HIGHPOINTE ASSISTED LIVING & MEMORY CARE

An administrative relicensure survey was completed on 7/1/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40356 was completed on 1/27/26. No deficiencies were cited.

A relicensure survey with complaint revisit was completed on 1/27/26 for the previous deficiencies cited on 3/12/25. The facility is in compliance with all regulations surveyed.

A licensure complaint revisit was completed on 1/27/26 for the previous deficiencies cited on 3/12/25. The residence/facility is in compliance with all regulations surveyed/A deficiency was cited/Deficiencies were cited.

A licensure complaint, prompted by #CO40132, was completed on 5/20/25. No deficiencies were cited.

A relicensure survey and complaint revisit was completed on 3/12/25 for all previous deficiencies cited on 10/10/24. Deficiencies were cited.

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 81 current residents. This deficiency was cited previously during a state licensure survey and complaint 10/10/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's discharge policy, dated 3/11/25, read in part the reasons that the residence discharged residents, and if the resident chose to appeal they must do so to the administrator within five days of receipt of the discharge notice. However, the policy failed to contain the correct timeline for grievance submission, the residence's response to the grievance, the opportunity to request a hearing from the Department if the outcome is not satisfactory and the circumstances that residence allowed readmittance. On 3/12/25 at 12:02 p.m., the administrator affirmed that the policy failed to contain all of the required timeframes for appeals as well as other elements. She added she was not familiar with all of the required elements of the discharge grievance policy. On 3/12/25 at 12:18 p.m., the regional director of operations stated that she did not update the discharge policy and that was the reason it had not been corrected.

Based on observation, record review, and interview, the residence failed to evaluate whether a resident could be assisted safely and provided lift assistance to a resident who was experiencing pain and/or had a change in their physical baseline status, affecting one current resident (#17). Specifically, Resident #17 fell on 3/10/25 and experienced pain, a skin tear to the knee, and hip bruising; however, the residence did not contact emergency medical services (EMS) upon the direction of the resident's legal representative (LR). The staff failed to contact EMS and lifted the resident despite the resident reporting pain. Resident #17 continued to feel pain and fell again on 3/11/25, and the resident was transported to the hospital, where she was diagnosed with hairline fractures in both hips. This deficiency was cited previously during a state licensure survey and complaint on 10/10/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Lift Policy, dated 1/6/25, read in part that the residence had trained staff that evaluated residents who had fallen. If the residence determined that the resident had increased pain, the residence contacted EMS immediately. 2. ObservationOn 3/11/25 at 7:58 a.m., Resident #17 screamed out and cried for help. When Staff #8 was alerted, she entered Resident #17's apartment and found the resident lying on the floor from a fall. 3. Resident #17 was admitted to the residence on 4/23/24 with a diagnosis of bilateral primary osteoarthritis. An incident report dated 3/11/25, read in part that on 3/10/25, the staff heard Resident #17 crying. She called for assistance, and two staff members lifted the resident from a sitting position on the floor. Progress notes dated 3/10/25-3/11/25 read in part:On 3/10, Staff found a bruise on the resident's hip and knee after a fall earlier in the day. The residence contacted a LR when the resident had pain, and the resident had no more acetaminophen. The LR stated that the resident had ibuprofen pain medication that the resident self-administered and that the LR would follow up with the resident the following day. On 3/11, staff heard the resident screaming when walking by her apartment, and the resident was on the floor due to a fall. The staff assisted the resident to stand. 4. InterviewsOn 3/11/25 at 8:45 a.m., the administrator said that the residence required staff to contact EMS if a resident fell and sustained a visible injury. She added that if a resident was in pain, the residence's nurse evaluated and determined if the staff should contact EMS, and if the residence's nurse was not onsite, the residence required staff to contact the offsite on-call manager and seek direction. She stated that staff were not permitted to provide lift assistance if a resident was in pain without direction from the onsite nurse or offsite on-call manager. She added she was unaware of the staff had lifted Resident #17 sought direction from residence management. She stated that if a resident's family member or LR directed the residence to not contact EMS, the residence should contact the practitioner to determine if the practitioner was able to override the decision. In a later interview, on 3/12/25 at approximately 11:05 a.m., the administrator stated that the residence was not permitted to provide lift assistance to a resident when the resident had increased pain. She stated that if Resident #17 reported pain and was screaming after her fall on 3/10/24, the residence should have contacted EMS instead of lifting the resident and did not. She added she was unaware that the resident sustained fractures to the hips and acknowledged that Resident #17 might have sustained the fractures on 3/10/24 after the previous fall. The administrator affirmed this deficiency that was previously cited was not corrected because the staff mayhave overcorrected as they had previously been contacting EMS for all lift assistance. On 3/11/25 at 8:50 a.m., Staff #10 stated that Resident #17 was in pain, and the residence provided lift assistance and did not call EMS upon LR's direction to not contact EMS. She added that when a resident's LR directed the residence not to contact EMS, the residence followed the LR's direction. On 3/11/25 at approximately 10:00 a.m., Staff #4 stated that Resident #17 had pain after she fell on 3/10/25. She added that the resident was unable to walk after the fall and had bruising to her hip and a skin tear. She stated that the LR directed the resident to self-administer (SA) over-the-counter (OTC) pain medication, and the LR planned to check on the resident the following day. In a later interview at 2:55 p.m., Staff #4 stated that the LR directed the residence not to contact EMS despite the pain, bruise, and skin tear, as the hospital had a history of recommending knee replacement that the resident required but was too high of a risk to have. She added that the process for when a resident fell was to contact an offsite on-call person if the resident was in pain to get directions regarding lift assistance, and in some cases, the staff lifted residents who had fallen and were in pain. She added that lifting residents in pain was a risk because the pain could have indicated a serious injury. On 3/11/25 at approximately 4:30 p.m., the LR for Resident #17 stated that she directed the residence not to contact EMS for Resident #17 on 3/10/25 after she fell and experienced pain as they would suggest a knee replacement that the resident was "too old" to have. She added that staff reported the resident was screaming and crying in pain after she fell, and she suggested the resident SA an OTC pain medication; however, she was unaware if Resident #17 did SA an OTC. The LR stated the resident fell again and went to the hospital, and the hospital diagnosed Resident #17 with fractures in both hips. She added the fractures could have been from the fall on 3/10/25, or 3/11/25, or both.

