Memory Care at Shalom Park LLC

“FluImmuEmp/Con-GenProv H/HU/ASC/NF-Ann FluVac PART 11. INFLUENZA IMMUNIZATION OF EMPLOYEES AND DIRECT CONTRATORS 11.2 General Provisions 11.2.4 Licensed hospitals, hospital units, ambulatory surgical centers, and nursing facilities shall provide or make available an annual influenza vaccine for employees and direct contractors when the influenza vaccine is readily available. (A) All other facilities and agencies shall ensure that employees and direct contractors are offered the opportunity to receive an annual influenza immunization.”

This is the rule that was cited, not the inspector’s specific finding.

“Prsnl-Prsnl Files Rq 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 7 - PERSONNEL - Personnel Files 7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items: (A) A description of the employee or volunteer duties; (B) Date of hire or acceptance of volunteer service and date duties commenced; (C) Orientation and training, including first aid and CPR certification, if applicable; (D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable; (E) Results of background checks and follow up, as applicable; and (F) Tuberculin test results, if applicable. (G) Documentation of initial dementia training and continuing education for direct-care staff members: (1) The residence shall maintain documentation of each employee's completion of initial dementia training and continuing education. Such records shall be available for inspection by representatives of the Department. (2) Completion shall be demonstrated by a certificate, attendance roster, or other documentation. (3) Documentation shall include the number of hours of training, the date on which it was received, and the name of the instructor and/or training entity. (4) Documentation of the satisfactory completion of an equivalent training as defined in sub-part 7.8(B)(2)(b) and as required in the criteria for an exception discussed in sub-part 7.8(B)(4), shall include the information required in this sub-part 7.12 (G)(2) and (3). (5) After the completion of training and upon request, such documentation shall be provided to the staff member for the purpose of employment at another covered facility. For the purpose of dementia training documentation, covered facilities shall include assisted living residences, nursing care facilities, and adult day care facilities as defined in Section 25.5-6-303(1), C.R.S.”

This is the rule that was cited, not the inspector’s specific finding.

“Stf Req-First Aid Stf CPR List 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 8 - STAFFING REQUIREMENTS - First Aid, Obstructed Airway Technique and Cardiopulmonary Resuscitation Trained Staff 8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both.”

This is the rule that was cited, not the inspector’s specific finding.

“Pol/Proc Visitation 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 9 - POLICIES AND PROCEDURES 9.2 The assisted living residence shall have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S. Such policies and procedures shall: (A) Set forth the visitation rights of the resident, consistent with 42 CFR 482.13(h); 42 U.S.C. 1396r(c)(3)(C); 42 U.S.C. 1395i(c)(3)(C); 42 CFR483.10(a), (b), and (f); and Section 25-27-104, C.R.S., as applicable to the facility type; (B) Describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the reasons for such restriction or limitation; (C) Be available for inspection at the request of the Department; (D) Be provided to residents and/or family members upon request; and (E) Include the right of each resident of an assisted living residence to have at least one visitor of the resident's choosing during their stay at the residence, unless restrictions or limitations under federal law or regulation, other state statute, or state or local public health order apply. This visitation right shall be exercised in accordance with the following: (1) A visitor to provide a compassionate care visit to alleviate the resident's physical or mental distress. (2) For a resident with a disability: (a) A visitor or support person, designated by the resident, orally or in writing, to support the resident during the course of their residency. The support person may visit the resident and may exercise the resident's visitation rights even when the resident is incapacitated or otherwise unable to communicate. (b) When the resident has not otherwise designated a support person and the resident is incapacitated or otherwise unable to communicate their wishes, an individual may provide an advance medical directive designating the individual as the resident's support person or another term indicating that the individual is authorized to exercise visitation rights on behalf of the resident. Pursuant to Section 15-18.7-102(2), C.R.S., "(2) 'Advance medical directive' means a written instruction concerning medical treatment decisions to be made on behalf of the adult who provided the instruction in the event that he or she becomes incapacitated. An advance medical directive includes, but need not be limited to: (a) A medical durable power of attorney executed pursuant to Section 15-14-506; (b) A declaration executed pursuant to the "Colorado Medical Treatment Decision Act", article 18 of this title; (c) A power of attorney granting medical treatment authority executed prior to July 1, 1992, pursuant to Section 15-14-501, as it existed prior to that date; or (d) A CPR directive or declaration executed pursuant to article 18.6 of this title." (3) For a resident who is under eighteen years of age, the parent, legal guardian, or person standing in loco parentis to the resident is allowed to exercise these visitation rights pursuant to any limitations described in Parts 9.2(F) and (G).”

This is the rule that was cited, not the inspector’s specific finding.

“Pol/Proc Dschrg Grievance 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 9 - POLICIES AND PROCEDURES 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the reside”

This is the rule that was cited, not the inspector’s specific finding.

“Med/Med Adm-Ordrs Cmpy w/Ordrs 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Orders 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.”

This is the rule that was cited, not the inspector’s specific finding.

“Med/Med Adm-Med Prep/Hnd Tr IC 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Medication Preparation and Handling 14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.”

This is the rule that was cited, not the inspector’s specific finding.

“Med/Med Adm-Rcrd Kpng Qrtly Audit 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Record Keeping 14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review.”

This is the rule that was cited, not the inspector’s specific finding.