Meadow Vista Assisted Living LLC

A certification complaint, prompted by #CO36037 was completed on 11/10/25. Deficiencies were cited. Based on observation and interviews, the facility (residence) failed to provide a well-maintained outdoor area, affecting eight current members (residents).Findings include:1. ObservationsOn 11/10/25 from 7:30 a.m. to 11:00 a.m., an exterior environmental tour revealed high weeds at the start of a walkway entering the residence, along the perimeter of the fence in the backyard and at two separate gates connecting the front and the back yard. There was a section of fencing in the backyard, approximately 4 feet in length and 4 feet in height, missing from the fence. The patio used by residents at the back of the residence had four box type fans, a flatscreen television, and cardboard box set off in a corner. There was a white trashbag, a cardboard box, a clear plastic bag, broken cyder blocks, and a small white paper bag in various locations on the ground of the back yard. 2. InterviewsOn 11/10/25 at 8:30 a.m., Staff #1 said the administrator was responsible for maintaining the grounds, which included mowing and weeding the lawn, and he was last at the residence on 11/7/25. On 11/10/25 at 10:05 a.m., the administrator stated keeping the grounds free of high weeds and trash was the staff responsibility. The administrator acknowledged the upkeep of the yard was not being done. The administrator said the missing portion of the fence in the backyard was caused by a tree that ha.. Based on observations and interviews, the facility (residence) failed to comply with the Colorado Clean Indoor Air Act (CCIAA), affecting eight current members (residents).Findings include:1. ObservationsOn 11/10/25 at 7:30 a.m., an exterior environmental tour revealed the residence had two designated smoking sections, one in the front yard and one in the backyard. Both smoking sections included chairs and a four foot tall cigarette receptacle placed within two feet of the front door and approximately two feet from the back door. Furthermore, both smoking sections had a sign posted next to the entryway doors that read, "No smoking within 25 feet."A continuous observation from 7:30 a.m. to 11:00 a.m., revealed the following: At 8:55 a.m. revealed Resident #1 smoking within twenty five feet of the front entranceAt 9:03 a.m. revealed Resident #2 smoking within twenty five feet of the back entrance.At 9:20 a.m. revealed Resident #3 smoking within twenty five feet of the front entrance.At 10:05 a.m. revealed Resident #2 smoking within twenty five feet of the back entrance. As resident #2 was stepping into the backyard at 9:03 a.m. the administrator requested for him to "Please smoke further from the home." Resident #2 was observed walking to a chair further away from the door, however he then relocated back to a chair within two feet of the back door. No other re..

A licensure complaint, prompted by #CO36036 was completed on 11/10/25. Deficiencies were cited. Based on observation and interview, the residence failed to keep the residence grounds free of high weeds, garbage and rubbish, affecting eight current residents. (Cross reference U2720).Findings include:1. ObservationsOn 11/10/25 from 7:30 a.m. to 11:00 a.m., an exterior environmental tour revealed high weeds at the start of a walkway entering the residence, along the perimeter of the fence in the backyard and at two separate gates connecting the front and the back yard. There was a section of fencing in the backyard, approximately 4 feet in length and 4 feet in height, missing from the fence. The patio used by residents at the back of the residence had four box type fans, a flatscreen television, and cardboard box set off in a corner. There was a white trashbag, a cardboard box, a clear plastic bag, b.. Based on observation and interviews, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting eight current residents. (Cross-reference U2720).Findings include:On 11/10/25 at 7:30 a.m., an exterior environmental tour revealed the concrete pathway leading to the main entrance at the front of the residence had four areas of missing concrete varying from approximately 6 inches to two feet. The concrete patio, located in the backyard, had a drop off approximately 4 inches to a sloped yard area. On 11/10/25 at 9:55 a.m., Resident #4 walked up the sloped yard, stepped up onto the concrete patio, swayed to the left slightly and extended his arms in a motion to balance himself and continued to walk into the residence. Resident #4 stated walking up the .. Based on observations and interviews, the residence failed to comply with the Colorado Clean Indoor Air Act, affecting eight current residents. (Cross reference U2510 and U2512).Findings include:1. ObservationsOn 11/10/25 at 7:30 a.m., an exterior environmental tour revealed the residence had two designated smoking sections, one in the front yard and one in the backyard. Both smoking sections included chairs and a four foot tall cigarette receptacle placed within two feet of the front door and approximately two feet from the back door. Furthermore, both smoking sections had a sign posted next to the entryway doors that read, "No smoking within 25 feet."A continuous observation from 7:30 a.m. to 11:00 a.m., revealed the following: At 8:55 a.m. revealed Resident #1 smoking within twenty five feet of the front e.. 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 7.21.4 Porches, stairs, handrails, and ramps shall be maintained in good repair.