A licensure complaint, prompted by #CO39316 and #CO39338 was completed on 3/12/25. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure the resident agreement included a list of specific residence services included and the agreed upon rates and charges, affecting one sample resident (#6). (Cross-reference S2230) Findings include: Resident #6 was admitted to the residence on 5/17/24. The Resident Agreement for Resident #6, dated 5/7/24, read in part that the residence may modify the amounts charged after providing the resident or the resident's legal representative (LR) with 30 days prior written notice. Further it read that the resident was charged $600 a month for a care level of one. The agreement contained no additional documentation of any rate changes. Progress notes and accounting of residence charges, dated 5/17/24-2/19/25 read in part:On 5/17/24-1/17/25, the residence charged the resident $600 a month for a care level of one. On 1/17/25, the residence met with the resident's LR to ensure the resident was receiving quality care. Will be meeting with the resident's family next week to discuss a care plan for the resident. On 1/18/25-2/19/25, the residence charged the resident $2400 a month for a care level of four. On 1/31/25, LR of Resident #6 aware of the current care level and that the resident was to remain at the current care level for at least 30 days before reassessment. Asked LR if they felt Resident #6 was "safe" if her care level was reduced they said "yes." On 3/11/25 at 2:28 p.m., the regional director of operations stated that the resident's LR was notified on 1/21/25 regarding the rate changes, which was three days after the residence implemented the new charges on 1/18/25. She affirmed that there was no documentation, such as a new resident agreement or agreement addendum that documented the charges were agreed to by the LR prior to the change. On 3/12/25 at 9:15 a.m., the LR for Resident #6 stated she did agree to the rate changes prior to the residence increasing them.

