Shana's Place Assisted Living

An initial licensure survey was completed on 1/10/23. A deficiency was cited. Based on interviews and record review, the residence failed to be in compliance with all applicable regulations.This failure created the potential for mismanagement of care and services for the residents who would be served by this residence.Findings include:Chapter 2 regulations governing assisted living residences, part 2.3.6, requires all applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S.According to 2017 Colorado Revised Statutes (C.R.S.) Title 26 - Human Services Code Article 3.1 - Protective Services for Adults at Risk of Mistreatment or Self-Neglect Part 1 - Protective Services for At-Risk Adults § 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 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. Subsection seven read (7) The following employers shall request a CAPS check pursuant to this section: (a) A health facility licensed pursuant to section 25-1.5-103, including those wholly owned and operated by any governmental unit.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.-The residence did not have a system in place to ensure a CAPS check was performed prior to hiring of staff who provided direct care to at-r..

An initial certification survey was completed on 1/10/23. Three deficiencies were cited. Based on record review and interview, the facility failed to ensure its House Rules did not limit rights in a manner imposed across-the-board. Findings include: Record Review A review of the facility' s House Rules revealed the following broadly restrictive statements: "The administrator should be informed of the desire to have alcoholic beverages by the resident or resident representative"; "All alcoholic beverages must be kept in a locked private refrigerator in the resident' s bedroom"; and, "Residents are aloud (sic) and encourage to conduct activities that include cooking and baking but must be supervised by a staff member."InterviewOn 1/10/23 an interview was conducted with the administrator beginning at 8:05 a.m. The administrator confirmed the House Rules were intended for all residents of the home. The administrator acknowledged the rules contained broad restrictions and needs to be revised. Based on record review and interview, the facility failed to ensure the Person-Centered Support Plans of other residents in the setting reflect that they have been informed in plain language of the camera(s)/monitor(s)/chime(s)/alert(s) and any methods in place to mitigate the impact on their privacy. Findings Include:Record ReviewA review of the facility file for Resident #1 revealed no documented methods to mitigate the impact of camera use in common areas on their privacy. InterviewOn 1/10/23 an interview was conducted with the administrator beginning at 8:05 a.m. The administrator reported she was not aware that each person-centered support plan must contain methods in place to mitigate the impact of camera use on their privacy. The administrator confirmed that no such documentation was present in the Person-Centered Support Plan. Based on record review and interview, the facility failed to follow regulatory requirements for completing and documenting the rights modification process for situations in which an individual is limited in the full exercise of their rights.Findings include:Record ReviewA review of the facility' s file for Resident #2 revealed that the documentation for use of cameras in bedrooms and common areas did not follow the required rights modification process. Specifically, the documentation did not contain: a plan to support the affected resident in learning skills so that the modification becomes unnecessary; the positive behaviors and objective results that the resident can achieve to demonstrate that the rights modification is no longer needed; an established timeline for periodic reviews of the data collected; the signed informed consent of the resident (or, if authorized, their guardian or other legally authorized representative) agreeing to the rights modification; an assurance that interventions and supports will cause no harm to the individual..