Mls Assisted Living Bc LLC

A certification complaint, prompted by #CO40677, was completed on 8/12/25. No deficiencies were cited. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary.8.7001.B.3.a.iii The Residential Setting does not have institutional features not found in a typical home, such as staff uniforms; entryways containing staff postings or messages; or labels on drawers, cupboards, or bedrooms for staff convenience.

A licensure complaint, prompted by #CO40676, was completed on 8/12/25. Deficiencies were cited. Based on observations and interviews, the residence failed to ensure all interior areas were free from the accumulation of extraneous material and potential combustible materials, affecting 25 current residents.Findings include:An environmental tour of the residence on 8/11/25 at 1:26 p.m. revealed the accumulation of extraneous materials and potentially combustible materials, such as a cardboard box, cat food, refuse, a blanket, and a playground ball, which were pressed between a locker tower and the fireplace. Additionally, an open space in a hallway was cluttered with blankets, refuse, and a dolly. One of the bathrooms had two pieces of detached trim boards leaning against the shower. In an open space next to a medication storage cart, a patio table top, two pieces .. Based on observations and interviews, the residence failed to ensure that refuse storage areas were kept clean and free of nuisances, as well as having impervious containers with tight-fitting lids, affecting 25 current residents.An environmental tour of the residence on 8/11/25 at 1:30 p.m. revealed three trash cans in various places around the perimeter of the residence. The trash cans did not have lids, which were fitted to the cans; two of the trash cans did not have lids and were overflowing, so that a lid could not be fitted. Additionally, refuse was found surrounding the trans cans and throughout the grounds of the residence.On 8/12/25 at 10:10 a.m., the administrator stated that she was unaware of the trash cans surrounding the residence, adding, "The facility has always been a little off". She agre.. Based on observations and interviews, the residence failed to provide pest control measures on all exterior openings except where prohibited by fire regulations, affecting 25 current residents.An environmental tour of the residence on 8/11/25 at 1:27 p.m. revealed four windows that did not have screens installed. Additionally, three windows were observed as having a window screen not fit sufficiently tightly to exclude pests. Finally, the front door was observed open when entering at 1:20 p.m., as well as for long periods from 1:20 p.m. to approximately 4:00 p.m. Additionally, flies were observed flying around the interior of the residence, including the kitchen area.On 8/12/25 at 10:10 a.m., the administrator stated that she was aware of the fly problem and acknowledged that the missing screens and gaps i.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.11.3 At the time the resident moves in, the assisted living residence shall ensure that the resident and/or the resident ' s legal representative has received a copy of the written resident agreement and agreed to the terms set forth therein. The assisted living residence shall ensure that the agreement is signed and dated by both parties.18.6 The confidentiality of the resident record including all medical, psychological, and sociological information shall be protected in accordance with all applicable federal and state laws and regulatio..

A revisit to the 01/23/2025 survey was completed on 05/14/2025. Three deficiencies were cited. Based on observation, interview, and record review the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for sprinkler systems, fire alarms, electrical systems, and evacuation. The facility failures had the potential to affect all occupants of the building.Findings include:Cross reference to A0001 for failure to test and maintain the fire sprinkler systems to DFPC standards resulting in the facility being placed on fire watch.Cross reference to A0002 for failure to complete fire alarm testing and maintenance to DFPC standards. Fire Alarm System – Testing and MaintenanceThrough document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Semi-Annual: Not Provided2) Sensitivity test (2 Years) (72 14.4.5.3.2): Not ProvidedBased on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarmand Signaling Code.NFPA 72 Table14.4.5 Testing FrequenciesThis deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference. Sprinkler System – Maintenance and TestingThrough document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Annual: The report provided is from 1.17.25 and is Red Tagged. Need an updated annual report showing compliance.2) Quarterly: Not Provided3) Semi-Annual: Not Provided4) 5 Year: Not Provided5) The Fire riser room on the first floor is open to the attic space and needs drywall separation for proper protection.6) The fire riser room does not have adequate heat7) Fire sprinklers dated 1999 due for UL testingNFPA 101, 9.7.5 Maintenance and Testing.All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.NFPA 25, Chapter 5 Sprinkler SystemsTable 5.1.1.2 shall be used to determine the minimum requi..

