Karens House

A revisit survey was completed on 12/12/25 for all previous deficiencies cited on 7/28/25. 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 revisit survey was completed on 12/12/25 for all previous deficiencies cited on 7/28/25. 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 revisit was completed on 7/28/25 for the previous deficiencies cited on 8/3/22. Deficiencies were cited.Tag T1146 was not cited in the previous event; however, the deficiency was included in the previous event' s informational 999 tag.The deficiencies cited for Event FFFM11 were cited prior to the regulation revision that was implemented on 7/1/25. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act atSections 25-14201 through 25-14-209, C.R.S. affecting eight current residents (Cross-reference T2724)Findings includeOn 7/28/25, from 8:00 a.m. to 5:00 p.m. residents were observed smoking cigarettes outside of the back doorapproximately five feet from the entrance.On 7/28/25 at approximately 3:45 p.m., the administrator stated that the smoking area was outside on the backdeck and said "really outside anywhere". She stated that she was aware of the Colorado Clean Indoor Air Act atSections 25-14201 through 25-14-209,C.R.S. Based on record review and interview the residence failed to document investigated and resolved irregularities ofthe medication administration record audit affecting eight current residents. This deficiency was cited previously during a state licensure survey 8/3/22. Although the residence corrected thedeficiency, based on the findings below, the residence has not maintained compliance with this regulatoryrequirement.Findings include:A medication audit, dated 7/24/25, did not have the investigation or resolution of medication irregularities noted.On 7/28/25 at approximately 1:15 p.m., Staff #5 stated that he wrote personal notes to himself while doingmedication administration audits. He did not document the investigation or resolution on the audit themselves. On 7/28/25 at approximately 3:45 p.m., the a.. Based on record review and interview, the residence failed to update residents comprehensive assessments atleast annually and whenever the resident' s baseline status changed, affecting three of three sample residents (#1,#8, and #9). (Cross-reference T1150)Findings include:1. Record ReviewResident #1 was admitted to the residence on 6/9/11 with diagnoses of paranoid schizophrenia, aggression, andanger.An assessment, dated 6/14/21, was provided; no other assessments were provided for Resident #1. 2. InterviewsOn 7/28/25 at approximately 2:00 p.m., Resident #1 stated that he was admitted to the hospital at the beginningof July 2025 for more than 24 hours due to his chronic condition, heart failure, which he believed was aggravatedby his medication. On 7/28/25 at approximately 3:20 p.m., Staff #6 s.. 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 7/28/25. Deficiencies were cited. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act atSections 25-14201 through 25-14-209, C.R.S. affecting eight current residents (Cross-reference T2724)Findings includeOn 7/28/25, from 8:00 a.m. to 5:00 p.m. residents were observed smoking cigarettes outside of the back doorap.. Based on observations and interview, the residence failed to have a fire resistant waste disposal container in asmoking area affecting eight current residents. (Cross-reference T2720)This deficiency was cited previously during a state licensure survey 8/3/22. Although the residence corrected thedeficiency, based on the findings below, the residence.. Based on record review and interview the residence failed to document investigated and resolved irregularities ofthe medication administration record audit affecting eight current residents. This deficiency was cited previously during a state licensure survey 8/3/22. Although the residence corrected thedeficiency, based on the findings below, the resi.. Based on record review and interview, the residence failed to ensure that each staff member had dementiatraining according to regulations, affecting eight current residents.Findings include:On 7/28/25 at 12:30 p.m., complete staff files were requested. When reviewed Staff #5 and Staff #6' s files did notinclude initial dementia training or continuin.. Based on record review and interview, the residence failed to have at least one staff member onsite at all timeswho had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from anationally recognized organization, affecting eight current residents. Findings include:1. Record ReviewOn 7/28/25 at approxim.. Based on record review and interview, the residence failed to provide at least three meals daily, at regular times,affecting eight current residents.Findings includeThe residence' s resident agreement, dated 7/15/25, read that the residence provided three meals a day.On 7/28/25 at approximately 1:15 p.m., Resident #5 stated that the reside.. Based on record review and interview, the residence failed to update resident care plans to reflect most currentassessment information, affecting three of three sample residents (#1, #8, and #9). (Cross-reference T1146)Findings include:1. Record ReviewResident #1 was admitted to the residence on 6/9/2011 with diagnoses of p.. Based on record review and interview, the residence failed to update residents comprehensive assessments atleast annually and whenever the resident' s baseline status changed, affecting three of three sample residents (#1,#8, and #9). (Cross-reference T1150)Findings include:1. Record ReviewResident #1 was admitted to the residence on 6/9/11 .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing programregulations found at 10 CCR 2505-10.22.24 Toilet paper in a dispenser, liquid soap, and paper towels or hand drying devices shall be av..

A recertification survey was completed on 7/28/25. Deficiencies were cited. Based on observation and interview, the facility (residence) failed to comply with the Colorado Clean Indoor AirAct at Sections 25-14201 through 25-14-209, C.R.S. affecting eight current members (residents).Findings includeOn 7/28/25, from 8:00 a.m. to 5:00 p.m. residents were observed smoking cigarettes outside of the back doorapproximately five feet from the entrance.On 7/28/25 at approximately 3:45 p.m., the administrator stated that the smoking area was outside on the backdeck and said "really outside anywhere". She stated that she was aware of the Colorado Clean Indoor Air Act atSections 25-14201 through 25-14-209, C.R.S. Based on observations and interviews the residence failed to provide a home-like quality and feel for members atall times affecting eight current members. Findings include:On 7/28/25 at approximately 8:00 a.m. during morning medication administration Staff #6 and #7told residents to wait outside of the medication administration room. Residents were observed lining up outside of the room two to three at a time to wait for their medications. On 7/28/25 a document was posted throughout the facility that directed residents to go to the medication room in the morning, afternoon, and evening at specific times for the staff to administer medications to them.On 7/28/25 at approximately 3:20 p.m., Staff #7 stated that she instructed residents to line up outside themedication room or take a seat while she administered medications to other residents. On 7/28/25 at approximately 3:45 p.m., the administrator stated that she was aware that residents lined upfor medication administration. She stated that if a resident did not come to get their medication they toldthem to come to the medication room so staff could administer it; however, she did not expect residents to lineup.