Willowbrook Place

“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.

“Res Care Srvs-Fall Mgt Pr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Fall Management Program 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (A) Providing fall management education and materials to residents and family members; (B) Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment; (C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C); (D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and (E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6).”

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.

“Res Rts-Inv Ab/Neg Alleg or Inj Unk Org IUO 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 13 - RESIDENT RIGHTS - Investigation of Abuse and Neglect Allegations or Injuries of Unknown Origin 13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements: (A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either: (1) The resident cannot explain how the injury occurred; or (2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries. (B) The assisted living residence shall document the following: (1) The investigation and identification of any injury identified in (A), above. (2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin: (a) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or (b) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse, neglect, or exploitation. Such steps may include, but not be limited to: (i) Staff or volunteer corrective action and/or additional training; or (ii) Modification of the assisted living residence's policies, procedures or physical environment. (3) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries. (C) All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request. (1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes. (D) The assisted living residence shall notify the resident's representative of the outcome of the investigation and steps taken.”

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

“Sec Env-Enhncd Rsdnt CP Incld 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 25 - SECURE ENVIRONMENT - Enhanced Resident Care Plan 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact; (B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR's plan to protect the resident from unwanted visitation by other residents; (C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and (D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.”

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