Ivy Cottage

A revisit survey was completed on 1/7/26 for all previous deficiencies cited on 9/30/25. 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 9/30/25. Deficiencies were cited. Based on record review and interview the residence failed to have an involuntary discharge grievance policy thatcomplied with section 25-27-104.3, C.R.S., affecting eight current residents. Findings IncludeA document titled Discharge Policy, undated, provided by the residence read in pertinent part that in the case ofan involuntary discharge the residence would notify the resident via email, written or oral notification that theywould assist the resident with relocation, and that the resident had the right to contact the local ombudsmanand/or adult protective services. The document failed to provide information detailing that the resident had theright to have assistance in preparing their grievance, that the residence would reply to the grievance within fivebusiness days with all pertinent information, and the terms which the resident would be able to return to theresidence. On 9/30/25 at approximately 1:00 p.m., the administrator stated that she was not aware that the involuntarydischarge grievance policy was updated with specifi.. Based on record review and interview, the residence failed to have an administrator in place who completed 40hours of administrator training affecting eight current residents. Findings IncludeA document dated September 2002 read that the administrator completed 30 hours of Owner/Operator training.On 9/30/25 at approximately 1:00 p.m., the administrator stated that she had not completed the additional 10hour of administrator training requirement before June 30, 2024. She stated she was not aware that it wasrequired. 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 existingprogram regulations found at 6 CCR 1011-1, Chapter 7.10.6 Each assisted living residence ' s emergency policies shall address, at a minimum, all of the following items: (I)In the event relocation of residents becomes necessary, written agreements with other health facilities and/orcommunity agencies.

A recertification survey was completed on 9/30/25. A deficiency was cited. Based on record review and interview the residence failed to have an involuntary discharge grievance policy thatdetailed the process residents or their representative could take to dispute the residences decision and failed toprovide agency contact information for assistance, affecting eight current residents. Findings IncludeA document titled Discharge Policy, undated, provided by the residence read in pertinent part that in the case ofan involuntary discharge the residence would notify the resident via email, written or oral notification that theywould assist the resident with relocation, and that the resident had the right to contact the local ombudsmanand/or adult protective services. The document failed to provide information detailing that the resident had theright to have assistance in preparing their grievance, that the residence would reply to the grievance within fivebusiness days with all pertinent information, and the terms which the resident would be able to return to theresidence. On 9/30/25 at approximately 1:00 p.m., the administrator stated that she was not aware that the involuntarydischarge grievance policy was updated with specific requirements.