BROOKSIDE ASSISTED LIVING

A complaint revisit was completed on 4/21/26 for all previous deficiencies cited on 8/21/25. The residence 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 certification complaint, prompted by #CO41072, #CO41283, #CO41648 and #CO41982, was completed on 4/21/26. No deficiencies were cited.

A recertification survey revisit was completed on 4/21/26 for the previous deficiencies cited on 8/25/25. The Facility is in compliance with all regulations surveyed.

A complaint revisit was completed on 4/21/26 for all previous deficiencies cited on 8/21/25. The facility is in compliance with all regulations surveyed.

A relicensure survey revisit was completed on 4/21/26 for the previous deficiencies cited on 8/25/25. The residence 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 licensure complaint, prompted by #CO41983, #CO41646, #CO41073 and #CO41280, was completed on 4/21/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40754, was completed on 8/21/25. Deficiencies were cited.

An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR 1011-1, Chapter 2, Part 4.2. Based on record review and interview the residence failed to comply with all occurrence reporting requirements by state law, affecting two of eight sample resident's (#17 and #20). (Cross-reference 12.1 and 13.11) Findings include:1. Record reviewResident #17 was admitted to the residence on 6/25/25 with a diagnosis of intellectual development disorder. Resident #20 was admitted to the residence on 9/14/18 with a diagnosis of bipolar disorder. An incident report, dated 8/16/25 at 1:30 p.m., read in part, Resident #17 approached the staff office and stated everyone was against him and had blamed him for breaking property. Resident #20 arrived at the staff office and both resident #17 and #20 began shouting at each other. Resident #17 pushed Resident #20 and Resident #20 shoved Resident #17 into a glass frame, breaking the frame. The incident report revealed possible nose bleed as a type of injury for Resident #17 and Resident #20 stated he had called the police and an officer was being sent to the residence. An incident report, dated 8/16/25 at 3:15 p.m., read in part, after an altercation with Resident #20, Resident #17 approached the staff, complaining of a headache and was transported to a hospital via an emergency medical response vehicle. The incident report revealed headache as type of injury for Resident #17. Both incident reports included the administrator's signature acknowledging review on 8/18/25. 2. InterviewsOn 8/20/25 at 9:30 a.m., Resident #20 said it was painful when Resident #17 pushed him and it was still painful. Resident #20 said he called the police on Resident #17 and reported it as assault. On 8/21/25 at 10:30 a.m., the administrator said Resident #20's pain was not reported to him and he was aware of Resident #17 went to the hospital for a headache after the incident. The administrator acknowledged the incident was a reportable occurrence that should have been reported to the Department.

Based on interview and record review, the residence failed to discharge a resident who posed a danger to self or others and the assisted living residence was unable to sufficiently address those issues through therapeutic approach for three of eight sample residents (#13, #17 and #19). (Cross-reference 12.1). Findings include:1. Policy The residence's Assessment Procedure policy, dated 3/2023, read in part: the residence administrator or designee conducts in-person assessments of individual residents. Resident's are reassessed whenever there is a significant change in physical, medical or mental condition or behavior. The assessment information is recorded on the proper forms and is filed in the resident's health information record. 2. Record reviewResident #19 admitted to the residence on 8/7/24, diagnoses included schizophrenia, bipolar 2 disorder and anxiety. An emergency care after visit summary, dated 7/4/25, read in part: Resident #19 was seen on 7/4/25 for suicidal ideations, schizophrenia and bipolar disorder. A safety plan outlining warning signs of suicidal ideation specifically for Resident #19 included "being at the residence, bad or aggressive people, stressful events, lack of sleep and anxiety."The resident record failed to include a re assessment prior to Resident #19's return on the same day. 3. InterviewOn 8/20/25 at 12:00 p.m., the QMAP supervisor said she was not aware resident's needed to be re-assessed for return when there was an emergency room visit or hospital admission. The QMAP supervisor said she was not sure how the residence was assessing for appropriateness of re admission without assessing the resident. The QMAP supervisor said the hospital usually dictated the care at discharge and told the residence if a higher level of care was needed. On 8/20/25 at approximately 1:00 p.m., the administrator said the residence was not always provided an opportunity to re-assess resident's because the hospital or emergency medical response transport dropped residents off without contacting the residence. 4. Similar deficient practice was identified for Resident's #13 and #17.

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 of eight sample resident's #17. (Cross-reference 11.18 and 9.1). Findings include:Resident #17 was admitted to the residence on 6/25/25 with a diagnosis of intellectual development disorder. A 30 day discharge notice, dated 7/31/25, read in part, Resident #17 was given a 30 day notice to vacate the residence related to repeatedly damaging windows. It did not include facts and evidence and actions taken to avoid discharge or a practitioner's assessment. The residence provided no other documentation related the involuntary discharge of Resident #17. On 8/19/25 at approximately 9:00 a.m., the Involuntary discharge policy and procedure was requested from the administrator but not provided. On 8/20/25 at 8:00 a.m., The administrator said he did not have a policy for an involuntary discharge process because he was unaware of the regulation.

Based on record review and interview the residence failed to provide a copy of an involuntary discharge notice to the state long-term care ombudsman, affecting one of eight sample residents (#17). (Cross-reference 11.17 and 9.1)Findings include:Resident #17 was admitted to the residence on 6/25/25 with a diagnosis of intellectual development disorder. A 30 day discharge notice, dated 7/31/25, read in part, Resident #17 was given a 30 day notice to vacate the residence related to repeatedly damaging windows. On 8/20/25 at 8:00 The administrator said he did not send a copy of the written involuntary discharge notice to the local or state long-term ombudsman because he was not aware he needed to.