Based on interviews and record review, the residence failed to update a comprehensive assessment whenever a resident's condition changed from baseline status, affecting four of four current sample residents (#14, #16, #17, #19). Specifically, Resident #16 had 13 falls since her last comprehensive assessment on 12/10/24. She had injuries in nine out of the 13 falls. The resident had two falls on 2/20/25 resulting in knee pain and a moderate hematoma with a laceration that required repair. After the second fall on 2/20/25, the emergency medical services (EMS) were telephoned and the resident refused to go despite the recommendation. Additionally, Resident #16 had significant behavioral changes. On 3/4/25 staff documented Resident #16 was a danger to herself. Findings include:1. Resident #16 was admitted to the residence on 12/23/23 with a diagnosis of traumatic ischemia of muscle and chronic kidney disease. A comprehensive assessment, dated 12/10/24, read in part that the resident required physical assistance from a staff member; however, the assessment for mobility and ambulation said she did not require assistance with escorting around the residence. Resident #16 had decreased repeated falls. The assessment identified Resident #16 as at risk for falling. A care plan dated 12/11/24 read in part the resident had several fall interventions in place. However the care plan did not have a history of disruptive, aggressive, verbal, or socially inappropriate behavior. Progress notes and incident reports dated 12/16-3/8/25 read in part, the resident had 13 falls. Nine of the falls resulted in injuries such as a hematoma with a laceration that required repair, bruises, and small cuts. Additionally, the records revealed the resident experienced four episodes of aggressive behaviors with one being documented as a danger to herself. 2. InterviewsOn 3/11/25 at approximately 7:45 a.m. Staff #2 said Resident #16 was at risk for falls and had behavioral problems. She said Resident #16 required two-hour checks. She said she had recently had behavioral changes and was difficult to redirect and became aggressive with staff. On 3/12/25 at approximately 11:30 a.m., the administrator said a change of baseline condition could be physical or cognitive. She said the residence performed reassessment for a change of condition when a resident experienced anything outside of baseline, if a resident had two or more falls, or if the resident's behaviors were a danger to themselves. She said change of condition assessments were done to see if there were any unmet needs for the resident. The administrator also said reassessments were done by a nurse or a physician. Further she stated if the resident had interventions in place and was still exhibiting the behavior, she would notify the physician and would want to reassess to see if the resident was appropriately placed in the residence. She said the residence would not know if the interventions were effective without performing a change in condition assessment. She said Resident #16 needed reminders to use her pendant to ask for help and was impulsive which resulted in many falls. She said Resident #16's last assessment was done on 12/10/24. She said Resident #16 should be reassessed after having 13 falls, some resulting in injuries. The administrator stated Resident #16 should have been reassessed after her behavioral changes, however she did not believe that not reassessing Resident #16 resulted in harm. She said injuries were an indication of harm and acknowledged Resident #16 had injuries resulting from her falls. Additionally, the residence failed to perform a change of condition assessment for Resident's #14, #17, and Former Resident #19.

