Sun Valley Assisted Living

A revisit survey was completed on 3/10/25 for all previous deficiencies cited on 10/9/24. The facility is in compliance with all deficiencies that 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 recertification survey was completed on 10/9/24. Deficiencies were cited. Based on interview and record review the residence (facility) failed to submit a verbal or written report for a Critical Incident, as defined in Section 8.7201.L.5, to the HCBS member' s Case Management Agency Case Manager within 24 hours of discovery of the actual or alleged Incident affecting one of the three sample residents (members) (#2).Findings include:1. Record ReviewResident #2 was admitted to the residence in March 2023 with a diagnosis of chronic alcoholism. A hospital discharge note, dated 9/23-9/26/24, read in part that the resident' s admission was due to cellulitis of the left lower extremity. 2. InterviewsOn 10/8/24 at 7:38 a.m., Resident #2 reported that he slipped on the floor, gashed his leg, and was transported to the emergency department (ED) a few weeks prior to the onsite visit. Resident #2 was unable to recall the specific dates of the incident.On 10/8/24 at 12:30 p.m., the administrator reported no critical incident reports or incident reports had been created in the last 60 days.On 10/8/24 at 2:03 p.m.. Based on record review and interview, the residence (facility) failed to ensure each qualified medication administration person (QMAP) accurately recorded all medications administered, affecting three of three sample residents (members) (#1- #3).Findings include:1. Resident #1 was admitted to the residence on 12/26/22 with diagnoses of intellectual disabilities, autism spectrum, and schizoaffective disorder.A written practitioner' s order, dated 4/11/24, directed the residence to administer gabapentin three times a day. However, the September 2024 medication administration record (MAR) revealed the residence failed to document the medication administration after administering the medication on 9/10-9/12/24, 9/19- 9/23/24, and 9/26/24. The October 2024 MAR revealed the residence failed to document that they administered the medication on 10/1/24-10/3/24. Additionally, the residence failed to include a legible list of the names of the persons utilizing the MARs, along with each of their signa.. Based on record review, observation, and interview, the residence (facility) failed to have an outdoor area that was well maintained, policies and procedures to ensure the continuation of care to all residents (members) for 72 hours following any emergency, and access to nutritious food and beverages at all times affecting five current residents.Findings include:1. Outdoor areasDuring an environmental tour on 10/8/24, the front yard had overgrown bushes, high weeds, a disposable cup, and plastic bottle cap rings near the porch. In the backyard of the residence were high weeds along the shed, fence, tree, and garden.On 10/8/24 at 4:34 p.m., the administrator acknowledged the residence' s front and backyards were not kept free of high weeds, garbage, and rubbish. 2. 72 hour emergency policyOn 10/8/24 at approximately 9:00 a.m., a 72 hour continuation of care policy and procedure was requested; however, it was not provided.On 10/8/24 at 5:15 p.m., the administrator stated he was unaware of the requirement ..

A relicensure survey was completed on 10/9/24. Deficiencies were cited. Based on observation and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting five .. Based on observation and interview, the residence failed to keep the residence porches in good repair, affecting five current residents.Findings include:During an environmental tour on 10/8/24, the front porch walkway had a crack in .. Based on observation and interview, the residence failed to keep the residence' s exterior grounds free of high weeds, garbage, and rubbish, affecting five current residents. Findings include:During an environmental tour on 10/8/24, th.. Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire(s), gas explosio.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was compl.. Based on record review and interview, the residence failed to ensure that each staff member met the dementia training requirements in 7.9(B), affecting five current residents.Findings include:On 10/8/24 at approximately 9:00 a.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting five current residents.Findings include:On 10/8/24 at approxim.. Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency affecting five current residents.Findings include:On 10/.. Based on record review and interview, the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S affecting five current resident.. Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting five current residents. (Cross-reference S1600)F.. Based on record review and interviews, the residence failed to ensure its emergency policies addressed or included (B) a schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, .. 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 a..

A revisit survey was completed on 5/23/23 for all previous deficiencies cited on 6/3/22. 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 5/23/23 for all previous deficiencies cited on 6/3/22. 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