Rocky Mountain Assisted Living - Reed

An involuntary discharge appeal survey, prompted by #CO36163, was completed on 7/9/24. A deficiency was cited. Based on interviews and record review, the residence failed to include a practitioner assessment of the resident' s current needs in relation to the resident' s medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence' s staff or an external service provider affecting one resident (#1).Findings include:The involuntary discharge notice, dated 4/24/2024, read in part: "We are no longer able to meet your needs due to frequent refusals of medications, care, and meals. (The residence) has attempted multiple interventions that have been unsuccessful. We have recommended you schedule an appointment with your (practitioner) so they can evaluate you, review your medication list, and discuss mental health support that may assist with your appetite and medication refusals. Unfortunately, you did not attend your doctor' s appointment and did not communicate with us so that we could assist you to reschedule." The discharge failed to contain a practitioner' s assessment of the resident' s current needs in relation to the resident' s medical condition that prompted the discharge.The residence' s written response to the resident' s initial appeal of the discharge, dated 5/1/24, revealed that the residence did not include a practitioner' s assessment of the resident' s current needs in rela.. 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 2.2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities:(A) Individual client records.(B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department.

A revisit survey was completed on 2/28/24 for all previous deficiencies cited on 12/6/23. No deficiencies 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 2/28/24 for all previous deficiencies cited on 12/6/23. No deficiencies 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 second initial revisit was completed on 12/6/23, for all previous deficiencies cited on 5/25/23. Deficiencies were cited. Based on observation, interview and record review, the licensee failed to notify the department of a change in administrator affecting 12 current residents.The findings:On 12/5/23 at approximately 7:15 a.m., a white board posted on the residence wall above the medication cart read the administrator on duty was the former administrator.On 12/5/23, review of the department database read that the former administrator had assumed her position as administrator on 2/1/22 and was currently in the role. On 12/5/23 at 9:49 a.m.,the resident care .. Based on observation, interview and record review, the residence failed to ensure there was at least one staff member on-site at all times who had current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization affecting 12 current residents. This deficiency was cited previously during a second initial licensure survey and complaint completed on 5/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Specifically, the residence fail.. Based on observation, interview and record review, the residence failed to ensure there was at least one staff member on-site at all times who had current certification in first aid from a nationally recognized organization affecting 12 current residents. This deficiency was cited previously during a second initial licensure survey and complaint completed on 5/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence Policy The residence' s.. Based on observations and interviews, the residence failed to ensure foods that were opened or prepared and not used within 24 hours were marked with a "use by" or "discard by" date, affecting 12 current residents. This deficiency was cited previously during a second initial licensure survey and complaint completed on 5/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. ReferencesThe residence' s, undated, Food Preparation Policy, read in par.. Based on observations and interviews, the residence failed to ensure the residence grounds were maintained to protect residents from hazards, affecting 12 current residents. This deficiency was cited previously during a second initial licensure survey and complaint completed on 5/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. ObservationsOn 12/5/23 at 7:35 a.m., an outside environmental tour was conducted of the backyard court.. 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 7.14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications14.38 All medications shall be stored in a locked cabinet, cart, or storage ar..

A licensure complaint prompted by #CO34327 was completed on 12/6/23. Deficiencies were cited. Based on observation, interview and record review, the licensee failed to notify the department of a change in administrator affecting 12 current residents.The findings:On 12/5/23 at approximately 7:15 a.m., a white board posted on the residence wall above the medication cart read the administrator on duty was the former administrator.On 12/5/23, review of the department database read that the former administrator had assumed her position as administrator on 2/1/22 and was currently in the role. On 12/5/23 at 9:49 a.m.,the resident care coordinator (RCC) arrived at the residence and stated she was the administrator designee.On 12/5/23 at 9:59 a.m., the RCC stated that the administrator' s last day was on 12/1/23.On 12/5/23 at approximately 10:40 a.m., the interi.. Based on observation, interview and record review, the residence failed to ensure residents had the right to the maximum degree of benefit of services offered by the assisted living affecting 12 sample residents. Findings include:1. ReferencesThe residence' s, undated, Food Preparation Policy read in part: "Food must be maintained at the proper temperature during preparation and service. Hot food shall be served at 140 degrees; cold food shall be served at 45 degrees or less ... Food must be prepared in a manner to conserve nutrients, to assure taste and to be attractive in appearance." 2. ObservationsOn 12/5/23 at 7:40 a.m., Contracted Staff #4 prepared breakfast which consisted of dry toast, oatmeal, oranges and watery orange juice. The toast and oranges were plated and the contracted staff was po.. Based on observations and interviews, the residence failed to ensure foods that were opened or prepared and not used within 24 hours were marked with a "use by" or "discard by" date, affecting 12 current residents. Findings include:1. ReferencesThe residence' s, undated, Food Preparation Policy, read in part: "Refrigerated foods opened or prepared and not used within twenty-four (24) hours must be marked with a "use by" or "discard by" date. The "use by" or "discard by" date is seven (7) calendar days following opening or preparation. The seven (7) days cannot surpass the manufacturer ' s expiration date for the product or its ingredients or seven (7) days since the date any of the ingredients in the food were opened or prepared. This requirement does not apply to commercially prepared condim.. 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 7.14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications14.38 All medications shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff.

A second initial survey with complaint #CO29120, was completed on 5/25/23. Deficiencies were cited. Based on interview and record review, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting nine current residents. (Cross-reference Q0732) Findings include: 1. Refere.. Based on observation and interviews, the residence failed to give residents the opportunity to choose where and with whom to sit in the dining area, affecting nine current residents.1. ObservationOn 5/25/23 at 7:34 a.m., the dining room table had pieces of paper with the names of Resident #1-#9 observed at each place setting.On 5/25/23 at 8:23 .. Based on observation, interviews and record review the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting three of four sample residents (#1-#3) and one former resident (#10). 1. Residence Policya. The residence' s Medication Administration and Medicati.. Based on observations and interviews, the residence failed to ensure foods that were opened or prepared and not used within 24 hours were marked with a "use by" or "discard by" date, affecting nine current residents. Findings include:On 5/25/23 at 7:36 a.m., the residence' s refrigerator, which was accessible to residents, did not have labels on any of t.. Based on observations and interviews, the residence failed to ensure the residence grounds were maintained to protect residents from hazards, affecting nine current residents. Findings include: 1. ObservationsOn 5/25/23 at 7:59 a.m., an outside environmental tour was conducted of the backyard courtyard area of the residence, which revealed .. Based on observations, record review and interview, the residence failed to implement a fall management program, affecting one of four sample residents who had a pattern of falls (#2).Findings include: 1. Residence Policya. The residence' s Fall Prevention Policy, dated 9/29/20, read in part: "the resident' s care plan will provide information nec.. Based on record review and interview, the residence failed to ensure house rules did not supersede or contradict any regulations, or in any way discourage a residents' exercise of his or her rights, affecting nine current residents. Findings include:1. Record ReviewThe residence' s Resident Rights Policy, updated 5/18/23, and also signed in the res.. Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting nine current residents. (Cross-reference Q0734) Findings include: 1. Reference and Residence Policya. According to VeryWell Health, .. 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 7.10.9 Each kit shall include, at a minimum, the following items: (A) Latex free disposable glo..