Western Slope Memory Care

A licensure and complaint revisit was completed on 7/11/24 for all previous deficiencies cited on 1/25/23. Deficiencies were cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 1/14/24.Tag S3060 was not cited in the previous event; however, the deficiency was included in the previous event' s informational 9999 tag. ased on record review and interview, the residence failed to investigate allegations of abuse of a resident, affecting one sample resident (#12). (Cross-reference S1326)This deficiency was cited previously during a state licensure survey on 1/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as any of the following acts or omissions:(A) The non-accidental infliction of bodily injury, serious bodily injury or death,(B) Confinement or restrain.. Based on observation and interview, the residence failed to ensure the residents' right to be free of restraint, affecting five of eight sample residents (#10-#12, #14, #15). (Cross-reference S1410)Findings include:1. Residence PolicyThe residence' s undated Resident Rights policy read in part that residents had the right to be free of confinement and restraint.The residence' s undated Restraint-Free Care policy read in part that, in most cases, the use of restraints was a form of neglect or abuse. The residence defined a restraint as a physical device, item, or practice that restricted a resident' s freedom of movement. Restraints may be used to prevent a resident from scratching and .. Based on observation, record review, and interview, the residence failed to establish a fall management program that included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of four sample residents (#9, #10, #13, #14) who experienced falls. (Cross-reference S3074, S1326)This deficiency was cited previously during a state licensure survey 1/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Specifically, Resident #9 fell on 6/1/24 at 3:00 p.m., 6/1/24 at 5:00 p.m., 6/22/24 .. Based on record review and interview, the residence failed to ensure resident care plans contained a description of the residents' personal grooming and hygiene items that were determined safe for the resident to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents or behavioral expressions and staff approaches to protect the resident, affecting eight of eight sample residents (#2, #9, #10-#15).1. Residence PolicyThe residence' s undated Enhanced Care Plan policy read in part that the residence included items for personal grooming and hygiene that were safe to remain in the residents' possession and which ite.. Based on record review and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one sample resident (#15).This deficiency was cited previously during a state licensure survey on 1/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.The residence ' s undated Administering Medication policy read in part that the residence was required to administer medications to the resident when ordered by an authorized practitioner. Resident #15 was admitted to the residence on 12/22/23 with ..

A licensure complaint, prompted by #CO36495, was completed on 7/11/24. Deficiencies were cited. Based on observation and interview, the residence failed to ensure the residents' right to be free of restraint, affecting five of eight sample residents (#10-#12, #14, #15). (Cross-reference S1410)Findings include:1. Residence PolicyThe residence' s undated Resident Rights policy read in part that residents had the right to be free of confinement and restraint.The residence' s undated Restraint-Free Care policy read in part that, in most cases, the use of restraints was a form of neglect or abuse. The residence defined a restraint as a physical device, item, or practice that restricted a resident' s freedom of movement. Restraints may be used to prevent a resident from scratching and .. Based on observation, record review, and interview, the residence failed to establish a fall management program that included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of four sample residents (#9, #10, #13, #14) who experienced falls. (Cross-reference S3074, S1326)Specifically, Resident #9 fell on 6/1/24 at 3:00 p.m., 6/1/24 at 5:00 p.m., 6/22/24 at 9:30 p.m., 6/22/24 at 4:49 p.m., and 6/27/24 at 9:10 a.m., and the residence failed to update the resident' s care plan with new individualized approaches necessary to address fall risk related to deficits in strength, balance, and ey.. Based on observation, record review, and interview, the residence failed to train each staff member on each resident' s care plan prior to the staff member working with the resident, affecting one sample resident (#9). (Cross-reference S1080)Specifically, Resident #9 sustained a fractured left shoulder blade after falling on 7/3/24. The residence failed to train Staff #10, #15, and #17 on how to transfer the resident with a fractured left shoulder blade. Subsequently, the resident called out in pain, moaned, and said "ow" several times while Staff #10, #15, and #17 transferred him. Resident #9' s hands were shaking during this process.a. ObservationsOn 7/11/24 at 8:22 a.m., Staff #10, #15, and #17.. Based on record review and interview, the residence failed to ensure resident care plans contained a description of the residents' personal grooming and hygiene items that were determined safe for the resident to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents or behavioral expressions and staff approaches to protect the resident, affecting eight of eight sample residents (#2, #9, #10-#15).1. Residence PolicyThe residence' s undated Enhanced Care Plan policy read in part that the residence included items for personal grooming and hygiene that were safe to remain in the residents' possession and which ite.. Based on record review and interview, the residence failed to investigate allegations of abuse of a resident, affecting one sample resident (#12). (Cross-reference S1326)Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as any of the following acts or omissions:(A) The non-accidental infliction of bodily injury, serious bodily injury or death,(B) Confinement or restraint that is unreasonable under generally accepted caretaking standards, or(C) Subjection to sexual conduct or contact that is classified as a crime.b. The residence' s undated Abuse/Neglect policy read in part that the initial response to allegati..

