Pine Grove Crossing

A licensure complaint, prompted by #CO41137, #CO41138, #CO41145 and #CO41156, was completed on 11/25/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure all prescribed and PRN (as needed) medication was listed on a medication administration record (MAR) and that the resident' s medication administration record (MA.. Based on interview and record review, the residence failed to provide quarterly basis audits ensuring accuracy, complete medication administration records, controlled substance lists, medication error reports and medication dis.. Based on interviews and record review, the residence failed to update a comprehensive assessment whenever a resident' s condition changed from baseline status, affecting two of two residents sample residents who experienced .. Based on observation, record review and interview, the residence failed to ensure the residents were free from neglect affecting one sample resident (#19). (Cross-reference U0540 & U1146)Specifically, Resident #19 .. Based on observations and interviews, the residence failed to protect the confidentiality of the residents' records, affecting 108 current residents. (Cross-reference U0540)Findings Include:On 11/24/25 at 8:08 a.m., an environmenta.. Based on record review and interview, the residence failed to prepare and administer medication that had been ordered by an authorized practitioner, affecting one of 14 sample residents (#13). (Cross-reference U0540, U1568, U.. Based on record review and interviews, the residence failed to comply with authorized practitioner ' s orders associated with medication administration, affecting four of 14 sample residents (#13, #14, #15, #19). (Cross-referen.. Based on record review, observations and interviews, the residence failed to ensure the administrator managed the day-to-day delivery of services, conducted medication audits, followed practitioners ' orders, ensured compre.. Based on records review and interviews, the residence failed to conduct annual reviews of residency agreements for eight of 14 sample residents (#11, #13–#19). (Cross-reference U0540, U1030)Findings Include:A review of residency ag.. Based on records review and interviews, the residence failed to ensure residency agreements were signed, dated, and complete at the time of move-in for two of 14 sample residents (#2, #23). (Cross-reference U0540, U1034, U1326)Fin.. Based on records review and interviews, the residence failed to promptly address a complaint filed by the financially responsible representative of Resident #23, affecting one of 14 sample residents. (Cross-reference U0540, U1326)Fin.. Based on records review and interviews, the residence failed to protect the resident ' s right to live free from financial exploitation by charging fees and service rates that were not assessed or agreed to in the residency agreement, resul.. Based on records review, observations, and interviews, the residence failed to maintain and provide a complete and accurate resident roster, room assignment list, and emergency contact information, affecting 108 current residents. .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program ..

A complaint revisit was completed on 10/21/25 for the previous deficiency cited on 8/20/25. A deficiency was cited. Based on observation and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 107 current residents. This deficiency was cited previously during a state licensure survey on 8/20/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ObservationOn 10/21/25 from 7:30 a.m. to 2:30 p.m., an environmental tour of the residence revealed the following:In the apartment of Resident #9, two oxygen cylinders were lying on their side and not stored upright. In the apartment of Resident #10, approximately 19 oxygen cylinders were in various locations of the living room, one was lying on its side and none were stored in cradles.In the medication room of the third floor, six oxygen cylinders were on the floor and not stored in cradles. 2. InterviewOn 10/21/25 at 2:45 p.m., the administrator stated she preferred oxygen cylinders to be stored outside of resident rooms, or at least in a cart or cradle if stored inside the rooms to prevent the cylinders from falling over. The administrator stated cylinders at risk of falling over or lying on their sides were unsafe if they were damaged by improper storage methods. The administrator stated the deficiency was not corrected from the previous survey because maintenance had not followed the plan to store the tanks outside of resident rooms or at least in crates or cradles.

