Constant Care V Cheyenne

A licensure complaint, prompted by #CO38889 and #CO39179, was completed on 4/17/25. A deficiency was cited. Based on observations and interview the residence failed to provide a physically safe environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting eight current residents. Findings include: An environment tour on 4/17/25 revealed that the secured outdoor walkway from the kitchen exit and throughout the seating area was uneven. The opposing ends of the concrete slabs were raised between two inches to six inches at any given point. Additionally, there were no railings on a sloped entrance towards the secure outdoor area. On 4/17/25 at approximately 1:00 p.m., the Director of Operations stated that she was aware that the raised slabs were a tripping hazard. She stated that they did not have a date for this issue to be fixed.

A relicensure revisit was completed on 4/17/25 for the previous deficiencies cited on 10/2/24. A deficiency was cited. Based on observations and interview the residence failed to provide a physically safe environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting eight current residents. This deficiency was cited previously during a state licensure survey 10/2/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: An environment tour on 4/17/25 revealed that the secured outdoor walkway from the kitchen exit and throughout the seating area was uneven. The opposing ends of the concrete slabs were raised between two inches to six inches at any given point. Additionally, there were no railings on a sloped entrance towards the secure outdoor area. On 4/17/25 at approximately 1:00 p.m., the Director of Operations stated that she was aware that the raised slabs were a tripping hazard. She stated that they did not have a date for this issue to be fixed at this time and that this is the reason that the deficiency was recited.

A relicensure survey was completed on 10/2/24. Deficiencies were cited. Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting eight current residents. Findings include:The residence ' s infecti.. Based on observation, record review, 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 eight current residents.The 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 f.. Based on observations and interviews, the residence failed to prohibit the use of portable heaters in resident rooms, affecting two sample residents (#1, #2). On 10/2/24 at approximately 8:00 a.m., a space heater was observed in Resident #1 and #2' s shared room.On 10/2/24 at approximately 11:30 a.m., the house manager confirmed the space .. Based on record review and interview the residence failed to develop and implement a visitation policy, affecting eight current residents.Findings Include:On 10/2/24 at approximately 9:30 a.m., a binder of the residence policies and procedure were provided; however, they did not include the residence' s visitation policy. On 10/2/24 at approximate.. Based on record review and interview the residence failed to develop and implement an emergency policy that ensured the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids and assignment of specific tasks and responsibilities to the staff members on each shift inclu.. Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy, affecting eight current residents.Findings include:On 10/2/24 at approximately 9:30 a.m., the residence discharge policy dated May 2021 failed to include the required elements stated in Section 25-27-104.3, C.R.. Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting eight current residents.Findings include:1. Residence PolicyThe residence' s undated Unanticipated Illness, Injury, Significant change in Status, and De.. Based on record review and interview, the residence failed to ensure the administrator completed the required 40-hour training prior to assuming the administrator role, affecting eight current residents.Findings include:On 10/2/24 at approximately 10:30 a.m., the administrator' s 40-hour training certificate was requested; however, the a.. Based on record review and interview, the residence failed to provide a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting eight current residents. Findings include:1. Residence PolicyT.. 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, Chapter 7.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accur..

A licensure complaint, prompted by #CO36414 was completed on 6/18/24. Deficiencies were cited. A change of ownership occurred on 5/27/21. Based on record review and interview, the residence failed to follow the residence' s policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one resident (#2).Findings include: 1. Residence Policy The residence' s undated Unanticipated Illness, Injury, Significant change in Status, and Death policy, read in part: "All injuries of unknown origin must be reported to the administrator, director, or house manager, and an incident report must be filled out and faxed to the appropriate medical provider and corporate fax ..."2. Record Review A progress note, dated 4/20/24, read Resident #2 had bruises on her arm; however, she was not complaining of any pain. The house manager was notified. On 6/18/24 at 11:00 a.m., the investigation of the unknown injury was requested; however, the house manager (HM) or the director of operations (DO) were unable to provide the documentation. 3. InterviewsOn 6/18/24 at 3:00 p.m., the HM stated that Staff #3 reported she had noticed bruises on Resident #2' s arms; however, she was unsure how the bruises occurred. She stated she sent an electronic message along with a picture of the bruise to all of the staff members and asked if anyone knew what had happened. The HM stated none of the staff, except for the staff who had reported it, were aware of the bruising. She stated the staff m.. Based on record review and interview, the residence failed to have a qualified skilled professional provide the training and competency evaluations for staff providing specialized services affecting one resident who was diabetic (#1). Findings include: 1. Record Review On 6/18/24, review of the personnel file for Staff #1 revealed no documentation of the required training and competency evaluations for performing blood glucose screenings (BGS). Documentation of Resident #1' s vital signs, dated 5/27/24, read: "Blood sugar 274/high." A second entry, dated 5/27/24, read: "Blood sugar back down to 96." 2. Interviews On 6/18/24 at 12:56 p.m., Staff #1 stated he had personal experience with BGS; however, he had not received training from the residence. He stated he was unaware of the state regulation that prohibited him from performing BGS without being trained by a skilled professional. Staff #1 further stated that he had only performed a BGS on Resident #1 only one time on 5/27/24. He stated Resident #1 complained her feet felt tingly and had become swollen. Staff #1 stated he knew this was a sign of high blood sugar, so he obtained permission from the resident' s family member, as well as from management, to perform the BGS. On 6/18/24 at 1:00 p.m., the director of operations stated that Resident #1 was diagnosed with type II diabetes; however, the resident did not req..