Just for Seniors Living Center I

A relicensure survey was completed on 9/30/25. Deficiencies were cited. Based on interview and record review, the residence failed to develop and implement emergency preparedness policies and procedures, which included all required elements, affecting four current residents.Findings include:On 9/30/25 at approximately 8:45 a.m., Staff #1 was asked to provide the residence' s emergency preparedness policy and procedure.On 9/30/25 at approximately 11:21 a.m., the residence' s emergency preparedness plan did not include a .. Based on interview and record review, the residence failed to ensure all prescribed and PRN (as needed) medication was listed on a medication administration record (MAR) and that the resident' s medication administration record (MAR) contained accurate information, affecting two of two sample residents (#1, #2). (Cross-reference U1604)Findings include:1. Resident #2 was admitted to the residence on 9/25/25 with diagnoses including schizophrenia. On 9/30/25.. Based on interview and record review, the residence failed to establish, maintain and implement an infectious disease mitigation, vaccine and treatment plan affecting all 4 residents. Findings Include:On 9/30/25 at approximately 8:45 a.m., Staff #1 was asked to provide the residence ' s infectious disease mitigation, vaccine and treatment plans. On 9/30/25 from approximately 9:00 a.m. to 3:30 p.m., no infectious disease mitigation vaccine and treatme.. Based on interview, and record review, the residence failed to develop and implement a visitation policy that described any restriction or limitation necessary to ensure the health and safety of residents, staff, and visitors, affecting four current residents.Findings include:On 9/30/25 at approximately 8:45 a.m., Staff #1 was asked to provide the residence' s visitation policy that described any restriction or limitation necessary to ensure the health an.. Based on observation and interview, the residence failed to keep the residence' s exterior grounds free of garbage and rubbish, affecting four current residents.Findings include:On 9/30/25 at approximately 7:45 a.m., an environmental tour of the backyard of the residence revealed multiple objects scattered on the walkways that spanned the length of the residence on the north and west sides. The exit to the outside of the residence was partially blocked by two mat.. Based on record review and interview, the residence failed to ensure two individuals who are qualified medication administration persons, nurses, or practitioners 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 of two sample residents (#1).Findings include:1. Resident #1 was admitted to the residence on 9/19/23.A written practitioner' s order, dated .. Based on record review and interview, the residence failed to have the administrator and the QMAP (qualified medication administration person) supervisor, on a quarterly basis, audit the accuracy and completeness of the medication administration records, affecting four current residents. (Cross-reference U1600)Findings include:On 9/30/25 at approximately 8:45 a.m., Staff #1 was asked to provide documentation of their last two medication audit.. 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 7.6.5 Each administrator shall have completed 40 hours of administrator training before assuming an administrator position. Individuals appointed as an interim administrator shall have completed 40 hours ..

A recertification survey was completed on 9/30/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting two sample residents (#1, #2). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.Resident #2 was admitted to the residence on 9/25/25 with diagnoses including schizophrenia. On 9/30/25 at approximately 9:00 a.m., the residence was unable to provide Resident #2' s September 2025 MAR.On 9/30/25 at approximately 9:00 a.m., Staff #1 said she had not created a MAR f.. Based on observation and interview, the facility (residence) failed to provide an outdoor area accessible to residents (members) without staff assistance that is well maintained, affecting four current residents.Findings include:On 9/30/25 at approximately 7:45 a.m., an environmental tour of the backyard of the residence revealed multiple objects scattered on the walkways that spanned the length of the residence on the north and west sides. The exit to the outside of the residence was partially blocked by two mattresses leaned against each side of the wall. A propane tank was in the middle of the walking path leading outside. There was a plastic bedsheet cover and a floor mop leaned against the wall. The items identified throughout the backyard were a collapsed bed frame, a glass table with two pi.. Based on record review and interview, the facility (residence) failed to provide a key or key code to their home, a bedroom door with a lock and key, lockable bathroom doors, privacy in changing areas, and a lockable place for belongings, with only appropriate staff/Contractors having keys to such doors and locks, affecting four current members (residents).Findings include:On 9/30/25 at approximately 8:00 a.m., there were no house keys observed for any residents. On 9/30/25 at approximately 8:00 a.m., Staff #1 stated Resident #2 was never provided with a key to her bedroom. On 9/30/25 at approximately 12:43 p.m., Staff #1 stated that no residents were offered keys to the main entrance of the residence and that the doors locked at 8:00 p.m. and residents had to call the residence staff t.. Based on record review and interview, the facility (residence) failed to, have a residency agreement, or other form of written agreement in place, affecting one of two sample members (residents) #2.Findings include:Resident #2 was admitted to the residence on 9/25/25.On 9/30/25 at approximately 12:00 p.m., lunch was prepared and served to Resident #2.Resident #2' s record contained an unsigned resident agreement, dated 10/1/25, five days after Resident #1 moved in.On 9/30/25 at 9:35 a.m., Staff #1 stated she was responsible for reviewing resident agreements with new residents. She added she had filled out the resident agreement for Resident #1, but Resident #1 did not review or sign the agreement. Staff #1 said Resident #1 was being cared for, but not being charged until her medicaid enrollment st..

