BROSS STREET ASSISTED LIVING

A complaint revisit was completed on 7/28/26 for all previous deficiencies cited on 4/7/26. The residence is in compliance with all regulations surveyed.

An administrative relicensure survey was completed on 6/29/26. No deficiencies were cited.

A licensure complaint, prompted by #CO42004, was completed on 4/7/26. Deficiencies were cited.

Based on observations, record review, and interviews, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting one of four sample residents (#1). Findings Include:1. ObservationsOn 4/7/26 at 7:51 a.m., during an environmental tour of the residence, two windows were observed in Resident #1's apartment. One was blocked by a window-mounted air conditioning unit. The other one, and the only other available means of egress in the event of an emergency, was not properly functioning. The window would only open to a height of approximately 10 inches. Additionally, the upper left quick-release latch was broken, allowing the window to be easily pushed inward, preventing it from being properly secured. 2. Record ReviewResident #1's signed resident agreement, dated 10/21/25 read in part: the resident has the right to a safe and sanitary living environment. Resident #1 was admitted to the residence on 10/27/25 with a diagnosis of Parkinson's Disease. A residence's maintenance log entry written by Staff #3, dated 10/29/25 at 9:12 a.m., read in part: Room #10's windows don't open or close properly and don't lock."The residence's complaint log dated 3/9/26 read in part: Resident #1 in Room 10, is stating his windows do not open or close easily. A residence's maintenance log entry, dated 3/9/26 from Resident #1 to the administrator requesting maintenance repairs, read in part: "Windows hard to open."3. InterviewsOn 4/7/26 at 12:23 p.m., a family member of Resident #1 stated he was very concerned about Resident #1 not being able to open or secure the window in his room. Additionally, he stated he had emailed the administrator about those concerns on more than one occasion. On 4/7/26 at 10:27 a.m., the administrator and regional director acknowledged that the window would not properly latch or open, especially for Resident #1, due to his diagnosis.

Based on observation, record review, and interviews, the residence failed to prohibit the use of portable heaters in resident rooms, affecting one of four sample residents (#1). Findings include:1. ObservationOn 4/7/26 at 7:51 a.m., during an environmental tour of the residence, a portable space heater was observed in Room 10, where Resident #1 was residing. The space heater was operating and hot to the touch. 2. Record ReviewResident #1 was admitted to the residence on 10/27/25. On 4/7/26 at 12:53 p.m., digital evidence provided by a family member from the administrator, dated 3/31/26, read in part: "First, the radiator cannot be fixed at this time. Resident #1's space heater is fully in compliance with the residence's rules and regs." 2. InterviewsOn 4/7/26 at 7:51 a.m., Resident #1 stated the residence had provided a portable space heater (date unknown) shortly after moving into the residence due to the primary heating being inoperable. On 4/7/26 at 12:23 p.m., a family member of Resident #1 stated a portable space heater was installed in Resident #1's room not long after being admitted to the residence. Additionally, he said that the residence continued to utilize the space heater even after he brought to the administrator's attention that it was non-compliant with state regulations. On 4/7/26 at 10:27 a.m., the administrator stated she was advised that if the portable space heater wasn't near combustible fabric, was an approved heater, and was plugged in to an acceptable outlet, then it was permissible. Additionally, both she and the regional director agreed that it was non-compliant with state regulations.

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 room locations. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 22.5 Each room shall have heat, lighting, and ventilation sufficient to meet the use of the room and the needs of the residents.

A revisit survey was completed on 11/14/24 for all previous deficiencies cited on 7/26/24. The facility is in compliance with all deficiencies that 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

An involuntary discharge appeal survey, prompted by #CO36164, was completed on 7/26/24. A deficiency was cited.