Based on record review and interviews, the residence failed to provide protective oversight, affecting four current residents. (#13, #17, #19, and #20). (Cross-reference 11.11, 12.10 and 13.11). Specifically, on 8/16/25 at 1:30 p.m., Resident #17 'shoved' Resident #20, and Resident #20 "shoved" Resident #17 into a glass frame, which broke the glass. Resident #20 subsequently experienced pain and alleged he was physically assaulted. Due to the incident, Resident #17 reported a headache and requested to be seen by emergency services. The residence failed to put protective measures in place to protect Residents #17 and #20 from further potential abuse. Additionally, Resident #13 and Resident #19 had histories of suicidal ideation. Resident #13 expressed suicidal ideation most recently on 6/10/25. Resident #19 was seen by emergency care on 7/4/24 for suicide and depression. The safety plan for Resident #19 included being around aggressive people as warning signs for future suicidal ideations. Resident #19 returned to the residence and was the roommate of Resident #17. Resident #17 had a substantial history of yelling, breaking windows, and demonstrated physical abuse toward Resident #20. The residence failed to provide protective oversight as they implemented no interventions to prevent further ideation or potential completion of suicide for Residents #13 and #19. Findings include:1. Record reviewResident #17 was admitted to the residence on 6/25/25 with a diagnosis of intellectual development disorder. Resident #19 admitted to the residence on 8/7/24, diagnoses included schizophrenia, bipolar 2 disorder and anxiety. An emergency care after visit summary, dated 7/4/25, read in part: Resident #19 was seen on 7/4/25 for suicidal ideations, schizophrenia and bipolar disorder. A safety plan outlining warning signs of suicidal ideation specifically for Resident #19 included "being at the residence, bad or aggressive people, stressful events, lack of sleep and anxiety." A 30 day eviction notice, dated 7/31/25, read in part, Resident #17 would need to vacate the residence regarding damage to residence windows. An incident report,dated 8/4/25, read in part, Resident #17 was screaming and yelling, when staff approached the resident he attempted to "head butt" the staff and walked away. An incident report, dated 8/14/25, read in part, Resident #17 and Resident #19, who are roommates, had an argument. Staff reported hearing Resident #17 scream and then a noise of something breaking. Resident #17 reported to staff that Resident #19 was trying to fight him and he [Resident #17} proceeded to call 911. Resident #17 informed police he wanted behavioral health crisis services and was transported to an agency by police. Staff reported seeing a hole in the wall near the location of argument. An incident report, dated 8/16/25, read in part, Resident #17 was yelling at other residents and using profanity, when staff attempted to intervene Resident #17 became "agitated and hysterical". An incident report, dated 8/16/25, read in part, Resident #17 approached the staff office and stated everyone was against him and had blamed him for breaking property. Resident #20 arrived at the staff office and both resident #17 and #20 began shouting at each other. Resident #17 pushed Resident #20 and Resident #20 shoved Resident #17 into a glass frame, breaking the frame. The incident report revealed possible nose bleed as a type of injury for Resident #17 and Resident #20 stated he had called the police and an officer was being sent to the residence. An incident report, dated 8/16/25 at 3:15 p.m., read in part, after an altercation with Resident #20, Resident #17 approached the staff, complaining of a headache and was transported to a hospital via an emergency medical response vehicle. The incident report revealed headache as type of injury for Resident #17. An incident report, dated 8/20/25 at 4:00 a.m., read in part, Resident #17 was screaming and upset with his roommate, Resident #19, for not smoking with him. Resident #17 and Resident #19 remained roommates. There was no evidence that care plans had been updated with interventions to prevent further hospitalizations nor could staff speak to interventions to protect residents from further incident, nor was information in incident reports being thoroughly investigated to rule out abuse. 2. InterviewsOn 8/19/25 at 10:13 a.m., Staff #6 said Resident #17 and Resident #19 asked to be roommates shortly after Resident #17 moved in on 6/25/25 (date unknown). Staff #6 said both residents had private rooms and could have private rooms again. Staff #6 said she was aware Resident #19 had asked to have a private room again (date unknown) and both Resident's #17 and #19 complained about living with each other. Staff #6 said the administrator is aware of the situation, however, when either resident is approached about moving, neither wants to go through with it. Staff #6 said she had not documented any of the conversations and is unsure if it was documented. On 8/20/25 at 10:30 a.m., Resident #19 said he did not want Resident #17 as a roommate or to have a roommate at all. Resident #19 said staff at the residence were aware he wanted a private room, but had done nothing about it. Resident #19 said he has post traumatic stress disorder (PTSD) and anxiety, which is negatively affected by Resident #17. However, Resident #17 and Resident #19 remained roommates. On 8/20/25 at 11:00 a.m., the administrator said he was not aware if staff had spoken to Resident's #17 and #19 regarding Resident #17 was screaming and becoming upset with his roommate, Resident #19, for not smoking with him as indicated in the incident report from 8/20/25 at 4:00 a.m. The administrator said he would be speaking to Resident's #17 and #19 regarding interview on 8/20/25 at 10:30 a.m regarding Resident #19 stating he no longer wanted Resident #17 as his roommate. On 8/20/25 at 11:44 a.m., Staff #8 said she was not working on 7/4/25 when Resident #19 was seen by emergency services for suicidal ideation and was not aware of the circumstances. Staff #8 said Resident #19 had made statements previously when he was "mad" and called emergency services on his own. Staff #8 said she could not remember specific statements by Resident #19 and she was unaware of interventions, specific to Resident #19, for reducing suicidal ideations. On 8/20/25 at 12:21 p.m., the administrator said he had spoken to Resident #19 and #17 about facilitating a move to private rooms after the 8/14/25 incident report and they [Resident's #17 and #19] wanted to remain in their current living situation. The administrator said there were not any specific interventions put in place to protect either Resident #17 or #19 nor had an abuse investigation been done on 8/14/25. The administrator said he had spoken to Resident #19 regarding the incident report on 8/20/25 at 4:00 a.m., about moving to a private room and Resident #19 said he did not want to be the one to move out of the room. The administrator said he would speak to Resident #17 regarding him moving to another room. The administrator said he was unaware of any interventions being implemented to prevent future harm for Resident's #17, #19 and #20. The administrator said he expected staff to follow the residences procedures on investigating abuse and to update care plans for unexpected events. On 8/20/25 at 12:45 p.m., the qualified medication administration personnel (QMAP) supervisor said she was aware of Resident #19 had made suicidal ideation statements. The QMAP supervisor said the information provided in Resident #19's safety plan from his emergency room visit was not documented in his chart. The QMAP supervisor said she was not aware of interventions to help prevent Resident #19 from recurring events of suicidal ideation. The QMAP supervisor said she was not aware abuse investigations needed to be done for verbal altercations or to plan new diagnosis and interventions to prevent future occurrences. On 8/20/25 at approximately 3:30 p.m., the administrator said Resident #17 stated he [Resident #17] was having a mental health crisis of wanting to self harm and had called emergency medical services on his own behalf. The administrator said Resident #17 was being transported to the hospital. 3. Immediate jeopardy The investigation established that the findings above placed Resident's #13, #17, #19, and #20 at immediate jeopardy risk for serious harm or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct thecircumstances that gave rise to the immediate jeopardy situation. On 8/20/25 at 5:00 p.m., the administrator submitted written evidence that read:"For the identified residents #17 and #20 staff will provide visual monitoring of each resident to protect residents #17 and #20 from further potential abuse. Staff document incidents and de-escalations as they occur. Should further assistance be needed police and the facility administrator will be notified. The administrator will interview each resident as to what can be done to avoid conflict and physical abuse from occurring. Staff will be trained on 8/20/25 about new safety interventions by the QMAP Supervisor to ensure resident #17 and #20 ' s safety with how to conduct constant visual supervision with documentation. Each oncoming shift will be trained to the new intervention protocol. The protocol will be documented as to which staff is assigned to each resident. As well as, date time and description of interactions as they occur. For the identified resident #19 the administrator will discuss moving him to his old private room in the main building. If resident is agreeable, resident will have the ability to remove himself from #17 ' s or other residents' aggressive behavior. The staff will document any aggressive people interactions with resident #19 and provide staff narrative of resolutions/interactions to protect resident #19 from triggers. Staff will be trained on 8/20/25 by the QMAP Supervisor as to how to document and de-escalate aggressive behaviors towards resident #19 on the newly developed safety form. For the identified resident #13, the administrator will interview residents and discuss what suicidal ideation triggers he has and what staff can do to help resident cope with suicidal ideation. After triggers are identified, those triggers will be monitored and documented as they occur with staff intervention to protect resident #13 from harm. If resident requires further psychiatric evaluation, staff will have resident #13 transfer to hospital to receive additional professional evaluation. Staff will be trained on 8/20/25 by the QMAP Supervisor as to how to identify and document resident #13 ' s suicidal ideation triggers and documents incidents as they occur on the newly developed safety form."However, the written evidence did not indicate what training material was being used, would staff be trained to investigate abuse and what would be done to protect resident's during investigations. How staff will be trained on de-escalation techniques. What materials are the intervention protocols coming from, at what frequency will visual monitoring occur, and how will it be documented. Who will be responsible for overseeing the monitoring, where it is being stored, and how will effectiveness be monitored. What steps will be taken if the residents are not agreeable to moving rooms and what interventions will be put in place if the residents did not want to be separated. On 8/20/25 at 6:20 p.m., the administrator submitted additional evidence that read:"The staff will document any aggressive people interactions with Resident #19 and provide staff narrative of resolution/interactions to protect Resident #19 from triggers. For the identified Resident #13, the administrator will interview the resident and discuss what suicidal ideation triggers he has, what staff can do to help resident cope with suicidal ideation. After triggers are identified, those triggers will be monitored and documented as they occur with staff intervention to protect Resident #13 from harm. If resident requires further psychiatric evaluation, staff will have Resident #13 transfer to hospital to receive additional professional evaluation. Training will be done on one to one with the facilities resident abuse policy. Staff will be required to sign that they have read and understand it. Staff will be trained to investigate abuse and notify police and facility administrator when abuse is suspected. Staff separating and redirecting residents away from each other with a calming, reassuring voice tone. Care plans will be appropriately updated with staff training on care directives. The facility abuse policy has directives on intervention protocols. Interventions look like removing residents from aggressive interactions, calming, reassuring voice tones and providing positive reinforcement and encouragement for peaceful interactions. 24/7 monitoring will be documented on the safety form. The facility abuse policy provides direction on when to call 911. Staff will be assigned at the beginning of a shift and documented on the safety form. The administrator will confirm monitoring is effective. Residence #17 will be reassessed prior to return to assure needs can be met and to coordinate care with Memorial Central. If Resident #17 is found appropriate to return, Resident #17 has agreed before leaving to the hospital on 8/20/25 to move into the main building back to his old room. Staff will assist Resident #17 with his room transfer. Should Resident #17 change his mind about moving back to the main building, staff will monitor the room from outside and intervene if aggressive behavior is detected by entering the room to deescalate the incident. Staff will be designated at the beginning of shift to monitor for aggressive behaviors (yelling, screaming and loud voices) and document on the incident safety log."The immediate jeopardy was removed on 8/20/25 at 7:00 p.m. 4. Similar deficient practice was found for Resident's #13.

