Solange at the Citadel

A certification complaint, prompted by #CO41623, was completed on 2/19/26. Deficiencies were cited. Based on observation, record review, and interview, the facility (residence) failed to provide a physically safe environment, including failing to implement measures to reduce foreseeable hazards associated with resident behaviors, thereby placing the health and safety of five sample members (residents) (#4, #5, #7, #9, #11) at risk. Specifically, Resident #4 was known to regularly smoke in his room and in Resident #5 ' s room, despite Resident #4 and Resident #5' s use of oxygen, creating a significant fire risk. Observations revealed ash and residue from cigarettes on the windowsill of a residents room and a prominent odor of smoke in the residents room. Progress notes dated 1/5, 2/5, and 2/10 read Resident #4 and #5 were smoking in their rooms however, no interventions were added to their care plans. Additionally, staff interviews confirmed that Residents #4, #7, #9, and #11 engaged in methamphetamine smoking within the residence. The residence acknowledged awareness of resident smoking behaviors and substance use; however, failed to implement effective interventions, enforce house rules, or provide protective oversight sufficient to control the hazards. This failure created an immediate jeopardy risk of neglect to all nine current residents residing in the residence. On 2/18/26, the department directed the residence to provide writt.. Based on record review and interview, the facility (residence) failed to comply with the Colorado Clean Indoor Air Act, Sections 25-14-201 through 25-14-209, C.R.S., affecting five (#4, #5, #7, #9, #11) sample members (residents) who smoke inside the residence. Findings include:1. Record Review Resident #4 was admitted to the residence on 5/1/25 with diagnoses including Bipolar disorder, post traumatic stress disorder, and congestive heart failure. Resident #5 was admitted to the residence on 5/20/25 with a diagnosis including oxygen-dependent and chronic obstructive pulmonary disease. A progress note dated 1/5/26 read in part, Resident #4 was smoking with Resident #5 in Resident #5 ' s room.A progress note dated 2/5/26 read in part, Resident #4 was verbally aggressive due to him and Resident #5 setting off fire alarms, smoking in Resident #5 ' s room. The fire department came out and stated they were concerned about people being put in danger by the oxygen use and oxygen tanks in the room.A progress note dated 2/10/26 at 3:25 a.m., read in part, Resident #4 was smoking with Resident #5 in Resident #5 ' s room. 2. Interview On 2/18/26 at approximately 11:00 a.m., the administrator acknowledged awareness of the resident' s smoking concerns and smoking in resident rooms. The administrator did not provide evidence of effective enforcement of smoking restr..

A complaint revisit was completed on 10/30/25 for the previous deficiencies cited on 6/9/25. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25. Based on record review and interview, the residence failed to ensure residents are free from sexual, verbal, physical or emotional abuse affecting one (#14) of four sample residents.This deficiency was cited previously during a state licensure survey on 6/9/25. The facility has not maintained compliance with this regulatory requirement.Findings include: 1. Records ReviewResident #14 was admitted on 11/1/23 with diagnoses including unspecified psychosis, major depressive disorder, post-traumatic stress disorder and traumatic brain injury.On 9/15/25 an incident report in Resident #14 records filed by the residence revealed that on 9/15/25 Resident #5 threw coffee at her and pushed her. The residence contacted the police and advised Resident #14 to avoid contact with Resident #5.On 9/20/25 an incident report in Resident #14 records filed by the residence revealed that Resident #5 showed her and two other residents pictures of his genitals. Resident #14 was arrested and taken to the Pueblo County Jail.On 10/29/25 a discharge note provided by the residence revealed Resident #14 went to stay with his brother after being released from the Pueblo County Jail and self discharged from the residence on 9/23/25.2. Interviews On 10/29/25 at approximately 3:45 p.m. Resident #14 was interviewed regarding the incidents involving Resident #5. Resident #14 said that Resident #5 made her feel frightened and uncomfortable and was told by the residence to avoid further contact with Resident #5.The administrator, interviewed on 10/30/25 at 10:07 a.m., agreed the two incidences involving Resident #14 constituted physical and sexual abuse.