A licensure complaint, prompted by #CO31669, was completed on 4/19/23. Deficiencies were cited. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one sample resident (#5).Findings include:1. Reference and Residence Policya. According to the Occurrence Reporting Manual, dated May 2018, "Any occurrence involving neglect of a patient or resident ... is a reportable occurrence." One of the defining elements to require reporting an occurrence of neglect included when a staff member intentionally failed to follow standard of practice and or residence policy with significant potential for harm. It is the allegation of the event, not the outcome of the provider' s investigation, which made it reportable.b. The residence' s undated abuse and neglect investigation policy read in part that the residence reported all allegations of abuse and neglect to the Department within 24 hours.2. Record ReviewDocumentation of an investigation regarding allegations of neglect initiated on 3/31/23 revealed that a family member of Resident #5 alleged the residence neglected the resident.On 4/19/23 at approximately 9:00 a.m., a review of the Department' s database revealed the residence failed to report the allegation of neglect to the Department as an occurrence.3. InterviewsOn 4/19/23 at 9:21 a.m., the administrator acknowledged she did not report the allegation of the neglect of Resident #5 to the dep.. Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 26 current residents.Findings include:1. ReferencesThe COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/22/23,required residences to:-Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month) and (period two, defined as days 15-31 of each month). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods.-Assign at least one staff member to oversee the infection prevention and control (IPC) within the residence and to complete the Colorado RCF Infection Prevention Training using COTRAIN within two weeks of the assignment of duties and each calendar year thereafter. This information must be reported in EMResource and remain updated.2. EMResourceOn 4/19/23 at 9:29 a.m., a review of the residence' s EMResource details revealed the last date the residence reported updated information was on 1/4/23..

A second initial licensure survey with complaint #CO30525 was completed on 1/25/23. Deficiencies were cited. Based on interview and record review the residence failed to contact the resident' s practitioner when the resident sustained an injury, affecting one of seven sample residents (#1). (Cross-reference Q810, Q1312, Q1360, Q1362)Findi.. Based on interview and record review, the residence personnel failed to report suspected caretaker abuse of an at-risk resident to law enforcement within 24 hours of discovery, affecting one of seven sample residents (#1). (Cross-refere.. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting four of six sample residents (#1, #2 ,#5, #6)... Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one of seven sample residents (#1.. Based on record review and interview, the residence failed to develop policies regarding unanticipated illness, injury, significant change of status from baseline, or death of a resident and practitioner assessment, affecting 19 current r.. Based on record review and interview, the residence failed to have defined procedures to prevent the spread of influenza from unvaccinated staff, affecting 19 current residents.Findings include:On 1/24/23 at 7:50 a.m. and again.. Based on record review and interview, the residence failed to have written documentation regarding a description of the employee duties, date of hire, orientation training and results of background checks in each personnel file, affec.. Based on record review and interview, the residence failed to investigate all allegations of abuse of residents in accordance with Part 5.3 and its written policy, affecting one of seven sample residents (#7). (Cross-reference Q410,.. Based on record review and interview, the residence failed to observe a resident' s right to be treated with dignity and respect and to be free from physical abuse, verbal abuse, and restraint, affecting two of seven sample residents (#1,.. Based on record review and interview, the residence failed to provide, within 60 days, a minimum of six (6) hours of general training and education on providing care and services for residents with dementia/cognitive impairment with.. Based on record review and interviews, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in .. 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..