Based on record review and interviews, the residence failed to ensure each resident had a care plan that detailed specific personal service needs and preferences, identified engagement opportunities that match each resident's personal choices, be developed with input from the resident and the resident;s representative, reflect the most current assessment and promoted resident safety, affecting four current residents. (#13, #18, #21, and #22). Findings include:1. Record ReviewResident #21 was admitted to the residence on 5/16/24 with diagnosis of paranoid schizophrenia. On 8/21/25 at approximately 9:28 a.m., a full chart including the most recent care plan and assessments were requested. The pre-admission assessment, dated 5/16/24, and the smoking evaluation/assessment were the only assessment provided for Resident #21. A blank Care Plan was included with Resident #21's file but did not include a careplan that was completed. No other care plans were provided for Resident #21.2. InterviewsOn 8/19/25 at 1:37 p.m., the qualified medication administration personnel (QMAP) supervisor stated she was unaware that the residence did not already have a dedicated form for care plans and reassessments. The QMAP stated she was unaware that reassessments were not happening and did not have an answer as to why care plans weren't updated. On 8/21/25 at approximately 10:30 a.m., the administrator stated he would expect the QMAP and resident assistant's to reassess residents before readmitting them into the residence and would expect that the residence would complete care plans. Similar deficient practice was discovered for Residents #13, #18, and #22.

Based on record review and interview, the residence failed to investigate allegations of abuse of residence in accordance with its written policy, including the protective and corrective action taken once the abuse or neglect was verified, affecting three of eight sample residents #17, #19 and #20. (Cross-reference : U1110 and U0430) Finings include:The Residence's abuse and neglect and abuse policy, dated 3/2023 read in part: "The Residence has developed and implemented policies and procedures that address the investigation of abuse and neglect. Any actual or suspected acts of physical, verbal, Financial, and/or other abuse will be reported to the appropriate authorities and a thorough investigation will take place. A thorough investigation will be conducted by the community administrator and or his or her designee.""The investigation will include the following: immediate actions taken to address the incident (occurrence). Actions taken to ensure that the Resident is safe during the investigation. All interviews and all observations made during the investigation process. The outcome of the investigation and what corrective action was taken. Ongoing observations of the Resident and the actions taken to address his or her concerns."1. Record reviewResident #17 was admitted to the Residence on 6/25/25 with a diagnosis of intellectual development disorder. Resident #19 admitted to the Residence on 8/7/24, diagnoses included schizophrenia, bipolar 2 disorder and anxiety. Resident #20 was admitted to the Residence on 9/14/18 with a diagnosis of bipolar disorder. An incident report, dated 8/14/25, read in part, Resident #17 and Resident #19, who are roommates, had an argument. Staff reported hearing Resident #17 scream and then a noise of something breaking. Resident #17 reported to staff that Resident #19 was trying to fight him, and he [Resident #17] proceeded to call 911. Resident #17 informed police he wanted behavioral health crisis services and was transported to an agency by police. Staff reported seeing a hole in the wall near the location of the argument. An incident report, dated 8/16/25, read in part, Resident #17 approached the staff office and stated everyone was against him and had blamed him for breaking property. Resident #20 arrived at the staff office, and both Resident #17 and #20 began shouting at each other. Resident #17 pushed Resident #2,0 and Resident #20 shoved Resident #17 into a glass frame, breaking the frame. The incident report revealed a possible nosebleed as a type of injury for Resident #17 and Resident #20 stated he had called the police and an officer was being sent to the Residence. An incident report, dated 8/16/25 at 3:15 p.m., read in part, after an altercation with Resident #20, Resident #17 approached the staff, complaining of a headache, and was transported to a hospital via an emergency medical response vehicle. The incident report revealed a headache as type of injury for Resident #17. On 8/19/25 at 3:50 p.m., an electronic correspondence was sent to the administrator requesting full investigations for Resident-to-Resident altercations on 8/14/25 and 8/16/25. However, these were not provided. An incident report, dated 8/20/25 at 4:00 a.m., read in part, Resident #17 was screaming and upset with his roommate, Resident #19, for not smoking with him. 2. InterviewsOn 8/21/25 at 10:30 a.m., the administrator acknowledged the Residence was not following the Residence policy by not fully investigating altercations to rule out abuse or implementing interventions to protect alleged victims while an investigation was being conducted.

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 7.18.8 Resident records shall contain, but not be limited to, the following items: (G) Advance directives, if applicable,with extra copies; and"11.13 Where a resident has demonstrated that he or she has become a danger to self or others, the assisted livingresidence shall promptly implement the following process pending discharge:(A) Take all appropriate measures necessary to protect other residents;(B) Reassess the resident to be discharged and revise his or her care plan to identify the resident ' s current needs andwhat services the assisted living residence will provide to meet those needs; and(C) Ensure all staff are aware of any new directives placed in the care plan and are properly trained to providesupervision and actions consistent with the care plan. "11.15 In the event a resident is transferred to another health care entity for additional care, the assisted livingresidence shall arrange to evaluate the resident prior to re-admission or discharge the resident in accordance with thedischarge procedures specified below.

A recertification survey revisit was completed on 8/21/25 for the previous deficiencies cited on 7/28/22. Deficiencies were cited. The deficiencies cited for Event NK3F11 were cited prior to the regulation revision that was implemented on 7/01/25.

