St Andrews Village

A licensure complaint, prompted by #CO36052 was completed on 2/24/25. No deficiencies were cited. 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 07.7.12 Personnel files for current employees and volunteers shall be readily available onsite for Department review.12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (A) Providing fall management education and materials to residents and family members;(B) Detailing in each resident' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment; (C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C); (D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and (E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6).13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: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 Depart..

A relicensure survey with complaint #CO30780 was completed on 2/9/23. Deficiencies were cited. Based on interview and record review, the residence failed to develop and implement a policy for investigation of injuries with unknown origin affecting one of three sample residents (#1). Findings include1. Residence Policy and Referencea. Chapter VII regulations governing assisted living residences, requires in part 13.12, that the assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the foll.. Based on interview and record review, the residence failed to ensure personnel files for current employees shall be readily available onsite for department review for three of three sample staff (#1-#3), affecting 58 current residents.Findings include: Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff' does not include individuals providing external services, as defined herein.Chapter VII regulations gov.. Based on observation, interview and record review, the residence failed to detail in each resident' s care plan the individualized approach necessary to address fall risk, affecting three of three sample residents (#1-#3).Specifically, Resident #1 was admitted to the residence on 1/14/23 with diagnoses including dementia. The resident had a fall in December 2022 which led to her admission to the assisted living residence on 1/14/23. Additionally, she had a fall on 2/5/23 that resulted in two skin tears to her left arm. However, the care plan, dated 1/31/23, did not include the in.. Based on record review and interview, the residence failed to ensure its quality management program (QMP) contained the required elements, affecting 58 current residents. Findings include:1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator' s designee. b. Chapter II regulations governing health facilities, part 4.1.2A, requires the QMP to include the following elements:Identification of quality management proj.. Based on record review and interview, the residence failed to ensure its quality management program (QMP) implemented improvement strategies, affecting 58 current residents. Findings include:1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator' s designee. b. Chapter II regulations governing health facilities, part 4.1.2B, requires the QMP to include the following elements:Implementation of improvement strategie.. Based on record review and interview, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 58 current residents.Findings include: 1. Referencesa. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(I) Completing, maintaining, and submitting all reports and records required by the Department.2. Record Review..