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An initial licensure survey was completed on 3/18/26. A deficiency was cited. Based on observation, record review and interview, the residence failed to be in compliance with all applicable regulations.This failure created the potential for mismanagement of the care of and services for the residents who would be served by this residence.Findings include:-9.2On 3/18/26 at approximately 9:29 a.m., the administrator was asked to provide the visitation policy. However, the policy was not provided.On 3/18/26 at approximately 9:30 a.m., the administrator stated she was unaware of the requirement to have a visitation policy and therefore did not have a policy to provide. -10.7 (U930) First aid equipment is maintained and readily available.On 3/18/26 at 7:57 a.m., the administrator was asked to provide the first aid kit. However, no first aid kit was provided. On 3/18/26 at 9:32 a.m., the administrator stated she was aware of the regulation regarding a first aid kit, but failed to purchase one before the survey. -13.1 (U1310) Double occupancy rooms: a retractable privacy curtain is installed to allow complete visual privacy around each bed that provides a minimum of 60 sqft within the curtain boundaries of each bed. The design must demonstrate that both residents have access to the following without physically encroaching into the other resident' s space: the room entrance door, the bathroomthe closet/wardrobethe window The residence' s undated Resident Rights policy, read in part, states: "resident rights include: right to privacy."1. Double occupancy rooms: A retractable privacy curtain is installed to allow complete visual privacy around each bedDuring the environmental tour on 3/18/26 between 7:40 a.m. and 8:15 a.m., observation revealed the residence failed to ensure double occupancy rooms had retractable privacy curtains installed to allow complete visual privacy without physically encroaching into the other resident' s space, including the room entrance door and bathroom. On 3/18/26 at approximately 9:35 a.m., the administrator stated she was aware of the requirement for double occupancy rooms to ..

An initial certification survey was completed on 3/18/26. Deficiencies were cited. Based on observation and interview, the residence failed to ensure the facility (residence) specified that staff or contractors will not enter a unit without providing advanced notice and agreeing upon a time with the facility' s members when to enter the unit.During the environmental tour on 3/18/26 between 7:40 a.m. and 8:15 a.m., observations revealed the residence failed to ensure Rooms 1-14 had locks for privacy.On 10/1/25 at 9:35 a.m., the administrator stated that she would install locks on the rooms to protect resident privacy. The administrator acknowledged there should have been locks on doors for Rooms 1-14 prior to the onsite investigation, to ensure residents had privacy. Based on record review and interview, the residence failed to ensure the residency agreement specified that staff or contractors will not enter a unit without providing advanced notice and agreeing upon a time with the individual come into the unit.On 3/18/26 at approximately 8:00 a.m., the administrator was asked to provide the residence agreement. However, the residence agreement failed to include that staff or contractors will not enter a unit without providing advanced notice and agreeing upon a time with the individual in the unit.On 3/18/26 at 9:02 a.m., the administrator agreed that the residence failed to add that staff and contractors had to give advanced notice prior to entering a resident' s room. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10, Section 8.7000.8.7411. Incident Reporting (B.) A Provider Agency must submit a verbal or written report for all Critical Incidents, as defined at Section 8.7201.L.5, to the HCBS Member' s Case Management Agency Case Manager within 24 hours of discovery of the actual or alleged Incident. All other incidents must be reported to the Case Manager within two business days. The report must include: 3. Member' s Medicaid identification number; 4. Name of persons involved or witnessing the Incident; 14. Name of the person responsible for follow-up; and 15. Resolution, if applicable.