Mls Assisted Living LLC

A licensure complaint, prompted by #CO41009, was completed on 10/9/25. Deficiencies were cited. Based on interview and record review, the residence failed to update comprehensive assessments at least annually and whenever a resident' s condition changed from baseline status, affecting two of four sample residents (#9 and #15). (Cross reference U1060) Cross reference U1146 and U1160)Findings include: Resident #15 was admitted to the residence on 6/27/25 with a diagnosis of dementia. The most recent assessment for Resident #15 dated 6/16/25 was not updated after a recent change in condition after the resident began having increased behaviors, which included, .. Based on observation and interview the residence failed to keep grounds maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction, affecting 7 current residents. Findings include:During an environmental tour on 10/8 and 10/9/25 along the outdoor courtyard there was a four and a half inch drop off, throughout most of the paved walkway that wrapped around the back of the property. A water hose was also observed to be stretched across the walkway on one area of the outdoor court.. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 7 current residents.1. ReferenceThe Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outside of the doorway. The specified radius may be determined by the local auth.. Based on observation, interview, and record review, the residence failed to discharge a resident who was disoriented and had safety concerns, posed a danger to self, and required services that the residence could not consistently provide, affecting one resident (#15). (Cross reference U1146 and U1160)Specifically, Resident #15 had increased wandering outside of the residence, increased disorientation demonstrated by verbal agitation, and entering other residents' rooms. Between September and October 2025, Resident #15 had 15 attempts, which she expressed p.. Based on record review and interview the residence failed to be responsible for the coordination of resident care services with known external hospice providers (EHPs), affecting two of two sampled residents (Former Resident #13 and Resident #15). Specifically, on 8/27/25 between 7:00 p.m. and 7:00 a.m., the residence found Former Resident #13 on the ground of the bathroom floor, called EHP, and EHP directed the residence to contact them again if anything changes. On 8/28/25 Former Resident #13 fell at 4:30 a.m. and complained of pain in her shoulder. The EH.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLYNo response is necessary This residence was advised it must review and maintain the following processes in accordance with existingprogram regulations found at 6 CRR 1011-1 Chapter 711.5 The assisted living residence shall review its resident agreements annually and update or amend them asnecessary. Amendments to the resident agreement shall also be signed and dated by both parties.

An initial certification survey was completed on 10/9/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to update comprehensive assessments at least annually and whenever a resident' s condition changed from baseline status, affecting two of four sample members (residents) (#9 and #15). Findings include: Resident #15 was admitted to the residence on 6/27/25 with a diagnosis of dementia. The most recent assessment for Resident #15 dated 6/16/25 was not updated after a recent change in conditionafter the resident began having increased behaviors, which included, wandering into other residents rooms smearing feces, verbal aggression toward staff and wandering up toward a busy road multiple times perday. The cha.. Based on observation and interview, the facility (residence) failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 7 current members (residents).1. ReferenceThe Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outside of the doorway. The specified radius may be determined by the local authority pursuant to section 25-14-207 (2)(a), but must be at least twenty-five feet unless section 25-14.. Based on observation, interview, and record review, the residence failed to discharge a resident who was disoriented and had safety concerns, posed a danger to self, and required services that the residence could not consistently provide, affecting one resident (#15).Specifically, Resident #15 had increased wandering outside of the residence, increased disorientation demonstrated by verbal agitation, and entering other residents' rooms. Between September and October 2025, Resident #15 had 15 attempts, which she expressed packing and/or leaving the residence, multiple attempts in the middle of the night. On 10/7/25, Resident #15 walked up the driveway to.. Based on record review and interview the facility (residence) failed to be responsible for the coordination of resident care services with known provider agencies (external hospice providers (EHPs)), affecting two of two members ( #13 and and #15). Specifically, on 8/27/25 between 7:00 p.m. and 7:00 a.m., the residence found Former Resident #13 on the ground of the bathroom floor, called EHP, and EHP directed the residence to contact them again if anything changes. On 8/28/25 Former Resident #13 fell at 4:30 a.m. and complained of pain in her shoulder. The EHP nurse did not note any bruising or swelling and requested to be notified if symptoms changed. On 8/28/25 F.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLYNo response is necessary This residence was advised it must review and maintain the following processes in accordance with existingprogram regulations found at 10 CCR 2505-10 8.7000.8.7413 Effective January 1 of each year, the Department establishes a uniform room and board payment for all Medicaid Members receiving residential HCBS in or through:Alternative Care Facility.Supportive Living Program.Transitional Living Program.Mental Health Transitional Living Homes.The standard room and board amount may not exceed an amount equal to the monthly Supplemental Security Income (SSI) benefit , less an amount specifi..

