Penny Lane Assisted Living Residence

A relicensure survey with complaint #CO34199 was completed on 1/29/25. A deficiency was cited. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting six current residents.Findings include:On 1/28/25 at 10:41 a.m., a record review of the residence' s emergency plans and procedures, dated 2024, did not address all of the required elements.On 1/29/25 at 12:53 p.m., the administrator reported the policy was reviewed and updated in 2024; however, the administrator designee was responsible for creating and reviewing the policy to ensure accuracy.On 1/29/25 at 1:23 p.m., the administrator designee (AD) reported the policy was updated in 2024. She reported being unaware that it did not meet expectations and expected it to meet expectations. The AD acknowledged she needed to create a policy more specific to meet the elements for each emergency type. 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 7.10.3 The assisted living residence shall develop and follow written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency including, but not limited to, a long-term power failure. 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.21.1 The assisted living residence grounds shall be kept free of high weeds, garbage, and rubbish.

A recertification survey was completed on 1/29/25. A deficiency was cited. Based on record review and interview the facility (residence) failed to submit a verbal or written report for all critical incidents, as defined in Section 8.7201.L.5, to the member' s case manager within 24 hours of the discovery of the actual or alleged incident, or reported to the case manager within two business days for all other incidents, affecting one of three sample members (residents) (#6).Findings include:On 1/28/25 at 10:41 a.m., documentation of critical incident reports for Resident #6 was requested due to a hospitalization on 12/8/24 and a fall on 1/17/25 that resulted in injury; however, none were provided.On 1/28/25 at 10:26 p.m., Staff #1 reported the residence did not report the critical incident for Resident #6' s fall on 1/17/25. Staff #1 reported they were not working that day.On 1/29/25 at 1:00 p.m., the administrator explained that she was aware when the residence were required to submit critical incident reports to the case manager; however they did not do so because they were not aware of who Resident #6' s case manager was. She explained that the case manager agencies had high staff turnover and merged with other entities, so they were unaware of the current case manager' s contact information. The administrator reported the administrator designee (AD) was responsible for reporting critical incident reports to the case manager.On 1/29/25 at 1:27 p.m., the AD confirmed the residence did not report the critical incident report to the case manager. The AD reported she expected the staff who was completing the incident report needed to also contact the case manager to report the critical incident.