Peaks at Old Laramie Trail, the

A revisit survey was completed on 9/30/24 for all previous deficiencies cited on 6/20/24. 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 with complaint #CO34336 was completed on 6/20/24. Deficiencies were cited. Based on interview and record review the residence failed to ensure there was at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization affecting 68 current residents. Findings include:1. Record Review On 6/19/24 at 8:55 a.m., CPR certifications were provided by the administrator. However, the CPR certifications revealed that Staff #17, #18, #20, #21 and #23 did no.. Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affected a resident' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident' s changing needs, affecting one current resident (#25) and one former resident (#32) who resided in the secure environ.. Based on interview and record review, the residence failed to ensure that each staff member met the dementia training requirements, affecting 27 current residents residing in the secure environment.Findings include:On 6/19/24 at approximately 11:02 a.m., personnel files for Staff #17-#22 were provided by the administrator and revealed no documentation that the direct care staff members met the dementia training requirements. On 6/19/24 at 11:02 a... Based on observation and interview, the residence failed to ensure residents had independent access to drinks at all times, affecting 27 current residents residing in the secure environment. Findings include:On 6/19/24 at 7:22 a.m., 10:17 a.m. , and 11:32 a.m., there was a water container in the small kitchen area on the inside of a small "C" shaped counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment ha.. 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 four of four sample residents (#23, #29-#31) whose medications were administered.Findings include:On 6/19/24 from approximately 7:30 a.m. to 8:30 a.m., during medication admi.. Based on observation, interview and record review, the residence failed to ensure that no individual was required move into a secure environment against their will unless legal authority for the admission of the individual has been established by guardianship, court order, medical durable power of attorney, health care proxy, affecting one current resident (#25). (Cross-reference S2230)Findings Include:1. Resident #25 was admitted to the unsecure portion of the .. Based on observation, record review and interview, the residence failed to ensure each staff member completed orientation relevant to their specific duties, affecting 68 current residents.Findings include:1. ObservationOn 6/19/24 from approximately 7:15 a.m. to 4:30 p.m., Staff #20 provided care and services to residents. 2. Record Review On 6/19/24 at 11:02 a.m., staff records for Staff #17-#22 revealed that they were hired on 6/14/24, 3/15/24, 3/29/24, .. 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 comp..

A licensure revisit was completed on 6/20/24 for all previous deficiencies cited on 7/5/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23. Based on observation and interview, the residence failed to ensure residents had independent access to drinks at all times, affecting 27 current residents residing in the secure environment. This deficiency was cited previously during a state relicensure survey 7/5/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 6/19/24 at 7:22 a.m., 10:17 a.m. , and 11:32 a.m., there was a water container in the small kitchen area on the inside of a small "C" shaped counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment had independent access to drinks at all times. On 6/20/24 from approximately 7:15 a.m. to 10:00 a.m., there was a water container in the small kitchen area on the inside of the same counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment had independent access to drinks at all times. On 6/20/23 at 8:55a.m., the administrator stated he expected there to be water and cups available for residents in the secure environment to have independent access to drinks at all times. The administrator said the reason the deficiency was recited was because the dietary manager was not aware it was his responsibility to ensure residents had water and cups available.

A licensure complaint, prompted by #CO30524, was completed on 7/5/23. Deficiences were cited. Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 72 current residents.Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (I) Completing, maintaining, and submitting all reports and records required by the Department.b. Chapter VII regulations governing assisted living residences, part 12.8, requires that the comprehensive assessment shall be documented in writing and kept in the resident' s health information record.c. Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records shall contain, but not be limited to, the following items:(C) Individualized resident care plan;(D) Progress notes which shall include information on resident st.. Based on record review and interview, the administrator failed to be responsible for the overall day-to-day operation of the assisted living residence and managing day-to-day delivery of services, affecting 72 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.A review of the department database on 7/5/23 read the administrator of record had been at the residence since 3/18/19. The acting administrator (AA) was not listed in the database. On 7/5/23 at 7:00 a.m., Staff #4 stated that he was unaware of who was responsible for the day-to-day operations of the residence since the administrator of record had left employment. He stated he thought it was the resident care director (RCD).On 7/5/23 at 7:33 a.m., the RCD .. Based on record review and interview, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of six sample residents who resided in the secure environment (#4, #8, #20 and #22). Specifically, Resident #22 had documented falls on 11/20/22, 12/3/23, 12/28/22 and 5/31/23 resulting in no injury. The residence failed to update Resident #22' s care plan to include individual approaches necessary to address the resident' s fall risk since 9/22/20. Subsequently, Resident #22 sustained a fall on 6/26/23 and was not admitted to the hospital until 6/28/23 after pain for two days. Upon admission Resident #22 was discovered to have multiple right rib fractures due to her fall.Specifically, Resident #4 had diagnoses that included osteopenia. Resident #4 had a documented fall on 5/31/23 without injury. The residence failed to update Resident #4' s care plan to include individ..

A licensure revisit was completed on 7/5/23 for all previous deficiences cited on 12/13/22. Deficiences were cited. Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 72 current residents.Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 6.8, requires tha.. Based on observation and interviews, the residence failed to ensure residents had independent access to drinks at all times, affecting 29 current residents residing in the secure environment. This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the r.. Based on record review and interview, the administrator failed to be responsible for the overall day-to-day operation of the assisted living residence and managing day-to-day delivery of services, affecting 72 current residents. (Cross-reference Q512 and Q262)This deficiency was cited previously during a state licensure survey 12/13/22. Altho.. Based on record review and interview, the residence failed to ensure a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective employee for three of three sample staff (#10-#12) affecting 72 current residents. This deficiency was cited previously during a state licens.. Based on record review and interview, the residence failed to ensure its quality management program (QMP) was reviewed annually, affecting 72 current residents. (Cross-reference Q540, Q262)This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings bel.. Based on record review and interview, the residence failed to ensure resident care plans contained a description of the resident' s known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, affecting two of two sample residents with b.. Based on record review and interview, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of six sample residents who resided in the secure environment (#4, #8, #20 and .. Based on record review and interviews, the licensee failed to notify the department of a change in administrator, affecting 72 current residents. (Cross-reference Q512 and Q540)This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the reside.. 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 2.2.3.6. Applicants must show compliance with the Colorado Adult Protective Services Data Sy..