Highpointe Assisted Living & Memory Care

“Res Ad/D/C-Res Agr Incld 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 11 - RESIDENT ADMISSION AND DISCHARGE - Resident Agreement 11.6 The written resident agreement shall specify the understanding between the parties concerning, at a minimum, the following items: (A) Assisted living residence charges, refunds, and deposit policies; (B) The general type of services and activities provided and not provided by the assisted living residence and those which the assisted living residence will assist the resident in obtaining; (C) A list of specific assisted living residence services included for the agreed upon rates and charges, along with a list of all available optional services and the specified charge for each; (D) The amount of any fee to hold a place for the resident in the assisted living residence while the resident is absent from the assisted living residence and the circumstances under which it will be charged; (E) Responsibility for providing and maintaining bed linens, bath and hygiene supplies, room furnishings, communication devices, and auxiliary aids; and (F) A guarantee that any security deposit will be fully reimbursed if the assisted living residence closes without giving resident(s) written notice at least thirty (30) calendar days before such closure, (G) Reasons that the assisted living residence could pursue an involuntary discharge of the resident, as listed in Parts 11.11 and 11.12,”

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

“Res Care Srvs-Comp Res Asmnt Annl/Chng Bsln 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 RESIDENT CARE SERVICES - Comprehensive Resident Assessment 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status.”

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

“Res Care Srvs-Lift As Tr Stff 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Lift Assistance 12.17 The assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders. (A) Each situation shall be evaluated to determine if the resident can be assisted in a safe manner such as when the resident has no pain and/or there is no change from baseline, the resident's mental status is unchanged from baseline, and there is no, or minor, bleeding. (B) Once the situation has been evaluated, assisted living residence policy shall require staff to take the following actions: (1) Physically perform the lift assistance using techniques provided in staff training and monitor the resident; or (2) Not lift and call 911 when the resident is unconscious, the resident's physical or mental status has declined from baseline, the resident experiences an increase in pain when lifting is attempted, the resident wants 9-1-1 called, and/or the resident either can't assist in any way or refuses to assist because of pain, injury, or other physical complications. (C) The assisted living residence shall promptly notify the resident's practitioner, family and/or legal representative of the occurrence of either circumstance identified in Part 12.17(B)(1) or (2), along with information regarding the ALR's response.”

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

“Res Rghts Rts/Rspn-Civ/Rel-Neglect 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 13 - RESIDENT RIGHTS 13.1 The assisted living residence shall adopt, and place in a publically 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: (B) The right to civil and religious liberties, including: (3) The right to be free from neglect;”

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

“HIR-Cntnt Incld 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 18 - RESIDENT HEALTH INFORMATION RECORDS - Content 18.8 Resident records shall contain, but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. (E) Medication Administration Record; (F) Documentation of on-going services provided by external service providers including, but not limited to, caregivers, essential caregivers, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and care providers; (G) Advance directives, if applicable, with extra copies; and (H) Final disposition of resident including, if applicable, date, time, and circumstances of a resident's death, along with the name of the person to whom the body is released.”

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

“Pol/Proc Dschrg Grievance 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 9 - POLICIES AND PROCEDURES 9.3 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) If 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: (1) 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 reside”

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

“Res Care Srvs-Lift As Tr Stff 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Lift Assistance 12.17 The assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders. (A) Each situation shall be evaluated to determine if the resident can be assisted in a safe manner such as when the resident has no pain and/or there is no change from baseline, the resident's mental status is unchanged from baseline, and there is no, or minor, bleeding. (B) Once the situation has been evaluated, assisted living residence policy shall require staff to take the following actions: (1) Physically perform the lift assistance using techniques provided in staff training and monitor the resident; or (2) Not lift and call 911 when the resident is unconscious, the resident's physical or mental status has declined from baseline, the resident experiences an increase in pain when lifting is attempted, the resident wants 9-1-1 called, and/or the resident either can't assist in any way or refuses to assist because of pain, injury, or other physical complications. (C) The assisted living residence shall promptly notify the resident's practitioner, family and/or legal representative of the occurrence of either circumstance identified in Part 12.17(B)(1) or (2), along with information regarding the ALR's response.”

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 MAR 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - Record Keeping 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.”

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

“In Env-BR TP 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 22 - INTERIOR ENVIRONMENT - Bathroom 22.23 Each assisted living residence shall provide toilet paper in each resident bathroom, except where a resident has a specific preference and agrees to supply it.”

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.

“Em Pr-Pol/Proc Res Rstr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 10 - EMERGENCY PREPAREDNESS - Emergency Policies and Procedures 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.”

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

“Em Pr-Pol/Proc 72 hrs Em 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 10 - EMERGENCY PREPAREDNESS - Emergency Policies and Procedures 10.3 The assisted living residence shall develop and follow written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency including, but not limited to, a long-term power failure.”

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

“LicProc-DeptOvrst-Srvy/Inspct Ensr Cmply-POC PART 2. LICENSURE PROCESS 2.10 Department Oversight 2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities: (A) Individual client records. (B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department.”

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