VI AT HIGHLANDS RANCH ASSISTED LIVING

A relicensure survey and complaint revisit was completed on 7/27/26 for the previous deficiency cited on 1/6/26. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaint #CO40262 was completed on 1/6/26. A deficiency was cited.

Based on record review and interviews, the residence failed to discharge a resident who needed more services than could be routinely provided by the residence, affecting one of five sample residents ( #4). Specifically, Resident #4 was admitted to the residence on 3/23/25 with a history of repeated falls. Resident #4 had nine falls from 10/1/25 to 1/4/26. Seven of the falls resulted in head injuries, broken bones, skin tears, abrasions, hematomas, and/or pain. Residence staff were aware of fall interventions that had been implemented between each of Resident #4's falls; however, the interventions were ineffective. On 1/4/26, Resident #4 was sent to the emergency department (ED) for stitches, and a computed tomography (CT) scan was performed to rule out bleeding. Further, the laceration to the back of the head was glued. The residence implemented the following interventions: Occupational Therapy (OT) for muscle strength, leaving the bathroom light on at night, utilization of a call light pendant, call light reminders, encouraging resident to use handrails in hallway, non skid socks, stand by assist, 1:1 showering, staff to remind resident to sit when dressing or undressing, and stand by assist with transfers. The residence declined to discuss each intervention and why it failed. Further, Resident #4's practitioner stated that the residence probably should have discharged the resident due to the number of falls with injuries. Although the residence documented and implemented numerous therapeutic approaches and interventions, Resident #4 continued to fall, which posed a danger to himself. Findings include:1. Residence PoliciesThe residence's 2023 Discharging/Transferring a Resident Protocol under "Documentation for Facility Initiated Transfers/Discharges," read in part that a discharge can be initiated when the resident is being transferred because the resident need(s) cannot be met. The residence's 2017 Fall Precaution Protocol read in part that for residents with memory issues, some interventions may or may not be appropriate ...Where appropriate, the healthcare provider with prescriptive authority may refer the resident to a rehabilitative service to provide interventions or recommendations to reduce fall occurrences. 2. Record Review Resident #4 was admitted to the residence on 3/23/25 with a history of repeated falls, progressive supranuclear ophthalmoplegia, and Parkinsonism. The residence's "Activity Report" dated 10/1/25-12/31/25 read in part that Resident #4 had a falls on the following days:10/9/25 unwitnessed fall11/1/25 unwitnessed fall11/8/25 unwitnessed fall 11/13/25 unwitnessed fall 12/29/25 unwitnessed fallThe report failed to include falls on 12/15 and 12/31/25. However, the unreported falls were reported in progress notes. A progress note, dated 10/10/25 at 5:35 a.m., read in part Resident #4 had an unwitnessed fall; staff noticed a bump to the right side of his head. A progress note, dated 11/1/25, read in part Resident #4 had an unwitnessed fall and was found by staff, and Resident #4 stated that he had fallen, but did not hit his head. A progress note, dated 11/9/25, read in part Resident #4 complained of head pain after an unwitnessed fall reported on 11/8/25, in which he sustained a bruise to the right side of his forehead. A progress note, dated 11/13/25 at 11:30 p.m., read in part, Resident #4 reported an unwitnessed fall where he sustained a head injury and pain to the right side and lower back. A progress note, dated 11/14/25, read in part Resident #4 had completed an X-ray that confirmed displaced broken ribs. A care plan, dated 11/14/25, read the following fall interventions were implemented following Resident #4 falls. Care plan evaluation - significant change:Cognitive- Frequent noticeable memory loss with some daily redirection needed. Sensory loss- Vision- left and right eye-" vision impaired with abnormal eye movements."Safety- three falls in last 30 days, on fall protocol, Needs- "res falling more frequently, cont use of call pendant."Ambulation- Independent- "Encourage to use hallway rails, fall on 11/13 neuro checks, leave bathroom light on during night (NOC), continue to encourage non-skid socks."Transfer- requires stand by assistance of one staff personDressing- "Staff to assist and encouraged res to sit when dressing and undressing and wk on safe reaching."Grooming- Needs help "stand by assist (SBA), 1:1 when showering", "staff to assist with showers." Toileting- Independent, " staff to leave bathroom light on for proper lighting at night." Other services- Rehabilitation - Occupational therapy (OT)A progress note, dated 11/17/25, read in part the resident service director (RSD) had called to inform nursing that Resident #4 could not sleep due to "so much pain." A progress note, dated 11/18/25, read in part Resident #4 had an unwitnessed fall. A progress note, dated 11/19/25, read in part that social services representative (SSR) had attempted to contact an additional outside source to find different strategies for Resident #4 to prevent falls due to vision and depth perception issues. A progress note dated 11/19/25, read in part, the power of attorney (POA) had contacted the residence to discuss a change in condition with Resident #4's vision. The licensed practical nurse (LPN) stated she had noticed a change in Resident #4's vision and an increase in care needs. POA requested a meeting to discuss next steps. A progress note, dated 11/21/25, read in part the RSD would continue to work with occupational therapy (OT) on activities of daily living (ADLs) and transfers. OT recommended increased supervision to reduce fall risk. A progress note, dated 12/15/25, read in part Resident #4 had an unwitnessed fall with a 'large skin tear' on his left arm. A progress note, dated 12/29/25, read in part