Golden Lodge Assisted Living LLC

“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.

“Fd/Din Srvs-Therap Diet 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 17 - FOOD AND DINING SERVICES - Therapeutic Diets 17.10 An assisted living residence may provide therapeutic diets when the following conditions are met: (A) The diet is prescribed by the resident's practitioner, and (B) The assisted living residence has trained staff to prepare the food in accordance with the diet and ensure it is being served to the appropriate resident.”

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

“Stf Req-First Aid 1 Stf Onsite Crtfd 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 8 - STAFFING REQUIREMENTS - First Aid, Obstructed Airway Technique and Cardiopulmonary Resuscitation Trained Staff 8.6 Each assisted living residence shall have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization such as the American Red Cross, the American Heart Association, National Safety Council, or American Safety and Health Institute. The certification shall either be in Adult First Aid or include Adult First Aid.”

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

“Stf Req-First Aid 1 Stf Onsite CPR 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 8 - STAFFING REQUIREMENTS - First Aid, Obstructed Airway Technique and Cardiopulmonary Resuscitation Trained Staff 8.7 Each assisted living residence shall have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization (e.g., the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute) or a training curriculum that meets the American Heart Association's Emergency Cardiovascular Care (ECC) or International Consensus on Cardio-pulmonary Resuscitation (ILCOR) guidelines. The certification shall either be in Adult CPR or include Adult CPR in its curriculum, and shall include a skills assessment observed and evaluated by an instructor.”

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.

“Em Pr-Pol/Proc Em Pol/Proc-Min Req 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 10 - EMERGENCY PREPAREDNESS - Emergency Policies and Procedures 10.6 Each assisted living residence's emergency policies shall address, at a minimum, all of the following items: (A) Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations; (B) A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; (C) When to evacuate the premises and the procedure for doing so; (D) A pre-determined means of communicating with residents, families, staff and other providers; (E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; (F) Storage and preservation of medications; (G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; (H) Protection and transfer of health information as needed to meet the care needs of residents; and (I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies.”

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.

“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-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.

“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-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.

“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.

“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.

“LicProc-ContOblig LOI chngs-Mgt PART 2. LICENSURE PROCESS 2.9 Continuing Obligations of Licensee 2.9.6 Each licensee shall submit to the Department a letter of intent of any change in the information required by Part 2.3.3 of this Chapter from what was contained in the last submitted license application. (A) Changes to the operation of the facility or agency shall not be implemented without prior approval from the Department. A licensee shall, at least thirty (30) calendar days in advance, submit a letter of intent to the Department regarding any of the following proposed changes. (2) Change in a management company or proposed use of a management agreement not previously disclosed.”

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

“In Env-H/L/Vent 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 22 - INTERIOR ENVIRONMENT - Heating, Lighting and Ventilation 22.5 Each room shall have heat, lighting, and ventilation sufficient to meet the use of the room and the needs of the residents.”

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.

“Fd Sfty-20 or More Beds 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 16 - FOOD SAFETY - 20 or More Beds 16.3 An assisted living residence that is licensed for 20 beds or more shall comply with the Department's regulations concerning Colorado Retail Food Establishments at 6 CCR 1010-2.”

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

“Fd/Din Srvs-Menu Wkly Menu 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 17 - FOOD AND DINING SERVICES - Menus 17.7 Weekly menus shall be readily available for residents and public viewing no less than 24 hours prior to serving.”

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