Suites at Holly Creek Assisted Living, the

A relicensure survey, with complaint #CO39388 was completed on 12/30/25. No deficiencies were cited. 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 7.25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (A) A description of the resident' s wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact; (B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR ' s plan to protect the resident from unwanted visitation by other residents; (C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and (D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.

A licensure complaint revisit was completed on 6/6/24 for all previous deficiencies cited on 5/22/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23. Based on observation, interview, and record review the residence failed to comply with authorized practitioner' s orders associated with medication administration affecting two of five sample residents (#8, #9).This deficiency was cited previously during a state licensure survey on 5/22/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #8 was admitted to the residence on 1/11/19 with a diagnosis of Alzheimer' s disease.A written practitioner' s order, dated 5/6/24, directed the residence to discontinue trazodone 25 mg at bedtime. However, the May and June 2024 medication administration records revealed the residence administered the medication from 5/6 to 6/5/24 for a total of 31 additional doses. A medication cart audit revealed that trazodone 25 mg was in stock. On 6/5/24 at 12:33 p.m., the responsible party for Resident #8 stated that in May 2024, Resident #8' s practitioner discontinued trazodone when she requested to lower the number of overall medications that were no longer required. She stated she was not aware the residence had not discontinued the medication.On 6/5/24 at 12:22 p.m., the administrator stated she had thought the order for trazodone went from 50 mg to 25 mg once daily on 5/6/24 and was not aware there was a discontinue order. 2. Similar deficient practice was found for Resident #9.