Pine Grove Crossing

“Res Care Srvs-Min Srvs Res Agr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Minimum Services 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; (B) Room and board; (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment; (D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach; and (E) Social care and resident engagement.”

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.

“ReRes Care Srvs-Lift As P/P Av EMR 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Lift Assistance 12.16 Each assisted living residence shall direct staff to assist residents who have fallen or are otherwise unable to independently get up off the floor. The assisted living residence's policy on staff providing lift assistance shall be made available to its local emergency medical responders.”

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

“Res Rts-Inv Ab/Neg Alleg or Inj Unk Org IUO 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 13 - RESIDENT RIGHTS - Investigation of Abuse and Neglect Allegations or Injuries of Unknown Origin 13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements: (A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either: (1) The resident cannot explain how the injury occurred; or (2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries. (B) The assisted living residence shall document the following: (1) The investigation and identification of any injury identified in (A), above. (2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin: (a) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or (b) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse, neglect, or exploitation. Such steps may include, but not be limited to: (i) Staff or volunteer corrective action and/or additional training; or (ii) Modification of the assisted living residence's policies, procedures or physical environment. (3) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries. (C) All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request. (1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes. (D) The assisted living residence shall notify the resident's representative of the outcome of the investigation and steps taken.”

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.

“HIR-Cnfd/Ac F/S Law 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 18 - RESIDENT HEALTH INFORMATION RECORDS - Confidentiality and Access 18.6 The confidentiality of the resident record including all medical, psychological, and sociological information shall be protected in accordance with all applicable federal and state laws and regulations.”

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

“Admin-Dts Resp 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 6 - ADMINISTRATOR - Duties 6.8 The administrator, or individual appointed as an interim administrator, shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (A) Managing the day-to-day delivery of services to ensure residents receive the care that is described in the resident agreement, the comprehensive resident assessment, and the resident care plan; (B) Organizing and directing the assisted living residence's ongoing functions including physical maintenance; (C) Ensuring that resident care services conform to the requirements set forth in Part 12 of this chapter; (D) Employing, training, and supervising qualified personnel; (E) Providing continuing education for all personnel; (F) Establishing and maintaining a written organizational chart to ensure there are well-defined lines of responsibility and adequate supervision of all personnel; (G) Reviewing the marketing materials and information published by an assisted living residence to ensure consistency with the services actually provided by the ALR; (H) Managing the business and financial aspects of the assisted living residence which includes working with the licensee to ensure there is an adequate budget to provide necessary resident services; (I) Completing, maintaining, and submitting all reports and records required by the Department; (J) Complying with all applicable federal, state, and local laws concerning licensure and certification; (K) Ensuring the assisted living residence's compliance with the involuntary discharge requirements in Section 25-27-104.3 C.R.S., and these rules; and”

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.

“Res Ad/D/C-Res Agr Wrt Agr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 11 - RESIDENT ADMISSION AND DISCHARGE - Resident Agreement 11.3 At the time the resident moves in, the assisted living residence shall ensure that the resident and/or the resident's legal representative has received a copy of the written resident agreement and agreed to the terms set forth therein. The assisted living residence shall ensure that the agreement is signed and dated by both parties.”

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

“Res Ad/D/C-Res Agr Anul Rvw/CHOW 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 11 - RESIDENT ADMISSION AND DISCHARGE - Resident Agreement 11.5 The assisted living residence shall review its resident agreements annually and update or amend them as necessary. Amendments to the resident agreement shall also be signed and dated by both parties. (A) When a change of ownership occurs, the new owner shall either acknowledge and agree to the terms of each existing resident agreement or establish a new agreement with each resident.”

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 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.

“Res Rghts Rts/Rspn-Civ/Rel-Explt 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: (4) The right to live free from financial exploitation, restraint as defined in this chapter, and involuntary confinement except as allowed by the secure environment requirements of this chapter;”

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

“Res Rghts-Intrnl Griev/Compl Res Pr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 13 - RESIDENT RIGHTS - Internal Grievance and Complaint Resolution Process 13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies: (A) The state long-term care ombudsman and local ombudsman; (B) The Adult Protection Services of the appropriate county Department of Social Services; (C) The advocacy services of the area's agency on aging; (D) The Colorado Department of Public Health and Environment; and (E) The Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence is licensed to provide services specifically for persons with intellectual and developmental disabilities.”

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

“Med/Med Adm-Gen Rq Pract Ordr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 14 - MEDICATION AND MEDICATION ADMINISTRATION - General Requirements 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to 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.

“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.

“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.

“Res Care Srvs-Min Srvs Res Agr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Minimum Services 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; (B) Room and board; (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment; (D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach; and (E) Social care and resident engagement.”

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

“In Env-H/L/Vent 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 22 - INTERIOR ENVIRONMENT - Heating, Lighting and Ventilation 22.5 Each room shall have heat, lighting, and ventilation sufficient to meet the use of the room and the needs of the residents.”

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

“In Env-Heat Dvcs Port Heat 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 22 - INTERIOR ENVIRONMENT - Heating Devices 22.27 The assisted living residence shall prohibit the use of portable heaters in resident rooms. The use of fireplaces, space heaters, and like units that generate heat shall be prohibited in the common areas of the assisted living residence unless the ALR is able to ensure that such devices have a UL (Underwriters Laboratory) or similar certification label, do not present a resident burn risk, and are used in accordance with manufacturer instructions.”

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

“Res Care Srvs-Min Srvs Res Agr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Minimum Services 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; (B) Room and board; (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment; (D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach; and (E) Social care and resident engagement.”

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

“Res Care Srvs-Min Srvs Res Agr 6 CCR 1011-1 CHAPTER 7 - ASSISTED LIVING RESIDENCES PART 12 - RESIDENT CARE SERVICES - Minimum Services 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; (B) Room and board; (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment; (D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach; and (E) Social care and resident engagement.”

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