Bross Street Assisted Living

A revisit survey was completed on 11/14/24 for all previous deficiencies cited on 7/26/24. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

An involuntary discharge appeal survey, prompted by #CO36164, was completed on 7/26/24. A deficiency was cited. Based on interview and record review, the residence failed to include detailed explanations of the reasons for the discharge, including facts and evidence and actions taken to avoid discharge, a practitioner assessment of the resident' s current needs in relation to the resident' s medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence' s staff or an external service provider affecting one former resident (#1).Findings include:The involuntary discharge notice, dated 4/24/2024, read in part, "(Former Resident #1) is unable to maintain self-care and personal hygiene within the verbal, visual and assisted prompts provided ... (Former Resident #1) is unable to follow his recommended diet plan based on his diabetes diagnosis which has led to an unhealthy increase in weight and risk of harm ... (Former Resident #1) has displayed a lack of community safety skills while accessing the community."The residence' s written response to the Former Resident #1' s family member' s appeal of the discharge, dated 5/2/24, read in part, "(Residence) communicated that at this time the concerns listed in the notice, including (Former Resident #1) self-care and hygiene in addition to increased care needs, are no longer within the scope of our care in an assisted living setting and our no.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.11.6 The written resident agreement shall specify the understanding between the parties concerning, at a minimum, the following items:(A) Assisted living residence charges, refunds, and deposit policies;(B) The general type of services and activities provided and not provided by the assisted living residence and those which the assisted living residence will assist the resident in obtaining;(C) A list of specific assisted living residence services included for the agreed upon rates and charges, along with a list of all available optional services and the specified charge for each;(D) The amount of any fee to hold a place for the resident in the assisted living residence while the resident is absent from the assisted living residence and the circumstances under which it will be charged;(E) Responsibility for providing and maintaining bed linens, bath and hygiene supplies, room furnishings, communication devices, and auxiliary aids; and(F) A guarantee that any security deposit will be fully reimbursed if the assisted living residence closes without giving resident(s) written notice at least thirty (30) calendar days before such closure,(G) R..

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