Based on record review and interview, the facility failed to investigate allegations of abuse of members in accordance with its written policy, including the protective and corrective action taken once the abuse or neglect was verified, affecting three of eight sample members #17, #19 and #20. Finings include:The facility's abuse and neglect and abuse policy, dated 3/2023 read in part: "The facility has developed and implemented policies and procedures that address the investigation of abuse and neglect. Any actual or suspected acts of physical, verbal, Financial, and/or other abuse will be reported to the appropriate authorities and a thorough investigation will take place. A thorough investigation will be conducted by the community administrator and or his or her designee.""The investigation will include the following: immediate actions taken to address the incident (occurrence). Actions taken to ensure that the member is safe during the investigation. All interviews and all observations made during the investigation process. The outcome of the investigation and what corrective action was taken. Ongoing observations of the member and the actions taken to address his or her concerns."1. Record reviewMember #17 was admitted to the facility on 6/25/25 with a diagnosis of intellectual development disorder. Member #19 admitted to the facility on 8/7/24, diagnoses included schizophrenia, bipolar 2 disorder and anxiety. Member #20 was admitted to the facility on 9/14/18 with a diagnosis of bipolar disorder. An incident report, dated 8/14/25, read in part, Member #17 and Member #19, who are roommates, had an argument. Staff reported hearing member #17 scream and then a noise of something breaking. member #17 reported to staff that Member #19 was trying to fight him and he [Member #17] proceeded to call 911. Member #17 informed police he wanted behavioral health crisis services and was transported to an agency by police. Staff reported seeing a hole in the wall near the location of argument. An incident report, dated 8/16/25, read in part, Member #17 approached the staff office and stated everyone was against him and had blamed him for breaking property. Member #20 arrived at the staff office and both Member #17 and #20 began shouting at each other. Member #17 pushed Member #20 and Member #20 shoved member #17 into a glass frame, breaking the frame. The incident report revealed possible nose bleed as a type of injury for Member #17 and Member #20 stated he had called the police and an officer was being sent to the facility. An incident report, dated 8/16/25 at 3:15 p.m., read in part, after an altercation with Member #20, Member #17 approached the staff, complaining of a headache and was transported to a hospital via an emergency medical response vehicle. The incident report revealed headache as type of injury for Member #17. On 8/19/25 at 3:50 p.m., an electronic correspondence was sent to the administrator requesting full investigations for member to member altercations on 8/14/25 and 8/16/25. However, these were not provided. An incident report, dated 8/20/25 at 4:00 a.m., read in part, Member #17 was screaming and upset with his roommate, Member #19, for not smoking with him. 2. InterviewsOn 8/21/25 at 10:30 a.m., the administrator acknowledged the facility was not following the facility policy by not fully investigating altercations to rule out abuse or implementing interventions to protect alleged victims while an investigation was being conducted.

Based on record review and interviews, the residence (facility) failed to ensure each resident (member) had a care plan that included specific service and care needs, goals/objectives of the services, a description of the specific services, supports ...interventions used to address their identified needs,and was not reviewed at least two times a year, affecting four current residents. (#13, #18, #21, and #22). Findings include:1. Record ReviewResident #21 was admitted to the residence on 5/16/24 with diagnosis of paranoid schizophrenia. On 8/21/25 at approximately 9:28 a.m., a full chart including the most recent care plan and assessments were requested. The pre-admission assessment, dated 5/16/24, and the smoking evaluation/assessment were the only assessment provided for Resident #21. A blank Care Plan was included with Resident #21's file but did not include a careplan that was completed. No other care plans were provided for Resident #21.2. InterviewsOn 8/19/25 at 1:37 p.m., the qualified medication administration personnel (QMAP) supervisor stated she was unaware that the residence did not already have a dedicated form for care plans and reassessments. The QMAP stated she was unaware that reassessments were not happening and did not have an answer as to why care plans weren't updated. On 8/21/25 at approximately 10:30 a.m., the administrator stated he would expect the QMAP and resident assistant's to reassess residents before readmitting them into the residence and would expect that the residence would complete care plans. Similar deficient practice was discovered for Residents #13, #18, and #22.

