Lark Springs

A licensure complaint, prompted by #CO40321, #CO40407, #CO40588, #CO40938, #CO41029 and #CO41034, was completed on 10/14/25. Deficiencies were cited. Based on observation, record review and interview the residence failed to individualize resident care plans, require staff members to document any out of the ordinary events or issues, before the end of shift, regarding a resident they personally observed or was reported to them along with actions taken to address the residents changing needs, affecting two (#12, #14) of fifteen sample residents. Findings include:1. Record review:Resident #12 was admitted to the residence on 12/27/21 with a diagnosis of dementia, psychotic disturbance, and anxiety. The most recent care pl.. Based on observation, record review and interview, the residence failed to have a sufficient number of staff members on duty in the secure environment to ensure each resident' s physical, social, and emotional health care and safety needs were met in accordance with their individualized care plan, affecting 13 current residents in the secure environment. Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 8.4, require the residence to have staff sufficient in number to help residents needing or potentially.. Based on observation, record review and interview, the residence failed to reassess residents for their continued need for a secure environment every six months or when the resident' s condition changed from baseline status, affecting 12 (#3-#5, #7-15) out of 15 sample residents. Findings include:1. Resident #12 was admitted to the residence on 12/27/21 with a diagnosis of dementia, psychotic disturbance, and anxietyThe record for Resident #12 contained evaluations for a secure environment, dated 4/18/24. The record contained no further evidence that the residence re-assessed the r.. Based on record review and interview, the residence failed to comply with the authorized practitioner' s ordersassociated with medication administration except for those medications which a resident self-administers, affecting three of three sample Residents whose medications were crushed (#13, #14, #16). Findings include:1. Record reviewResident #14 was admitted to the residence on 1/31/23, with diagnoses including dementia and psychotic delusion disorders.A review of Resident #14 ' s October Medication Administration Record (MAR) and corresponding pr.. Based on record review and interview, the residence failed to investigate an allegation of abuse affecting two of two sample residents (#6 and #8).Findings Include:Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Departmen.. Based on record review, observation, and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting 62 current residents.Findings include:1. ObservationOn 10/14/25 at 7:32 a.m., Staff #1 walked away from the unlocked medication cart. On 10/14/25 at 8:05 a.m., Staff #1 walked away from the unlocked medication cart and went inside the resident room. The medication cart remained unlocked and while the residents were present nearby...

A licensure complaint, prompted by #CO37275, #CO37750, #CO39703, was completed on 5/14/25. No deficiencies were cited.

A recertification survey with complaints #CO37124, #CO35902 and #CO35578 were completed on 8/20/24. Deficiencies were cited. Based on observation and interview the facility failed to ensure that a residency agreement would be in place for each member that addressed eviction processes and appeals comparable to those provided under the jurisdiction' s landlord tenant law, affecting 55 current members.Findings include:A resident agreement for Member #9, dated 12/30/21, read in part, "We may terminate this Agreement, upon providing you or your Responsible Party forty-five (45) days written notice". However, the agreement failed to include an appeals process comparable to those provided under landlord and tenant laws.On 8/20/24 at 12:40 p.m., the administrator stated the resident agreements did not include an appeals process as required. She acknowledged the resident agreements were not up to date.Additional deficient .. Based on observation, record review and interview the facility (residence) failed to ensure care plans documented the identification of the individual' s needs and incorporation of these elements into the supports and services outlined in the care plan, affecting two of 55 members (residents) (#2, #8) and one former member (#11).Findings include:1. Resident #8 was admitted on 5/31/23 with a diagnosis of frontotemporal dementia.A care plan, dated 6/4/24, read in part, Resident #8 was at risk for falls and directed care staff to become familiar with their daily routine and attempt to anticipate and meet their needs daily. The care plan for Resident #8 was last updated on 11/09/23.A fall assessment, dated 7/24/24, only indicated Resident #8 was at high risk for falling. There were no other interventions.. Based on record review and interview, the facility failed to ensure the residency agreement included a particular room or unit, specify the duration of the agreement, or specify rent or room-and-board charges, affecting 55 current members (residents).Findings include:The resident agreement for Resident #9, dated 12/30/21, failed to include a particular room, an agreement duration period, or specify in full the charges of room-and-board.On 8/20/24 at 12:40 p.m., the administrator stated the resident agreements did not have all the required information on them. She acknowledged the resident agreements required participant rooms, the duration of the agreement, and the full cost of room-and-board.Additional deficient practice was found for Residents #5, #8, and #10. 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 10 CCR 2505-10 8.400.8.484 HOME- AND COMMUNITY-BASED SERVICES 8.484.5 RIGHTS MODIFICATIONS8.484.5.C For a Rights Modification to be implemented, the following information must be documented in the individual' s Person-Centered Support Plan, and any provider implementing the Rights Modification must maintain a copy of the documentation:1. The right to be modified.2. The specific and individualized assessed need for the Rights Modification.3. The positive interventions and supports used prior to any Rights Modification, as well as the plan goin..

