The Ivy Mountain View

“IDMC-Gen Reqs-ICO-Reporting Standards for Hospitals and Health Facilities Ch 2 - General Licensure Standards Part 12. Infectious Disease Mitigation and Control 12.2 General Requirements 12.2.2 Infection Control Officer (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for: (4) Ensuring the facility complies with Departmental reporting requirements related to infectious diseases;”

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.

“Survey Details Citation coded "0000" or "9999" may not have regulation text as they are used for informational purposes, if regulation is not coded as "0000" or "9999", there are no regulation text available, please contact the Health Facilities divison for more information about this regulation”

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

“Em Pr-Pol/Proc Rtn Drill 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 10 - EMERGENCY PREPAREDNESS - Emergency Policies and Procedures 10.5 Each assisted living residence shall identify its highest potential risk and hold routine drills to facilitate staff and resident response to that risk. There shall be written documentation of such drills.”

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

“Med/Med Adm-Rcrd Kpng MAR 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES 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.

“Rpt Req-At Risk/Mndtry Rprt 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES 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-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 Rghts Rts/Rspn-Choice/Invlv Cr/Svc-Comm 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: (D) The right to choice and personal involvement regarding care and services, including: (4) The right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence; (a) For residents with limited English proficiency or impairments that inhibit communication, the assisted living residence shall find a way to facilitate communication of care needs.”

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

“Med/Med Adm-Gen Rq PRN 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - General Requirements 14.9 No medication shall be administered by a qualified medication administration person on a pro re nata (PRN) or "as needed" basis except: (A) In a residential treatment facility that is licensed to provide services for the mentally ill; (B) Where the resident understands the purpose of the medication, is capable of voluntarily requesting the medication, and the assisted living residence has documentation from an authorized practitioner that the use of such medication in this manner is appropriate; or (C) Where specifically allowed by statute.”

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.

“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.

“Sec Env-Stff Sfcnt Stff 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 25 - SECURE ENVIRONMENT - Staffing 25.17 The assisted living residence shall have a sufficient number of trained staff members on duty in the secure environment to ensure each resident's physical, social, and emotional health care and safety needs are met in accordance with their individualized care plan.”

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