Based on record review and interviews, the facility (residence) failed to provide protective oversight, affecting four current members (residents). (#13, #17, #19, and #20). Specifically, on 8/16/25 at 1:30 p.m., Resident #17 'shoved' Resident #20, and Resident #20 "shoved" Resident #17 into a glass frame, which broke the glass. Resident #20 subsequently experienced pain and alleged he was physically assaulted. Due to the incident, Resident #17 reported a headache and requested to be seen by emergency services. The residence failed to put protective measures in place to protect Residents #17 and #20 from further potential abuse. Additionally, Resident #13 and Resident #19 had histories of suicidal ideation. Resident #13 expressed suicidal ideation most recently on 6/10/25. Resident #19 was seen by emergency care on 7/4/24 for suicide and depression. The safety plan for Resident #19 included being around aggressive people as warning signs for future suicidal ideations. Resident #19 returned to the residence and was the roommate of Resident #17. Resident #17 had a substantial history of yelling, breaking windows, and demonstrated physical abuse toward Resident #20. The residence failed to provide protective oversight as they implemented no interventions to prevent further ideation or potential completion of suicide for Residents #13 and #19. Findings include:1. Record reviewResident #17 was admitted to the residence on 6/25/25 with a diagnosis of intellectual development disorder. Resident #19 admitted to the residence on 8/7/24, diagnoses included schizophrenia, bipolar 2 disorder and anxiety. An emergency care after visit summary, dated 7/4/25, read in part: Resident #19 was seen on 7/4/25 for suicidal ideations, schizophrenia and bipolar disorder. A safety plan outlining warning signs of suicidal ideation specifically for Resident #19 included "being at the residence, bad or aggressive people, stressful events, lack of sleep and anxiety." A 30 day eviction notice, dated 7/31/25, read in part, Resident #17 would need to vacate the residence regarding damage to residence windows. An incident report,dated 8/4/25, read in part, Resident #17 was screaming and yelling, when staff approached the resident he attempted to "head butt" the staff and walked away. An incident report, dated 8/14/25, read in part, Resident #17 and Resident #19, who are roommates, had an argument. Staff reported hearing Resident #17 scream and then a noise of something breaking. Resident #17 reported to staff that Resident #19 was trying to fight him and he [Resident #17} proceeded to call 911. Resident #17 informed police he wanted behavioral health crisis services and was transported to an agency by police. Staff reported seeing a hole in the wall near the location of argument. An incident report, dated 8/16/25, read in part, Resident #17 was yelling at other residents and using profanity, when staff attempted to intervene Resident #17 became "agitated and hysterical". An incident report, dated 8/16/25, read in part, Resident #17 approached the staff office and stated everyone was against him and had blamed him for breaking property. Resident #20 arrived at the staff office and both resident #17 and #20 began shouting at each other. Resident #17 pushed Resident #20 and Resident #20 shoved Resident #17 into a glass frame, breaking the frame. The incident report revealed possible nose bleed as a type of injury for Resident #17 and Resident #20 stated he had called the police and an officer was being sent to the residence. An incident report, dated 8/16/25 at 3:15 p.m., read in part, after an altercation with Resident #20, Resident #17 approached the staff, complaining of a headache and was transported to a hospital via an emergency medical response vehicle. The incident report revealed headache as type of injury for Resident #17. An incident report, dated 8/20/25 at 4:00 a.m., read in part, Resident #17 was screaming and upset withhis roommate, Resident #19, for not smoking with him. Resident #17 and Resident #19 remained roommates. There was no evidence that care plans had been updated with interventions to prevent further hospitalizations nor could staff speak to interventions to protect residents from further incident, nor was information in incident reports being thoroughly investigated to rule out abuse. 2. InterviewsOn 8/19/25 at 10:13 a.m., Staff #6 said Resident #17 and Resident #19 asked to be roommates shortly after Resident #17 moved in on 6/25/25 (date unknown). Staff #6 said both residents had private rooms and could have private rooms again. Staff #6 said she was aware Resident #19 had asked to have a private room again (date unknown) and both Resident's #17 and #19 complained about living with each other. Staff #6 said the administrator is aware of the situation, however, when either resident is approached about moving, neither wants to go through with it. Staff #6 said she had not documented any of the conversations and is unsure if it was documented. On 8/20/25 at 10:30 a.m., Resident #19 said he did not want Resident #17 as a roommate or to have a roommate at all. Resident #19 said staff at the residence were aware he wanted a private room, but had done nothing about it. Resident #19 said he has post traumatic stress disorder (PTSD) and anxiety, which is negatively affected by Resident #17. However, Resident #17 and Resident #19 remained roommates. On 8/20/25 at 11:00 a.m., the administrator said he was not aware if staff had spoken to Resident's #17 and #19 regarding Resident #17 was screaming and becoming upset with his roommate, Resident #19, for not smoking with him as indicated in the incident report from 8/20/25 at 4:00 a.m. The administrator said he would be speaking to Resident's #17 and #19 regarding interview on 8/20/25 at 10:30 a.m regarding Resident #19 stating he no longer wanted Resident #17 as his roommate. On 8/20/25 at 11:44 a.m., Staff #8 said she was not working on 7/4/25 when Resident #19 was seen by emergency services for suicidal ideation and was not aware of the circumstances. Staff #8 said Resident #19 had made statements previously when he was "mad" and called emergency services on his own. Staff #8 said she could not remember specific statements by Resident #19 and she was unaware of interventions, specific to Resident #19, for reducing suicidal ideations. On 8/20/25 at 12:21 p.m., the administrator said he had spoken to Resident #19 and #17 about facilitating a move to private rooms after the 8/14/25 incident report and they [Resident's #17 and #19] wanted to remain in their current living situation. The administrator said there were not any specific interventions put in place to protect either Resident #17 or #19 nor had an abuse investigation been done on 8/14/25. The administrator said he had spoken to Resident #19 regarding the incident report on 8/20/25 at 4:00 a.m., about moving to a private room and Resident #19 said he did not want to be the one to move out of the room. The administrator said he would speak to Resident #17 regarding him moving to another room. The administrator said he was unaware of any interventions being implemented to prevent future harm for Resident's #17, #19 and #20. The administrator said he expected staff to follow the residences procedures on investigating abuse and to update care plans for unexpected events. On 8/20/25 at 12:45 p.m., the qualified medication administration personnel (QMAP) supervisor said she was aware of Resident #19 had made suicidal ideation statements. The QMAP supervisor said the information provided in Resident #19's safety plan from his emergency room visit was not documented in his chart. The QMAP supervisor said she was not aware of interventions to help prevent Resident #19 from recurring events of suicidal ideation. The QMAP supervisor said she was not aware abuse investigations needed to be done for verbal altercations or to plan new diagnosis and interventions to prevent future occurrences. On 8/20/25 at approximately 3:30 p.m., the administrator said Resident #17 stated he [Resident #17] was having a mental health crisis of wanting to self harm and had called emergency medical services on his own behalf. The administrator said Resident #17 was being transported to the hospital. 3. Immediate jeopardy The investigation established that the findings above placed Resident's #13, #17, #19, and #20 at immediate jeopardy risk for serious harm or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct thecircumstances that gave rise to the immediate jeopardy situation. On 8/20/25 at 5:00 p.m., the administrator submitted written evidence that read:"For the identified residents #17 and #20 staff will provide visual monitoring of each resident to protect residents #17 and #20 from further potential abuse. Staff document incidents and de-escalations as they occur. Should further assistance be needed police and the facility administrator will be notified. The administrator will interview each resident as to what can be done to avoid conflict and physical abuse from occurring. Staff will be trained on 8/20/25 about new safety interventions by the QMAP Supervisor to ensure resident #17 and #20 ' s safety with how to conduct constant visual supervision with documentation. Each oncoming shift will be trained to the new intervention protocol. The protocol will be documented as to which staff is assigned to each resident. As well as, date time and description of interactions as they occur. For the identified resident #19 the administrator will discuss moving him to his old private room in the main building. If resident is agreeable, resident will have the ability to remove himself from #17 ' s or other residents' aggressive behavior. The staff will document any aggressive people interactions with resident #19 and provide staff narrative of resolutions/interactions to protect resident #19 from triggers. Staff will be trained on 8/20/25 by the QMAP Supervisor as to how to document and de-escalate aggressive behaviors towards resident #19 on the newly developed safety form. For the identified resident #13, the administrator will interview residents and discuss what suicidal ideation triggers he has and what staff can do to help resident cope with suicidal ideation. After triggers are identified, those triggers will be monitored and documented as they occur with staff intervention to protect resident #13 from harm. If resident requires further psychiatric evaluation, staff will have resident #13 transfer to hospital to receive additional professional evaluation. Staff will be trained on 8/20/25 by the QMAP Supervisor as to how to identify and document resident #13 ' s suicidal ideation triggers and documents incidents as they occur on the newly developed safety form."However, the written evidence did not indicate what training material was being used, would staff be trained to investigate abuse and what would be done to protect resident's during investigations. How staff will be trained on de-escalation techniques. What materials are the intervention protocols coming from, at what frequency will visual monitoring occur, and how will it be documented. Who will be responsible for overseeing the monitoring, where it is being stored, and how will effectiveness be monitored. What steps will be taken if the residents are not agreeable to moving rooms and what interventions will be put in place if the residents did not want to be separated. On 8/20/25 at 6:20 p.m., the administrator submitted additional evidence that read:"The staff will document any aggressive people interactions with Resident #19 and provide staff narrative of resolution/interactions to protect Resident #19 from triggers. For the identified Resident #13, the administrator will interview the resident and discuss what suicidal ideation triggers he has, what staff can do to help resident cope with suicidal ideation. After triggers are identified, those triggers will be monitored and documented as they occur with staff intervention to protect Resident #13 from harm. If resident requires further psychiatric evaluation, staff will have Resident #13 transfer to hospital to receive additional professional evaluation. Training will be done on one to one with the facilities resident abuse policy. Staff will be required to sign that they have read and understand it. Staff will be trained to investigate abuse and notify police and facility administrator when abuse is suspected. Staff separating and redirecting residents away from each other with a calming, reassuring voice tone. Care plans will be appropriately updated with staff training on care directives. The facility abuse policy has directives on intervention protocols. Interventions look like removing residents from aggressive interactions, calming, reassuring voice tones and providing positive reinforcement and encouragement for peaceful interactions. 24/7 monitoring will be documented on the safety form. The facility abuse policy provides direction on when to call 911. Staff will be assigned at the beginning of a shift and documented on the safety form. The administrator will confirm monitoring is effective. Residence #17 will be reassessed prior to return to assure needs can be met and to coordinate care with Memorial Central. If Resident #17 is found appropriate to return, Resident #17 has agreed before leaving to the hospital on 8/20/25 to move into the main building back to his old room. Staff will assist Resident #17 with his room transfer. Should Resident #17 change his mind about moving back to the main building, staff will monitor the room from outside and intervene if aggressive behavior is detected by entering the room to deescalate the incident. Staff will be designated at the beginning of shift to monitor for aggressive behaviors (yelling, screaming and loud voices) and document on the incident safety log."The immediate jeopardy was removed on 8/20/25 at 7:00 p.m. 4. Similar deficient practice was found for Resident's #13.

A certification complaint, prompted by #CO40755, was completed on 8/21/25. Deficiencies were cited.

Based on interview and record review, the facility (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 member's (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 of eight sample resident's (#17). Findings include:Resident #17 was admitted to the residence on 6/25/25 with a diagnosis of intellectual development disorder. A 30 day discharge notice, dated 7/31/25, read in part, Resident #17 was given a 30 day notice to vacate the residence related to repeatedly damaging windows. The residence provided no other documentation related the involuntary discharge of Resident #17. On 8/20/25 at 8:00 a.m., The administrator said he was unaware of the regulatory components when issuing an involuntary discharge.