A revisit survey was completed on 9/27/23 for all previous deficiencies cited on 5/2/23. 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 9/27/23 for all previous deficiencies cited on 5/2/23. 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 with complaint #CO30010 was completed on 5/2/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that the resident records contained progress notes which included information on resident status and wellbeing, as well as documentation regarding out of the or.. Based on interview and record review, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting four curre.. Based on interview and record review, the residence failed to have at least one staff member onsite at all times who had a current certification in CPR (cardiopulmonary resuscitation) from a nationally recognized organization, affectin.. Based on interview and record review, the residence failed to have at least one staff member onsite at all times who had a current certification in first aid from a nationally recognized organization, affecting four current residents. Fin.. Based on observation and interview, the residence failed to have a fire resistant waste disposal container in the designated outdoor smoking area, affecting four current residents. Findings include:On 5/2/23 at 8:38 a.m., ground .. Based on observation, record review and interview the residence failed to ensure residents had the right to full use of the assisted living residence common areas in compliance with the written house rules, affecting four current reside.. Based on observation, record review and interview, the residence failed to ensure residents were provided with and acknowledged receipt of, information regarding whether or not the assisted living residence had video surveillance m.. Based on observation, record review and interview, the residence failed to ensure the process for raising and addressing grievances and complaints was placed in a visible on-site location along with the full contact information .. Based on observations and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets, affecting two of two current residents who smoked (#1 and #2)Findings include:On 5/2/23 at .. Based on record review and interview, the residence failed to develop policies and procedures regarding the infection control and medication errors and medication destruction and disposal. Additionally, the residence failed to ensure t.. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration supervisor (QMAP) conducted quarterly audits of medication administration records, controlled substa.. Based on record review and interview, the residence failed to have defined procedures to prevent the spread of influenza from unvaccinated staff, affecting four current residents. Findings include:On 5/2/23 at approximately 2:0.. Based on record review and interview, the residence failed to include written documentation regarding orientation and training and results of a background check, affecting one of two staff (#2).Findings include:On 5/2/23, at approx.. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, affecting four .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised they must review and maintain the following process in accordance with existing Assisted Living Residences (..

A recertification survey with complaint #CO30009 was completed on 5/2/23. Deficiencies were cited. Based on observations, interviews, and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII and Chapter XXIV, Medication Administration Regulations, affecting four current participants (residents).Findings include:Chapter VII regulations governing assisted living residences, part 14.31, requires that the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence' s Quality Management Program assessment and review.On 5/2/23 at 2:00 p.m., the residence' s quarterly audits of medication administration records, controlled substance lists, medication error reports, and medication disposal rec.. Based on record review and interview the facility (residence) failed to ensure services were not discontinued unless documented efforts to resolve conflict leading to the discontinuance of services was ineffective affecting one former participant (resident) (#3).Findings include:Former Resident #3 was admitted to the residence on 4/3/22 with multiple diagnoses including epilepsy. The record for Former Resident #3 did not include documentation regarding difficult behaviors or discontinuation of services. On 5/2/23 at approximately 12:00 p.m., Staff #1 stated Former Resident #3 resided at the residence for four to five months and behaviors began after his family began to provide marijuana to Former Resident #3. Staff #1 stated Former Resident #3 became frequently abused marijuana and became aggressive. She stated he broke a glass table at the residence, began stealing and police were called on him. Staff #1 stated Former Resident #3 was sent to the hospital and they could not accept the resident back as they were unable to care.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised they must review and maintain the following process in accordance with existing Alternative Care Facility(ACF) program regulations:8.495.3.A. Alternative Care Services which include, but are not limited to, personal care and homemaker services pursuant to 10 CCR 2505-10, Sections 8.489 and 8.490, are benefits to participants residing in an ACF.C. Participant engagement opportunities shall be provided by the ACF, as outlined in 6 CCR 1011-1, Chapter VII, Section 12.19-26B. Participant Engagement1. Providers shall, in consultation with the participants, provide social and recreational engagement opportunities both within and outside the facility.a. Opportunities for social and recreational engagement shall take into consideration the individual interests and wishes of the participants.b. In determining the types of opportunities and activities offered, the provi..