Pal's Acf

A revisit survey was completed on 2/24/26 for all previous deficiencies cited on 10/29/25. 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 recertification survey was completed on 10/29/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to ensure a lease, residency agreement, or other written agreement for each member (resident) was updated annually, affecting two of three sample residents (#1, #3).Findings include: The records for Residents #1 and #3 revealed that resident agreements were signed on 2/2/23. The resident agreements were not updated annually as required by regulation 8.7.001.B.3.a.i. On 10/29/25 at 11:15 a.m., the administrator designee stated she was aware that all residents were required to have a signed resident agreement; however, she was unaware that the resident agreements were required to have been updated annually. Based on record review and interview, the facility (residence) failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 12 current members (residents).Findings include:On 10/29/25 at 8:00 a.m., a 72-hour continuation of care policy and procedure was requested; however, it was not provided.On 10/29/25 at 11:15 a.m., the administrator designee stated that the residence did not have policies for a 72-hour plan and was unaware that a policy was needed.

A relicensure survey was completed on 10/29/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure at least one staff member was responsible for the onsite management of the facility' s infection prevention and control program, and had completed the required training, affecting 12 current residents. Findings include: On 10/29/25 at 8:00 a.m., the infection control person (ICP) certification was requested; however, the residence was unable to provide the documentation. On 10/29/25 at 11:15 a.m., the administrator designee stated she was unaware of the Chapter II 12.2.2 regulation requiring the residence to assign at least one staff member as the ICP for the residence. 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 (A-I), affecting 12 current residents. Findings include:On 7/29/25 at approximately 8:17 a.m., the Involuntary Discharge Grievance Policy was requested. The residence was unable to provide an Involuntary Discharge Grievance Policy. On 10/92/25 at 11:15 a.m., the administrator designee stated she was unaware of the requirement for an involuntary discharge grievance policy that met the requirements of Chapter VII Regulation 9.3 (A-I). 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 any emergency, affecting 12 current residents.Findings include:On 10/29/25 at 8:00 a.m., a 72-hour continuation of care policy and procedure was requested; however, it was not provided.On 10/29/25 at 11:15 a.m., the administrator designee stated that the residence did not have policies for a 72-hour plan and was unaware that a policy was needed. Based on record review and interview, the residence failed to request, prior to hire, a criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for three of three sample staff (#1-#3) affecting 12 current residents. Findings include: Review of personnel records revealed Staff #1-#3 were hired on 7/10/25, 11/3/21, and 11/16/18, respectively. However, there was no evidence that a CBI background check had been completed for Staff #1-#3 prior to their hire dates. The October 2025 staff schedule revealed Staff #1-#3 worked the following shifts: Staff #1 worked Saturdays from 7:00 p.m. to 7:00 a.m. Staff #2 worked Sunday through Wednesday from 7:00 p.m. to 7:00.. 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 7.18.9 The face sheet shall be updated at least annually and contain the following information: (B) Resident' s sex, date of birth, and marital status; (C) Resident ' s most recent former address; (E) Date of admission and readmission, if applicable.

A revisit survey was completed on 8/28/23 for all previous deficiencies cited on 2/2/23. 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 conducted on 2/2/23. Deficiencies were cited. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents, their room assignments and emergency contact information, along with a diagram showing room locations, affecting 11 current residents.Findings include:On 2/2/23 at approximately 8:15 a.m., the administrator provided a resident roster, dated 7/17/21. However, the provided resident roster did not include resident room assignments or a diagram that showed room locations. Additionally, the resident roster was not current and had one resident crossed off the roster by the administrator. On 2/2/23 at 9:00 a.m., the administrator confirmed the resident roster provided was the only roster the residence had. She said she was not aware the roster was required to contain resident room assignments or a residence diagram that showed room locations. 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 VII. (insert the appropriate Chapter for the program being cited).14.15 The assisted living residence shall ensure each resident' s right to privacy and dignity with respect to medication monitoring and administration.16.5 Staff preparing or serving food shall complete recognized food safety training and maintain evidence of completion on site. Food safety training shall be provided by recognized food safety experts or agencies, such as the Department' s Division of Environmental Health and Sustainability, local public health agencies, or Colorado State University Extension Services. At a minimum, a certificate of completion of the available online modules is sufficient to comply with this part. The successful completion of other accredited food safety courses is also acceptable.21.4 Porches, stairs, handrails, and ramps shall be maintained in good repair.22.4 Designated areas where smoking is allowed shall be equipped with fire resistant wastebaskets. Resident rooms occupied by smokers, even when house rules prohibit smoking in resident rooms, shall have fire resistant wastebaskets.