A relicensure survey with complaint #CO39612 and #CO39572 was completed on 4/10/25. Deficiencies were cited. Based on interview and record review the residence failed to ensure the administrator and qualified medication administration personnel (QMAP) supervisor audited the accuracy and completeness of the medication administration.. Based on observation and interviews the residence failed to keep exterior grounds free and clean of rubbish and garbage including metal siding and cigarette buttes, affecting 24 residents.Findings include:ObservationOn 4/8/25 at.. Based on observation, interview and record review the residence failed to ensure each staff member who provided assisted living services completed orientation in emergency response policies and procedures prior to providing care .. Based on observation, interview and record review, the residence failed to include a variety of food and appealing substitutes to satisfy residents' appetites that were of nutritional value, affecting 24 current residents. Findings inclu.. Based on observation, interview, and record review, the residence failed to ensure that the residence' s emergency policies included the circumstances and procedures to evacuate the premises, assignment of specific staff duties on .. Based on observation, record review, and interview the residence failed to ensure designated areas where smoking was allowed was equipped with fire resistant wastebaskets, affecting 24 current residents. Findings include: Residen.. Based on observation, record review, and interview, the residence failed to either directly or indirectly provide protective oversight and a physically safe and sanitary environment, affecting 24 current residents.Specifically, the r.. Based on record review and interview the residence failed to admit or continue to care for residents whose care exceeds the residence' s ability to meet the needs of a resident, affecting two of three (#4 and #9) sample residents .. Based on record review and interview the residence failed to complete a written authorization that specifies the terms and duration of the financial management services, maintain any funds over the amount of five hundred dollar.. Based on record review and interview the residence failed to ensure a comprehensive assessment was updated at least annually or whenever the residents condition changed from baseline status, affecting ten of ten sample residents (1-.. Based on record review and interview the residence failed to ensure the comprehensive assessment included reactions to the environment and others, including changes that may occur at certain times or in certain circumstances, affect.. Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire(s), gas explosio.. Based on record review and interview, the residence failed to comply with the occurrence reporting requirements, affecting two of three sample residents (#9, #10) who reported misappropriation of property.Findings include:Refere.. Based on record review and interview, the residence failed to identify the highest potential risk and hold routine drills to facilitate staff and residents to that risk, affecting 24 current residents.Findings include:The residence Fire Drill p.. Based on record review and interviews, the residence failed to investigate an allegation of exploitation of a resident in accordance with Part 5.3 and its written policy, affecting 24 current residents.Specifically, the residence did not inv..