A licensure complaint, prompted by #CO41027, was completed on 10/21/25. Deficiencies were cited. Based on observation and interview, the residence failed to prohibit the use of portable heaters in resident rooms, affecting two (#6 and #7) of 10 sample residents. (Cross reference U2620)Findings include:1. Observation and interviewOn 10/21/25 at 9:05 a.m., Resident #7 said the residence had provided a small space heater (date unknown) while the heating, ventilation and air conditioning (HVAC) system was being repaired. A small space heater was located in the bedroom of the apartment. On 10/21/25 at 9:16 a.m., a family member of Resident #6 said the residence had provided a space heater (date unknown) to Resident #6 while the HVAC system was being repaired. Upon entering the apartment of Resident #6 a space heater was located in the bedroom. 2. InterviewOn 10/21/25 at 2:47 p.m., the administrator said the use of space heaters in resident apartments was prohibited and a fire hazard. Based on observation and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 107 current residents. Findings include:1.ObservationOn 10/21/25 from 7:30 a.m. to 2:30 p.m., an environmental tour of the residence revealed the following:In the apartment of Resident #9, two oxygen cylinders were lying on their side and not stored upright. In the apartment of Resident #10, approximately 19 oxygen cylinders were in various locations of the living room, one was lying on its side and none were stored in cradles.In the medication room of the third floor, six oxygen cylinders were on the floor and not stored in cradles. 2. InterviewOn 10/21/25 at 2:45 p.m., the administrator stated she preferred oxygen cylinders to be stored outside of resident rooms, or at least in a cart or cradle if stored inside the rooms to prevent the cylinders from falling over. The admini.. Based on observations, record review and interviews the residence failed to heat sufficiently to meet the needs of the residents, affecting four of ten (#2, #4, #6 and #7) sample residents. (Cross reference U2690)Findings include:1. Observation and interviewOn 10/21/25 at 8:54 a.m., Resident #4 said her apartment was cold, there was no heat and her thermostat was not working and displayed only a blank screen. A thermostat located on the wall of the apartment failed to turn on when the power button was pushed and the screen was blank. On 10/21/25 at 9:30 a.m., Resident #7 said her apartment was cold and her thermostat was not working. The thermostat revealed a temperature of 68 degrees. Resident #7 said she had adjusted the thermostat for a higher temperature but the vents had not produced heat and the temperature continued to read 68 degrees F. 2. Record reviewAn electronic correspondence, dated 9/17/25, from a heating, ventilation and air conditioning (HVAC) company to the administrator of the residen..

A licensure complaint, prompted by #CO40756, was completed on 8/20/25. A deficiency was cited. Based on observations, record reviews, and interviews, the residence failed to provide a physically safe and sanitary environment, affecting 107 current residents. Findings Include:1. ObservationsAn environmental tour of the residence on 8/20/25 from 10:00 to 10:45 a.m. revealed wasp nests above the main doors, bird nests on the roof and overhangs, and bird droppings accumulating on resident chairs and windows. Furthermore, there were missing and damaged window screens, a discarded and disassembled washer, broken pallets, and wooden boards. Additionally, two discarded propane tanks and a mattress were located near a shed that contained oxygen canisters, which were not secured in cradles. Sidewalks with rocks next to them had drop-offs of more than five inches. Resident #1' s room contained five green oxygen tanks that were also improperly stored. Furthermore, a door had been propped open with a rock, and the air conditioning system is not functioning adequately in several areas of the residence. 2. InterviewsOn 8/20/25 at approximately 10:00 a.m., Resident #3 reported that the portable air conditioning (AC) unit does not work. She added that she has had been using an extra fan to cool off her apartment and circulate the air. During the interview, Resident #3 requested to prop her door open to improve ai.. 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 7.10.1 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.18.9 The confidentiality of the resident record including all medical, psychological, and sociological information shall be protected in accordance with all applicable federal and state laws and regulations. Each resident or legal representative of a resident shall be allowed to inspect that resident ' s own record in accordance with Section 25-1-801, C.R.S. Upon request, resident records shall also be made available for inspection by the state long-term care ombudsman and local ombudsman pursuant to Section 26-11.5-108, C.R.S., Department representatives and other lawfully authorized individuals. Resident records shall contain, but not be limited to, the following items: (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s p..