Based on record review and interview, the facility (residence) failed to investigate allegations of abuse of members (residents) in accordance with its written policy, including the protective and corrective action taken once the abuse or neglect was verified, affecting three of eight sample members #17, #19 and #20. Finings include:The facility's abuse and neglect and abuse policy, dated 3/2023 read in part: "The facility has developed and implemented policies and procedures that address the investigation of abuse and neglect. Any actual or suspected acts of physical, verbal, Financial, and/or other abuse will be reported to the appropriate authorities and a thorough investigation will take place. A thorough investigation will be conducted by the community administrator and or his or her designee.""The investigation will include the following: immediate actions taken to address the incident (occurrence). Actions taken to ensure that the member is safe during the investigation. All interviews and all observations made during the investigation process. The outcome of the investigation and what corrective action was taken. Ongoing observations of the member and the actions taken to address his or her concerns."1. Record reviewMember #17 was admitted to the facility on 6/25/25 with a diagnosis of intellectual development disorder. Member #19 admitted to the facility on 8/7/24, diagnoses included schizophrenia, bipolar 2 disorder and anxiety. Member #20 was admitted to the facility on 9/14/18 with a diagnosis of bipolar disorder. An incident report, dated 8/14/25, read in part, Member #17 and Member #19, who are roommates, had an argument. Staff reported hearing member #17 scream and then a noise of something breaking. member #17 reported to staff that Member #19 was trying to fight him and he [Member #17] proceeded to call 911. Member #17 informed police he wanted behavioral health crisis services and was transported to an agency by police. Staff reported seeing a hole in the wall near the location of argument. An incident report, dated 8/16/25, read in part, Member #17 approached the staff office and stated everyone was against him and had blamed him for breaking property. Member #20 arrived at the staff office and both Member #17 and #20 began shouting at each other. Member #17 pushed Member #20 and Member #20 shoved member #17 into a glass frame, breaking the frame. The incident report revealed possible nose bleed as a type of injury for Member #17 and Member #20 stated he had called the police and an officer was being sent to the facility. An incident report, dated 8/16/25 at 3:15 p.m., read in part, after an altercation with Member #20, Member #17 approached the staff, complaining of a headache and was transported to a hospital via an emergency medical response vehicle. The incident report revealed headache as type of injury for Member #17. On 8/19/25 at 3:50 p.m., an electronic correspondence was sent to the administrator requesting full investigations for member to member altercations on 8/14/25 and 8/16/25. However, these were not provided. An incident report, dated 8/20/25 at 4:00 a.m., read in part, Member #17 was screaming and upset with his roommate, Member #19, for not smoking with him. 2. InterviewsOn 8/21/25 at 10:30 a.m., the administrator acknowledged the facility was not following the facility policy by not fully investigating altercations to rule out abuse or implementing interventions to protect alleged victims while an investigation was being conducted.

