St Bernadette Assisted Living

A revisit survey was completed on 1/26/26 for all previous deficiencies cited on 9/30/25. The facility 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 recertification survey was completed on 9/30/25. Deficiencies were cited. Based on a review of records and interviews, the facility (residence) failed to ensure that the residency agreements specified the assigned room and the duration of the agreement for all four current residents.Findings Include:A review of the residency agreements for all four current residents revealed that none of the residency agreements specified the specific room and/or unit the residents would occupy. Additionally, the residency agreements did not include the duration of the agreement.On 9/30/25 at 1:35 p.m., the administrator stated that he was unaware of the requirements that the residency agreement have a duration or specify the room the resident resided in. He added that the residency agreement is "indefinite". Based on observation and interviews, the facility (residence) failed to ensure all medications were stored under proper conditions with regard to safety, affecting all four current members (residents).Findings Include:Observation on 9/30/25 from 7:35 a.m. to 8:15 a.m. revealed the medication cart in the kitchen was unlocked and unattended while Resident #2 was present.An interview on 9/30/25 at 1:35 p.m. with the administrator revealed that his expectation was for staff to keep the medication storage cart locked whenever it is unattended. Based on observations and interviews, the (facility) residence failed to comply with the Colorado Clean Indoor Air Act by permitting smoking within 15 feet of entrances, affecting all four current members (residents).Findings Include:Observation on 9/30/25 at 8:00 a.m. revealed the designated smoking area within 15 feet of the residence entrance, with two ashtrays positioned within one foot of the rear entrances.Observation on 9/30/25 at 10:50 a.m. revealed Resident #1 smoking within 15 feet of a rear entrance.An interview on 9/30/25 at 1:35 p.m. with the administrator confirmed the smoking area had been temporarily relocated due to deck construction and acknowledged the location was not compliant.

A relicensure survey was completed on 9/30/25. Deficiencies were cited. Based on observations and interviews, the residence failed to comply with the Colorado Clean Indoor Air Act by permitting smoking within 15 feet of entrances, affecting all four current residents.Findings Include:Observation on 9/30/25 at 8:00 a.m. revealed the designated smoking area within 15 feet of the residence entrance, with two ashtrays positioned within one foot of the rear entrances.Observation on 9/30/25 at 10:50 a.m. revealed Resident #1.. Based on observations and interviews, the residence failed to ensure paper towels or hand-drying devices were available in the common bathroom, affecting all four current residentsFindings Include:Observation on 9/30/25 at 10:00 a.m. revealed the common bathroom lacked paper towels or other hand-drying devices.An interview on 9/30/25 at 10:00 a.m. with Resident #4 stated he could provide a towel from the linen closet.An interview on 9/30/25 at 10:.. Based on observations and interviews, the residence failed to store medications in a locked cart when unattended, affecting all four current residents.Findings Include:Observation on 9/30/25 from 7:35 a.m. to 8:15 a.m. revealed the medication cart in the kitchen was unlocked and unattended while Resident #2 was present.An interview on 9/30/25 at 1:35 p.m. with the administrator revealed that his expectation was for staff to keep the medication storage cart l.. Based on records review and interviews, the residence failed to maintain a legible list of staff names, signatures, and initials for the medication administration record (MAR), affecting all four current residents.Findings Include:Records review of August and September 2025 MARs for Residents #1–#4 revealed no legible list of names, signatures, or initals for staff utilizing the MARs.An interview on 9/30/25 at 12:50 p.m. with the administrator confirmed the residence di.. Based on records review and interviews, the residence failed to maintain an involuntary discharge grievance policy that included required elements, affecting all four current residents.Findings Include:Record review of the residence ' s discharge and grievance policies, undated, revealed that the policies did not identify:(1) The individual designated by the assisted living residence to receive involuntary discharge grievances.(2) The ability for any of the persons the .. Based on records review and interviews, the residence failed to maintain required personnel documentation in staff files for all three current caregiver staff, affecting all four current residents.Findings Include:Records review on 9/30/25 at 11:00 a.m. revealed personnel files for Staff #1, #2, and #3 did not contain:(1) A description of the employee or volunteer duties;(2) Date of hire or acceptance of volunteer service and date duties commenced;(3) Ori.. Based on records review and interviews, the residence failed to review and update the residency agreements annually as required, affecting one (#2) of four current residents.Findings Include:Records review on 9/30/25 revealed Resident #2 ' s agreement, dated 9/1/19, had no evidence of annual review or update.An interview on 9/30/25 at 1:35 p.m. with the administrator confirmed that the residency agreement was not reviewed annually. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing ..