Modena Cherry Creek

“Res Care Srvs-Min Srvs Res Agr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES 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.

“Med/Med Adm-Gen Rq Pract Ordr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - General Requirements 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.”

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

“Pol/Proc Visitation-Limits 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: (F) The policies and procedures may impose limitations on visitation rights. During a period when the risk of transmission of a communicable disease is heightened, an assisted living residence may: (1) Require visitors to enter the residence through a single, designated entrance; (2) Deny entrance to a visitor who has known symptoms of the communicable disease; (3) Require visitors to use medical masks, face-coverings, or other personal protective equipment while on the assisted living residence premises or in specific areas of the residence; (4) Require visitors to sign a document acknowledging: (a) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and (b) That menacing and physical assaults on health-care workers and other employees of the residence will not be tolerated; (5) Require all visitors, before entering the residence, to be screened for symptoms of the communicable disease and deny entrance to any visitor who has symptoms of the communicable disease; (6) Require all visitors to the residence to be tested for the communicable disease and deny entry for those who have a positive test result; and (7) Restrict the movement of visitors within the residence, including restricting access to where immunocompromised or otherwise vulnerable populations are at greater risk of being harmed by a communicable disease. (8) If an assisted living residence requires that a visitor use a medical mask, face covering, or other personal protective equipment or to take a test for a communicable disease in order to visit a resident at the assisted living residence, nothing in these regulations: (a) Requires the residence allow a visitor to enter, if the required equipment or test is not available due to lack of supply; (b) Requires the residence to supply the required equipment or test to the visitor, or bear the cost of the equipment for the visitor; or (c) Precludes the health-care residence from supplying the required equipment or test to the visitor. (G) The policies and procedures may impose additional limitations for the visitors of a resident with a communicable disease who is isolated. In this case, the residence may impose additional restrictions including: (1) Limiting visitation to essential caregivers who are helping to provide care to the resident; (2) Limiting visitation to one caregiver at a time per resident with a communicable disease; (3) Scheduling visitors to allow for adequate time for screening, education, and training of visitors and to comply with any limits on the number of visitors permitted in the isolated area at the time; and (4) Prohibiting the presence of visitors during aerosol-generating procedures or during collection of respiratory specimens. (H) Any limitations imposed shall be consistent with applicable federal law and regulation and other state statute.”

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

“Res Care Srvs-Pract Asmnt 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Practitioner Assessment 12.5 The assisted living residence shall have a policy and procedure regarding when a practitioner's assessment of a resident is appropriate. At a minimum, the assisted living residence shall contact the resident's primary practitioner when any of the following circumstances occur and follow the practitioner's recommendation regarding further action. (A) The resident experiences a significant change in their baseline status, (B) The resident has physical signs of possible infection (open sores, etc.), (C) The resident sustains an injury or accident, (D) The resident has known exposure to a communicable disease, and/or (E) The resident develops any condition which would have initially precluded admission to the assisted living residence.”

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 Rghts Rts/Rspn-Civ/Rel-Abuse/Neg/Misapro 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: (2) The right to be free from sexual, verbal, physical or emotional abuse, humiliation, intimidation, or punishment;”

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 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 13 - RESIDENT RIGHTS - Investigation of Abuse and Neglect Allegations or Injuries of Unknown Origin 13.11 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.

“Res Care Srvs-Res CP 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Resident Care Plan 12.10 Each resident care plan shall: (A) Be developed with input from the resident and the resident's representative; (B) Reflect the most current assessment information; (C) Promote resident choice, mobility, independence and safety; (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs; (E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence's visitation policy as required by Part 9.2, along with care coordination arrangements; and (F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs.”

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-Care Coord Ntfy Rep Sig Chng B 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Care Coordination 12.12 The assisted living residence shall notify the resident's representative whenever the resident experiences a significant change from baseline status.”

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

“Res Rghts-Intrnl Griev/Compl Res Pr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 13 - RESIDENT RIGHTS - Internal Grievance and Complaint Resolution Process 13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies: (A) The state long-term care ombudsman and local ombudsman; (B) The Adult Protection Services of the appropriate county Department of Social Services; (C) The advocacy services of the area's agency on aging; (D) The Colorado Department of Public Health and Environment; and (E) The Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence is licensed to provide services specifically for persons with intellectual and developmental disabilities.”

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.

“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.

“HIR-Cnfd/Ac Secure 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 18 - RESIDENT HEALTH INFORMATION RECORDS - Confidentiality and Access 18.5 The assisted living residence shall have a means of securing resident records that preserves their confidentiality and provides protection from loss, damage, and unauthorized access.”

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