Based on record review and interviews, the facility (residence) failed to provide protective oversight, affecting four current members (residents). (#13, #17, #19, and #20). Specifically, on 8/16/25 at 1:30 p.m., Resident #17 'shoved' Resident #20, and Resident #20 "shoved" Resident #17 into a glass frame, which broke the glass. Resident #20 subsequently experienced pain and alleged he was physically assaulted. Due to the incident, Resident #17 reported a headache and requested to be seen by emergency services. The residence failed to put protective measures in place to protect Residents #17 and #20 from further potential abuse. Additionally, Resident #13 and Resident #19 had histories of suicidal ideation. Resident #13 expressed suicidal ideation most recently on 6/10/25. Resident #19 was seen by emergency care on 7/4/24 for suicide and depression. The safety plan for Resident #19 included being around aggressive people as warning signs for future suicidal ideations. Resident #19 returned to the residence and was the roommate of Resident #17. Resident #17 had a substantial history of yelling, breaking windows, and demonstrated physical abuse toward Resident #20. The residence failed to provide protective oversight as they implemented no interventions to prevent further ideation or potential completion of suicide for Residents #13 and #19. Findings include:1. Record reviewResident #17 was admitted to the residence on 6/25/25 with a diagnosis of intellectual development disorder. Resident #19 admitted to the residence on 8/7/24, diagnoses included schizophrenia, bipolar 2 disorder and anxiety. An emergency care after visit summary, dated 7/4/25, read in part: Resident #19 was seen on 7/4/25 for suicidal ideations, schizophrenia and bipolar disorder. A safety plan outlining warning signs of suicidal ideation specifically for Resident #19 included "being at the residence, bad or aggressive people, stressful events, lack of sleep and anxiety." A 30 day eviction notice, dated 7/31/25, read in part, Resident #17 would need to vacate the residence regarding damage to residence windows. An incident report,dated 8/4/25, read in part, Resident #17 was screaming and yelling, when staff approached the resident he attempted to "head butt" the staff and walked away. An incident report, dated 8/14/25, read in part, Resident #17 and Resident #19, who are roommates, had an argument. Staff reported hearing Resident #17 scream and then a noise of something breaking. Resident #17 reported to staff that Resident #19 was trying to fight him and he [Resident #17} proceeded to call 911. Resident #17 informed police he wanted behavioral health crisis services and was transported to an agency by police. Staff reported seeing a hole in the wall near the location of argument. An incident report, dated 8/16/25, read in part, Resident #17 was yelling at other residents and using profanity, when staff attempted to intervene Resident #17 became "agitated and hysterical". An incident report, dated 8/16/25, read in part, Resident #17 approached the staff office and stated everyone was against him and had blamed him for breaking property. Resident #20 arrived at the staff office and both resident #17 and #20 began shouting at each other. Resident #17 pushed Resident #20 and Resident #20 shoved Resident #17 into a glass frame, breaking the frame. The incident report revealed possible nose bleed as a type of injury for Resident #17 and Resident #20 stated he had called the police and an officer was being sent to the residence. An incident report, dated 8/16/25 at 3:15 p.m., read in part, after an altercation with Resident #20, Resident #17 approached the staff, complaining of a headache and was transported to a hospital via an emergency medical response vehicle. The incident report revealed headache as type of injury for Resident #17. An incident report, dated 8/20/25 at 4:00 a.m., read in part, Resident #17 was screaming and upset with his roommate, Resident #19, for not smoking with him. Resident #17 and Resident #19 remained roommates. There was no evidence that care plans had been updated with interventions to prevent further hospitalizations nor could staff speak to interventions to protect residents from further incident, nor was information in incident reports being thoroughly investigated to rule out abuse. 2. InterviewsOn 8/19/25 at 10:13 a.m., Staff #6 said Resident #17 and Resident #19 asked to be roommates shortly after Resident #17 moved in on 6/25/25 (date unknown). Staff #6 said both residents had private rooms and could have private rooms again. Staff #6 said she was aware Resident #19 had asked to have a private room again (date unknown) and both Resident's #17 and #19 complained about living with each other. Staff #6 said the administrator is aware of the situation, however, when either resident is approached about moving, neither wants to go through with it. Staff #6 said she had not documented any of the conversations and is unsure if it was documented. On 8/20/25 at 10:30 a.m., Resident #19 said he did not want Resident #17 as a roommate or to have a roommate at all. Resident #19 said staff at the residence were aware he wanted a private room, but had done nothing about it. Resident #19 said he has post traumatic stress disorder (PTSD) and anxiety, which is negatively affected by Resident #17. However, Resident #17 and Resident #19 remained roommates. On 8/20/25 at 11:00 a.m., the administrator said he was not aware if staff had spoken to Resident's #17 and #19 regarding Resident #17 was screaming and becoming upset with his roommate, Resident #19, for not smoking with him as indicated in the incident report from 8/20/25 at 4:00 a.m. The administrator said he would be speaking to Resident's #17 and #19 regarding interview on 8/20/25 at 10:30 a.m regarding Resident #19 stating he no longer wanted Resident #17 as his roommate. On 8/20/25 at 11:44 a.m., Staff #8 said she was not working on 7/4/25 when Resident #19 was seen by emergency services for suicidal ideation and was not aware of the circumstances. Staff #8 said Resident #19 had made statements previously when he was "mad" and called emergency services on his own. Staff #8 said she could not remember specific statements by Resident #19 and she was unaware of interventions, specific to Resident #19, for reducing suicidal ideations. On 8/20/25 at 12:21 p.m., the administrator said he had spoken to Resident #19 and #17 about facilitating a move to private rooms after the 8/14/25 incident report and they [Resident's #17 and #19] wanted to remain in their current living situation. The administrator said there were not any specific interventions put in place to protect either Resident #17 or #19 nor had an abuse investigation been done on 8/14/25. The administrator said he had spoken to Resident #19 regarding the incident report on 8/20/25 at 4:00 a.m., about moving to a private room and Resident #19 said he did not want to be the one to move out of the room. The administrator said he would speak to Resident #17 regarding him moving to another room. The administrator said he was unaware of any interventions being implemented to prevent future harm for Resident's #17, #19 and #20. The administrator said he expected staff to follow the residences procedures on investigating abuse and to update care plans for unexpected events. On 8/20/25 at 12:45 p.m., the qualified medication administration personnel (QMAP) supervisor said she was aware of Resident #19 had made suicidal ideation statements. The QMAP supervisor said the information provided in Resident #19's safety plan from his emergency room visit was not documented in his chart. The QMAP supervisor said she was not aware of interventions to help prevent Resident #19 from recurring events of suicidal ideation. The QMAP supervisor said she was not aware abuse investigations needed to be done for verbal altercations or to plan new diagnosis and interventions to prevent future occurrences. On 8/20/25 at approximately 3:30 p.m., the administrator said Resident #17 stated he [Resident #17] was having a mental health crisis of wanting to self harm and had called emergency medical services on his own behalf. The administrator said Resident #17 was being transported to the hospital. 3. Immediate jeopardy The investigation established that the findings above placed Resident's #13, #17, #19, and #20 at immediate jeopardy risk for serious harm or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 8/20/25 at 5:00 p.m., the administrator submitted written evidence that read:"For the identified residents #17 and #20 staff will provide visual monitoring of each resident to protect residents #17 and #20 from further potential abuse. Staff document incidents and de-escalations as they occur. Should further assistance be needed police and the facility administrator will be notified. The administrator will interview each resident as to what can be done to avoid conflict and physical abuse from occurring. Staff will be trained on 8/20/25 about new safety interventions by the QMAP Supervisor to ensure resident #17 and #20 ' s safety with how to conduct constant visual supervision with documentation. Each oncoming shift will be trained to the new intervention protocol. The protocol will be documented as to which staff is assigned to each resident. As well as, date time and description of interactions as they occur. For the identified resident #19 the administrator will discuss moving him to his old private room in the main building. If resident is agreeable, resident will have the ability to remove himself from #17 ' s or other residents' aggressive behavior. The staff will document any aggressive people interactions with resident #19 and provide staff narrative of resolutions/interactions to protect resident #19 from triggers. Staff will be trained on 8/20/25 by the QMAP Supervisor as to how to document and de-escalate aggressive behaviors towards resident #19 on the newly developed safety form. For the identified resident #13, the administrator will interview residents and discuss what suicidal ideation triggers he has and what staff can do to help resident cope with suicidal ideation. After triggers are identified, those triggers will be monitored and documented as they occur with staff intervention to protect resident #13 from harm. If resident requires further psychiatric evaluation, staff will have resident #13 transfer to hospital to receive additional professional evaluation. Staff will be trained on 8/20/25 by the QMAP Supervisor as to how to identify and document resident #13 ' s suicidal ideation triggers and documents incidents as they occur on the newly developed safety form."However, the written evidence did not indicate what training material was being used, would staff be trained to investigate abuse and what would be done to protect resident's during investigations. How staff will be trained on de-escalation techniques. What materials are the intervention protocols coming from, at what frequency will visual monitoring occur, and how will it be documented. Who will be responsible for overseeing the monitoring, where it is being stored, and how will effectiveness be monitored. What steps will be taken if the residents are not agreeable to moving rooms and what interventions will be put in place if the residents did not want to be separated. On 8/20/25 at 6:20 p.m., the administrator submitted additional evidence that read:"The staff will document any aggressive people interactions with Resident #19 and provide staff narrative of resolution/interactions to protect Resident #19 from triggers. For the identified Resident #13, the administrator will interview the resident and discuss what suicidal ideation triggers he has, what staff can do to help resident cope with suicidal ideation. After triggers are identified, those triggers will be monitored and documented as they occur with staff intervention to protect Resident #13 from harm. If resident requires further psychiatric evaluation, staff will have Resident #13 transfer to hospital to receive additional professional evaluation. Training will be done on one to one with the facilities resident abuse policy. Staff will be required to sign that they have read and understand it. Staff will be trained to investigate abuse and notify police and facility administrator when abuse is suspected. Staff separating and redirecting residents away from each other with a calming, reassuring voice tone. Care plans will be appropriately updated with staff training on care directives. The facility abuse policy has directives on intervention protocols. Interventions look like removing residents from aggressive interactions, calming, reassuring voice tones and providing positive reinforcement and encouragement for peaceful interactions. 24/7 monitoring will be documented on the safety form. The facility abuse policy provides direction on when to call 911. Staff will be assigned at the beginning of a shift and documented on the safety form. The administrator will confirm monitoring is effective. Residence #17 will be reassessed prior to return to assure needs can be met and to coordinate care with Memorial Central. If Resident #17 is found appropriate to return, Resident #17 has agreed before leaving to the hospital on 8/20/25 to move into the main building back to his old room. Staff will assist Resident #17 with his room transfer. Should Resident #17 change his mind about moving back to the main building, staff will monitor the room from outside and intervene if aggressive behavior is detected by entering the room to deescalate the incident. Staff will be designated at the beginning of shift to monitor for aggressive behaviors (yelling, screaming and loud voices) and document on the incident safety log."The immediate jeopardy was removed on 8/20/25 at 7:00 p.m. 4. Similar deficient practice was found for Resident's #13.

A relicensure survey revisit was completed on 8/21/25 for the previous deficiencies cited on 7/28/22. Deficiencies were cited. Tags 11.11, 12.1, 12.10 and 13.11 were not cited in the previous event; however, the deficiencies were included in the previous event's informational 999 tag. The deficiencies cited for Event SE2R11 were cited prior to the regulation revision that was implemented on 7/01/25.

