Retreat at Church Ranch, the

A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 10/11/22. Deficiencies were cited. Based on record review and interview, the residence failed to ensure applicants completed the Colorado Adult Protective Data Systems (CAPS) requirements prior to hiring staff who provided direct care to at-risk residents for three of three sample staff (#6, #7, #8).This deficiency was cited previously during a state licensure survey on 10/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Referencesa. According to 2022 Colorado Revised Statutes (C.R.S.) Title 26 - Human Services Code Article 3.1 - 101 Protective Services for At-risk Adults - C.R.S 26-3.1-111. Access to CAPS - employment checks, read (1) The general assembly finds and declares that individuals receiving care and services from persons employed in programs or facilities described in subsection (7) of this section are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state dep.. Based on record review and interview, the residence failed to immediately comply with conditions issued by the department, affecting 49 current residents. Findings include:The department concluded a revisit survey on 8/1/23. The original event dated 10/11/22 resulted in five deficiencies, which included TAG 1180 at a D-Level, a pattern of actual harm affecting one or more residents, regarding the facilities fall management program and individualized approach and staff training. Considering the risk of the challenging event, the department imposed a $750 civil fine payable by 12/1/22.As of the 7/28/23 onsite visit, the residence had not paid the required fine of $750 due to the department on 12/1/22.On 8/1/23 at 12:15 p.m.,the administrator stated the owner was unaware of a fine. On 8/1/23 at 12:17 p.m., the administrator stated that she would contact the owners and see if they knew of the fine.On 8/1/23 at 1:45 p.m., the owner stated the previous administrator had failed to inform her of a survey with deficiencies completed in October 2022.