Open Arms Assisted Living Suite a

A revisit survey was completed on 4/28/25 for all previous deficiencies cited on 11/5/24. 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 revisit survey was completed on 4/28/25 for all previous deficiencies cited on 11/5/24. 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 recertification survey was completed on 11/5/24. Deficiencies were cited. Based on record review and interview the residence (facility) failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting 10 current residents (members).Findings include:On 11/4/24 at 8:30 a.m., the residence' s visitation policy was requested, however, it was not provided.On 11/5/24 at 4:18 p.m., the administrator reported they did not have a visitation policy due to lack of oversight. She reported being unaware the residence needed to have one but would expect the residence to have one that met the requirements in Chapter VII, Regulation 9.2 (A-H). Based on record review and interview, the residence (facility) failed to comply with Colorado Adult Protective Services (CAPS) Data System prior to hiring staff who provided direct care to at-risk residents for one of one sample Staff (#1), affecting ten current residents (members).Findings include:The personnel file for Staff #1 revealed no CAPS request or report documentation. The record revealed that Staff #1 was hired and began providing services to residents on 8/26/24.On 11/5/24 at 4:15 p.m., the administrator reported that the residence did not have a CAPS on file for Staff #1 due to misplacing it. She reported she would expect a CAPS check to be on file for Staff #1. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.7000 8.7001.3.a.v. Provider owned/controlled residential settings must have the following qualities and protect all the following individual rights, subject to the Rights Modification process in Section 8.7001.B.4: Individuals have access to food at all times

A relicensure survey was completed on 11/5/24. Deficiencies were cited. Based on record review and interview the residence failed to define procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting 10 current residents.Findings include:On 11/4/24 at 11:45 a.m., an undated and untitled policy included topics of, "encouraging employees to stay home if experiencing symptoms, communicating leave policies, providing a safe and healthy work environment, considering the Family and Medical Le.. Based on record review and interview the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting 10 current residents.Findings include:On 11/4/24 at 8:30 a.m., the residence' s visitation policy was requested, however, it was not provided.On 11/5/24 at 4:18 p.m., the administrator reported they did not have a visitation policy due to a lack .. Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire(s), gas explosion, power outages, tornado, flooding, and threatened or actual acts of violence, affecting 10 current residents.Findings include:On 11/4/24 at approximately 10:30 a.m., a risk assessment of all hazards and preparednes.. Based on record review and interview, the residence failed to comply with Colorado Adult Protective Services (CAPS) Data System prior to hiring staff who provided direct care to at-risk residents for one of one sample staff (#1), affecting 10 current residents.Findings include:The personnel file for Staff #1 revealed no CAPS request. The record revealed that Staff #1 was hired and began providing services to residents on 8/26/24.On 11/5/24 at 4:15 p.m., the .. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 10 current residents.Findings include:On 11/4/24 at 8:30 a.m., the involuntary discharge grievance policy was requested; however, it was not provided.On 11/5/24 at 4:20 p.m., the administrator reported they did not have an involuntary discharge grievance policy due to a lack of oversight. She re.. Based on record review and interview, the residence failed to identify the highest potential risk, hold, and document routine drills to facilitate staff and resident response to that risk, affecting 10 current residents.Findings include:On 11/4/24 at approximately 12:49 p.m., the residence' s proof of routine drills for their highest potential risk was requested, however, it was not provided.On 11/5/24 at 4:21 p.m., the administrator reported they completed drills .. Based on record review and interviews, the residence failed to ensure its emergency policies addressed or included the required elements, affecting 10 current residents.Findings include:On 11/4/24, record review of the residence' s undated emergency plans and procedures did not address all of the required elements as listed above.On 11/5/24 at approximately 4:23 p.m., the administrator reported the policies were created in 2019 and reviewed in 2024. She re.. 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 VII 8.7 Each assisted living residence shall have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techni..