Temenos Assisted Living

A relicensure and complaint revisit was completed on 2/18/25 for the previous deficiencies cited on 8/20/24. Deficiencies were cited. The residence is currently licensed for seven beds. Based on observation and interview, the residence failed to keep the residence' s exterior grounds free of garbage and rubbish affecting seven potential residents.This deficiency was cited previously during a state licensure survey and complaint on 8/20/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:During an environmental tour on 2/18/25, the backyard of the residence had a pile of sticks and branches, a broken bed headboard, a discarded fish tank near the shed, and a pile of broken fence posts with bricks and branches near the western corner of the yard.On 2/18/25 at 12:28 p.m., the administrator confirmed those items were garbage and rubbish that needed to be dispose.. Based on record review and interview the residence failed to ensure that each staff member met the dementia training requirements in 7.9(B) affecting seven potential residents.This deficiency was cited previously during a state licensure survey and complaint on 8/20/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 2/18/25 at 8:10 a.m., proof of dementia training of all staff was requested, however, the documentation provided failed to meet the requirements of 7.9(B).On 2/18/25 at 12:10 p.m., the administrator reported the house manager was responsible for ensuring all staff completed the dementia training. She explained they were planning to complete the required tr.. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting seven potential residents.This deficiency was cited previously during a state licensure survey and complaint on 8/20/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 2/18/25, a record review of the residence' s emergency plans and procedures did not include flooding and threatened acts of violence procedures nor addressed all of the required elements.On 2/18/25 at 12:25 p.m., the administrator reported that both she and the house manager created the emergency policies in Octo.. Based on record review and interview, the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S affecting seven potential residents.This deficiency was cited previously during a state licensure survey and complaint on 8/20/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 2/18/25, the residence' s visitation policy was requested; however, it lacked all the required elements of Chapter 7, Regulation 9.2 (A-H).On 2/18/25 at 12:16 p.m., the administrator reported that both she and the house manager were responsible for creating the visitation policy. She reported it wa..

A recertification revisit was completed on 2/18/25 for all previous deficiencies cited on 8/20/24. One deficiency was cited.The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 12/30/24.The facility is currently certified for seven beds. Based on record review and interview, the facility (residence) failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting seven potential members (residents).This deficiency was cited previously during a recertification survey and complaint on 8/20/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 2/18/25, a record review of the residence' s emergency plans and procedures did not include flooding and threatened acts of violence procedures nor addressed all of the required elements.On 2/18/25 at 12:25 p.m., the administrator reported that both she and the house manager created the emergency policies in October 2024. She reported due to a lack of awareness the emergency policies lacked the required elements. She reported she expected the policies and procedures to meet the required elements.

A recertification survey was completed on 8/20/24. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to develop and follow emergency policies that addressed, at a minimum, a plan that ensured the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids, affecting seven current residents.Findings include:On 8/20/24 at 8:30 a.m., the residence' s policy on emergency power for essential functions was requested but not provided.On 12/5/23 at approximately 11:00 a.m., the owner and administrator acknowledged the residence did not have a written emergency power for essential function policy. Based on observation, record review and interview, the facility (residence) failed to maintain a home-like quality and feel for members (residents) at all times, affecting three sample residents.Findings include:On 8/20/24 at approximately 4:00 p.m., a lock that required a key was observed on a refrigerator designated for resident use.On 8/20/24 at approximately 4:15 p.m. the administrator stated the refrigerator was locked at night and resident' s did not have access to the refrigerator at that time. The administrator stated that she was unaware that the lock was against regulations. Based on record review and interview, the facility (residence) failed to develop a written policy and procedure to ensure the continuation of necessary care to all members (residents) for at least 72 hours following an emergency affecting seven current residents.Findings Include:On 8/20/24, at approximately 8:30 a.m., a policy for 72-hour care was requested but not provided.On 8/20/24, at approximately 12:00 p.m., the administrator and owner acknowledged the residence failed to develop a written policy and procedure to ensure the continuation of necessary care to all residents for at least 72 hours following an emergency.

A relicensure survey with complaint #CO37211 was completed on 8/20/24. Deficiencies were cited. Based on observation and interview the residence failed to ensure all interior areas including attics, basements, and garages shall be free from accumulations of extraneous material such as refuse, unused or discarded furniture, and p.. Based on observation and interview, the residence failed to ensure all bathtubs/shower floors had proper safety features to prevent slips and falls, affecting five sample residents.Findings include:On 8/20/24 at approximately 8:0.. Based on observation and interview, the residence failed to ensure each sleeping room shall have at least one window of 8 square feet which shall have opening capability, affecting one sample resident Findings include:On 8/20/.. Based on observation and interview, the residence failed to keep the residence ' s exterior grounds free of high weeds, garbage and rubbish, affecting three current and two sample residents.Findings include:During the environmental to.. Based on observation, record review and interview, the residence failed to ensure a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environm.. Based on observation, record review and interview, the residence failed to ensure the emergency preparedness policies contained all the required information and failed to ensure the emergency preparedness policies were readil.. Based on observations, record review, and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting seven current residents.1. ReferenceThe Colorado .. Based on record review and interview the residence failed to ensure that each staff member met the dementia training requirements in 7.9(B), affecting seven current residents.Findings include:On 8/20/24 at approximately 8:30.. Based on record review and interview, the residence failed to develop an involuntary discharge grievance policy, affecting seven current residents. (Cross-reference S810, S812)Findings include:On 8/20/24 at approximately 8:30 a... Based on record review and interview, the residence failed to develop and implement a visitation policy to ensure the health and safety of residents, staff and visitors, affecting seven current residents. (Cross-reference S810, S816)Findi.. Based on record review and interviews, the residence failed to develop and implement a written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following a.. Record review and interview revealed the residence failed to develop and implement policies and procedures regarding grievance procedure and complaint resolution, a grievance procedure for involuntary discharge; investigati.. This portion of the report is for informational purposes only. No response 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, ..

A complaint survey prompted by #CO37210. No deficiency was cited.The initial comments (ID Prefix Tag #P000) are informational only and represent the facility' s general characteristics.The facility is a one-story, wood-frame structure with a basement. The residents do not use the basement. The basement is staff living quarters. The facility has an automatic residential fire sprinkler system, designed under National Fire Protection Association (NFPA) Standard 13D. It is supplied by a 50 gpm fire pump with a 30-minute water supply (3 - 300 gallon tanks). Sprinklers are installed in all habitable areas, closets, and bathrooms. The kitchen hood system is protected by a residential fire extinguishing system located in the cabinet above the stove hood. The facility is licensed for seven beds.NOTES: The facility is not equipped with a minimum of two (2) wheelchair-accessible egress routes and shall not accept or have residents who utilize wheelchairs for mobility.The facility was surveyed on August 20,2024, for compliance with the National Fire Protection Association (NFPA) Life Safety Code, 2003 edition, Chapter 32, New Residential Board and Care Occupancies, Small Facilities. The previous survey used the Life Safety Code, 2003 edition, Chapter 32 for a Small Facility. The facility will not meet the Life Safety Code until the following deficiencies are corrected.Existing life safety features that met the requirements for new buildings at the time of licensure shall be maintained and not diminished. The findings substantiated that no corrections have been made to the previous Life Safety report. The exterior gates will not allow the resident to leave the facility. The facility has multiple places throughout without a clear path of egress, and the egress windows do not operate appropriately