Aspen, the

A revisit survey was completed on 11/14/24 for all previous deficiencies cited on 6/25/24. 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 relicensure survey was completed on 6/25/24. Deficiencies were cited. Based on observation, record review and interview the residence failed to ensure each staff member completed training relevant to their specific duties and responsibilities prior to working independently for three of three sample staff (#1-#3), affecting 21 current residents. (Cross-references S0640,S0642)Findings include:1. Observation On 6/25/24 at approximately 7:45 a.m. through 4:47 p.m., Staff #1 and #3 provided care and services to residents. 2. R.. Based on observation, record review and interview the residence failed to ensure that each staff member met the dementia training requirements prior to providing any care or services to a resident for three of three sample staff (#1-#3), affecting 21 current residents. (Cross Reference S0640)Findings include:1. ObservationOn 6/25/24, at approximately 7:45 a.m. through 4:47 p.m., Staff #1 and #3 provided care and services to residents.2. Record Revie.. Based on observation, record review and interview the residence failed to ensure that each staff member received initial orientation prior to providing any care or services to a resident for three of three sample staff (#1-#3), affecting 21 current residents.Findings include:1. ObservationsOn 6/25/24, from 7:45 a.m. to 4:47 p.m., Staff #1 and #3 provided care and services to residents. 2. Record ReviewOn 6/25/24 at 8:52 a.m. staff orientation documentation w.. Based on observation, record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for three of three staff (#1-#3), affecting 21 current residents.Findings include:1. References a. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who prov.. Based on record review and interview the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis audited the accuracy and completeness of the medication administration records (MARs), affecting 21 current residents.Findings include:1. Record ReviewThe residence ' s medication cart audit documentation was reviewed and revealed an audit was completed in January 202.. Based on record review and interview, the residence failed to develop a policy for a grievance procedure for involuntary discharge and a visitation policy, affecting 21 current residents. Findings include: On 6/25/24 at 8:52 a.m., the involuntary discharge grievance policy and the visitation policy were requested from the administrator. On 6/25/24 at 10:00 a.m., the administrator provided an involuntary discharge policy; however, it did not contain the r.. Based on record review and interview, the residence failed to have defined procedures to prevent the spread of influenza from unvaccinated staff, affecting 21 current residents. Findings include: On 6/25/24 at 8:52 a.m., the influenza policy was requested from the administrator; however, the administrator was unable to provide the requested documentation. On 6/25/24 at 3:15 p.m. the administrator stated he was unaware of the state regulation .. 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, Chapters 2 and 7.2.3.6 Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S. 12.2.1 Infectious Disease Mitigation..