Assisted Living of Northglenn LLC

1.2 Assisted living residences, as defined herein, shall comply with all applicable federal and state statutes and regulations including, but not limited to, the following:(A) This Chapter 7;(B) 6 CCR 1011-1, Chapter 2, General Licensure StandardsBased on observation, interview and record review, the residence failed to be in compliance with all applicable regulations. This failure created the potential for mismanagement of the care of and services for the residents who would be served by this residence.Findings include:1. Resident' s rights to privacy under Chapter II regulations for Facility Guidelines Institute (FGI) and Chapter VII6 CCR 1011-1 Chapter 2 Regulations -1.25 "FGI Guidelines" means the Guidelines for Design and Construction of Hospitals, Guidelines for Design and Construction of Outpatient Facilities, and Guidelines for Design and Construction of Residential Health, Care, and Support Facilities, published by the Facilities Guidelines Institute.-1.28 "Guideline compliance review" means the review of design documents submitted to the department, in the format required by the Department, for determination of compliance with FGI Guidelines.-3.2.3 For any construction or renovations of a facility or agency initiated on or after July 1, 2020, the following requirements of the 2018 Editions, Facilities Guidelines Institute (FGI) including any errata and guideline interpretations adopted as of November 1, 2019, are incorporated by reference, as applicable to facility or agency license type:(C) for residential facilities, including but not limited to Assisted Living Residences, Behavioral Health Entities, Facilities for Persons with Developmental Disabilities, Nursing Care Facilities, and Hospice care: Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.-3.2.4 Facilities and agencies are expected to maintain the facility to the FGI Guidelines under which the Department approved the facility ' s or agency ' s initial license until such time as a new guideline compliance review occurs as required by this Part 3.-3.6 No appro.. An initial licensure survey was completed on 4/3/24. A deficiency was cited. The residence was comprised of a North building and a South building.

8.484.3.A All HCBS Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.484.5:3. The setting ensures an individual ' s rights of privacy, dignity, and respect, and freedom from coercion and restraint.Based on observation and interview, the setting (residence) failed to ensure the right of privacy to all individuals (residents) who would be served by this setting.Findings include:During the environmental tour on 4/1/24 from approximately 12:15 p.m. to 3:00 p.m. and on 4/2/24 from approximately 11:15 a.m. to 12:00 p.m. with the administrator and department representative #1, the following interviews and observations revealed the residence failed to ensure a design for adequate privacy for residents who would reside in double occupancy rooms. This included that resident access to toilets, room entrance, windows and other shared common areas was not restricted. On 4/1/24 at approximately 12:20 p.m., the administrator stated the residence was requesting licensure as a mental health transitional living setting for 16 beds in both the South and North buildings, totaling 32 beds.a. South buildingThe administrator stated Rooms 1, 2, 3, 7 and 11 were designated as double occupa.. 8.495.6 PROVIDER ROLES AND RESPONSIBILITIESI. Staffing Requirements1. Each facility will divide the 24-hour day into two 12-hour blocks which will be considered daytime and nighttime. The designation of daytime and nighttime hours shall be permanently documented in facility policy and disclosed in the written resident agreements. In determining appropriate staffing levels, the facility shall adjust staffing ratios based on the individual acuity and needs of the participants in the facility. At a minimum, staffing must be sufficient in number to provide the services outlined in the Care Plans, considering the individual needs, level of assistance, and risks of accidents. A staff person can have multiple functions, as long as they meet the definition Direct Care Staff defined at , Sections 8.495.1. Staff counted in the staff-participant ratio are those who are trained and able to provide direct services to participants.Based on record review and interview, the setting failed to ensure the resident agreement' s staffing policy included how the two 12-hour blocks were identified, affecting all individuals who would be served by this setting.Findings include:The administrator provided the resident agreement which included the staffing policy; however, the policy did not include how the setting identified the two 12-hour blocks. On 4/2/24 at approximately 12:00 p.m., the administrator acknow.. An initial certification of the mental health transitional living program was completed on 4/3/24. Deficiencies were cited. The residence was comprised of a North building and a South building.