Resident #4 had reported an unwitnessed fall with no injuriesA progress note, dated 12/31/25, read in part Resident #4 had an unwitnessed fall with a laceration to his right arm. A progress note, dated 1/4/26, read in part Resident #4 reported an unwitnessed fall at approximately 1800. A ED After Visit Summary, dated 1/4/26 read Resident #4 had been admitted to the emergency department (ED) for a head injury where he had a computed tomography (CT) scan performed to rule out bleeding; the laceration to the back of the head was glued. A progress note, dated 1/5/26, read in part Resident #4 was sent to the ED after an unwitnessed fall with a head injury. Resident #4 complained of headache and pain. A computed tomography (CT) scan was performed to rule out bleeding; the laceration to the back of the head was glued. A care plan, updated 1/5/26 during the onsite visit, read sole interventions of ambulating- "requires chair with no wheels when standing or sitting."3. InterviewsOn 1/5/26 at 8:56 a.m., the LPN stated Resident #4 was a high fall risk and had a recent change in condition. She stated they had several interventions; however, he continued to have falls. On 1/5/26 at 11:50 a.m. Resident #4's practitioner stated that she was unfamiliar with all of Resident #4's falls that had caused pain and harm. She stated that there were several practitioners in the group, and she had been asked to examine Resident #4 during his ED visit on 1/5/26. She stated the residence probably should have discharged the resident due to the number of falls with injuries. On 1/5/26 at 1:49 p.m., the social services representative (SSR) stated that she was not aware that Resident #4 had had several falls or an ED visit on 1/5/26. She stated that due to the onsite investigation, all meetings regarding residents had been postponed. Further, she stated that she had been playing "phone tag" with an external service provider (ESP) since November of 2025, to set up additional external services for Resident #4. She stated she was aware that Resident #4 was a high fall risk. She stated that his diagnosis made it a challenge to place working interventions. She stated that due to his inability to make good decisions, it was best that he remained in a secure environment. On 1/5/26 at 3:55 p.m., Staff #1 stated that Resident #4 was at high risk for falls and described several fall prevention interventions that had been implemented, including partial one-on-one companionship provided by an external service provider. Staff #1 reported that Resident #4 was impulsive and "ambulated too quickly for companions to keep pace." Staff #1 further stated that Resident #4 would have benefited from 24/7 one-on-one supervision. On 1/5/26 at approximately 2:30 p.m., the director of nursing (DON), administrator, and registered nurse (RN) stated that the residence would have stand-up meetings to discuss at-risk residents, but that they had been cancelled due to the onsite visit. The DON stated that Resident #4 had been identified as a high fall risk. Interventions had been implemented; however, due to his impulsive behavior, memory deficits, and impaired judgment, Resident #4 had experienced multiple falls that continued despite these measures, which he had resisted. She acknowledged that multiple falls resulted in injuries such as broken bones, skin tears, lacerations, pain, and bruising, and the injuries caused harm to Resident #4. She stated that moving him to the Skilled Nursing side would not be a solution and possibly detrimental due to his vision and impulsivity. Additionally, the DON stated that they also considered the use of a helmet for Resident #4 due to the amount of head injuries and his past diagnosis of a traumatic brain injury and other diagnoses that had contributed to Resident #4's continued falls; however, they did not believe he would leave the helmet on. Furthermore, she stated that Resident #4 did not tolerate being touched, which made escorting the resident a challenge. Despite all of the falls that caused pain and harm, and multiple unsuccessful interventions, she stated that the secure environment in assisted living was appropriate for the level of care needs. She stated he would continue to fall no matter where he resided. The DON, RN, and administrator were unwilling to discuss when a discharge would be necessary for a resident with falls with injuries that caused harm. On 1/6/26 at 10:04 a.m., Resident #4's family member stated he had mentioned that he wanted to "escape." She stated that he would rather be with family than at the residence. On 1/6/26 at approximately 3:30 p.m., the medical director stated that she believed the resident was still appropriate for assisted living and that the residence could provide the services Resident #4 needed, despite the resident's numerous falls and unsuccessful interventions. The medical director would not discuss when to discharge a resident, even with the number of falls and harm and pain the falls had caused. She stated that skilled nursing side would not be appropriate and that moving him could increase falls and he would have an "active decline."On 1/6/26 at approximately 3:30 p.m., the administrator stated that he shared the medical director's beliefs. He stated that they could provide care for Resident #4 despite repeated falls with injuries. The administrator would not discuss how or when they would determine whether any resident needed to be discharged but stated the "Threshold is difficult to speak to."

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.10 Each resident care plan shall: (B) Reflect the most current assessment information; (C) Promote resident choice, mobility, independence and safety14.21 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. 14.27 No stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident ' s full name. 18.1 Each assisted living residence shall have a confidential health information record for each resident and maintain it in a manner that ensures accuracy of information. 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.