Based on observation, interview, and record review, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining the life safety code for fire drills, and smoking policy. The facility failures had the potential to affect all occupant of the building.Findings include:Cross-reference to A0001 for interview and record review that showed less than 12 fire drills in the last calendar year and no activation of the alarm during drills.Cross-reference to A0003 for observations and interviews of smoking activities in violation of applicable codes.The deficient items were discussed with facility owner and staff at the exit conference. Based on the observation and staff interviews, it was determined that the facility failed to implement a smoking policy in accordance with the Life Safety Code 101. The deficient practice affected all smoke compartmentsall residents, and an indeterminable number of staff and visitors.Observation of the building entrance showed ash trays and evidence of smoking less than 25 feet from the door. An interview with the caregiver, who was the only staff on duty, confirmed that smoking occurred less than 25 feet from the building entrance.33.7.4 Smoking.33.7.4.1* Smoking regulations shall be adopted by the administration of board and care occupancies.33.7.4.2 Where smoking is permitted, noncombustible safety-type ashtrays or receptacles shall be provided in convenient locations.COLORADO CLEAN INDOOR AIR ACTARTICLE 14, TITLE 25, C.R.S(7) "Entryway" means the outside of the front or main doorway leading into a building orfacility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includesthe area .. Based on the record review and staff interviews, it was determined that the facility failed to conduct fire drills in accordance with NFPA 101A. The deficient practice affected all smoke compartments, all residents, and an indeterminable number of staff and visitors.1. After reviewing the fire drill documents furnished by the caregiver, who was the only staff on duty, it was found that only three fire drills were conducted in the previous calendar year.2. The caregiver stated he simulated fire alarm sounds on the television when conducting drills. The caregiver confirmed he did not activated the fire alarm during fire drills.NFPA 101A, section 6.5.2.5 Fire drills shall be conducted monthly, and at least 12 fire drills shall have been conducted during the previous year. A facility in operation for less than one year shall be permitted to have conducted a fire drill for each month of its operation.NFPA 101A, Worksheet 6.8.6 Staff Response and Training requires at least 12 fire drills to be conducted during the previous year. 33.7.3 Emergenc.. Revisit to the 5/14/2025 revisit survey was completed on 9/18/2025. Three deficiencies were cited.

A life safety code survey, prompted by #CO39962, was completed on 5/14/2025. Four deficiencies were cited. The facility is a one (1) story, Type V (000) wood frame structure with a basement and licensed for eight (8) residents. The facility is not equipped with a fire suppression system.This survey, conducted on May 14, 2025, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing small facilities. Based on observation, interview, and record review, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining the life safety code for fire drills, fire alarm, and smoking policy. The facility failures had the potential to affect all occupant of the building.Findings include:Cross-reference to A0001 for interview and record review that showed less than 12 fire drills in the last calendar year and no activation of the alarm during drills.Cross-reference to A0002 for interview and record review of no fire alarm annual and semi-annual inspections in the last calendar year.Cross-reference to A0003 for obs.. Based on record review and staff interviews, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 Section 9.6 and NFPA 72. The deficient practice affected all smoke compartments, all residents, and an indeterminable number of staff and visitors..The caregiver, who was the only staff on duty, provided the last fire alarm inspection report for review. The inspection was from April 2024. The caregiver confirmed this was the most recent inspection. The building owner was interviewed. The owner stated the fire alarm company had not been returning calls for service, affirming the April 2024 report was the most current system review.1.1.1 NFPA 72 covers the application, installation, location, perform.. Based on the observation and staff interviews, it was determined that the facility failed to implement a smoking policy in accordance with the Life Safety Code 101. The deficient practice affected all smoke compartmentsall residents, and an indeterminable number of staff and visitors.Observation of the building entrance showed ash trays and evidence of smoking less than 25 feet from the door. An interview with the caregiver, who was the only staff on duty, confirmed that smoking occurred less than 25 feet from the building entrance.33.7.4 Smoking.33.7.4.1* Smoking regulations shall be adopted by the administration of board and care occupancies.33.7.4.2 Where smoking is permitted, noncombustible safety-type ashtrays or receptacles shall be provided in convenient locations.COLORADO CLEAN INDO.. Based on the record review and staff interviews, it was determined that the facility failed to conduct fire drills in accordance with NFPA 101A. The deficient practice affected all smoke compartments, all residents, and an indeterminable number of staff and visitors.1. After reviewing the fire drill documents furnished by the caregiver, who was the only staff on duty, it was found that only five fire drills were conducted in the previous calendar year.2. The caregiver stated he simulated fire alarm sounds on the television when conducting drills. The caregiver confirmed he did not activated the fire alarm during fire drills.NFPA 101A, section 6.5.2.5 Fire drills shall be conducted monthly, and at least 12 fire drills shall have been conducted during the previous year. A facility in operation for less than one..

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 10/26/23. 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 was completed on 10/26/23. Deficiencies were cited. Based on observation and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets, affecting five of seven current residents who smoked (#1, #3-#6). Findings include:On 10/26/23 from 8:11 a.m. to 8:26 a.m., an environmental tour of the residence revealed the wastebaskets for Residents #1, #3-#6 were not fire resistant and were either made of plastic, fabric, or metal. On 10/26/23 at approximately 10:15 a.m., Staff #1 identified Resident #1 and Residents #3-#6 as smokers.On 10/26/23 at approximately 12:15 p.m., the administrator designee stated she was not aware that fire resistant wastebaskets needed to be in each resident room who were identified as smokers, as required. Additionally, she was unaware that Residents #1, #3-#6 did not have fire resistant wastebaskets in their rooms. Based on observation and interview, the residence failed to have a fire resistant waste disposal container in the designated outdoor smoking area, affecting seven current residents.Findings include:On 10/26/23 at 7:57 a.m., ground coffee metal cans were in the outdoor designated smoking area and were full of cigarette butts and ashes.On 10/26/23 at 12:15 p.m. the administrator designee stated that the metal coffee cans were used for cigarettes. She also stated that she was aware the smoking areas needed to have a fire resistant waste disposal container. 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 7.14.38 All medications shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff.

A recertification survey was completed on 10/26/23. No deficiencies were cited. 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 8.495.6.H. Provider Service Requirements2. Alternative Care Facility Providers shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations.Chapter VII regulations governing assisted living residences:14.38 All medications shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff.