Crossroads at Delta Alf

A licensure complaint, prompted by #CO40845, was completed on 2/25/26. A deficiency was cited. Based on record review and interview the residence failed to follow policies and procedures restricting on-site access by staff or volunteers with drug or alcohol use that would adversely impact their ability to provide resident care and services, affecting one (#4) staff out of three staff members.Findings include1. Facility policyThe Drug and Alcohol Free Workplace policy was provided by the administrator on 2/25/26 at 11:45 a.m. It read in pertinent part: "[residence] follows both federal and state law when determining whether use of a drug is lawful and whether a drug is illegal. For example, federal law prohibits using marijuana for any purpose. Accordingly, testing positive for or coming to work under the influence of marijuana, even if state law would permit the employee;s use of marijuana for medical or recreational purposes, is a violation of this policy."If, however, an individual violates the Alcohol and Drug Free Workplace Policy, the consequences are serious and could include termination."2. Record reviewReview of Staff #4 ' s personnel file revealed two drug tests results from 2019 and 2025. In 2019 Staff #4 tested positive for marijuana and was required to test again in 30 days and needed to test positive or she was going to be terminated. In 2025, Staff #4 tested positive for marijuana and cocaine. She was required to undergo eight weeks of random drugs tests and was required to test negative in order to not be terminated.-However, the administrator was unable to provide documentation of the eight weeks worth of drug tests and what the results were for Staff #4.3. InterviewsThe administrator was interviewed on 2/25/26 at 12:24 p.m. She said she was unaware Staff #4 tested positive in 2019 or she would have been terminated when she tested positive again in 2025. She said she was aware the residence did not follow their drug free workplace policy and it was because the administrator recently took over the residence in February of 2025 and was not aware Staff #4 tested positive in 2019.The administrator was interviewed again on 2/2..

A revisit survey was completed on 3/17/25 for all previous deficiencies cited on 11/20/24. 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 revisit survey was completed on 3/17/25 for all previous deficiencies cited on 11/20/24. 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 recertification survey with complaint #CO38149 was completed on 11/20/24. A deficiency was cited. Based on record review and interview, the facility failed to develop written policies and procedures to ensure the continuation of care to all members for at least 72 hours immediately following any emergency, affecting 49 current members.Findings include:The facility' s emergency action plan, dated 8/19/24, failed to include procedures to ensure the continuation of care to all members for at least 72 hours following any emergency. On 11/20/24 at 4:51 p.m., the administrator stated he was aware of the requirement to have evacuation plans and agreements but was unaware of the specific plan for the 72-hour continuation of care. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10, Section 8.7000 - A1350 Alternate Care Facility Provider Agency. 8.7414.A Provider Agencies shall provide sufficient support to members in the use of prescription and nonprescription medications. Members shall be presumed capable of self-administration unless they are determined otherwise. The type and level of medication administration support provided shall be determined by the results of an assessment performed by a qualified person. Medications shall be administered only by persons authorized in accordance with 6 CCR 1011-1, Chapter VII and XXIV.8.7505.F.5.h The Alternative Care Facility provider shall assess each member' s cooking capacity shall be assessed as part of the pre-admission process and updated in the person-centered support plan as necessary.

A relicensure survey with complaint #CO38151 was completed on 11/20/24. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure it had trained staff available to provide lift assistance to residents who fell, instead of relying on emergency medical responders, affecting two of two (#2, #8) sample residents who recently required lift assistance.Findings include:The residence' s undated lift assistance policy read in part that when a resident sustained a witnessed or an un-witnessed fall, staff did not attempt to change the resident' s position or assist the resident up off the floor until the nature of the resident' s injuries was evaluated. Whe.. Based on interviews and records review the residence failed to develop a written policy meeting the required criteria regarding visitation affecting 49 current residents.Findings include:The residence' s visitation policy, dated 2016, failed to include all of the required elements.On 11/20/24 at 4:45 p.m., the administrator stated the residence had an open-door policy for visitation, further explaining that the residence' s visitation policy did not have all required elements because they wanted to keep an "open-door policy." Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy which included all required elements, affecting 49 current residents.Findings include:The residence' s undated involuntary discharge policy failed to include all of the required elements.On 11/2024 at 5:00 p.m., the administrator stated he might have been aware of the missing elements and explained that the missing elements could have been added to the policy. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 49 current residents.Findings include:The residence' s emergency action plan, dated 8/19/24, failed to include a plan to ensure the continuation of care to all residents for 72 hours following any emergency. On 11/20/24 at 4:51 p.m., the administrator stated he was aware of the requirement to have evacuation plans and agreements bu.. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 49 current residents.Findings include:The residence' s emergency action plan, dated 8/19/24, failed to include the following required elements:A pre-determined means of communicating with residents, families, staff, and other providers. A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; A plan.. 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 7.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the aud..