HIGHLINE PLACE

A revisit survey was completed on 7/17/26 for all previous deficiencies cited on 4/8/26. The facility is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO40867, was completed on 4/8/26. A deficiency was cited.

Based on record review and interview, the residence failed to ensure trained staff were available to evaluate residents who have fallen to provide lift assistance instead of relying on emergency medical responders affecting 68 current residents. Findings include:I. Record ReviewA. Residence RecordsA review of residence documents revealed a policy titled, "Head Injuries" (no date) which read, specific in part, "The resident who falls .... In which he/she strikes her head will be evaluated by emergency services." The policy further read, specific in part, "It is often difficult to determine the extent of injury when a resident strikes their head, and it is the policy of [Residence name] to have all head injuries (closed or open) evaluated by emergency services."B. A review of resident records for Residents #4-#6, from 12/13/2025 to 3/25/26, revealed these residents had falls with no injuries, however, emergency services were notified to provide evaluation and lift assistance. II. InterviewA. On 4/8/26 from 11:48 a.m. to 12:05 p.m., Staff #1 and #2 stated when a resident fell, staff were instructed to call the nurse or qualified medication administration person (QMAP) to check the resident. They said the nurse or the QMAP would call the emergency service for further assessment if the evaluation proved a head strike or head injury was sustained. B. An interview was conducted with the health and wellness director (HWD) on 4/8/26 at 2:06 p.m. She stated nurses or staff were not allowed to lift the residents, perform evaluations of residents ' condition, or perform a neurological examination (neuro check) when there was a fall with head injury or head strike. She further explained it is the residence ' s policy to call the emergency services (911) for any falls with head injury even if it is a mild scratch on the forehead or if the resident received external hospice services. In addition the HWD said when there was a fall, staff were instructed not to lift the resident off the floor. The HWD said emergency services were called even when a resident stated they were okay and could walk independently after a fall with a head strike, per the residence's policy.. She said the residence relied on the emergency respondent to perform an evaluation, assist the resident, and decide if the resident needed to be transferred to the emergency room. The HWD confirmed that there was a need for developing a lift policy and additional training to avoid unnecessary calls to emergency services.

An administrative relicensure survey was completed on 4/7/26. No deficiencies were cited. A change of ownership occurred on 4/7/26.

A revisit survey was completed on 9/4/24 for all previous deficiencies cited on 7/16/24. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey was completed on 7/16/24. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure that each personnel file included written documentation regarding orientation and training, results of background checks, and documentation of initial dementia training for four (#1-#4) of four sample staff, affecting 64 current residents. Findings include:On 7/16/24, the personnel files for Staff #1-#4 contained no documentation that staff received training prior to contact with residents. Additionally, personal records for staff #2 and #3 had no documentation of completion of initial dementia training nor results of the Colorado Adult Protective Services (CAPS) background checks. On 7/16/24 at 1:22 p.m. the administrator stated that staff should have had dementia training in December 2023, however she did not know whether the residence had documentation. On 7/16/24 at 2:40 p.m., the staff development director acknowledged the residence was required to have documentation of staff orientation and training in the personnel files for staff #1-#4, but they did not. She also stated the residence did not have the results for CAPS checks for staff #2 and #3. The SDD also said the residence staff should have had initial dementia training; however, there was no documentation of the training for Staff #2 or #3.

Based on observation, record review and interview, the residence failed to ensure residents were provided with, and acknowledged receipt of, information regarding whether the assisted living residence had video surveillance monitoring throughout the residence, affecting 64 current residents. Findings include:1. ObservationOn 7/16/24 at approximately 8:15 a.m., during an environmental tour, cameras were located at both entrances of the secure environment. Both cameras were pointed at the doors where residents and visitors entered and exited the secure environment. 2. Record Review The residence's undated resident agreement revealed no acknowledgement that the assisted living residence used video surveillance. 3. Interviews On 7/16/24 at approximately 8:45 a.m., the receptionist confirmed there were cameras inside each of the residence's two secure environments. She stated the cameras were always on and the video feed could be seen from the monitor at the front desk to see who was coming from inside the secure environments. On 7/16/24 at 1:31 p.m., the administrator confirmed there were cameras inside the secure environments and were in place for security reasons. She stated the residence did not have written documentation in the resident agreement whether the assisted living residence had video surveillance monitoring throughout the residence.

Based on record review and interview the residence failed to prevent qualified medication administration persons (QMAP) from masking or deceiving administration of medication administered, affecting 64 current residents. Findings include:1. Residence PolicyThe residence's medication refusal and/or missed doses policy, dated 3/29/21, read in part: "No resident will be forced to take any medication. Steps will be taken to avoid missed or refused doses and related adverse reactions."The residence's undated medication administration policy read in part: "Our medications are administered either by licensed nurses, certified medication or medication techs. The primary objective related to medication administration is safety of our residents, we take this responsibility very serious, the driving force why we maintain comprehensive policies and procedures for medication administration."2. InterviewsOn 7/16/24 at approximately 7:45 a.m., Staff #1 stated that when residents refuse medications, she was trained to wait a few minutes and then go back to retry administering the medications. She stated, "They usually forget by this time," and would then tell the resident that every medication was their "daily vitamins," regardless of what the medication was. She stated that every QMAP was trained to administer all medications to all residents in this manner.. She said that this worked because the residents remembered that they needed to take their daily vitamins. On 7/16/24 at approximately 3:30 p.m., the administrator confirmed that QMAPs were trained to tell the residents that they were administering them vitamins, regardless of what the medication was. She said this prevented them from refusing medications that could then cause unwanted side effects.

Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting seven (#8, #9, #10, #11, #12, #13, and #14) of seven residents whose medications were administered. Findings include:1. ObservationsOn 7/16/24 from approximately 12:05 p.m. to 12:55 p.m., during medication administration, the following was observed:Staff #4 dispensed Resident #8's medications into her bare hand then placed them into a medication bag to be crushed. After placing the crushed medications into a medication cup, Staff #4 used a spoon to mix pudding with the crushed medication. She touched a key then walked out of the medication room and administered the medication to Resident #8. Staff #4 walked back to the medication room and again used the key to unlock the door. Staff #4 then touched the computer mouse and keyboard to document in Resident #9 ' s chart. She did not perform hand hygiene before or after dispensing medication to Resident #8. Staff #4 touched the handle of the medication cart to open the cart and dispensed Resident #9 ' s acetaminophen into her bare hand then placed the medication into a bag to be crushed. She handled a new medication cup, spoon and pudding then mixed the crushed medication with the pudding. Staff #4 locked the medication cart and medication room door with a key, then administered the medication to Resident #9. She did not perform hand hygiene before or after administering medications to Resident #9. Staff #4 went back to the medication room, unlocking it with a key then touched the computer mouse and keyboard to document in Resident #10 ' s chart. Staff #4 did not use hand sanitizer or wash her hands before opening the medication cart drawer and dispensed Resident #10 ' s medication into her bare hand then into another medication bag to be crushed. She mixed the crushed medication with a new spoon and pudding. Staff #4 locked the medication cart and medication room door with a key then administered the medications to Resident #10. Staff #4 unlocked the medication room door a key then touched the computer mouse and keyboard to document in Resident #11 ' s chart. She unlocked the medication cart, touched a chair to move it out of the way and touched the keys. Staff #4 dispensed Resident #11 ' s medication into her bare hand then placed it into a medication cup, locked the medication cart and medication room and administered Resident #11 ' s medications. She did not perform hand hygiene before or after administering medications to Resident #11. She unlocked the med room door, touched the computer mouse and keyboard to document in Resident #12 ' s chart then unlocked the medication cart, dispensed Resident #12 ' s medication into her bare hand then placed them in a medication cup. She locked the medication cart, medication room door and administered Resident #12 his medication. Staff #4 did not perform hand hygiene before or after administering medications to Resident #12. Staff #4 went back to the medication room, unlocked the door and touched the computer mouse and keyboard to document in Resident #13 ' s chart. She unlocked the medication cart and dispensed three different medications into her bare hand then placed them in a medication cup. Staff #4 locked the medication cart and medication room then placed the medication into Resident #13 ' s hand. The resident accidentally dropped one of the pills onto the floor. Staff #4 picked up the pill from the floor, touching the floor, then placed the pill back in the medication cup. The resident ingested the two medications that did not fall onto the floor. Staff #4 walked back to the medication room with the contaminated pill in her hand. She unlocked the door, disposed of the contaminated medication, unlocked the medication cart and dispensed a new pill into her bare hand then into the medication cup. Staff #4 locked the medication cart and medication room door, then administered Resident #13 her medication. After touching the ground, Staff #4 did not sanitize or wash her hands. Staff #4 walked back to the medication room, unlocked the door and touched the computer mouse and keyboard to document in Resident #14 ' s chart. She unlocked the medication cart, poured the medication from the bottle into the lid then into the medication cup, locked the medication cart and medication room door and administered the medication to Resident #14. Throughout this observation, Staff #4 touched various objects and handled multiple medications without washing her hands or using hand sanitizer. 2. InterviewsOn 7/16/24 at approximately 12:45 p.m., Staff #4 stated she should have washed her hands after every medication administration and acknowledged that she did not perform hand hygiene as required. She stated she did not remember having any training in hand hygiene or infection control because the last time the residence did the training was about three years prior to the onsite visit. On 7/16/24 at approximately 1:30 p.m., the administrator stated she expected QMAPs to wash their hands between administering medications to different residents. She acknowledged that QMAPs were not completing hand hygiene as required.

Based on record review and interview, the residence failed to ensure that, on a quarterly basis, the administrator and the qualified medication administration (QMAP) supervisor audited the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, affecting 64 current residents. Documentation of medication audits completed on 6/11/24 for the east and west wings, revealed that the audits were completed by a QMAP and other staff, not by the required administrator and QMAP supervisor. On 7/16/24 at approximately 1:30 p.m., the administrator stated she did not participate in medication audits, and the last time she participated in a quarterly medication audit was in December 2022.

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 existingprogram regulations found at 6 CCR 1011-1, Chapter 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: The right to be treated with dignity and respect.

A complaint survey, prompted by #CO30639 and #CO32351, was completed on 6/13/223. No deficiencies were cited.

A revisit survey was completed on 6/1/23 for all previous deficiencies cited on 7/19/22. No deficiencies were cited.