Based on observation, record review, and interview, the residence failed to evaluate whether a resident could be assisted safely and provided lift assistance to a resident who was experiencing pain and/or had a change in their physical baseline status, affecting one current resident (#17). (Cross-Reference S1146, S1324, S2230)Specifically, Resident #17 fell on 3/10/25 and experienced pain, a skin tear to the knee, and hip bruising; however, the residence did not contact emergency medical services (EMS) upon the direction of the resident's legal representative (LR). The staff failed to contact EMS and lifted the resident despite the resident reporting pain. Resident #17 continued to feel pain and fell again on 3/11/25, and the resident was transported to the hospital, where she was diagnosed with hairline fractures in both hips. Findings include:1. Residence PolicyThe residence's Lift Policy, dated 1/6/25, read in part that the residence had trained staff that evaluated residents who had fallen. If the residence determined that the resident had increased pain, the residence contacted EMS immediately. 2. ObservationOn 3/11/25 at 7:58 a.m., Resident #17 screamed out and cried for help. When Staff #8 was alerted, she entered Resident #17's apartment and found the resident lying on the floor from a fall. 3. Resident #17 was admitted to the residence on 4/23/24 with a diagnosis of bilateral primary osteoarthritis. An incident report dated 3/11/25, read in part that on 3/10/25, the staff heard Resident #17 crying. She called for assistance, and two staff members lifted the resident from a sitting position on the floor. Progress notes dated 3/10/25-3/11/25 read in part:On 3/10, Staff found a bruise on the resident's hip and knee after a fall earlier in the day. The residence contacted a LR when the resident had pain, and the resident had no more acetaminophen. The LR stated that the resident had ibuprofen pain medication that the resident self-administered and that the LR would follow up with the resident the following day. On 3/11, staff heard the resident screaming when walking by her apartment, and the resident was on the floor due to a fall. The staff assisted the resident to stand. 4. InterviewsOn 3/11/25 at 8:45 a.m., the administrator said that the residence required staff to contact EMS if a resident fell and sustained a visible injury. She added that if a resident was in pain, the residence's nurse evaluated and determined if the staff should contact EMS, and if the residence's nurse was not onsite, the residence required staff to contact the offsite on-call manager and seek direction. She stated that staff were not permitted to provide lift assistance if a resident was in pain without direction from the onsite nurse or offsite on-call manager. She added she was unaware of the staff had lifted Resident #17 sought direction from residence management. She stated that if a resident's family member or LR directed the residence to not contact EMS, the residence should contact the practitioner to determine if the practitioner was able to override the decision. In a later interview, on 3/12/25 at approximately 11:05 a.m., the administrator stated that the residence was not permitted to provide lift assistance to a resident when the resident had increased pain. She stated that if Resident #17 reported pain and was screaming after her fall on 3/10/24, the residence should have contacted EMS instead of lifting the resident and did not. She added she was unaware that the resident sustained fractures to the hips and acknowledged that Resident #17 might have sustained the fractures on 3/10/24 after the previous fall. The administrator affirmed this deficiency that was previously cited was not corrected because the staff may have overcorrected as they had previously been contacting EMS for all lift assistance. On 3/11/25 at 8:50 a.m., Staff #10 stated that Resident #17 was in pain, and the residence provided lift assistance and did notcall EMS upon LR's direction to not contact EMS. She added that when a resident's LR directed the residence not to contact EMS, the residence followed the LR's direction. On 3/11/25 at approximately 10:00 a.m., Staff #4 stated that Resident #17 had pain after she fell on 3/10/25. She added that the resident was unable to walk after the fall and had bruising to her hip and a skin tear. She stated that the LR directed the resident to self-administer (SA) over-the-counter (OTC) pain medication, and the LR planned to check on the resident the following day. In a later interview at 2:55 p.m., Staff #4 stated that the LR directed the residence not to contact EMS despite the pain, bruise, and skin tear, as the hospital had a history of recommending knee replacement that the resident required but was too high of a risk to have. She added that the process for when a resident fell was to contact an offsite on-call person if the resident was in pain to get directions regarding lift assistance, and in some cases, the staff lifted residents who had fallen and were in pain. She added that lifting residents in pain was a risk because the pain could have indicated a serious injury. On 3/11/25 at approximately 4:30 p.m., the LR for Resident #17 stated that she directed the residence not to contact EMS for Resident #17 on 3/10/25 after she fell and experienced pain as they would suggest a knee replacement that the resident was "too old" to have. She added that staff reported the resident was screaming and crying in pain after she fell, and she suggested the resident SA an OTC pain medication; however, she was unaware if Resident #17 did SA an OTC. The LR stated the resident fell again and went to the hospital, and the hospital diagnosed Resident #17 with fractures in both hips. She added the fractures could have been from the fall on 3/10/25, or 3/11/25, or both.

