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Source: CO Dept. of Public Health & Environment
No deficiencies are reported in this inspection record.
A revisit survey was completed on 2/11/25 for all previous deficiencies cited on 8/14/24. 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
No deficiencies are reported in this inspection record.
A certification survey was completed on 8/14/24. Deficiencies were cited. Based on record review and interviews, the facility failed to develop emergency policies that address a plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids, affecting five current members.Findings include: 1. Record reviewa. The residence' s Power Outage Plan, dated 9/8/97, read in part "In the event of a temporary power outage, the following will be available: A. Flashlights for each room of the house. These flashlights must be kept in a very accessible place in each room, i.e., in the top drawer on the left hand side, or in the kitchen in the top drawer on the left hand side. B. The batteries in these flashlights must be checked monthly to assure working ability. C. There must be a full oxygen tank (E tank) made available for any resident who has an oxygen concentration. The back-up tank can be stored in the resident' s closet for easy accessibility. D. Help residents move to a safe area such as the closest school or shelter. E. Management must be notified immediately in order that they may work with the public utilities company to restore power on a priority basis." b. The residence' s Evacuation Policies and Procedures Plan, undated, read in part if there was a tornado, flood, power outage, water outage or bomb threat, residents were required to evacuate to the closes.. Based on record review, interviews and observations the facility failed to provide a key or key code to their home, a bedroom door with a lock and key, affecting five current members.Finding include:The facility' s Door Locks and House Keys policy, undated, read in part, "All residents bedroom doors have door locks that lock on the inside giving all residents the right to lock their doors. All residents have their own keys. There are extra keys in the staff room should any resident misplace their key or there is an emergency with a resident and a staff member needs to get in the room. All residents are given a house key upon admission. This key is kept in their possession. If they lose or misplace their key they should ask a staff member for a new one."During an environmental tour on 8/14/24 at 9:00 a.m., the bedroom doors had door knobs with locking mechanisms.On 8/14/24 at 9:00 a.m., Staff #1 stated that the members did not have keys to their bedroom doors as the members lost them but were aware that the members should have keys to their bedrooms and the facility' s main entrance door. On 8/14/24 at 11:00 a.m., Member #2 stated she did not have a key to her bedroom or the facility' s entrance door.On 8/14/24 at 11:20 a.m., Member #3 stated she did not have a key to her bedroom or the facility' s entrance door. She further stated she might ask for a key.On 8/14/24 at 1..
A licensure survey was completed on 8/14/24. Deficiencies were cited. Based on interview and record review the residence failed to maintain written minutes of resident meetings, affecting five current residents. Findings include:On 8/14/24 the meeting minutes were requested at 8:21 a.m. However, as of 12:47 p.m., no resident meeting minutes were provided. On 8/14/24 at 11:20 a.m., Resident #3 stated that the residents talked at the dining room table frequently, but not in a formal meeting as everything was fine in the residence.On 8/14/24 at 12:47 p.m., the administrator stated that she was aware that resident meetings should be held regularly and that they were being held but she did not have documentation of the meeting minutes a.. Based on interview and record review the residence failed to on a quarterly basis audit the accuracy and completeness of medication administration records, affecting five current residents. Findings include:On 8/14/24 at 8:21 a.m., the last two quarterly medication audits were requested from the administrator. On 8/14/24 at 12:12 p.m., the administrator stated that she and Staff #1 conducted medication audits but did not document the audits as required. Based on interview and record review, the residence failed to update a comprehensive assessment whenever a resident' s condition changed from baseline status, affecting three of three sample residents (#1-#3)Findings include:1. Residence policyThe residence' s Assessments Policy, undated, read in part, "Reassessments: Residents are reassessed yearly or more frequently, if necessary, to address significant changes in the residents physical, behavioral, cognitive and functional condition and identify the services that the facility shall provide to address the residents changing needs. The care plan is updated to reflect the results of the reassessment."2. Record reviewA comprehensive assess.. Based on record review and interview, the residence failed to ensure its emergency policies addressed a plan that ensures the availability of, or access, emergency power for essential functions and all resident-required medical devices or auxiliary aids, storage and preservation of medications during emergencies, specific tasks and responsibilities for staff members during emergencies, and the protection and transfer of health information as needed to meet the care needs of the residents during emergencies, affecting five current residents. Findings include: 1. Record reviewa. The residence' s Power Outage Plan, dated 9/8/97, read in part "In the event of a temporary powe.. 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 7.6.5 Each administrator shall have completed 40 hours of administrator training before assuming an administrator position. Individuals appointed as an interim administrator shall have completed 40 hours of administrator training within 30 days of appointment. Written proof regarding the successful completion of such training program shall be maintained in the administrator' s personnel file. The 40 hours shall be met by one of the fo..
A revisit survey was completed on 5/2/24 for all previous deficiencies cited on 4/5/22. 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
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