Dorothys Soft Touch II

A revisit survey was completed on 12/23/24 for all previous deficiencies cited on 8/29/24. 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 8/29/24. Deficiencies were cited. Based on observation and interview, the residence failed to have a fire resistant waste disposal container in the designated outdoor smoking area, affecting three residents who smoked (#1, #4, #5).Findings include:On 8/29/24 at 7:57 a.m., a metal can was placed in the outdoor designated smoking area and was full of cigarette butts and ashes.On 8/29/24 at approximately 8:00 a.m., Resident #4 was observed outside smoking. On 8/29/24 at 11:00 a.m., the administrator stated she was aware of the regulation to have a fire resistant wastebasket in the outdoor smoking area. The administrator stated she was unaware the metal can was not fire resistant. The administrator confirmed that Resident #1, #4 and #5 were the current smokers within the residence. Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting six current residents.Findings include:On 8/29/24 at approximately 7:30 a.m., the residence' s involuntary discharge grievance policy was requested but not provided.On 8/29/24 at 11:00 a.m., the administrator stated she was unaware of the regulation updated 1/1/24 requiring the residence to develop and implement an involuntary discharge grievance policy. Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following an emergency including, but not limited to, a long-term power failure, affecting six current residents.On 8/29/24 at approximately 7:45 a.m., a 72 hour continuation of care policy and procedure was requested but was not provided.On 8/29/24 at 11:00 a.m., the administrator confirmed she did not have a 72 hour continuation of care policy and procedure. The administrator stated she was unaware of the requirement to have a written policy and procedure for the 72 hours following an emergency. 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 7.10.1: The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.22.30: The assisted living residence shall prohibit smoking in areas where oxygen is stored and/or used and shall post a conspicuous "No Smoking" sign in those areas.