Based on observation interview and record review, the residence failed to ensure residents were free from neglect, affecting one current resident (#17) and one former resident (#19). (Cross reference S1146, S1192, S2230). Specifically, Former Resident #19 fell on 12/28/24 with pain and an increased inability to stand. The residence failed to contact emergency medical services (EMS) or his practitioner. Subsequently, the resident died on 2/9/25 from complications of a femur fracture and rib fractures from an unwitnessed fall that occurred months prior to his death. The timing of the unwitnessed fall and fractures mentioned on the death certificate was consistent with the fall the resident sustained on 12/28/24. Specifically, Resident #17 had a past knee injury. In January of 2025 the resident reported knee pain; however, the residence identified it as chronic pain and provided no intervention. Subsequently, the resident continued to report knee pain throughout February and March 2025. Findings include:1. References Chapter VII regulations governing assisted living residences, part 2.12, defines "Caretaker Neglect" as neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision, or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person. 2. Resident #19 was admitted to the residence on 9/1/22 with diagnoses including aphasia and dementia. Progress notes for Resident #19, dated 12/21/24-1/13/25 read in part: On 12/21, Former Resident #19 had a "big bump" on the top of his foot and was unable to stand or walk. The residence contacted EMS and the resident was transported to the hospital. On 12/28, Resident #19 had an unwitnessed fall and was found by staff, sitting on the floor with no clothes. On 1/13, the former Resident Care Director (RCD) followed up on the fall that occurred on 12/28. When the resident tried to stand up he expressed pain; however, he expressed no pain when his previously injured foot was touched. An EMS report, dated 12/21/24, read in part that after transport the hospital staff reported the resident had a cyst on his right foot and was treated. Resident #19 was transported back to the residence, and the residence staff transferred the resident without incident. An incident report, dated 12/28/24 at 10:38 a.m., read that, Resident #19 was found sitting on the floor with no clothes. An EMS, dated 2/8/25, read in part that hospital staff reported to EMS that Resident #19 had an unrepaired right- femoral fracture from approximately one month prior and would not be treated. Resident #19 was not alert and was unresponsive. A death certificate, dated 2/18/25, read in part that Resident #19 was pronounced dead on 2/9/25, the cause of death was from complications of a femur fracture and rib fractures from an unwitnessed fall that occurred months prior to his death on 12/28/24.3. InterviewsOn 3/11/25 at approximately 8:45 a.m., Staff #9 stated that after the fall Resident #19 required a two person staff assist for all activities of daily living (ADLs) due to aggression, and fighting with staff when they were trying to assist him. On 3/11/25 at approximately 8:50 a.m., Staff #10 stated that Resident #19 was not an aggressive person prior to his fall on 12/28/24 and only required prompting with his ADLs. After his fall, he became very aggressive and required two staff, sometimes more, to assist him with his ADLs. She further stated that he had a foot infection and had a hard time standing prior to his fall, but was able to stand. Staff #10 stated that she could tell that Resident #19 was in pain because he stopped standing and stopped participating in activities, "this was definitely unlike him."On 3/11/25 at approximately 11:50 a.m., the power of attorney (POA) stated that before 12/28/24 Resident #19 lived in what she called a "happy bubble," he was a very happy person, he loved participating in activities and was easy for staff to prompt with ADLs. The POA stated that after his fall he was not reassessed and she was told that he was fine. However, the POA stated that after his fall, his behaviors changed dramatically, and staff reported he had become very aggressive and would punch, kick and grab them when they tried to assist him with his ADLs, and he required multiple staff to assist with his ADLs. The POA stated that she moved Resident #19 out of the residence on 1/30/25 and within seven days of the move he went to the hospital then hospice and died on 2/9/25. On 3/11/25 at 2:55 p.m., the wellness nurse (WN) stated that Resident #19 had become very aggressive after the fall on 12/28/24, he would grab staff hands and clothing when they would attempt to assist him with his ADL's. The WN stated that this was the way he communicated. The WN stated that it took up to four people to assist Resident #19. On 3/11/25 at 2:56 p.m., Staff #11 stated that Resident #19 was very aggressive after his fall on 12/28/24. He would grab staff by the hand and squeeze very tightly, they would require help from other staff to get out of his grip. Staff #11 stated that Resident #19 would grab staff clothing and the arms of the wheelchair when they tried to assist him and they would need assistance in getting Resident #19 to release his grip. Staff #11 stated that sometimes it took up to four staff to successfully assist Resident #19. On 3/12/25 at 11:00 a.m., the administrator stated on 12/28/24 when Resident #19 fell, the on-call nurse was notified but the progress notes did not reflect this. The note should have reflected, who was notified, the directions given and if the resident was in pain. The administrator acknowledged that Resident #19 should have been sent to the emergency department after his unwitnessed fall on 12/28/24. The administrator acknowledged that on 12/29/24 after the former RCD evaluated Resident #19 and found him to be in pain, she should have followed the direction of his practitioner or sent him to the emergency department. The administrator stated that based on the progress notes she could not tell that there was a change in Resident #19 ' s communication or behavioral expression after his fall. The administrator acknowledged that based on what staff reported during their interviews in regards to the change that they saw in Resident #19 ' s communication and behavioral expression, that he could have been communicating that he was in pain. The administrator acknowledged that the former RCD's choice to not send Resident #19 out or seek medical advice regarding the pain was neglect and to not have him reassessed after his change in condition was neglectful. 4. Additionally, the residence failed to ensure Resident #17 had the right to be free from neglect.

