Soul Haven Homes LLC

A revisit survey was completed on 8/21/25 for all previous deficiencies cited on 12/16/24. 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 12/16/24. Deficiencies were cited. Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting three of three sample residents (#1-#3).Findings include: 1. Resident #3 was admitted to the residence on 3/6/24.a. SimvastatinA written practitioner' s order, dated 6/14/24, directed the residence to administer simvastatin 20 mg daily. However, the Nov.. Based on observation, interview and record review, the residence failed to ensure there was at least one staff member onsite at all times with a current certification in cardiopulmonary resuscitation (CPR), affecting five current residents. (Cross-reference S732)Findings include:On 12/16/24 from approximately 7:30 a.m. to 9:00 a.m., Staff #1 was observed working independently at the residence. Staff #1' s CPR certification dated 7/10/22, revealed the certification .. Based on observation, interview and record review, the residence failed to ensure there was at least one staff member onsite at all times with a current certification in first aid, affecting five current residents. (Cross-reference S734)Findings include:On 12/16/24 from approximately 7:30 a.m. to 9:00 a.m., Staff #1 was observed working independently at the residence. Staff #1' s first aid certification dated 7/10/22, revealed the certification had .. Based on observation, interview and record review, the residence failed to provide documentation indicating evidence to the successful completion of the accredited food safety course, affecting five current residents. Findings include:The residence' s Food Safety Policy, dated 2/1/24 read in part: "staff preparing or serving food shall complete a recognized food safety training and maintain evidence of completion on site."On 12/16/24 at 7:40 a.m., Staff #1 put .. Based on record review and interview, the residence failed to develop and implement a visitation policy which described any restriction or limitation necessary to ensure the health and safety of residents, staff, and visitors, affecting five current residents.Findings include:On 12/16/24 at 9:00 a.m., the residence' s visitation policy was requested.On 12/16/24 at 10:25 a.m., a visitation policy which was part of the residence' s house rules was provided... Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting five current residents.Findings include:On 12/16/24 at 9:00 a.m., the residence' s involuntary discharge grievance policy was requested.On 12/16/24 at 10:25 a.m., a grievance policy was provided. However, the policy did not meet the requirements. On 12/16/24 at 3:30 p.m., the administrator stat.. 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 and 6 CCR 1011-1, Chapter 2.2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities: (A) Individ..

A revisit survey was completed on 3/19/24 for all previous deficiencies cited on 2/1/24. No deficiencies 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

7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (B) Dementia Training Requirements (3) Initial Training: Each assisted living residence is responsible for ensuring that all direct-care staff members are trained in dementia diseases and related disabilities. (a) Initial training shall be available to direct-care staff at no cost to them. (b) The training shall be competency-based and culturally-competent and shall include a minimum of four hours of training in dementia topics including the following content: (i) Dementia diseases and related disabilities; " A licensure revisit was completed on 2/1/2024. A deficiency was cited. Based on record review and interviews, the current licensee failed to submit a letter of intent (LOI) to the Colorado Department of Public Health and Environment (CDPHE) and the prospective licensee failed to submit an application, supporting documentation and requisite fees for a change of ownership (CHOW) at least 30 calendar days before the CHOW, affecting four current residents. Findings include:1. Record ReviewOn 2/1/24, review of the Department' s licensing system failed to show evidence that the previous agency owner (current licensee) submitted an official LOI to the department indicating the agency' s intent to change owners.Further review of the department' s records failed to show evidence the current owner (prospective licensee) submitted an application, supporting documentation and requisite fee prior to purchasing the agency on 1/25/24.On 2/1/24 at approximately 7:20 a.m., a document found in the residence read in part; as of 1/25/24, Agency A will be acquired by Agency B. 2. InterviewsOn 2/1/24, at 7:58 a.m., Staff #2 stated Agency B became the new owners on 1/25/24. The prospective new owners came to Agency B on 1/25/24 and introduced themselves to all staff and residents. On 2/1/24 at 9:32 a.m., the administrator stated, she did not know if the new owners had submitted the proper documentation to the department.On 2/1/24 at 9:41 a.m.,..

