Point of the Pines Gardens Assisted Living

A recertification survey with complaint #CO40089, #CO38821, #CO38529, and #CO38198 was completed on 8/26/25. Deficiencies were cited. Based on observation and interview, the facility (residence) failed to ensure members' (residents' ) right to privacy, including the right not to have one' s names or other confidential information posted in common areas for 102 current.Findings include:An environmental tour on 8/26/25 at 7:08 a.m. revealed two instances of public PHI disclosure:1. A mail basket hung in a main corridor outside the resident care coordinator ' s (RCC ' s) office contained discarded prescription packaging bearing resident names and other PHI. Residents were observed near this unsecured basket.2. Resident room doors were labeled with the first name, last initial, code status, and smoking status for each occupant.Federal regulation 45 C.F.R. § 160.103 defines such information (name, medical data) as Protected Health Information (PHI). Regulation 45 C.F.R. § 164.502(a) prohibits disclosure of PHI except as permitted or authorized.On 8/26/25 at 5:25 p.m., the Administrator agreed the exposed information was confidential PHI and acknowledged its .. Based on observation and interview, the facility (residence) failed to maintain a non-institutional environment for 102 current members (residents).Findings include:An environmental tour on 8/26/25 at 7:05 a.m. revealed multiple signs posted throughout common areas, including: "DO NOT TOUCH DIRECT TV BOX", "Do Not Hook Up Any Device to T.V. unless Supervised!", "Do NOT Touch!!!", and "Please keep window closed to help maintain the building temperature." Additional signs were posted throughout all common areas.On 8/26/25 at 2:50 p.m. and 3:30 p.m., announcements were made to residents and staff using an overhead paging system.On 8/26/25 at 5:25 p.m., the Administrator agreed that the posted signs and other institutional features did not promote a home-like environment. Based on observations and interviews, the facility (residence) failed to comply with the Colorado Clean Indoor Air Act, Section 25-14-204(1)(ff), C.R.S., for 102 current members (residents). (Cross-reference B0132)Findings include:1. Residence PolicyThe residence policy ALR/ACF policy and procedure disclosure form dated November 2023 read in part, smoking prohibitions and designated areas for smoking.2. ObservationsAn environmental tour at 9:00 a.m. revealed that residents were smoking outside of the smoking area within five feet of an entrance to the residence because the smoking area was flooded.3. InterviewsOn 8/26/25 at 9:13 a.m., the administrator stated, "The residents don' t follow the rules for smoking."On 8/26/25 at 4:01 p.m., the administrator stated, "The residents smoke by the doors." She acknowledged that she was aware of the regulation.

A relicensure survey with complaint #CO4088, #CO38819, and #CO38527, and #CO38197 was completed on 8/26/25. Deficiencies were cited. Based on observation and interview, the residence failed to ensure that opened or prepared refrigerated foods were date-marked with a "use by" or "discard by" date for 102 current residents.Findings include:An environmental tour on 8/26/25 at 7:10 a.m. of five communal resident refrigerators revealed multiple unmarked containers of food in each refrigerator.On 8/26/25 at 5:25 p.m., the Administrator stated she was aware of the undated food in the refrigerators and acknowledged the lack of date markings was non-compliant. She added she would discuss the issue in resident council meetings and add rules for the refrigerators to the residency agreement. Based on observation and interview, the residence failed to maintain grounds free of hazards for 102 current residents. (Cross-reference U2720) Findings include:An environmental tour on 8/26/25 at 8:30 a.m. revealed that the rear courtyard was flooded. The water covered the walking path and at least half of the designated smoking area, requiring residents to use alternate paths to access it. An additional environmental tour at 9:00 a.m. revealed that because the smoking area was flooded, residents were smoking outside of the smoking area, including within five feet of an entrance to the residence.On 8/26/25 at 8:40 a.m., Resident #11 stated the flooding was a problem.On 8/26/2.. Based on observation and interview, the residence failed to safeguard protected health information (PHI) from public disclosure for 102 current residents.Findings include:An environmental tour on 8/26/25 at 7:08 a.m. revealed two instances of public PHI disclosure:1. A mail basket hung in a main corridor outside the resident care coordinator ' s (RCC ' s) office contained discarded prescription packaging bearing resident names and other PHI. Residents were observed near this unsecured basket.2. Resident room doors were labeled with the first name, last initial, code status, and smoking status for each occupant.Federal regulation 45 C.F.R. § 160.103 defines such information (name, medic.. Based on record review, observations, and interviews, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 102 current residents. (Cross-reference U2512)Findings include:1. Residence PolicyThe residence policy ALR/ACF policy and procedure disclosure form dated November 2023 read in part, smoking prohibitions and designated areas for smoking.2. ObservationsAn environmental tour at 9:00 a.m. revealed that residents were smoking outside of the smoking area within five feet of an entrance to the residence because the smoking area was flooded.3. InterviewsOn 8/26/25 at 9:13 a.m., the administrator stated,.. 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 7.5.3 An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR 1011-1, Chapter 2, Part 4.2.(A) An assisted living residence shall investigate an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations.(1) Documentation regarding the investigation, including the appropriat..

A revisit survey was completed on 1/14/25 for all previous deficiencies cited on 8/21/24. 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 revisit survey was completed on 1/14/25 for all previous deficiencies cited on 8/21/24. 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 licensure revisit was completed on 8/21/24 for all previous deficiencies cited on 5/24/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 7/1/24. 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