Based on observation, record review, and interview, the residence failed to ensure that resident records contained documentation of any out of the event or issue regarding a resident that they personally observed before the end of their shift, affecting four of seven sample residents (#6, #14, #16, #17) and one former resident (#19). (Cross-reference S1146, S1192, S1324)Findings include: 1. ObservationOn 3/11/25 at 7:58 a.m., Resident #17 screamed and cried for help. When the housekeeping staff was alerted, she entered Resident #17's apartment and found the resident lying on the floor from a fall. 2. Record Review Resident #17 was admitted to the residence on 4/23/24 with a diagnosis of bilateral primary osteoarthritis. Progress notes dated 3/10/25-3/12/25 read in part:On 3/10, Resident #17 sustained a skin tear and bruising. The day shift staff reported the resident sustained a fall. On 3/11, staff heard the resident screaming when walking by her apartment, and the resident was on the floor due to a fall. The staff assisted the resident to stand. On 3/12, Resident #17 had a fall in the morning on 3/11/25 and was sent to the hospital. The administrator wrote the note. 3. InterviewsOn 3/12/25 at approximately 11:00 a.m., the administrator acknowledged that the staff that observed the event should have completed progress notes before the end of their shifts. She added that progress notes were entered late. She also stated the progress notes were not entered at the end of the shift as required and therefore entered by staff that had not witnessed the fall. 4. The residence failed to ensure that resident records contained documentation of any out of the event or issue regarding a resident that they personally observed before the end of their shift for Residents #6, #14, #16, #17 and Former Resident #19.

A relicensure survey with complaint #CO29342, #CO35063, #CO36964, #CO37474, #CO37699 was completed on 10/10/24. Deficiencies were cited.

Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 70 current residents. Findings include:On 10/8/24 at 7:30 a.m., quarterly medication audits and medication error reports were requested, but were not provided upon request. On 10/8/24 at 10:00 a.m., personnel files for Staff #1-#3 and #6 and full resident records for Former Residents #10-#12 were requested, but were not provided upon request. On 10/9/24 at 6:54 a.m., access to electronic documents were requested from the ED#2. An email read she could not set up the access on 10/9/24. Online access was requested from the administrator at 7:00 a.m.; it was requested a second time at approximately 8:00 a.m. On 10/10/24 at 10:31 a.m., a request for an 8/8/24 narcotic sheet for Former Resident #10 that had been previously requested on 10/8/24 and 10/9/24 had to be requested a third time. This document was provided on 10/10/24 at 12:10 p.m., approximately two business days after it was originally requested. On 10/10/24 at 1:04 p.m., the administrator stated she was aware of the requirement to provide timely documentation and "did their best" in providing what was requested. The administrator further stated she believed some of the delay in receiving former resident records was due to former resident records being relocated to a location the administrator was unaware of. She stated she had to telephone call the former health and wellness director to find out where the records were moved to.

Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy, affecting 70 current residents. Findings include:1. Residence Policy and Referencea. The residence's involuntary discharge policy dated 6/18/21, read in part, " if the community determines that it is necessary to terminate a Residency Agreement, the community will provide you/your legal representative 30 day advance written termination notice of termination of the residency agreement. However, shorter notice may be required in certain extenuating circumstances."b. According to Chapter 7 regulations governing assisted living residences, part 9.3, requires "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. 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(!)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 resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3)The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 2. Record reviewThe residence's involuntary discharge policy failed to include all required elements listed in the 6 CCR 1011-1 Chapter 7, part 9.3.3. InterviewOn 10/10/24 at 11:00 a.m., the administrator stated she was aware of the requirements of Chapter 7, part 9.3 and the involuntary discharge policy. She added that she would work with the residence's legal team to update the policy.

Based on record review and interview, the residence failed to have readily available a roster of current residents with the emergency contacts for each resident, affecting 70 current residents. Findings include:On 10/8/24 at 7:28 a.m. a roster of current residents for emergency preparedness was requested. On 10/8/24 at 8:12 a.m., a roster was provided which did not include emergency contact information. A second roster was provided at approximately 9:56 a.m. however; it also did not include emergency contact information. On 10/10/24 at 11:00 a.m., the administrator stated she was unaware emergency contact information was required to be part of the resident roster and stated she had thought their first provided roster had met the requirements. The administrator stated she attempted to add emergency contact information to the second roster; however, it had printed incorrectly.

Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following an emergency including, but not limited to, a long-term power failure, affecting 70 current residents. On 10/8/24 at approximately 7:30 a.m., a 72 hour continuation of care policy and procedure was requested but was not provided. On 10/10/24 at 11:00 a.m., the administrator stated the agency had a plan in place which did not specifically address continued care for 72 hours following an emergency.

Based on record review and interview, the residence failed to ensure staff were trained to evaluate residents and performed lift assistance instead of relying on emergency medical responders (EMR) when a resident was unable to independently get up from the floor after an evaluation established that the resident was safe to be lifted, affecting 70 current residents. Findings include:Record reviewsThe residence's Lift policy, dated 6/18/21, read, "Community staff will take appropriate action if You(SIC) fall. Community staff will not lift You (SIC) after a fall due to the possibility of further injury. The Community(SIC) may offer stand-by assistance if You (SIC) are conscious, do not verbalize pain, and are able to get up on Your(SIC) own. 911 will be called immediately if You(SIC) have sustained a head injury; are unresponsive, bleeding, or in pain; have an obvious broken limb; or You(SIC) request that 911 be called". InterviewsOn 10/8/24 at approximately 7:40 a.m., Staff #1 said that if residents were too heavy, they notified emergency medical services (EMS) to help lift the resident off the floor. On 10/9/24 at 8:38 a.m., the local fire authority stated that the residence had responded to several telephone calls from residents who had fallen. Staff stated they did not want to hurt their backs when lifting a resident, so they relied on EMS to assist the residents off the floor. 10/9/24 at 3:10 p.m., the administrator acknowledged that the lift policy provided was their current policy.

Based on observation, record review, and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of three sample residents (#1) and four former residents (#7, #10-#12). (Cross-reference S1600)Findings include:1. Former Resident #10 was admitted to the residence on 3/27/24 with diagnoses including anxiety disorder. Lorazepam A written practitioner's order dated 6/4/24 directed the residence to discontinue lorazepam 0.5 mg every eight hours and change it to administration every six hours. However, the June 2024 medication administration record (MAR) read the residence did not change the medication administration from every eight hours to every six hours until 6/10/24.3. InterviewsOn 10/8/24 at 10:29 a.m., Former Staff #3 said medication was not administered properly and four doses instead of three were administered. On 10/9/24 at 8:45 a.m., the regional director of operations, regional director of resident care, and director of nursing acknowledged the residence's failure to comply with practitioner orders. They attributed the failure to the former director of nursing. On 10/9/24 at 9:00 a.m., Staff #3 stated in June 2024, Former Resident #10 had multiple medication changes, and at one point, there were multiple orders on the MAR which caused incorrect medication administration. On 10/10/24 at 11:00 a.m., the administrator stated that the residence failed to pull discontinued medications from the cart and acknowledged that this failure contributed to the medication errors. She also acknowledged that she expected the residence to comply with the practitioner's orders. 4. Evidence revealed the residence failed to follow the practitioner's orders for Resident #1 and three former residents (#7, #11, #12).