A relicensure survey revisit was completed on 8/19/25 for the previous deficiencies cited on 7/23/25. A deficiency was cited.The Deficiencies cited for Event 4FZ912 were cited prior to the regulation revision that was implemented on 7/1/25. Based on records review and interviews, the residence failed to have at least one staff member on site at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting eight current residents.Findings Include:On 8/12/25, a review of the residence' s staff CPR certifications revealed that Staff #10 was not CPR certified, but was certified only in first aid by the American Heart Association.The residence' s July and August 2025 staff schedules revealed that Staff #10 worked alone from 7:00 p.m. to 7:00 a.m. on: 7/3/25, 7/4/25, 7/5/25, 7/10/25, 7/11/25, 7/12/25, 7/17/25, 7/18/25, 7/19/25, 7/24/25, 7/25/25, 7/26/25, 7/31/25, 8/1/25, and 8/2/25.On 8/13/25 at 12:10 p.m., the administrator designee agreed that she was unaware and was informed that Staff #10 was only first-aid certified. She agreed that every time Staff #10 worked alone, there was no CPR-certified staff on-site. She agreed that this was deficient practice. The administrator designee acknowledged that the administrator had been out on medical leave for a few months; additionally, she was filling in shifts when staff called out. She added that she wasn' t even aware that someone could be first-aid certified without being CPR certified, stating, "This is a good learning moment".On 8/25/25, at 12:23 p.m., the administrator designee left a voice message eight days after the onsite visit stating that the administrator had stored the CPR certifications in a file located in her office. She stated the staff' s CPR certifications had been completed in February 2025. However, during the on-site visit on 8/12 -13/ 2025, the administrator designee was unable to provide these documents but had provided other certifications.

A licensure complaint, prompted by #CO39029, #CO39397, was completed on 8/13/25. Deficiencies were cited. Based on observations and interviews, the residence failed to make available a physically safe and sanitary environment, affecting eight current residents.Findings Include:An environmental tour of the residence on 8/12/25 at 8:00 a.m. revealed that both common shower rooms had loose and removable baseboard tile; behind the tiles, a large amount of mold was observed.On 8/13/25 at 8:00 a.m., Confidential Staff #1 reported that she had alerted the admi.. Based on records review and interviews, the residence failed to comply with all occurrence reporting required by state law and follow reporting procedures set forth in Chapter 2, Part 4.2, affecting one former of eight sample residents (#8).Findings Include:1. ReferencesThe residence' s undated policy reads in part, "Should an incident or suspected incident of Resident abuse be reported, the administrator will investigate the alleged incident." The admi.. Based on records review and interviews, the residence failed to have at least one staff member on site at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting eight current residents.Findings Include:On 8/12/25, a review of the residence' s staff CPR certifications revealed that Staff #10 was not CPR certified, but was certified only in first aid by.. Based on records review and interviews, the residence failed to investigate an allegation of abuse of a resident under Chapter 7, Part 5.3; Specifically, following reporting and documentation requirements, affecting one former resident of eight sample residents (#8).Findings Include:1. ReferencesThe residence' s undated policy reads in part, "Should an incident or suspected incident of Resident abuse be reported, the administrator will investigate the alleged incident... Based on records review and interviews, the residence failed to provide a detailed explanation of the reasons for involuntary discharge in the notice provided, affecting one former resident of eight sample residents (#8).Findings Include:1. Record ReviewThe residence' s Resident Rights read in part, ' A 30-day written notice of changes in services will be provided by the residence.' The residence ' s undated discharge policy reads in part that a thirty-day (30-day) .. Based on records review and interviews, the residence failed to respect the right to choice and personal involvement; specifically, the right to 30 days written notice of changes in services provided, affecting one former resident of eight sample residents (#8).Findings Include:1. Record ReviewFormer Resident #8 was admitted to the residence on 2/1/22 with diagnoses that include Chronic Kidney disease, myocardial infarction, hypertension, atrial fibrillation, and neuro.. 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 7.18.8 Resident records shall contain, but not be limited to, the following items:(H) Final disposition of resident including, if applicable, date, time, and circumstances of a resident ' s death, ..

A licensure complaint revisit was completed on 8/13/25 for the previous deficiencies cited on 7/23/24. A deficiency was cited. The deficiencies cited for Event I2NX11 were cited prior to the regulation revision that was implemented on 7/1/25. Based on records review and interviews, the residence failed to have at least one staff member on site at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting eight current residents.Findings Include:On 8/12/25, a review of the residence' s staff CPR certifications revealed that Staff #10 was not CPR certified, but was certified only in first aid by the American Heart Association.The residence' s July and August 2025 staff schedules revealed that Staff #10 worked alone from 7:00 p.m. to 7:00 a.m. on: 7/3/25, 7/4/25, 7/5/25, 7/10/25, 7/11/25, 7/12/25, 7/17/25, 7/18/25, 7/19/25, 7/24/25, 7/25/25, 7/26/25, 7/31/25, 8/1/25, and 8/2/25.On 8/13/25 at 12:10 p.m., the administrator designee agreed that she was unaware and was informed that Staff #10 was only first-aid certified. She agreed that every time Staff #10 worked alone, there was no CPR-certified staff on-site. She agreed that this was deficient practice. The administrator designee acknowledged that the administrator had been out on medical leave for a few months; additionally, she was filling in shifts when staff called out. She added that she wasn' t even aware that someone could be first-aid certified without being CPR certified, stating, "This is a good learning moment".On 8/25/25, at 12:23 p.m., the administrator designee left a voice message eight days after the onsite visit stating that the administrator had stored the CPR certifications in a file located in her office. She stated the staff' s CPR certifications had been completed in February 2025. However, during the on-site visit on 8/12 -13/ 2025, the administrator designee was unable to provide these documents but had provided other certifications.

