Grace Pointe Continuing Care Senior Campus Assisted Living

“Prsnl-Stf/Vol Ornt/Trng Spcfc 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: (C) The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training, and shall include, but is not limited to, the following topics: (1) Overview of state regulatory oversight applicable to the assisted living residence; (2) Person-centered care, or accept proof of portable training in accordance with Part 7.9(D); (3) The role of and communication with external service providers; (4) Recognizing behavioral expression and management techniques, as appropriate for the population being served; (5) How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served; (6) Training related to fall prevention, or accept proof of portable training in accordance with Part 7.9(D); (7) Training related to ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility; (8) How to safely provide lift assistance, or accept proof of portable training in accordance with Part 7.9(D); (9) How to safely provide accompaniment, and transport of residents; (10) Maintenance of a clean, safe and healthy environment including appropriate cleaning techniques; (11) Food safety, or accept proof of portable training in accordance with Part 7.9(D); and (12) Understanding the staff or volunteer's role in end of life care including hospice and palliative care.”

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.

“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-Comp Res Asmnt Annl/Chng Bsln 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 RESIDENT CARE SERVICES - Comprehensive Resident Assessment 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status.”

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.

“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.

“Ext Env Haz 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 21 - EXTERIOR ENVIRONMENT 21.2 The assisted living residence grounds shall be maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction.”

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

“Sec Env-Re As 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 25 - SECURE ENVIRONMENT - Re-Assessment 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment.”

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