Oakshire Commons

A complaint revisit was completed on 11/18/25, for all previous deficiencies cited on 8/27/25. The facility (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

A complaint revisit was completed on 11/18/25, for all previous deficiencies cited on 8/27/25. 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

A licensure complaint, prompted by #CO38778, #CO40766 and #CO40855, was completed on 8/27/25. Deficiencies were cited. Based on interviews and record review, the residence failed to update a comprehensive assessment whenever a resident' s condition changed from baseline status, affecting three of five sample residents whose assessments were reviewed (#4, #13, #14, #15, #17). Specifically, Prior to Resident #14 being admitted to the residence he was required to not be under the influence of drugs and alcohol for 90 days. The residence was informed that Resident #1.. Based on observation and interview, the residence failed to ensure that meals were appealing and served at atemperature that was appetizing, affecting 110 current residents. Findings include:On 8/27/25 at 8:42 a.m., a sample of breakfast was evaluated. At breakfast, the chicken and waffle were found tobe inedible due to unappetizing and bland taste. Additionally, the waffle was not served at an appetizingtemperature, 118 degrees Fahrenheit. The r.. Based on record review and interview the residence failed to comply with authorized practitioners ordersassociated with medication administration for one of five sample residents (#7). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the residence has not maintained compliance with this regulatoryrequirement.Findings Include:Resident #7 was admitted.. Based on record review and interview the residence failed to update resident records with documentation onon-going services provided by external service providers affecting four of nine sample residents (#7, #13, #16, and#17). Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of history of falls, major depressivedisorder, anxiety disorder, heart disease, pain in the left knee, pain in right leg, and pain in low back. On .. Based on record review and interview, the residence failed to ensure that each medication administration record(MAR) included the time of administration for each medication and failed to ensure that each qualified medicationadministration person (QMAP) accurately documented each medication administration event at the time theevent was completed for each resident, affecting one of 12 sample residents (#13). Findings include:Residence Po.. Based on record review, observation, and interview, the residence failed to promote resident choice, mobility, independence, and safety and failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs in a resident care plan, affecting one of nine sample residents (#17).Findings include:Reference and Resident AgreementChapter VII regulations governing assisted living residences, part 2.10, def.. 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 2505-10.7.14 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee ' s or volunteer ' s personnel file: (A) Documentation that the individual meets ..

A complaint revisit was completed on 8/27/25 for all previous deficiencies cited on 11/19/24. Deficiencies were cited. The deficiencies cited for Event 9BRA11 were cited prior to the regulation revision that was implemented on 2/15/25. Based on record review and interview the facility (residence) failed record medication prescribed in themedication administration record (MAR) affecting one of five sample members (residents) (#7). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the residence has not maintained compliance with this regulatoryrequirement.Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of chronic obstructive pulmonary disease(COPD) and asthma. On 8/26/25 at approximately 12:00 p.m., all signed practitioner orders for Resident #7 were requested. A signed practitioner order dated 10/7/2024 for Symbicort 80-4.5mg actuation inhaler two puffs twice daily wasprovided. A July and August 2025 medication administration record did not have Symbicort Symbicort 80-4.5mg actuationinhaler two puffs twice daily recorded for medication administration. On 8/27/25 at approximatel.. Based on record review and interviews, the facility (residence) failed to follow the modification of rights outlinedin Section 8.7001.B Pursuant to 6 C.C.R. 1011-1, Chapter V11, Part 13.1, the right of members (residents) to makedecisions and choices in the management of personal affairs, funds, and property in accordance with resident' sability, affecting one of 18 sample residents (#4). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatoryRequirement.Findings include:A signed assisted living residency agreement dated 6/5/24 for Resident #4 read "You, or your Legal Representative(as applicable), are solely responsible for managing your own financial affairs. We will not manage your personalfunds on your behalf". A signed notice of resident rights dated 6/5/24 for resident #4 read in part "The right to make decisions andchoices in the ma.. 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 2505-10.8.7506.F.5 Alternative Care Facility Provider Agency Requirements Environmental Standards (a) The Alternative Care Facility shall be an environment that supports individual comfort, independence, and preference, maintains a home-like quality and feel for Members at all times, and provides Members with unrestricted access to the Alternative Care Facility in accordance with the residency agreement or modifications as agreed to and documented in the Member ' s Provider Care Plan.

A complaint revisit was completed on 8/27/25 for all previous deficiencies cited on 11/19/24. Deficiencies were cited. The deficiencies cited for Event 4HELE11 were cited prior to the regulation revision that was implemented on 3/17/25. Based on record review and interview the residence failed to claim responsibility for the coordination of residentcare services with known external service providers affecting two of twelve sample residents (#7 and #17).This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement.Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of history of falls, major depressivedisorder, anxiety disorder, heart disease, pain in the left knee, pain in right leg, and pain in low back. On 6/27/25 an observation note read that staff discovered Resident #7 on her bathroom floor. Resident #7 lost herbalan.. Based on record review and interview the residence failed to comply with authorized practitioners ordersassociated with medication administration for one of five sample residents (#7). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of chronic obstructive pulmonary disease(COPD) and asthma. On 8/26/25 at approximately 12:00 p.m., all signed practitioner orders for Resident #7 were requested. A signed practitioner order dated 10/7/2024 for Symbicort 80-4.5mg actuation inhaler two puffs twice daily wasprovided. A J.. Based on record review and interview the residence failed to update resident records with documentation onon-going services provided by external service providers affecting four of nine sample residents (#7, #13, #16, and#17). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of history of falls, major depressivedisorder, anxiety disorder, heart disease, pain in the left knee, pain in right leg, and pain in low back. On 6/27/25 an observation note read that staff discovered Resident #7 on her bathroom floor. Resident #7 lost .. Based on record review and interviews, the residence failed to observe the right of residents to make decisions and choices in the management of personal affairs, funds, and property in accordance with resident' s ability, affecting one of 18 sample residents (#4). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatoryRequirement.Findings include:A signed assisted living residency agreement dated 6/5/24 for Resident #4 read "You, or your Legal Representative(as applicable), are solely responsible for managing your own financial affairs. We will not manage your personalfunds on your behalf". A signed notice of resident rights ..