The Ivy Pueblo

“Res Ad/D/C-D/C Res Dngr Slf/Othrs 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 11 - RESIDENT ADMISSION AND DISCHARGE - Discharge 11.13 Where a resident has demonstrated that he or she has become a danger to self or others, the assisted living residence shall promptly implement the following process pending discharge: (A) Take all appropriate measures necessary to protect other residents; (B) Reassess the resident to be discharged and revise his or her care plan to identify the resident's current needs and what services the assisted living residence will provide to meet those needs; and (C) Ensure all staff are aware of any new directives placed in the care plan and are properly trained to provide supervision and actions consistent with the care plan.”

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

“Res Ad/D/C-D/C Invol D/C-Wrtn Ntc Req 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 11 - RESIDENT ADMISSION AND DISCHARGE - Discharge 11.17 Written notice of involuntary discharge must include the following: (A) A detailed explanation of the reason or reasons for the discharge, including, at a minimum: (1) Facts and evidence supporting each reason given by the residence, and (2) A recounting of events leading to the involuntary discharge, including interactions with the resident over a period of time prior to the notice and actions taken to avoid discharge, specifying the timing of the events and actions. (B) Statements conveying the following information: (1) That the individual receiving the notice has the right to file a grievance with the residence challenging the involuntary discharge within 14 days of the written notice, regardless of whether the resident has already been removed from the assisted living residence, (2) That if a grievance is filed, the assisted living residence must provide a response to the grievance within five business days, and (3) If the resident or person filing the grievance is dissatisfied with the response, that the resident or person filing the grievance may appeal to the executive director of the Colorado Department of Public Health and Environment or their designee. (C) Names and contact information, including phone numbers, physical addresses, and email addresses, for the state long-term care ombudsman, the designated local ombudsman, and the Colorado Department of Public Health and Environment. (D) If the involuntary discharge is initiated due to a medical or physical condition resulting in a required level of care that cannot be treated with medication or services routinely provided by the residence's staff or an external service provider, the notice must also include an assessment by the resident's applicable health-care or behavioral health provider of the resident's current needs in relation to the resident's medical and physical condition.”

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

“Res Ad/D/C-D/C Invol D/C-Wrtn Ntc Req 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 11 - RESIDENT ADMISSION AND DISCHARGE - Discharge 11.17 Written notice of involuntary discharge must include the following: (A) A detailed explanation of the reason or reasons for the discharge, including, at a minimum: (1) Facts and evidence supporting each reason given by the residence, and (2) A recounting of events leading to the involuntary discharge, including interactions with the resident over a period of time prior to the notice and actions taken to avoid discharge, specifying the timing of the events and actions. (B) Statements conveying the following information: (1) That the individual receiving the notice has the right to file a grievance with the residence challenging the involuntary discharge within 14 days of the written notice, regardless of whether the resident has already been removed from the assisted living residence, (2) That if a grievance is filed, the assisted living residence must provide a response to the grievance within five business days, and (3) If the resident or person filing the grievance is dissatisfied with the response, that the resident or person filing the grievance may appeal to the executive director of the Colorado Department of Public Health and Environment or their designee. (C) Names and contact information, including phone numbers, physical addresses, and email addresses, for the state long-term care ombudsman, the designated local ombudsman, and the Colorado Department of Public Health and Environment. (D) If the involuntary discharge is initiated due to a medical or physical condition resulting in a required level of care that cannot be treated with medication or services routinely provided by the residence's staff or an external service provider, the notice must also include an assessment by the resident's applicable health-care or behavioral health provider of the resident's current needs in relation to the resident's medical and physical condition.”

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 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.