A licensure complaint, prompted by #CO30520, was completed on 7/23/24. Deficiencies were cited. A change of ownership occurred on 1/31/24. Based on observation, record review, and interview the residence failed to ensure the exterior grounds were free of hazards such as bees, affecting seven current residents. Findings include: 1. Residence Policy The residence' s undated Pest Control Policy read in part: "The (residence) will monitor and manage any and all pest control issues that present themselves as soon as possible. These issues are related to rodents, ants, insects and other pests."2. ObservationsOn 7/23/24 at approximately 9:00 a.m., an environmental tour of the exterior grounds revealed that in between the bottom part of the gutters and the exterior walls of the house there were 14 active beehives around the residence. There were four active hives in the common outdoor area, four on the right side of the residence, four on the left side and two above the front entrance. On 7/23/24 at 9:27 a.m., Resident #14 walked around the residence, exiting from the front entrance, walking to the right side of the residence, passing four beehives then walked towards the back e.. Based on record review and interview, the residence failed to ensure there was at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, (e.g., the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute), affecting seven current residents.Findings include:1. Record ReviewOn 7/23/24 at approximately 9:00 a.m., a review of current staff CPR records revealed Staff #9 and #10 did not have current certification in CPR.The July 2024 staff schedule revealed that on 7/12/24, 7/19/24 and 7/26/24 from 7:00 p.m. to 7:00 a.m. Staff #9 and #10 were the only staff onsite. Furthermore, the staff schedule read that on 7/13/24, 7/14/24, 7/20/24, 7/21/24, 7/27/24, and 7/28/24, Staff #10 was the only staff onsite from 7:00 p.m. to 7:00 a.m. The residence scheduled nine 12-hour shifts in July 2024 that had no CPR certified staff.2. Intervie.. Based on record review, observation, and interview, the residence failed to have an infection control program that provided initial and annual staff training on infection prevention and control. Such training shall cover, at a minimum, the following items: Modes of infection transmission; the importance of hand washing and proper techniques; and the use of personal protective equipment (PPE), affecting seven current residents.Findings include:1. Record ReviewThe residence undated infection control policy read in pertinent part: "(The residence) has implemented an infection control policy that staff are trained on, both by reading materials and hands on training;""Gowns must be worn always in combination with gloves prior to entering a patient environment where a resident is deemed for isolation or contamination precautions."Staff educational meeting minutes, dated 1/16/24, read in part that the meeting agenda included the topic of regulations regarding the respiratory protection program. There was no other record that the r..

A licensure revisit was completed on 7/23/24 for the previous deficiencies cited on 11/15/22. Deficiencies were cited. Based on record review and interview, the residence failed to ensure there was at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, (e.g., the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute), affecting seven current residents.This deficiency was cited previously during a state licensure survey 11/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewOn 7/23/24 at approximately 9:00 a.m., a review of current staff CPR records revealed Staff #9 and #.. Based on record review and interview, the residence failed to have a care plan that (E) Identified all external service providers along with care coordination arrangements, and (F) Identified formal, planned, and informal spontaneous engagement opportunities that match the resident' s personal choices and needs, affecting three (#11, #12 and #14) of three sample residents whose care plans were reviewed. This deficiency was cited previously during a state licensure survey 11/15/22. 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 PolicyThe residence' s undated resident agreement read in part that the care plans were reviewed at least annually or more frequently to note signi.. Based on record review and interview, the residence failed to have a quality management program (QMP) that improved client safety and well-being, affecting seven current residents.This deficiency was cited previously during a state licensure survey 11/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 7/23/24 at 8:57 a.m., the residence' s QMP was requested. However, the administrator was unable to provide an implemented QMP for the residence.On 7/23/24 at 2:16 p.m., the administrator stated the residence did not currently have a QMP, she did not have a reason as to why the citation was not corrected and acknowledged that she needed to work on one. Based on record review and interview, the residence failed to have a readily available roster of current residents that included a residence diagram showing room locations, affecting seven current residents.This deficiency was cited previously during a state licensure survey 11/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewOn 7/23/24 at approximately 7:40 a.m., a resident roster was requested from the resident services director (RSD). At 11:18 a.m. the RSD provided a roster that did not include a diagram of the residence. The residence failed to provide a complete resident roster for emergency preparedness during the onsite visit.2. InterviewsOn 7/23..