Crossroads at Delta Memory

A relicensure survey with complaint #CO37425 was completed on 9/12/24. Deficiencies were cited. Based on interview and record review, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 26 current residents.Findings include:1. Record Review Documentation of CPR certifications for Staff #4 revealed that the staff had CPR certifications; however, they were not issued from a nationally recognized organization.The July and August 2024 staff schedules revealed the residence did not ensure there was at least one staff member with current CPR certification from a nationally recognized organization for all shifts.The administrator also provided a list of all staff, stating that everyone on the second shift and in the building would complete their CPR training in October 2024.2. InterviewOn September 12, 2024, at 12:14 p.m., the administrator acknowledged that he had not ensured that there was someone in the residence at all times with CPR certification from a nationally recognized organization. He also stated that he was aware that not having someone who was CPR certified on every shift was a deficient practice and nodded his head in agreement that all staff needed skills training included. Based on record review and interview, the residence failed to investigate allegations of abuse, including the requirement that the residents shall be protected from potential future abuse, affecting 26 current residents.Specifically, the residence failed to investigate an allegation of resident-to-resident abuse on 9/5/24 involving Residents #5 and #2. Notably, Resident #2 had previously been involved in another incident that resulted in significant injuries and ultimately the death of a resident on 9/2/24. This failure created an immediate jeopardy risk of abuse to all 26 current residents residing in the residence. On 9/11/24, the department directed the residence to provide written evidence that the risk had been removed.Findings include:1. Residence Policy The residence' s resident care services policy, dated February 2022, read in part: the residence made available, either directly or indirectly, services sufficient to meet the needs of the residents including protective oversight, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that required an immediate individualized approach.The residence' s resident records policy, dated February 2022, read in part: progress notes included documentation regarding any out ..

A licensure complaint, prompted by #CO31119, was completed on 5/23/23. A deficiency was cited. Based on observation, interview and record review, the residence failed to appoint a qualified designee to satisfactorily fulfill the administrator' s duties and ensure the name and contact information of the qualified designee were readily available to residents, residence staff and the public while the administrator was unavailable, affecting 20 current residents. Findings include:Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1.On 5/23/23 at between approximately 7:00 a.m. and 5:00 p.m. and upon entrance to the residence, the business office manager assisted surveyors in obtaining required documentation throughout the survey process. The business office manager answered questions related to the operation of the residence and referred surveyors to the qualified medication administration person (QMAPs) and caregivers. The administrator of record was not involved with the survey process and his only interaction with surveyors was at the survey exit. On 5/23/23 a review of the department' s database listed the administrator of record as the administrator of t.. Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 20 current residents.Findings include:1. Referencesa. The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/22/23,required residences to:-Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month) and (period two, defined as days 15-31 of each month). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods.-Assign at least one staff member to oversee the infection prevention and control (IPC) within the residence and to complete the Colorado RCF Infection Prevention Training using COTRAIN within two weeks of the assignment of duties and each calendar year thereafter. This information must be reported in EMResource and remain updated.b. Chapter II regulations governing assisted living residences, part 12.2.2, requires the following: Infection Control Officer(1) The requirements of this part 12.2.2 shall..