Pilgrim House Assisted Living LLC

A relicensure survey with complaint #CO40099, was completed on 11/18/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure the administrator completed the additional 10 hours of training as required, affecting nine current residents. Findings include: On 11/18/25 at 9:44 a.m., the 40-hour administrator training certification was requested. However, the administrator training certification provided, dated 7/30/2018, contained only 30 hours of the required training. The administrator was unable to provide the additional 10-hour training required. On 11/18/25 at 9:50 a.m., the administrator stated he was not aware of the additional 10 hours of training and had not completed it. Based on observations and interviews, the residence failed to comply with the Colorado Clean Indoor Air Act (CCIAA), affecting nine current residents.On 11/18/25 at 7:00 a.m., an initial tour of the residence revealed the designated smoking area was located less than 25 feet from the main entrance of the residence. On 11/18/25 at 7:10 a.m., Resident #9 and Resident #10 were smoking within five feet of the entrance of the residence, in the designated smoking area.On 11/18/25 at 12:00 p.m., Resident #7 was smoking within five feet of the entrance to the residence, in the designated smoking area. On 11/18/25 at 1:00 p.m., the administrator confirmed that the designated smoking area was less than 25 feet from the entrance of the residence. The administrator said he was not aware residents needed to be at least 25 feet from an entrance when smoking.

A relicensure revisit was completed on 11/18/25 for the previous deficiencies cited on 9/28/22. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event VOSM11 were cited prior to the regulation revision that was implemented on 7/1/25. 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 #CO40100, was completed on 11/18/25. Deficiencies were cited. Based on observations and interviews, the facility (residence) failed to comply with the Colorado Clean Indoor Air Act (CCIAA), affecting nine current members (residents).On 11/18/25 at 7:00 a.m., an initial tour of the residence revealed the designated smoking area was located less than 25 feet from the main entrance of the residence. On 11/18/25 at 7:10 a.m., Residents #9 and #10 were smoking within five feet of the entrance of the residence, in the designated smoking area.On 11/18/25 at 12:00 p.m., Resident #7 was smoking within five feet of the entrance to the residence, in the designated smoking area. On 11/18/25 at 1:00 p.m., the administrator confirmed that the designated smoking area was less than 25 feet from the entrance of the residence. The administrator said he was not aware residents needed to be at least 25 feet from an entrance when smoking.