Crestone Place Assisted Living

A revisit survey was completed on 4/3/24 for all previous deficiencies cited on 9/12/23. 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 11/16/23. No deficiencies were cited. 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 7.14.31 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.21.1 The assisted living residence grounds shall be kept free of high weeds, garbage, and rubbish.

A recertification survey was completed on 11/16/23. No deficiencies were cited. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.495.6(H)(2) Alternative Care Facility Providers shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII and XXIV, Medication Administration Regulations."

A licensure complaint prompted by #CO32080 was completed on 9/12/23. A deficiency was cited. Based on observation, interview and record review, the residence failed to notify a resident' s representative whenever the resident experienced a significant change from baseline status, affecting two of three sample residents (#1, #2). Findings include:Chapter VII regulations governing assisted living residences, part 2.21, defines "External services" as personal services and protective oversight services provided to a resident by family members or healthcare professionals who are not employees, contractors, or volunteers of the facility. External service providers include, but are not limited to, home health, hospice, private pay caregivers and family members.Resident #1 was admitted to the residence on 3/1/21, with a diagnosis of bi-polar type schizoaffective disorder.Resident #2 was admitted to the residence on 2/1/23, with a diagnosis of bi-polar type schizoaffective disorder. An investigation, dated 9/8/23, read that Resident #2 had been talking to himself, however, Resident #1 thought Resident #2 was talking to him, so Resident #1 punched Resident #2. Staff #1 witnessed the incident and had to physically grasp Resident #1 to get him away from Resident #2. There was blood on Resident #2' s face, a swollen lip, and a few bumps on his head. Resident #1 also has a swollen right hand with a visible injury. Neither residents wanted law enforcement contacted. On 9/12.. 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 7.Q910 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.Q1332 13.4 The house rules shall list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident. House rules shall not supersede or contradict any regulation herein, or in any way discourage or hinder a resident ' s exercise of his or her rights. Q1360 13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation..