Rocky Mountain Assisted Living Quincy Avenue Memory Care Facilities

An initial secure environment licensure survey was completed on 7/10/24. A deficiency was cited. Based on observation, interview and record review, the residence failed to have prior approval from the department to operate a secure environment, affecting 13 current residents. Findings include:1. ObservationsOn 7/10/24 at approximately 8:15 a.m., the front entrance of the residence had a keypad that required a code to be entered in order to open the front door. The door to the entrance was locked. On 7/10/24 from approximately 8:15 a.m. to 12:00 p.m., there were multiple residents present either eating or participating in activities. 2. Record ReviewOn 7/10/24 at 8:31 a.m., the residence' s posted license read the residence had no secured beds. On 7/10/24 at 8:55 a.m. a representative from the Department said, "This facility applied to become secure for the first time ever on an application submitted 2/15/2022 ... their initial app (application), and all renewals apps (applications) have not been approved for a secure unit. They have never been licensed as a secure unit, and if they' ve been operating as one, it' s been without our approval."Resident #1- #13 had a signed practitioner' s order to reside in a secure environment and were admitted to the residence, on the following dates:Resident #1: 5/24/24Resident #2: 5/27/23Resident #3: 2/9/23Resident #4: 5/20/24Resident #5: 3/6/24Resident #6: 6/20/22Resident #7: 1/17/24Resident #8: 3/8/23Resident #9: 3/5/24Resident #10: 2/16/24Resident #11: 2/5/24Resident #12: 2/8/24Resident #13: 5/18/24The residence' s Safety Check form for 12/6/23, 3/6 and 6/12/24 read the "Memory care doors (inside doors, back gate) are secure and in working order. All parts appear in good order."3. InterviewsOn 7/10/24 at 8:27 a.m., Staff #1 stated the residence had been operating as a secure environment since it had been built. On 7/10/24 at 9:00 a.m., the resident care coordinator said every resident at the residence required a secure environment. She added the residence had been operating as a secure environment since she started six months ago...

A relicensure survey was completed on 3/16/23. Deficiencies were cited. Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting eight current residents. Findings include: 1. ReferenceThe Residential Care Facility (RCF) Comprehensive Mitigation Guidance dated 2/22/23, required residences to:-Ensure EMResource was updated bi-monthly.2. Record ReviewReview of EMResource, dated 3/16/23, revealed it had not been updated twice per month as required by the RCF comprehensive mitigation guidance. The last update occurred on 1/31/233. InterviewsOn 3/16/23 at approximately 1:15 p.m., the administrator stated the wellness nurse (WN) was responsible for reporting to EMResource twice a month.On 3/16/23 at approximately 1:16 p.m., the WN stated she was responsible for reporting to EMResource. She stated she was aware the reporting requirement to EMResource was bi-weekly; however, she could not explain why the last update occurred on 1/31/23. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, affecting three of three sample residents (#1-#3).1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... 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 department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult."b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older, or any person wh..