Highpointe Assisted Living & Memory Care

A licensure complaint, prompted by #CO39316 and #CO39338 was completed on 3/12/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure the resident agreement included a list of specific residence services included and the agreed upon rates and charges, affecting one sample resident (#6). (Cross-reference S2230) Findings include: Resident #6 was admitted to the residence on 5/17/24.The Resident Agreement for Resident #6, dated 5/7/24, read in part that the residence may modify the amounts charged after providing the resident or the resident' s legal representative (LR) with 30 days prior written notice. Further it read that the resident was charged $600 a month for a care level of one. The agreement contained no additional documentatio.. Based on interviews and record review, the residence failed to update a comprehensive assessment whenever a resident' s condition changed from baseline status, affecting four of four current sample residents (#14, #16, #17, #19). Specifically, Resident #16 had 13 falls since her last comprehensive assessment on 12/10/24. She had injuries in nine out of the 13 falls. The resident had two falls on 2/20/25 resulting in knee pain and a moderate hematoma with a laceration that required repair. After the second fall on 2/20/25, the emergency medical services (EMS) were telephoned and the resident refused to go despite the recommendation. Additionally, Resident #16 had significant be.. Based on observation interview and record review, the residence failed to ensure residents were free from neglect, affecting one current resident (#17) and one former resident (#19). (Cross reference S1146, S1192, S2230).Specifically, Former Resident #19 fell on 12/28/24 with pain and an increased inability to stand. The residence failed to contact emergency medical services (EMS) or his practitioner. Subsequently, the resident died on 2/9/25 from complications of a femur fracture and rib fractures from an unwitnessed fall that occurred months prior to his death. The timing of the unwitnessed fall and fractures mentioned on the death certificate was consistent with the fall the resident sustained.. Based on observation, record review, and interview, the residence failed to ensure that resident records contained documentation of any out of the event or issue regarding a resident that they personally observed before the end of their shift, affecting four of seven sample residents (#6, #14, #16, #17) and one former resident (#19). (Cross-reference S1146, S1192, S1324)Findings include: 1. ObservationOn 3/11/25 at 7:58 a.m., Resident #17 screamed and cried for help. When the housekeeping staff was alerted, she entered Resident #17' s apartment and found the resident lying on the floor from a fall.2. Record Review Resident #17 was admitted to the residence on 4/23/24 with .. Based on observation, record review, and interview, the residence failed to evaluate whether a resident could be assisted safely and provided lift assistance to a resident who was experiencing pain and/or had a change in their physical baseline status, affecting one current resident (#17). (Cross-Reference S1146, S1324, S2230)Specifically, Resident #17 fell on 3/10/25 and experienced pain, a skin tear to the knee, and hip bruising; however, the residence did not contact emergency medical services (EMS) upon the direction of the resident' s legal representative (LR). The staff failed to contact EMS and lifted the resident despite the resident reporting pain. Resident #17 continued to feel..

A relicensure survey and complaint revisit was completed on 3/12/25 for all previous deficiencies cited on 10/10/24. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to evaluate whether a resident could be assisted safely and provided lift assistance to a resident who was experiencing pain and/or had a change in their physical baseline status, affecting one current resident (#17). Specifically, Resident #17 fell on 3/10/25 and experienced pain, a skin tear to the knee, and hip bruising; however, the residence did not contact emergency medical services (EMS) upon the direction of the resident' s legal representative (LR). The staff failed to contact EMS and lifted the resident despite the resident reporting pain. Resident #17 continued to feel pain and fell again on 3/11/25, and the resident was transported to the hospital, where she was diagnosed with hairline fractures in both hips. This deficiency was cited previously during a state licensure survey and complaint on 10/10/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s Lift Policy, dated 1/6/25, read in part that the residence had trained staff that evaluated residents who had fallen. If the residence determined that the resident had increased pain, the residence contacted EMS immediately. 2. ObservationOn 3/11/25 at 7:58 a.m.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 81 current residents.This deficiency was cited previously during a state licensure survey and complaint 10/10/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:The residence' s discharge policy, dated 3/11/25, read in part the reasons that the residence discharged residents, and if the resident chose to appeal they must do so to the administrator within five days of receipt of the discharge notice. However, the policy failed to contain the correct timeline for grievance submission, the residence' s response to the grievance, the opportunity to request a hearing from the Department if the outcome is not satisfactory and the circumstances that residence allowed readmittance.On 3/12/25 at 12:02 p.m., the administrator affirmed that the policy failed to contain all of the required timeframes for appeals as well as other elements. She added she was not familiar with all of the required elements of the discharge grievance policy.On 3/12/25 at 12:18 p.m., the regional director of operations stated that she did not update the discharge policy and that was the reason it had not been corrected.

A relicensure survey with complaint #CO29342, #CO35063, #CO36964, #CO37474, #CO37699 was completed on 10/10/24. Deficiencies were cited. Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy, affecting 70 current residents.Findings include:1. Residence Policy and Referencea. The residence' s involuntary discharge policy dated 6/18/21, read in part, " if the community determines that it is necessary to termi.. Based on observation, record review, and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of three sample residents (#1) and four former residents (#7, #10-#12). (Cross-reference S1600)Findings.. Based on observations and interviews, the residence failed to provide toilet paper in each resident' s bathroom, affecting four sample residents (#3, #4, #5, #6) and one former resident (#7). (Cross-reference S3060)Findings include:On 10/9/24, during an environmental tour of the residence from 7:40 a.m. to approximately 8:00 a.m., Resid.. Based on record review and interview the facility failed to accurately document medication administration on the medication administration record (MAR), affecting two (#1, #10) of 12 sample residents. (Cross-reference 1568).Findings include:1. Resident #1 was admitted to the residence on 9/24/24.a. TrazodoneA written practitioner' s.. Based on record review and interview, the residence failed to ensure resident care plans contained a description of the residents' personal grooming and hygiene items that were determined safe for the resident to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents or behavi.. Based on record review and interview, the residence failed to ensure staff were trained to evaluate residents and performed lift assistance instead of relying on emergency medical responders (EMR) when a resident was unable to independently get up from the floor after an evaluation established that the resident was safe to be lifted, affecting .. 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 70 current residents. On 10/8/24 at approximately 7:30 a.m., a 72 hour continuation of care policy and pro.. Based on record review and interview, the residence failed to have readily available a roster of current residents with the emergency contacts for each resident, affecting 70 current residents. Findings include:On 10/8/24 at 7:28 a.m. a roster of current residents for emergency preparedness was requested. On 10/8/24 at 8:12 a.m., a roster was provid.. Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 70 current residents.Findings include:On 10/8/24 at 7:30 a.m., quarterly medication audits and medication error reports were requested, but were not provided upon request. On 10/8/24 at ..