The Ivy Thornton

“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.

“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.

“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 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.

“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-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.

“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.

“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-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.

“Fd/Din Srvs-M/Dr/Sn Obs Cnmptn 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 17 - FOOD AND DINING SERVICES - Meals, Drinks and Snacks 17.4 Assisted living residence staff shall observe resident food consumption on a regular basis in order to detect unplanned changes such as weight gain, weight loss, or dehydration. Changes in consumption that may indicate the need for assistance with eating shall be reported to the resident's practitioner and case manager, if applicable.”

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.

“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.