Based on interview and record review, the residence failed to include detailed explanations of the reasons for the discharge, including facts and evidence and actions taken to avoid discharge, a practitioner assessment of the resident's current needs in relation to the resident's medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence's staff or an external service provider affecting one former resident (#1). Findings include:The involuntary discharge notice, dated 4/24/2024, read in part, "(Former Resident #1) is unable to maintain self-care and personal hygiene within the verbal, visual and assisted prompts provided ... (Former Resident #1) is unable to follow his recommended diet plan based on his diabetes diagnosis which has led to an unhealthy increase in weight and risk of harm ... (Former Resident #1) has displayed a lack of community safety skills while accessing the community."The residence's written response to the Former Resident #1's family member's appeal of the discharge, dated 5/2/24, read in part, "(Residence) communicated that at this time the concerns listed in the notice, including (Former Resident #1) self-care and hygiene in addition to increased care needs, are no longer within the scope of our care in an assisted living setting and our notice remains as provided."Progress notes in Former Resident #1's records did not contain detailed explanations of the reasons for the discharge and actually provided detailed notes to the contrary. Progress notes for Former Resident #1 in January, February, March, April and May 2024 revealed:On 1/6/24 Former Resident #1 was encouraged by staff and showered. On 1/7/24 Former Resident #1 showered and changed clothes. On 2/3/24 Former Resident #1 showered. On 2/17/24 Former Resident #1 showered. On 3/11/24 Former Resident #1 was wearing the same clothes as the day before so staff encouraged him to change his clothes and he did. On 3/30/24 Former Resident #1 showered and changed clothes. On 4/6/24 Former Resident #1 showered and changed clothes. On 5/28/24 Former Resident #1 showered. A practitioner's progress note for Former Resident #1 dated 2/6/24 read, "(Former Resident #1) ... obesity, schizophrenia, and cognitive deficits, he resides at (Residence). (Former Resident #1) participates in the day center three days per week, he enjoys walking in the park near his residence and keeping up to date with politics ... Weight gain of 24 pounds over the last six months. Weight gain despite maximally dosed Ozempic and dietitian efforts. (Former Resident #1) expressed his weight was a concern and the plan was to discuss something for appetite control."There were no other progress notes that included evidence to support the involuntary discharge of Former Resident #1. On 7/26/24, the former administrator acknowledged that the residence staff should have documented more progress notes to show detailed explanations of the reasons listed on the discharge notice. Additionally, the former administrator said the residence was the one who decided they were unable to meet Former Resident #1's care needs and it was not the decision of Former Resident #1's practitioner.

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 7.11.6 The written resident agreement shall specify the understanding between the parties concerning, at a minimum, the following items:(A) Assisted living residence charges, refunds, and deposit policies;(B) The general type of services and activities provided and not provided by the assisted living residence and those which the assisted living residence will assist the resident in obtaining;(C) A list of specific assisted living residence services included for the agreed upon rates and charges, along with a list of all available optional services and the specified charge for each;(D) The amount of any fee to hold a place for the resident in the assisted living residence while the resident is absent from the assisted living residence and the circumstances under which it will be charged;(E) Responsibility for providing and maintaining bed linens, bath and hygiene supplies, room furnishings, communication devices, and auxiliary aids; and(F) A guarantee that any security deposit will be fully reimbursed if the assisted living residence closes without giving resident(s) written notice at least thirty (30) calendar days before such closure,(G) Reasons that the assisted living residence could pursue an involuntary discharge of the resident, as listed in Parts 11.11 and 11.12.12.10 Each resident care plan shall:(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence's visitation policy as required by Part 9.2, along with care coordination arrangements. 13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(A) The right to privacy and confidentiality.

A revisit survey was completed on 10/11/23 for all previous deficiencies cited on 7/11/23. The facility is in compliance with all deficiencies that were cited.

A relicensure survey was completed on 7/11/23. A deficiency was cited.

Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records, controlled substances list, medication error reports, and medication disposal records, quarterly, affecting 10 current residents. Findings include: On 7/11/23 at 7:45 a.m., the administrator was requested to provide the residence's medication cart audits; however, the administrator was unable to provide the documentation. On 7/11/23 at 8:00 a.m., the administrator stated a nurse from an outside agency came to the residence once a month and they both conducted the medication cart audits; however, she did not believe the residence had the documentation onsite. She stated once the audit was completed, the nurse took the documentation with her for their records. The administrator stated she was unaware the residence was required to maintain the audit documentation. On 7/11/23 at 8:30 a.m., the administrator stated she was unable to locate the medication cart audit documentation. She stated she contacted the outside agency and requested the documentation; however, it was not provided during the onsite visit.