Bright Sun Assisted Living LLC

A revisit survey was completed on 12/30/25 for all previous deficiencies cited on 9/17/25. 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 complaint survey, prompted by #CO40948 was completed on 9/17/25. A deficiency was cited. Based on observation, record review and interview revealed the residence (facility) failed to develop and/or implement policies and procedures regarding grievance procedure and complaint resolution and investigation of injuries of known or unknown source/origin affecting seven residents (members). Findings include:A. Residence (Facility) policy for Grievance Procedure and Complaint Resolution. 1. PolicyOn 9/17/25 at approximately 11:00 a.m., the residence (facility) provided a Grievance Procedure and Complaint Resolution policy, dated 11/2023, that read in part: If a resident has a grievance or complaint, the individual is encouraged to complete a Grievance Form which can be found in a central location in the community. A grievance or complaint may also be shared orally with the Administrator. "The nature of the complaint, investigation, findings, and steps taken to resolve the complaint will be documented and will be reviewed with the individual who registered the complaint within 3 – 5 business days of the complaint."ObservationOn 9/17/25, during an initial walk-through of the residence (facility), complaint forms were not observed to be in any central locations. 3. Record review A document titled, House Meeting and dated 8/16/25, read in part: "Concern: Residents are not happy.. 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 7.7.9The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (A) The assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. A - E

A certification complaint, prompted by #CO40947, was completed on 9/17/25. A deficiency was cited. Based on observation, record review and interview revealed the residence (facility) failed to develop and/or implement policies and procedures regarding grievance procedure and complaint resolution and investigation of injuries of known or unknown source/origin affecting seven residents (members). Findings include:A. Residence (Facility) policy for Grievance Procedure and Complaint Resolution.1. PolicyOn 9/17/25 at approximately 11:00 a.m., the residence (facility) provided a Grievance Procedure and Complaint Resolution policy, dated 11/2023, that read in part: If a resident has a grievance or complaint, the individual is encouraged to complete a Grievance Form which can be found in a central location in the community. A grievance or complaint may also be shared orally with the Administrator. "The nature of the complaint, investigation, findings, and steps taken to resolve the complaint will be documented and will be reviewed with the individual who registered the complaint within 3 – 5 business days of the complaint."ObservationOn 9/17/25, during an initial walk-through of the residence (facility), complaint forms were not observed to be in any central locations. 3. Record review A document titled, House Meeting and dated 8/16/25, read in part: "Concern: Residents are not happy with the care they are receiving with new staff.Solutions: Discuss with staff how to properly talk and manage residents"4. InterviewOn 9/17/25 at 11:00 a.m., the administrator said Resident (member) #7 specifically voiced dissatisfaction with Staff #3. The administrator said Resident (member) #7 said Staff #3 was not using a loofah in the shower and didn' t like the way Staff #3 applied hands on assist when she [Resident (member) #7 ] was walking. The administrator said she [administrator] educated staff #3 on working with residents (members) because staff #3 was new. The administrator said she did not document the nature of the complaint, investigation, findings, or steps taken to resolve the complaint. The administrator said she ..

A recertification and complaint revisit was completed on 9/17/25 for all previous deficiencies cited on 12/6/24. A deficiency was cited. Based on observation and interview, the facility (residence) failed to provide sufficient support to its members (residents) in the use of prescription and nonprescription medications, affecting four sample residents (#3, #5-#7).Findings include: 1. Infection control with medication administrationOn 9/17/25 at 9:05 a.m., Staff #2 unlocked the medication cart with gloved hands.. Staff #2 proceeded to prepare the medications for four different residents. At 9:06 a.m., Staff #2 prepared the medication for resident #3 put on new gloves with out handsantizing or washing her hands, she picked up trash off of the floor, helped Resident #3 with cleaning up water spills on herself/the table, went back to the medication cart to grab the pill splitter, grabbed the medication with the unchanged gloves split the pill. . Staff #2 with the same gloves touched the medication cart, computer, prepared the medication for Resident #5, grabbed a cup from the cabinet, handed Resident #5 the cup of water, walked back to the medication cart grabbed the keys to the narcotics drawer, prepared Resident #5' s narcotic medication, gave the resident her nasal spray, cleaned the nasal spray from any residue with her unchanged gloved hands, then proceeded back to the medication cart to prepare the medication for Resident #6. With the same unchanged gloves Staff #2 pro..