An initial certification revisit was completed on 2/1/24. A deficiency was cited. Based on record review and interview the agency failed to provide individuals with a key or key code to their home, or a bedroom door with a lock and key, affecting four current participants. Findings include: 1. Record reviewOn 2/1/24 at approximately 12:00 p.m., Participant #2 ' s 5/2/23, key receipt read in part; the participant did not receive a key and was signed by his Power of Attorney (POA). On 2/1/24 at approximately 12:00 p.m., Participant #3 ' s 1/24/24, key receipt read in part; the family did not want a key for the participants room or house and was signed by his POA. 2. InterviewsOn 2/1/24 at 12:45 p.m., the administrator stated, none of the four current participants had a key. The facility did not ask individual participants if they wanted a key to their room and the house. Also, the POA of the participants were the ones who filled out the paperwork so they were the ones to make the decision for participants who did not receive a key.

A certification revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no participants resided at the facility. A certification revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no participants resided at the facility. The department was unable to determine if the facility demonstrated an understanding of regulatory requirements for modifying a right, as no participants resided at the facility. A certification revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no participants resided at the facility. The department was unable to determine if the facility demonstrated an understanding of regulatory requirements for staff/contractors are trained on person-centered practices, as no participants resided at the facility. A certification revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no participants resided at the facility. The department was unable to determine if the facility demonstrated an understanding of regulatory requirements for that residents have the right to dignity and privacy, including having a key or key code to their home, and a bedroom door with a lock and key, as no participants resided at the facility. A certification revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no participants resided at the facility. The department was unable to determine if the facility demonstrated it was integrated in and supported full access of residents to the greater community, including supporting residents in accessing public transportation and other available transportation resources; as no participants resided in the facility. A certification revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no participants resided at the facility. The department was unable to determine if the facility ensured participants had controlled access to their quarters, as no participants resided at the facility. A certification revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no participants resided at the facility. The department was unable to determine if the facility provided a designated smoking area, as no participants resided at the facility.

A licensure revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no residents resided at the residence. The department was unable to determine if the facility complied with Chapter 2 licensure standards pertaining to influenza vaccination, as no residents resided at the residence. A licensure revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no residents resided at the residence. The department was unable to determine if the residence maintained personnel files containing the required documentation, as no residents resided in the residence. A licensure revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no residents resided at the residence. The department was unable to determine if the residence placed in a visible location a list of staff who had current first aid or CPR (cardiopulmonary resuscitation) certification, that was readily available to staff at all times, as no residents resided at the residence. A licensure revisit was attempted to be completed on 3/13/23. A revisit could not be conducted for the previous deficiencies cited on 2/23/22 to determine compliance, as no residents resided at the residence. Deficiencies were cited. Based on observation and interview, the residence failed to ensure the department was able to conduct an unannounced review. (Cross-reference B0332)Findings include: On 3/13/23, the department attempted to conduct an unannounced licensure revisit at the residence. On 3/13/23 at 7:40 a.m., the residence was observed to have ceased operations and no longer had residents or staff onsite.On 3/13/23 at 7:53 a.m., the owner was contacted via telephone. He stated the residence had not had residents for approximately two weeks due to renovations at the residence. Based on observation and interview, the residence failed to submit a letter of intent to the department for suspension of operations at the residence. (Cross-reference B0286)Findings include: On 3/13/23 at 7:40 a.m., the surveyor attempted to initiate an unannounced licensure revisit at the residence. No staff or residents were present at the residence. On 3/13/23, the following was observed: there were no vehicles outside of the residence; the doorbell went unanswered three times; knocks on the door went unanswered twice; there were beds inside the residence stripped and leaning against walls; and, there were boxes in living room.On 3/13/23 at 7:53 a.m., the owner was con..