Brookside Assisted Living

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 involunt.. 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 invest.. 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 w..

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.. 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 conduc.. 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 .. 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 notic.. 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 develope.. 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). Finding.. 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, Resi.. 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 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.. 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 r.. 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 perso..

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. 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.. 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 t.. 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 w.. 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 assessme.. 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