The Retreat at Sunny Vista

“Res Rghts Rts/Rspn-Civ/Rel-Explt 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 13 - RESIDENT RIGHTS 13.1 The assisted living residence shall adopt, and place in a publically 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: (B) The right to civil and religious liberties, including: (4) The right to live free from financial exploitation, restraint as defined in this chapter, and involuntary confinement except as allowed by the secure environment requirements of this chapter;”

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

“LicProc-DeptOvrst-Srvy/Inspct Ensr Cmply-POC PART 2. LICENSURE PROCESS 2.10 Department Oversight 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 Department.”

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

“Prsnl-Crmnl HX Rcrd Chcks CBI 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 7 - PERSONNEL - Criminal History and Adult Protective Services Record Checks 7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer. (A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI). (B) If the applicant has lived in Colorado for three years or less at the time of application, the assisted living residence shall obtain a name-based criminal history report for each state in which the applicant has lived for the past three years, conducted by the respective states' bureaus of investigation or equivalent state-level law enforcement agency or other name-based report as determined by the Department. (C) The cost of obtaining such information shall be borne by the assisted living residence, the contract staffing agency or the individual who is the subject of such check, as appropriate.”

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

“Prsnl-Stf/Vol Ornt/Trng Dementia Trng Rq 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 7 - PERSONNEL - Staff and Volunteer Orientation and Training 7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (B) Dementia Training Requirements (1) As of January 1, 2024, each assisted living residence shall ensure that its direct-care staff members meet the dementia training requirements in this part 7.8(B). (2) Definitions: For the purposes of dementia training as required by Section 25-1.5-118, C.R.S. (a) "Direct-care staff member" means a staff member caring for the physical, emotional, or mental health needs of residents in a covered facility and whose work involves regular contact with residents who are living with dementia diseases and related disabilities. (b) "Equivalent Training" in this sub-part shall mean any initial training provided by a covered facility meeting the requirements of this sub-part 7.8(B)(3).”

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

“Em Pr-Pol/Proc Res Rstr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 10 - EMERGENCY PREPAREDNESS - Emergency Policies and Procedures 10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.”

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

“Res Care Srvs-Lift As Req Doc 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Lift Assistance 12.18 The assisted living residence's policy shall also require documentation of the action taken by staff and ongoing efforts to prevent a reoccurrence of the situation in the future.”

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

“Res Care Srvs-Lift As Tr Stff 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Lift Assistance 12.17 The assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders. (A) Each situation shall be evaluated to determine if the resident can be assisted in a safe manner such as when the resident has no pain and/or there is no change from baseline, the resident's mental status is unchanged from baseline, and there is no, or minor, bleeding. (B) Once the situation has been evaluated, assisted living residence policy shall require staff to take the following actions: (1) Physically perform the lift assistance using techniques provided in staff training and monitor the resident; or (2) Not lift and call 911 when the resident is unconscious, the resident's physical or mental status has declined from baseline, the resident experiences an increase in pain when lifting is attempted, the resident wants 9-1-1 called, and/or the resident either can't assist in any way or refuses to assist because of pain, injury, or other physical complications. (C) The assisted living residence shall promptly notify the resident's practitioner, family and/or legal representative of the occurrence of either circumstance identified in Part 12.17(B)(1) or (2), along with information regarding the ALR's response.”

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

“HIR-Cntnt Incld 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 18 - RESIDENT HEALTH INFORMATION RECORDS - Content 18.8 Resident records shall contain, but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. (E) Medication Administration Record; (F) Documentation of on-going services provided by external service providers including, but not limited to, caregivers, essential caregivers, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and care providers; (G) Advance directives, if applicable, with extra copies; and (H) Final disposition of resident including, if applicable, date, time, and circumstances of a resident's death, along with the name of the person to whom the body is released.”

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

“Rprt Rq-At Risk/Mndtry Rprt PART 5 - REPORTING REQUIREMENTS - At-Risk Persons Mandatory Reporting 5.1 Assisted living residence personnel engaged in the admission, care or treatment of at-risk persons shall report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement within 24 hours of observation or discovery pursuant to Section 18-6.5-108, C.R.S.”

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

“Res Care Srvs-Min Srvs Res Agr PART 12 - RESIDENT CARE SERVICES - Minimum Services 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; (B) Room and board; (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment; (D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach; and (E) Social care and resident engagement.”

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

“Res Rghts Rghts/Rspn-Civil/Relig PART 13 - RESIDENT RIGHTS 13.1 The assisted living residence shall adopt, and place in a publically 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: (B) The right to civil and religious liberties, including: (1) The right to be treated with dignity and respect; (2) The right to be free from sexual, verbal, physical or emotional abuse, humiliation, intimidation, or punishment; (3) The right to be free from neglect; (4) The right to live free from financial exploitation, restraint as defined in this chapter, and involuntary confinement except as allowed by the secure environment requirements of this chapter; (5) The right to vote; (6) The right to exercise choice in attending and participating in religious activities; (7) The right to wear clothing of choice unless otherwise indicated in the care plan; and (8) The right to care and services that are not conditioned or limited because of a resident's disability, sexual orientation, ethnicity, and/or personal preferences.”

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

“Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/N PART 13 - RESIDENT RIGHTS - Investigation of Abuse and Neglect Allegations or Injuries of Unknown Origin 13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: (A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review.”

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

“Med/Med Adm-Ordrs Cmpy w/Ordrs 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-Rcrd Kpng MAR PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Record Keeping 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.”

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

“Med/Med Adm-Rprt Pract/Rep Ntfd PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Reporting 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (A) A decline from a resident's baseline status; (B) A resident's pattern of refusal; (C) A resident's repetitive request for and use of PRN medication; (D) Any observed or reported unfavorable reactions to medications; (E) The administration of medications used to emergently treat angina; and (F) Medication errors that affect the resident.”

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

“Lndry Srvs-ALR Lndry Srvs PART 15 - LAUNDRY SERVICES - Assisted Living Residence Laundry Service 15.4 If providing laundry service for residents, the assisted living residence shall ensure the following: (A) Washing machines and dryers are properly maintained according to the manufacturer's instructions; (B) Bed and bath linens are cleaned at least weekly or more frequently to meet individual resident needs while blankets are cleaned as necessary; (C) Laundry personnel or designated staff handle, store, process, transport, and return laundry in a way that prevents the spread of infection or cross contamination; (D) Personal clothing is returned to the appropriate resident in a presentable, ready-to-wear manner in order to promote resident respect and dignity; and (E) The appropriate resident representative is notified if a resident needs additional clothing or linens.”

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