Retreat at Vineyards

12.2.2 Infection Control Officer(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility' s Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider or the Department' s training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseasesBased on record review, and interview, the residence failed to ensure tha.. A relicensure survey was completed on 5/27/25. Deficiencies were cited. The residence consisted of two seperate buildings named West House and East House. Based on interview and record review, the residence failed to investigate allegations of abuse in accordance with the residence' s written policy, affecting 21 current residents. (Cross-reference T3060)1. PolicyThe residence' s undated Abuse: Neglect policy read in part that the residence promptly and thoroughly investigated reported abuse. Identification of abuse included identification through complaints. The residence researched the who, what, where, when, how, and why of the incident. The purpose of the investigation was to determine the circumstances surrounding the alleged incident and to assess the available evidence to make a final determination. The policy contained the fol.. Based on observation, record review, and interview, the residence failed to contain wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact and how the residents had continuous independent access to their rooms, along with a plan to protect the residents from unwanted visitation by other residents, affecting three sample resident (#1-#3) and two non-sample residents (#4 and #5). (Cross-reference T1110 and T1410).Findings include:1. Resident AgreementThe undated Resident Agreement read in part that the residents had a right to privacy, and that .. Based on observation, record review, and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 11 current residents in the West House of the residence. (Cross-reference T3060)Specifically, Resident #1 resided in a secure environment (SE) and had a history of attempted exit-seeking through the windows of the residence. On 5/27/25, the window of his room had no method to prevent it from opening approximately three to four feet, therefore providing full egress in the SE. The window faced a street with consisten.. 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 7.5.1 Assisted living residence personnel engaged in the admission, care or treatment of at-risk persons shall report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement within 24 hours of observation or discovery pursuant to Section 18-6.5-108, C.R.S.5.3 An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 C..