A complaint revisit was completed on 8/20/24 for all previous deficiencies cited on 9/18/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 7/1/24.

A relicensure survey with complaints #CO34203, #CO35901, #CO35577 and #CO37123, were completed on 8/20/24. Deficiencies were cited. Based on observation, record review and interview the residence failed to ensure the most current assessment information is reflected in the care plan; as well as, detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting two of 55 residents (#2, #8) and one former resident (#11).Findings include:1. Resident #8 was admitted on 5/31/23 with a diagnosis of frontotemporal dementia.A care plan, dated 6/4/24, read in part, Resident #8 was at risk for falls and directed care staff to become familiar with their daily routine and attempt to anticipate and meet their needs daily. The care plan for Resident #8 was last updated on 11/09/23.A fall assessment, dated 7/24/24, only indicated Resident #8 was at high risk for falling. There were no other interventions included that detailed specific needs and preferences to address fall risks for Resident #8. A progress note dated 8/18/24, read in part, the resident had an unwitnessed fall in her apartment by her bedside aro.. Based on record review and interview, the residence failed to provide a readily available roster of current residents which included a residence diagram showing room locations, affecting 55 current residents.Findings include:On 8/19/24 at approximately 8:10 a.m., the administrator provided a resident roster with resident names, room assignments, and emergency contact information. However, the resident roster provided did not contain a residence diagram showing room locations.On 8/19/24 at 10:05 a.m., the administrator stated the resident roster did not include a residence diagram showing room locations. 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-administers.14.31 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.

A certification complaint, prompted by #CO33592, was completed on 9/18/23. A deficiency was cited. Based on observation, record review and interview, the setting (residence) failed to ensure each individual (resident) was afforded the opportunity to be protected from all forms of sexual exploitation, affecting three of six sample residents (#1, #2 and #5) abused by Resident #7. Specifically, on 9/6/23, staff witnessed Resident #1 shaking and crying on the floor in the room of Resident #7 with her pants pulled down. Resident #7 had diagnoses including mild cognitive impairment and communication challenges due to a developmental delay. Resident #7 was standing over Resident #1 with his pants pulled down and he confirmed he had sexually touched Resident #1. However, due to a diagnosis of Alzheimer' s Disease, Resident #1 was unable to verbally express thoughts and feelings. The health and wellness director (HWD) recognized crying was not normal behavior for Resident #1. The HWD contacted emergency medical services (EMS) for transport of Resident #7 to the emergency department because the HWD felt after this incident that the female residents who resided in the secure environment were no longer safe around Resident #7. The residence submitted a sexual abuse occurrence to the department and local law enforcement and adult protective services (APS) conducted an investigation. The practitioner stated Resident #7 had "predatory behavior" and she was worried an incident such as this would occur as it did to Resident #1 since Resident #7 had a history of sexual advances toward other staff members at the residence and at the practitioner' s office. Staff interviews revealed Resident #7 had a history of sexually inappropriate behaviors and advances toward other at-risk residents with limited verbal expressions related to their diagnoses of dementia including Residents #1, #2 and #5. None of the sexual advances toward Residents #1, #2 and #5 were documented in progress notes. However, the residence' s care plan revealed Resident #7 had inappropriate sexual behaviors documented by the former health and wellness director (HWD) shortl..