Based on record review and interview the facility failed to accurately document medication administration on the medication administration record (MAR), affecting two (#1, #10) of 12 sample residents. (Cross-reference 1568). Findings include:1. Resident #1 was admitted to the residence on 9/24/24.a. TrazodoneA written practitioner's order, dated 9/25/24, directed the residence to administer Trazodone HCl oral tablet 50 mg 1.5 at bedtime every day at 8:00 p.m. However, the September 2024 electronic medication administration record (eMAR), contained blank spaces on 9/29/24, 10/1/24, 10/2/24, 10/4/24 and 10/5/24.b. Similar deficient practice was found for calmoseptine ointment and lidocaine patches. 2. InterviewsOn 10/10/24 at 11:00 a.m., the administrator acknowledged the blank spaces on the eMAR for Resident #1 meant the medications were not administered. She added the residence input orders as soon as needed to ensure medications were always available. 3. Evidence revealed the residence failed to accurately document medication administration for Resident #1 and Former Resident #10.

Based on observations and interviews, the residence failed to provide toilet paper in each resident's bathroom, affecting four sample residents (#3, #4, #5, #6) and one former resident (#7). (Cross-reference S3060)Findings include:On 10/9/24, during an environmental tour of the residence from 7:40 a.m. to approximately 8:00 a.m., Resident's #3-6 bathrooms did not have toilet paper. A care plan for Resident #3 read that the resident did not require assistance with dressing, ambulating, or toileting. On 10/8/24 at 7:45 a.m., Resident #3 said she was looking for the staff because she had run out of toilet paper and needed to blow her nose. She said she had written a note to the staff asking for more toilet paper in her bathroom, but they had not brought any. Additionally, she said she needed to use the restroom, but without toilet paper, it would be difficult. On 10/8/24 at 8:33 a.m., the director of maintenance said that families typically provided toilet paper, but if a resident asked for it, they would give it to them. On 10/9/24 at approximately 4:00 p.m., the regional director of resident care said the residence was responsible for providing toilet paper to residents. On 10/10/24 at 11:00 a.m., the administrator said residents should have toilet paper in their bathrooms.

Based on record review and interview, the residence failed to ensure resident care plans contained a description of the residents' personal grooming and hygiene items that were determined safe for the resident to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents or behavioral expressions and staff approaches to protect the resident, affecting 30 current residents in the secured environment. (Cross-reference S2678) 1. ObservationOn 10/8/24 from 7:50 a.m. to 8:10 a.m., during an environmental tour of the residence, Resident's #3-6 bathrooms had locked drawers that contained self-care items, including toothpaste, hand soap, and other personal toiletries. 2. Record reviewA care plan for Resident #3 read that the resident did not contain a description of resident #3's personal grooming and hygiene items deemed safe for the resident to have in their possession. 3. InterviewsOn 10/8/24 at 7:45 a.m., Resident #3 said she did not have a key to the drawer. She said that if she wanted to wash her hands after she used the toilet, she would be unable to because she did not have a key to get into the drawer. On 10/8/24, at 8:15 a.m., the resident care director acknowledged that all resident's soap was locked up for their safety. However, she added they took a bucket of warm, soapy water around to residents and used a towel to wash their hands before eating. She added that residents must lock up all toiletries because they may consume them. Conversely, she stated that she was unaware of any residents who would be of concern or if evaluations had been completed. She acknowledged the care plans should have reflected that. On 10/8/24 at 8:45 a.m., the director of maintenance said that all residents in the secured environment must have their hygiene items stored in a locked drawer in their rooms. He stated that they were locked away for safety, and residents do not have a key to their hygiene drawer. On 10/10/24 at 11:00 a.m., the administrator stated she was not aware of the regulation requiring residents to have care plan documentation describing the personal grooming and hygiene items that were deemed safe for the residents to have in their possession for self-care.