Mls Assisted Living Cc LLC

A licensure complaint, prompted by #CO40674, was completed on 7/30/25. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to provide each staff member with training relevant to their specific duties and responsibilities for one sample staff member (#22), cook/caregiver, and two former staff (#24, #25), affecting 31 current residents. (Cross-reference U1110 )Findings Include: Policy and Residency AgreementChapter VII regulations governing assisted living residences, part 2.56, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.Record Review Personnel files for Staff 22 and Former Staff 24 read:Staff #22 was hired on 3/13/25, the July 2025 staff schedule read Staff #2.. Based on record review and interview the residence failed to comply with all occurrence reporting requirements by state law affecting one of one sample residents (#32). ( Crossreference U648, U1110)Findings Include:1. Record ReviewResident #32 was admitted to the residence 10/24/24 with a diagnosis of major depressive disorder and paranoid schizophrenia. A care plan dated 11/21/24 read that Former Resident #32 would receive assistance with all of their medications.A care plan dated 4/30/25 read that Former Resident #32 had no psychotropic medications administered.An incident report dated 7/22/25 read in part, Former Resident #32 was found by staff hanging in a back shed behind the residence. Resident #32 had a recent medication change. Former Resident #32 stated 7/21/2.. Based on record review and interview, the residence failed to either directly or indirectly provide protective oversight, including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event affecting one current residents (#31) and one former resident (#32). [Cross-reference U648, U0430) Specifically, Former Resident #32 had died of suicide by hanging in the residence ' s maintenace shed on 7/22/25. The resident had discontinued Olanzapine and was not administered a different psychiatric medication which affected his mental and emotional state of mind. Former Resident #32 had verbalized his struggle and progressed psychosis in the days prior to his death. The residence had not implemented effective measures for staff to ensure Former Res.. Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated whenever the resident' s condition changed from baseline status, affecting two (#2, #31) of two sample residents.Findings include:1. Record ReviewResident #31 was admitted to the residence on 2/4/2025. Resident #31' s diagnosis was not documented.A progress note, dated 7/2/25, "Resident (#31) told another staff member that he was having some suicidal thoughts and that he was just not okay. Resident #31 let staff know that he had been using methamphetamine and showed her his veins on his arm. Cops were called and mental health as well came out and spoke with (Resident #31). Cops stated that they were going to keep him at the residence for now."The comprehensiv..

A certification survey, prompted by #CO40675. Deficiencies were cited. Based on record review and interview the facility (residence) failed to comply with all reporting requirements including occurrence reporting requirements, affecting one of one sample member (resident) (#32). (Cross-reference B1702)Findings Include:1. Record ReviewResident #32 was admitted to the residence 10/24/24 with a diagnosis of major depressive disorder and paranoid schizophrenia. A care plan dated 11/21/24 read that Former Resident #32 would receive assistance with all of their medications.A care plan dated 4/30/25 read that Former Resident #32 had no psychotropic medications administered.An incident report dated 7/22/25 read in part, Former Resident #32 was found by staff hanging in a back shed behind the residence. Resident #32 had a recent medication change. Former Resident #32 stated 7/21/25 that he was worried about aliens coming to get him. A staff member around 12:16p.m., walked out back and was picking up trash, staff member peaked in the shed and noticed Former R.. Based on record review and interview, the facility (residence) failed to provide protective oversight, including, monitoring the members' (residents' ) needs, and ensuring that the resident received the services and care necessary to protect their health and welfare, affecting one current residents (#31) and one former resident (#32). [Cross-reference B0130; B0880) Specifically, Former Resident #32 had died of suicide by hanging in the residence ' s maintenace shed on 7/22/25. The resident had discontinued Olanzapine and was not administered a different psychiatric medication which affected his mental and emotional state of mind. Former Resident #32 had verbalized his struggle and progressed psychosis in the days prior to his death. The residence had not implemented effective measures for staff to ensure Former Resident #32s safety, the maintenance shed held hazardous tools and materials and was left unlocked, unsupervised and easily accessible to the residents. Findings include:1. Referen.. Based on record review and interviews, the facility did not adequately ensure that each staff member received training on person-centered practices and the concept of dignity of risk, affecting one current (#31) and one former member. (#32).Findings Include: Policy and Residency AgreementChapter VII regulations governing assisted living residences, part 2.56, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.Record Review Personnel files for Staff 22 and Former Staff 24 read:Staff #22 was hired on 3/13/25, the July 2025 staff schedule read Staff #22 worked on 7/1-7/3, 7/7-7/9, and 7/21-7/23. Former Staff #24 ' s first shift at the residence was on 7/22/25. Staff #24 did not have a personnel file. InterviewOn 7/29/25 at 12:12 p.m., Former Staff #24 and #25 stated that they had not received training specifically on techniques for managing expressions of behavi..

A licensure complaint revisit was completed on 7/30/25 for the previous deficiency cited on 9/22/23. The residence is in compliance with all regulations surveyed. 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