8.7506.C Alternative Care Facility Inclusions (1) Member Eligibility a. Members enrolled in the HCBS Elderly, Blind and Disabled (EBD) and the HCBS Community Mental Health Supports (CMHS) Waivers are eligible to receive services in an Alternative Care Facility. (i) Potential Members shall be assessed, at a minimum, by a team that includes the Membe.. 8.7506.C Alternative Care Facility Inclusions (1) Member Eligibility a. Members enrolled in the HCBS Elderly, Blind and Disabled (EBD) and the HCBS Community Mental Health Supports (CMHS) Waivers are eligible to receive services in an Alternative Care Facility. (i) Potential Members shall be assessed, at a minimum, by a team that includes the Membe.. A recertification survey with complaint #CO39573 was completed on 4/10/25. Deficiencies were cited. Based on interview and record review the facility (residence) failed to notify a member' s (resident) case management agency case manager of a critical incident within 24 hours of discovery of the actual or alleged Incident, affecting 10 of 10 sample members (residents) (#1-#10). Findings include:Resident #1 was admitted to the facility on 11/30/22 wi.. Based on interviews and record review, the facility (residence) failed to ensure a lease, residency agreement, or other written agreement was in place for each resident, affecting 24 current residents. Findings include: The record for Resident #4 revealed the resident agreement was last signed on 3/24/24. The monthly dollar amount on the agreeme.. Based on observation and interview, the facility (residence) implemented rights modifications without a specific assessed need and justification in the Person-Centered Support Plan (PCSP), affecting four of four sample members (residents) with a rights modification (#3, #4, #6 and #9).Findings include:On 4/8/25 at approximately 8:00 a.m., Res.. Based on record review and interview the facility (residence) failed to develop a Person Centered Support Plan (PCSP) that included all the required information, affecting 24 sample members (residents). Findings include:On 4/8/25 at approximately 8:30 a.m., access to complete resident records were requested from the Administrator. The residence.. Based on record review and interview, the facility (residence) failed to complete all required elements for the implementation of a rights modification, affecting four of four current members (residents) with rights modifications (#3, #4, #6 and #9).Findings include:Resident #9 was admitted on 11/30/22 with a diagnosis of vascular dementia ass.. Based on record review and staff interview, the facility (residence) failed to ensure refusals to follow the physician' s orders were recorded and ongoing refusals were addressed by the physician affecting 24 current members (residents). Findings include:On 4/9/24 at 2:55 p.m., documentation of the communication between the residence and the resid.. Based on record review, observation, and interview, the facility (residence) failed to provide the opportunity for members (residents) to have meaningful input in menu planning, affecting 24 current residents.Findings include:Resident council meeting notes for January through March 2025 read that the residence provided resid..

A recertification revisit was completed on 4/10/25 for the previous deficiencies cited on 10/25/22. Deficiencies were cited. Based on record review and staff interview, the facility (residence) failed to ensure refusals to follow the physician' s orders were recorded and ongoing refusals were addressed by the physician affecting 24 current members (residents). Findings include:On 4/9/24 at 2:55 p.m., documentation of the communication between the residence and the residents provider regarding medication refusals was requested and reviewed. The residence provided documents labeled as "Missed Medication alert" which included the residents name, provider name and fax number, date of missed medication, medication name and why the medication was not passed. There was no date of communication with the provider or if the document had been faxed or received. On 4/10/25 at 8:36 a.m., the Resident Care Coordinator stated she communicated with the provider via fax and occasionally via email. She stated there was no further communication with the provider including follow up to ensure they received the communication regarding the refused medication. On 4/10/25 at 1:36 p.m., the Administrator stated she was not aware of communications to the provider regarding refused medications. Also, she acknowledged there was no evidence of the missed medication alert being faxed, the provider being notified and the lack of follow up by the residence. 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 relicensure revisit was completed on 4/10/25 for the previous deficiencies cited on 10/25/22. Deficiencies were cited. Based on observation, interview and record review, the residence failed to include a variety of food and appealing substitutes to satisfy residents' appetites that were of nutritional value, affecting 24 current residents. This deficiency was cited previously during a complaint investigation on 10/25/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence Policy The residence' s undated Resident Agreement, read in part: "The residence provides three nutritionally balanced meals. Between meals snacks of nourishing quality were also available" 2. ObservationOn 4/8/25 at 7:30 a.m. a tour of the residence revealed there was a dry erase board in the kitchen which indicated the three meals that were being served that day; however, the board had the month of March 2025 at the top and the words breakfast, lunch and dinner written, as well as "The full week menu will be posted here from now on, please keep the menu on this board" written, no alternatives were listed and the weekly menu was taped to the white board. Additionally, no other menus were posted anywhere in the residence. The daily menu posted read as follows:Breakfast: biscuits and gravy, potatoes O ' Brein and fresh fruitLunch: stacked enchiladas, refried beans, mex.. 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