Columbine Commons Assisted Living LLC

A revisit survey was completed on 3/14/25 for all previous deficiencies cited on 10/8/24. 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 10/8/24. Deficiencies were cited. Based on record review and interview, the residence failed to direct staff to assist residents who have fallen or are otherwise unable to get up off the floor independently, affecting 51 current residents.Findings include:1. ReferencesThe residence' s undated Lift Assist Policy read in part, the residence was a "no lift facility", staff were required to immediately contact the nurse or Emergency Medical Services (EMS) to evaluate and assist the resident up. However, the policy did not direct staff to assist residents who have fallen or were otherwise unable to get up off the floor independently.2. Interview On 10/8/24 at 11:44 a.m., Staff #5 stated the residence ' s policy was to not assist a resident after a fall, she was told to remain with the resident, notify the nurse or EMS to evaluate the resident and assist them after a fall. On 10/8/24 at 1:30 p.m., the qualified medication administration personnel supervisor stated the residence informed staff not to lift residents after a fall, staff were required to call a nurse or EMS to assist the r.. 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 51 current residents.Findings include:On 10/8/24 at approximately 7:45 a.m., a 72 hour continuation of care policy and procedure was requested but was not provided. On 10/8/24 at 2:37 p.m., the administrator confirmed the residence did not have a 72 hour continuation of care policy and acknowledged it was a requirement. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 07. 18.9 The face sheet shall be updated at least annually and contain the following information. 12.10 Each resident care plan shall: (A) Be developed with input from the resident and the resident ' s representative; (B) Reflect the most current assessment information; (C) Promote resident choice, mobility, independence and safety; (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence ' s visitation policy as required by Part 9.2, along with care coordination arrangements; and Identify formal, planned, and informal spontaneous engagement opportunities that match the resi..