affecting 15 current residents.Findings include:On 1/6/26 at 8:30 a.m., emergency drill documentation was requested. However, the most recent documented drill occurred in July 2025.On 1/6/26 at 11:30 a.m., the administrator stated the last drill was conducted in August 2025, but was not documented, and acknowledged that drills failed to meet regulatory requirements. 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 7.12.10 Each resident care plan shall: (A) Be developed with input from the resident and the resident ' s representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purpo..

A relicensure revisit was completed on 12/14/23 for the previous deficiency cited on 3/8/23. The residence is in compliance with all regulations surveyed. 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 3/8/23. Deficiencies were cited. Based on interview and record review, 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 15 current residents. (Cross-reference B0732)Findings include: 1. Referencesa. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that' s useful in many emerge.. Based on observation and interview, the residence failed to ensure exterior grounds were kept free of rubbish, affecting 15 current residents. Findings include:On 3/8/23 at approximately 2:19 p.m., during an environmental tour of the backyard, the following was noted: Seven old mattresses stacked up behind the shed and a broken stove and swamp cooler between the shed and the house. At the edge of the walkway, approximately 70(+) cigarette butts litt.. Based on observation, record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 15 current residents. (Cross-Reference Q0734)Findings include: According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them .. Based on record review and interview, the residence failed to have an administrator who had taken the training program that met all Assisted Living requirements, affecting 15 current residents.Findings include:On 3/8/23 the department' s database listed the administrator of record (AOR) as the administrator since 3/25/21. On 3/8/23 at approximately 7:45 a.m., the director of operations (DOO) arrived at the residence. She stated the (AOR) was no lon.. Based on record review and interview, the residence failed to have defined procedures to prevent the spread of influenza from unvaccinated staff, affecting 15 current residents. Findings include:On 3/9/23 at approximately 7:45 a.m., the director of operations (DOO) was asked to provide the residence' s procedures to prevent the spread of influenza from unvaccinated staff. However, no such policy/procedure was provided.On 3/8/23 at approximately 8:3.. Based upon record review and interview, the administrator, failed to review and/or approve the quality management plan (QMP), at least annually, affecting 15 current residents. Findings include:1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator' s designee. 2. Record ReviewOn 3/8/23 at 10:45 a.m., the residence' .. 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-ad..