St Francis Assisted Living Facility

A licensure complaint, prompted by #CO39337, was completed on 3/13/25. Deficiencies were cited. Based on interview and record review, the residence failed to update comprehensive assessments whenever a resident' s condition changed from baseline status, affecting one sample resident (#1).Findings include: Resident #1 was admitted to the residence on 4/25/19 with a diagnosis of schizoaffective disorder.The most recent assessment, dated 5/3/23, read in part Resident #1 had a history of schizoaffective disorder and she had tendencies to get agitat.. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting six current residents.1. ReferenceThe Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private .. Based on observation and interview, the residence failed to ensure oxygen tanks were secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other, affecting six current residents. Findings include:On 3/13/25 from approximately 9:00 a.m. to 9:30 a.m., an environmental tour of the backyard environment was conducted at the residence. Observed in the backyard were two oxygen tanks chained to a BBQ gril.. Based on observation and interview, the residence failed to keep the residence' s exterior grounds free of high weeds, garbage, and rubbish, affecting six current residents. Findings include:On 3/13/25 from approximately 9:00 a.m. to 9:30 a.m., an environmental tour of the backyard environment was conducted at the residence. The backyard had multiple areas full of clutter. One area on the porch had multiple cigarette packs on the ground around stored.. Based on record review and interview the residence failed to conduct a comprehensive assessment affecting one of two sample residents (#2).Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 2.3, defines "Activities of daily living" as those personal functional activities required by an individual for continued well-being, health, and safety. As used in this Chapter 7, activities of daily living include, but are not limit.. Based on record review and interview, the residence failed to complete progress notes at the end of each shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident' s physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident' s changing needs, affecting six current residents who experienced out of the ordinary events. Findings include: Resident #1 was .. Based on record review and interviews, the residence failed to ensure each resident care plan contained all of the required elements, affecting one of two sample residents (#1).Findings include:Resident #1 was admitted to the residence on 4/25/19 with a diagnosis of schizoaffective disorder.A progress note dated 2/1/25 read in part, a staff member heard something fall in the kitchen and found blood and a knife. An external hospital note, dated 2/1/25 re..

"12.2.2 Infection Control Officer 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; (2) Completing a minimum of 1.5 hours of continuing education in infection prevention and control on an annual basis from a nationally-recognized provider or the Department ' s training program sufficient to stay current on changing guidance and requirements in the field; (3) Providing on-site .. A relicensure survey was completed on 11/13/24. Deficiencies were cited. Based on record review and interview, the agency failed to maintain a quality management program (QMP) designed to improve consumer safety and well-being and identify continuous quality improvement opportunities to enhance service delivery, affecting five current residents.Findings include:On 11/13/24 at 9:15 am the residence' s QMP was requested for review, however it was not received. The QMP was requested again at 10:45 a.m. At that time, a QMP notebook was provided, however it contained no documentation.On 11/13/24 at 10:45 a.m., the assistant administrator stated she had found QMP forms, however they were not completed. She acknowledged the residence did not have a current QMP program. Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP), on a quarterly basis, audited the accuracy and completeness of the medication administration records, affecting five current residents. Findings include:On 11/13/24 at 9:15 a.m., and again at 1:47 p.m., the quarterly medication audits were requested from the assistant administrator. No documentation was provided.On 11/13/24 at 1:30 p.m., Staff #1 stated she did not know if she had participated in a medication audit.On 11/13/24 at 1:47 p.m., the assistant administrator stated she was not sure where the documentation of the medication audits was, adding she did not think audits were completed. The assistant administrator acknowledged th.. 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 and Chapter 7.2.3.6. 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.8.7 Each assisted living residence shall have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization (e.g., the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Hea..

A licensure revisit was completed on 1/27/23 for the previous deficiency cited on 4/21/22. A deficiency was cited. Based on record review and interview, the residence failed to ensure its quality management program (QMP) implemented improvement strategies, affecting five current residents.Findings include:1. Referencea. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management program 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 strategies.-How the improvement strategies would be developed.-Documentation for each improvement strategy, to include:-How information about patterns and trends will be shared with staff and how the underlying systemic problem(s) that led to the pattern or trend will be addressed. -How staff will be allocated and/or trained to implement the strategy.-How the strategy will be evaluated for effectiveness.-Timelines for implementation and evaluation of the strategy and how the facility is tracking the meeting of these milestones.2. QMP ReviewThe residence administrator designee had no documentation or evidence to demonstrate that the QMP had been maintained. The QMP was not available onsite. 3. Interview1/27/23 at 8:50 a.m. The administrator designee stated she believed corrections were made to the QMP; she said she had been working on putting QMP into notebook binders, however, she had not brought it with her to the residence. The administrator designee stated that she had completed a class at the end of 2022 which taught her how to develop the QMP. The administrator designee stated that the QMP should have been onsite and available for review.