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

Based on record review and interview the administrator failed to ensure staff were trained, submit required reports to the department, and that the residence was in compliance with the involuntary discharge requirements of Section 25-27-104.3. C.R.S., affecting 42 current residents. (Cross-reference U0430, U0810, U1074Findings include:1. Record reviewOn 8/19/25 at approximately 12:00 p.m., the residence's two personnel files failed to include training for Staff #1 and Staff #2. Staff #1's file failed to include evidence that supported that Staff #1 had training prior to being hired to be the new director of activities. Staff #2's file also failed to include evidence of on-the-job training when she was promoted to the Qualified Medication Administration Personnel (QMAP) supervisor in October 2024. On 8/19/25 at approximately 1:00 p.m., the residence presented several incident reports. Two incident reports dated 8/14/25 and 8/16/25 included that residents had a physical altercation where residents were physically hurt and the residence failed to submit and report the incident to the state department when the event occurred. On 8/19/25 at 3:49 p.m., an involuntary discharge policy was requested and not provided throughout the onsite visit, which ended on 8/21/25. 2. InterviewOn 8/20/25 at 8:00 a.m., the administrator stated he was not aware of the regulations required for involuntary discharge. He continued to say he was unaware that the discharge notification was supposed to include the nine different elements listed in Part 9.3 of chapter seven regulations. On 8/21/25 at approximately 12:55 p.m., the qualified medication administration personnel (QMAP) supervisor stated that any staff member who was a witness or heard about an incident writes the report then they give the incident report to the administrator and he would report to the state department what needed to be reported. On 8/21/25 at 10:30 p.m., the administrator stated that he failed to report because he thought that residents pushing each other did not meet the criteria, he thought the residence would make a report when blood is present. Later he stated he was unaware that the residents were hurt after the incident. When it was revealed that he was aware that Resident #17 stated he had a headache and wanted to go to an external provider to get it checked out the same day the incident occurred. With that information presented the administrator confirmed and acknowledged that he was the one who should have reported the incidents to the state department and that he would expect that the residence to report and submit an occurrence report when pain or other injury occurs.

Based on record review and interview revealed the residence failed to develop and implement policies and procedures regarding a visitation policy and infection control policy, affecting 42 current residents. (Cross-reference U1060, U1072, and U1074)Findings include: 1. Record ReviewThe infection control policy and visitation policy did not include all elements included in chapter seven regulations. 2. InterviewOn 8/21/25 at approximately 10:35 a.m., the administrator agreed that the visitation, infection control policies that were provided was not acceptable by state regulation standards and also acknowledged it had no specific information for the residence. He continued in saying that he "didn't have a good answer" as to why the regulations that were in the policy and signed off on annually were not updated properly.

Based on record review and interviews, the residence failed to ensure each resident had a care plan that detailed specific personal service needs and preferences, identified engagement opportunities that match each resident's personal choices, be developed with input from the resident and the resident;s representative, reflect the most current assessment and promoted resident safety, affecting four current residents. (#13, #18, #21, and #22). Findings include:1. Record ReviewResident #21 was admitted to the residence on 5/16/24 with diagnosis of paranoid schizophrenia. On 8/21/25 at approximately 9:28 a.m., a full chart including the most recent care plan and assessments were requested. The pre-admission assessment, dated 5/16/24, and the smoking evaluation/assessment were the only assessment provided for Resident #21. A blank Care Plan was included with Resident #21's file but did not include a careplan that was completed. No other care plans were provided for Resident #21.2. InterviewsOn 8/19/25 at 1:37 p.m., the qualified medication administration personnel (QMAP) supervisor stated she was unaware that the residence did not already have a dedicated form for care plans and reassessments. The QMAP stated she was unaware that reassessments were not happening and did not have an answer as to why care plans weren't updated. On 8/21/25 at approximately 10:30 a.m., the administrator stated he would expect the QMAP and resident assistant's to reassess residents before readmitting them into the residence and would expect that the residence would complete care plans. Similar deficient practice was discovered for Residents #13, #18, and #22.

Based on observation, record review, and interview, the residence failed to have air condintioning (A/C) or ventilation sufficient to meet the needs of a resident, affecting four current resident (#13, #18, #21 and #23). (Cross-Reference S1322)Specifically, the temperature in Resident #23's room measured over 80 degrees Fahrenheit (F) during the onsite investigation. The resident stated he had reported the dangerously high room temperature to the administrator multiple times (most recently last month), but the administrator did not respond or take action at all and the room continued to reach temperatures up to 82.6 degrees F. Resident #23 stated the high temperature of his room caused him to feel nauseous daily. Additionally, Resident #13, #18, and #21 revealed how hot it had been in the residence. Resident #13 was sweating profusely and stated his new room did not have an A/C unit and that he will miss that. Resident #18 was also sweating beads of sweat and stated the barometer in his room measured the humidity levels at 70% and the temperature79 degrees F. He stated he was informed that, "the residence would help the residents' install an AC unit but [the residents] have to buy one," he also stated he was saving up for one. Resident #21 stated she also felt nauseous when the heat would get hot in her room and went out to the hospital after vomitting and feeling nauseaous, fatigue, dizziness, and was diagnosed with dehydration. Findings include:1. Record ReviewResident #23 was admitted to the residence on 7/18/23 with diagnoses including hypertension, depression, and developmental disability. Progress notes from 6/1/25 to 8/17/25 revealed that Resident #23 walked around almost daily. Resident #21 was admitted to the residence on 5/16/24 with diagnoses of paranoid schizophrenia. Progress notes from 7/3/25 revealed that Resident #21 went out to an external hospital provider and returned. 2. ObservationsOn 8/19/25 at 8:57 a.m., the temperature of basement living room measured 79.2 degrees F. On 8/19/25 at 10:57 a.m., the temperature in Resident #18's room measured 79 degrees F and 70% humidity. On 8/19/25 at 2:27 p.m., the temperature of Resident #23's room measured 82.8 degrees F. Resident #23 turned off the radiator heat in the room. On 8/19/25 at 3:11 p.m., the temperature of the basement living room was 85.6 degrees F. On 8/19/25 at 3:50 p.m., the temperature of the basement living room was 82.4 degrees F. On 8/21/25 at 8:41 a.m., the temperature of the basement living room was 78.4 degrees F.On 8/21/25 at 8:50 a.m., the temperature on the second floor ranged from 78.6 degrees F to 78.4 degrees F. On 8/21/25 at 8:52 a.m., the temperature in Resident #13's room measured 78.4 degrees F. On 8/21/25 at 8:56 a.m., the temperature in Resident #21's room measured 76 degrees F.3. InterviewsOn 8/19/25 at approximately 10:30 a.m., Resident #18 expressed how hot he was in his room. He continued to express his regrets for taking the copper out of an AC unit he found when dumpster diving instead of bringing it back to the residence to use. Resident #18 also stated that he was told the residence would help the residents install the AC unit but would not provide one to them. On 8/19/25 at 2:14 p.m., Resident #23 stated that he had to continually turn off the radiator heat because the residence kept the heat on in the summer. On 8/21/25at 8:56 a.m., Resident #21 stated she often felt nauseous from the heat in her room. She continued saying that she had to go to the hospital becuase she was vomitting, felt dizzy and was diagnosed with dehyrdation from the heat. On 8/21/25 at 9:41 a.m., Resident #23 stated that he had notified the administrator that the heat in his room was too hot. He stated the last time he told the administrator about the excessive heat in his room and in the basement living room was "a month ago." Resident #23 added that the administrator had not got back to him. On 8/21/25 at approximately 10:45 a.m., the administrator stated that at one point the AC units were being monitored, the qualified medication administration personnel (QMAPs) had a monitoring form on their medication carts where they would ask each resident how the temperatures were and receive feedback like that. He added that he is not sure why that dropped off and that he was not made aware of any issues or grievances about the heat but would expect staff to provide an AC unit if requested. The administrator stated this deficiency that was previously cited was not corrected because he was not made aware that the residents still had issues with the temperatures as no resident brought their grievance to him and brought up that due to the buildings age, blueprints had to be re-drawn, local city had to be involved to get power the power box to be installed, and inspections and ensuring things were aligned with the city code which took time. He also stated that he was not sure what the current temperature monitoring process looked like.

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