Manor on Marion Circle, the

A revisit survey was completed on 11/18/25 for all previous deficiencies cited on 3/13/25. 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 11/18/25 for all previous deficiencies cited on 3/13/25. 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 recertification survey with complaint #CO39237 was completed on 3/13/25. Deficiencies were cited. Based on observation and interview, the facility failed to ensure a routine house cleaning sufficient to meet the members' (residents) needs, affecting six current residents.Findings include:1. ObservationOn 3/12/25 at 7:51 a.m., the upstairs bathroom had a pungent urine odor with stains that appeared to be urine on the tile and surrounded the toilet bolt. On 3/12/25 at approximately 8:56 a.m., Staff #1 smelled the pungent odor, saw evidence of feces in the toilet, covered his nose with his shirt, and pointed out the urine stains at the back of the toilet. On 3/12/25 at 9:03 a.m., Staff #1 cleaned the bathroom. On 3/12/25 at 9:21 a.m., the toilet still had urine stains near the base of the toilet. On 3/12/25 at 3:08 p.m., the administrator, operations manager (OM), and Staff #1 saw that the upstairs toilet still had a urine stain near the toilet bolt. 2. InterviewOn 3/12/24 at 8:52 a.m., Staff #1 acknowledged that the urine stains on the toilet were not clean. He also stated that the residence staff cleaned the bathrooms, and he had seen h.. Based on record review and interview, the agency (residence) failed to complete timely reporting, recording, or reviewing of incidents for three (#3-#5) of five members (residents). Findings include: Resident #3 was admitted to the residence on 6/13/24 with diagnosis of bipolar and schizophrenia. Resident #4 was admitted to the residence on 3/26/24 with diagnosis of dementia. Resident #5 was admitted to the residence with diagnoses of bipolar and schizophrenia.An investigation of physical abuse was reported on 1/23/25 due to an occurrence on 1/21/25. The investigation, dated 1/22/25, read in part Resident #3 was yelling at Resident #4 for an unknown reason. When Resident #5 came to their room to investigate, Resident #5 was pushed to the ground by Resident #3 with a door. No injuries were sustained and Resident #5 got himself back off the floor before staff could assist. The operations manager (OM) emailed the final occurrence investigation to the surveyor on 3/12/25. The final report was due on 1/.. 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 program regulations found at 10 CCR 2505-10, Section 8.7000.8.7410Provider Agencies (PAs) provide all PAs identified in the Person-Centered Support Plan (PCSP) a copy of the PCSP (care plan). Maintain the plan on file and ensure it is accessible to all staff. All PAs identified in PCSP develop a Provider Care Plan for each Member identifying at minimum: Service and care needs Goals/Objectives of the servicesDescription of the specific services, supports, methodologies, interventions used to address their identified needs, written in plain language including: Relevant medical information from medical/therapy providers (PCP, OT, PT, Speech, etc.) Duration of services delivered, with duration of the service corresponding to Member' s abilities Frequency of service/support per their needs and prefere..

A relicensure survey with complaint #CO39234 was completed on 3/13/25. Deficiencies were cited. Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of medication administration records affecting six current residents.Findings include:On 3/12/25 at 9:11 a.m. the last two quarterly medication audits were requested from the administrator. However, on 3/12/25 at approximately 1:04 p.m., the administrator stated the residence failed to perform medication audits quarterly. He continued to say the residence performed an internal audit with an external consultant and discovered that an audit had not been performed since 2023. Based on observation and interview, the residence failed to ensure a physically safe and sanitary environment to reduce potential hazards in the physical environment, affecting six current residents.Findings include:1. ObservationOn 3/12/25 at 7:51 a.m., the upstairs bathroom had a pungent urine odor with stains that appeared to be urine on the tile and surrounded the toilet bolt. On 3/12/25 at approximately 8:56 a.m., Staff #1 smelled the pungent odor, saw evidence of feces in the toilet, covered his nose with his shirt, and pointed out the urine stains at the back of the toilet. On 3/12/25 at 9:03 a.m., Staff #1 cleaned the bathroom. On 3/12/25 at 9:21 a.m., the toilet still had u.. Based on observation and interview, the residence failed to keep the residence grounds free of garbage and rubbish, affecting five current residents.Findings include:On 3/12/25, throughout the onsite visit from approximately 7:30 a.m. to 3:30 p.m., the backyard of the residence had several cigarette butts scattered throughout the patio, trashcan, dry grass, a large swept pile near the broom in the house, along the patio sidewalk, around the grass surrounding the designated smoking area and the patio near the house. In the front yard, there were also cigarette butts scattered throughout the rocks of the front yard and in the dry grass. On 3/12/25 at 9:25 a.m., Staff #1 went to the backyard t.. Based on record review and interview, the residence failed to comply with all occurrence reporting required by state law and submit its final investigation report to the Department within five business days after the initial report of the occurrence, affecting three (#3-#5) of five residents. Findings include:Resident #3 was admitted to the residence on 6/13/24 with diagnosis of bipolar and schizophrenia. Resident #4 was admitted to the residence on 3/26/24 with diagnoses of dementia. Resident #5 was admitted to the residence with diagnoses of bipolar and schizophrenia.An investigation of physical abuse was reported on 1/23/25 due to an occurrence on 1/21/25. The investigation, dated 1.. 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 2.11.2.3 Facilities and agencies shall ensure that ninety percent (90%) of employees and direct contractors have received the influenza vaccine during a given influenza season. In order to demonstrate that the ninety percent (90%) rate has been meet, facilities and agencies shall: (A) By May 15th of every year, report to the Department, in the form and manner specified by the Department, the vaccination rate for employees and dir..

A licensure revisit was completed on 6/14/23 for all previous deficiencies cited on 9/27/22. 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