Willows at Crestview, the

A revisit survey was completed on 2/18/26 for previous deficiencies cited on 10/20/25. The agency 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 10/20/25. Deficiencies were cited. Based on record review and interview the facility (residence) failed to address the storage and preservation ofmedications and document a pre-determined means of communicating with members (residents), families, staffand other providers in the residence' s emergency policies and procedures affecting nine current residents. Findings Include:The residence emergency policies provided on 10/20/2025 at approximately 10:00 a.m. did not includeinformation of how the residence planned to preserve and store medications in the case of an emergency or apre-determined method of communicating with residents, families, staff, and other providers. On 10/20/2025 at approximately 4:30 p.m., the administrator stated that he was not aware the resident' semergency contact information was at the office in case of an emergency, rather than in the emergency binder. Hestated that for medication storage and preservation, the residence would have all medications refilled from thepharmacy rather than have a plan to preserve and store medication during an emergency. Based on record review and interview the facility (residence) failed to have an involuntary discharge grievancepolicy that complied with Section 25-27-104.3, C.R.S., affecting nine current members (residents). Findings Include:A document titled Transfer or Discharge, undated, provided instructions to residents for involuntary dischargegrievance, however, did not include residence response to grievances, no retaliation for residents, andterms under which the resident could return to the residence. On 10/20/2025 at approximately 4:30 p.m., the administrator stated that he was aware of the change to theinvoluntary discharge grievance policy and the elements required in the policy.

A relicensure survey was completed on 10/20/25. Deficiencies were cited. Based on record review and interview the residence failed to address the storage and preservation of medicationsand a pre-determined means of communicating with residents, families, staff and other providers in theresidence' s emergency policies and procedures affecting nine current residents. (Cross-reference U0910)Findings Include:The residence emergency policies provided on 10/20/2025 at approximately 10:00 a.m. did not includeinformation on how the residence planned to preserve and store medications in the case of an emergency or apre-determined method of .. Based on record review and interview the residence failed to establish and implement policies and proceduresthat addressed the prevention and spread of influenza from unvaccinated workers affecting nine current residents. Findings Include:On 10/20/2025 at approximately 8:00 a.m., the residence infection prevention policies and procedures wasrequested. A document titled ongoing vaccination and treatment plan, dated 3/2/2023, was provided. The document did notprovide infection prevention policies and procedures for influenza. On 10/20/2025 at approximatel.. Based on record review and interview the residence failed to provide a resident roster that included emergencycontact information affecting nine current residents. (Cross-reference U0920)Findings Include:On 10/20/2025 the residence provided a resident roster that did not include emergency contact information fornine of nine current residents. On 10/20/2025 at approximately 4:30 p.m., the administrator stated that he was not aware that emergencycontact information was required on the resident roster. Based on record review and interviews the residence failed to have an involuntary discharge grievance policy thatcomplied with Section 25-27-104.3, C.R.S. affecting nine current residents. Findings Include:A document titled Transfer or Discharge, undated, provided instructions to residents for involuntary dischargegrievance, however, did not include residence response to grievances, no retaliation for residents, andterms under which the resident could return to the residence. On 10/20/2025 at approximately 4:30 p.m., the administrator stated that he was awar.. Based on record review and interviews the residence failed to require staff members who prepared food tocomplete food safety training and maintain evidence of completion on site, affecting nine current residents. Findings Include:On 10/20/2025 at approximately 3:00 p.m., the staff files for Staff #1 and Staff #2 were reviewed. Both staff filesdid not include a food safety training recognized by food safety experts or agencies. On 10/20/2025 at approximately 11:30 a.m., Staff #2 stated that she did not have her food safety training. On 10/20/2025 at approximately 4:30 p.m., the .. 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 existingprogram regulations found at 6 CCR 1011-1, Chapter 7.7.2 In order to ensure that staff members and volunteers are of good, moral, and responsible character, theassisted living residence shall obtain a check of the Colorado adult protective services data system pursuant toSection 26-3.1-111, C.R.S. Based on the results of the check, the assisted living resid..

A revisit survey was completed on 6/7/23 for all previous deficiencies cited on 12/08/22. The facility is in compliance with all 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