Grace Pointe Continuing Care Senior Campus Assisted Living

A revisit survey was completed on 12/15/25 for all previous deficiencies cited on 8/12/25. 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 with complaint #CO40673 was completed on 8/12/25. Deficiencies were cited. Based on observation and interview the residence failed to keep grounds maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction in the secure environment outdoor courtyard, affecting 44 residents in the assisted living residence.Findings include:During an envi.. Based on observation, interview, and record review, the residence failed to ensure each staff member receivedtraining prior to working independently with a resident for two of three sample staff (#1), (#3) affecting 67 currentresidents. Findings include:1. Observations On 8/12/25 at 8:00 a.m., Staff #3 was observed providing care an.. Based on record review and interview the residence failed to update each resident' s comprehensive assessment at least annually and whenever the resident' s condition changes from baseline status, affecting seven of eight sample residents (#1, #2, #4 - #8).Findings Include:1. Residence PolicyThe residence ' s undated change of condition p.. Based on record review and interview, the residence failed to ensure each care plan had details specific to personal service needs and preferences, along with the staff tasks necessary to meet those needs, affecting six of eight sample residents (#1, #4 - #8).Findings include:Resident #8 was admitted to the residence on 5/1/24 with diagn.. Based on record review and interview, the residence failed to ensure staff documented, 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, affecting eight of eight sample residents (#1-#8).Findings include:Resident #4 was admitted to the residence on 6/9/.. Based on record review and interview, the residence failed to establish a policy for when a practitioner' s assessment is appropriate, and contact a resident' s primary practitioner when the resident experiences a significant change in their baseline status, affecting six of eight sample residents (#1, #4 - #8 ). Findings include:1. Residence PolicyOn 8/12/25.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy thatincluded all required elements, affecting 67 current residents.Findings include:A review of the residence' s discharge and grievance policies and the termination section of the resident agreement revealed that the residence .. Based on record review and interview, the residence failed to reassess residents every six months for the need of a secure environment, affecting three of three sample residents in the secure environment (#7, #8, #9). Findings include: Resident #7 was admitted to the residence on 7/15/22 with a diagnosis of Alzheimer' s disease. The record fo.. 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 existingprogram regulations found at 6 CCR 1011-1, Chapter 7.12.15 The assisted living residence shall develop policies and procedure..

A revisit survey was completed on 3/5/24 for all previous deficiencies cited on 10/12/23. 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 with complaints #CO33783 and #CO28666 was completed on 10/11/23. Deficiencies were cited. Based on interview and record review the residence failed to contact the resident' s practitioner when the resident has physical signs of possible infection (open sores, etc.) and/or develops any condition which would have initially precluded admission to the facility, affecting one former resident (#7). (Cross-reference Q1110)Findings include:1. R.. Based on interview and record review, the residence failed to hold quarterly meetings to allow residents, their family members, friends and representatives to provide mutual support and share concerns about the care and services with the secure environment, affecting 21 current residents who resided in the secure environment.Findings Include:On 1.. Based on interview and record review, the residence failed to only allow a personal care worker to perform tasks that have a chronic, stable, predictable outcome and do not require routine nurse assessment, affecting one former resident (#7). (Cross-reference Q1110)Findings Include:1. ReferenceChapter VII regulations governing assisted living r.. Based on interview and record review, the residence failed to provide 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, affe.. Based on interview and record review, the residence failed to update the comprehensive assessment whenever the resident' s condition changed from baseline status, affecting one former resident (#7). (Cross-reference Q1110)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, r.. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioners orders associated with medication administration, affecting one of five sample residents (#3) and one former resident (#7). (Cross-reference Q1110, Q1514, Q1522) Findings Include:1. References and Residence Pol.. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor conducted quarterly audits of medication administration records, controlled substance lists, medication error reports, and medication disposal records for completeness and accuracy, affecting f.. Based on record review and interview, the residence failed to ensure the resident' s authorized practitioner was notified of a medication error that affected a resident, affecting one Former Resident (#7). (Cross-reference Q1468)Findings include:1. References and Residence Policya. "Coumadin is an anticoagulant (blood thinner). Warfarin.. 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 10 CCR 2505-10 8.400.8.7 Each assisted living residence shall have at least one staff member onsite at all times who ..