Assisted Living on Broadway

A relicensure survey was completed on 1/20/26. No deficiencies were cited 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.(U1180) 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following:(A) Providing fall management education and materials to residents and family members;(B) Detailing in each resident ' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment.

A licensure complaint, prompted by #CO37921, was completed on 10/16/24. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to ensure that each staff member received initial orientation for four of five sample staff (#7-#10), affecting 11 current residents.Findings include: 1. Record ReviewOn 10/16/24, staff files for Staff #7-#9 contained no evidence that the residence conducted orientation before working with residents. An email correspondence with a contract staffing agency, dated 10/16/24, read in part that Staff #7-#10 worked at the residence on the following dates and times: On 9/30/24, Staff #7 worked from 2:00 p.m. to 10:00 p.m. On 9/22/24, Staff #8 worked from 6:00 a.m. to 8:00 a.m.On 9/24/24, Staff #9 worked from 10:00 p.m. to 6:15 a.m.On 9/27/24 and 9/28/2024, Staff #10 worked from 2:00 p.m. to 10:00 p.m.On 10/16/24, at approximately .. Based on record review and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each staff member prior to staff hire for four sample staff (#7-#10), affecting 11 current residents.Findings include:1. Record Review On 10/16/24, staff files for Staff #7-#9 contained no evidence that the residence obtained documentation of a name-based criminal history check conducted by the CBI before working with residents. An email correspondence with a contract staffing agency, dated 10/16/24, read in part that Staff #7-#10 worked at the residence on the following dates and times: On 9/30/24, Staff #7 worked from 2:00 p.m. to 10:00 p.m. On 9/22/24, Staff #8 worked from 6:00 a.m. to 8:00 a.m.On 9/24/24, Staff #9 worked .. Based on record review and interview, the residence failed to ensure two individuals who are qualified medication administration persons, nurses, or practitioners jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting four current residents with controlled medications (#1, #2, #4, #5) Findings include:1. Record ReviewA controlled substance sheet, dated 10/15/24, read Staff #1 signed in and Staff #5 signed out.A review of the staff file for Staff #1 revealed no documentation that Staff #1 was a qualified medication administration personnel (QMAP). 2. InterviewsOn 10/16/24 at 1:01 p.m., the nursing consultant stated that she told the residence that a staff member who was not a QMAP could s.. Based on record review and interview, the residence failed to have a readily available updated and current roster, which affected two current residents (#2, #3).Findings include:1. Record Review On 10/16/24 at 7:35 a.m., a roster of current residents for emergency preparedness was requested. On 10/8/24 at 7:36 a.m., the roster that was provided included three former residents (#12-#14) and did not include Residents #2 and #3. 2. InterviewOn 10/16/24 at 7:45 a.m., the interim administrator stated that she was aware the resident roster did not have current resident information prior to the on-site visit and that if there was an emergency, the list was incorrect and could have caused issues for emergency responders.On 10/16/24 at 9:38 a.m., the administrator stated she failed to update the residen..

A revisit survey was completed on 8/29/24 for all previous deficiencies cited on 6/3/24. 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

A certification revisit was completed on 6/3/24 for all previous deficiencies cited on 3/8/23. A deficiency was cited.The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 3/15/23. Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting three of three sample participants (residents) (#1-#3).This deficiency was cited previously during a state licensure survey 3/8/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Chapter VII regulations governing assisted living residences, part 14.11, requires that only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.Resident #5 was admitted to the residence on 8/17/22.The May 2024 medication administration record (MAR) read the residence administered K-Y pearls in the evenings of 5/1-5/31/24 for a total of 31 days. However, the residence did not provide a written practitioner' s order for the medication. There was similar deficient practice for Resident #9.On 6/3/24 at 3:23 p.m., the administrator stated she was unable to find the written practitioner' s orders for Resident #5 and Resident #9. She further stated she expected there to have been an order in the residents' records, and she believed that staff had misplaced the orders. The administrator stated she believed this deficiency that was previously cited had been corrected; however, she did not find the written orders. 2. Chapter VII regulations governing assisted living residences, part 14.21, requires the residence to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Resident #13 was admitted to the residence on 5/20/24 with a diagnosis of dementia.SertralineA written practitioner' s order, dated 5/17/24, directed the residence to administer sertraline 100 mg daily. However, the May 2024 medication administration record (MAR) revealed the residence faile..