Belleview Heights Alzheimer's Special Care Center

A revisit survey was completed on 1/15/25 for all previous deficiencies cited on 8/8/24. 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 complaint revisit was completed on 8/8/24 for all previous deficiencies cited on 6/20/23. Deficiencies were cited. Tag 1604 was not cited in the previous event; however, the deficiency was included in the previous event' s informational 9999 tag.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting three of five sample residents whose medications were reviewed (#14, #16 and #17).This deficiency was cited previously during a state licensure complaint on 6/20/22. 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 Medication Administration policy, dated 7/15/24, read in part: "The administration of medication shall be as ordered by the resident' s (practitioner)."2. Resident #14 was admitted to the residence on 7/10/24 with a diagnosis of Alzheimer' s disease. PradaxaA written practitioner' s order, dated 7/11/24, directed the residence to administer pradaxa 150 mg twice daily. However, the July and August 2024 electronic medication administration records (eMARs) read the residence failed to administer the medication for a total of eight missed doses. Potassium chlorideA written practitioner' s order, dated 7/11/24, directed the residence to administer potassium chloride 10 MEQ twice daily. However, the July 2024 eMAR read the residence failed to administer the medication for a total of eight missed doses. ZenpepA written practitioner' s order dated 7/1.. Based on record review and interview, the residence failed to, on a quarterly basis, audit the controlled substance list, medication error reports and medication disposal records, affecting 49 current residents. Findings include:On 8/7/24 at 9:11 a.m., the administrator provided medication audits of electronic medication administration records (eMARs) for three quarters prior to the onsite visit. However, there was no evidence the administrator audited controlled substance lists, medication error reports and medication disposal records. On 8/8/24 at approximately 9:30 a.m., the administrator stated she was unaware of the requirement to conduct quarterly medication audits of the controlled substance lists, medication error reports and medication disposal records. The administrator stated she thought she only was required to audit eMARs.

A relicensure revisit was completed on 8/8/24 for the previous deficiencies cited on 9/20/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on interviews and record review, the residence failed to comply with conditions imposed by the department on the license, affecting 49 current residents. Findings include:The department completed a re-licensure survey on 6/20/23. The residence failed to implement a fall management plan and was cited tag Q1180 at a C level for harm.The department determined the residence violated statutory and regulatory requirements necessitating that the department impose an intermediate condition on 11/27/23. The residence was required to pay a civil fine of $1000 by 12/27/23.The residence did not appeal the intermediate condition.Review of the department database revealed the residence had not yet paid the civil fine as of 8/8/24.A department representative confirmed that the residence had not paid the civil fine as of 8/8/24.On 8/8/24 at 9:30 a.m., the administrator stated she was aware of the fine and assigned the previous business office manager to pay the fine. She was unaware that the residence failed to pay the fine associated with the last survey. Based on observation and interview, the residence failed to ensure there was a list of all staff who had a current certification in first aid and cardiopulmonary resuscitation (CPR) in a visible location and readily available at all times, affecting 49 current residents. This deficiency was previously cited during a state licensure survey on 9/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:An environmental tour on 8/7/24 from approximately 7:00 a.m. to 12:00 p.m., revealed no evidence of a visible list of staff with current CPR and first aid certifications. On 8/7/24 at approximately 1:30 p.m., a list of CPR/first aid certified staff was provided. However, the list was dated the day of the onsite investigation and was not updated to include Staff #8-#10, who were CPR and first aid certified. On 8/7/24 at 7:39 a.m., Staff #7 stated she had not noticed a list of CPR and first aid certified staff in a visible location and readily available at all times within the residence. On 8/7/24 at 8:30 a.m., the business office manager stated she had a list of staff who were CPR and first aid certified that she was editing; however, it was only posted in the business office and she had never seen a list -visible and readily available in the secure environment of the resid..

A relicensure survey with complaints #CO35664 and #CO36669 was completed on 8/8/24. Deficiencies were cited. Based on observation and interview, the residence failed to ensure there was a list of all staff who had a current certification in first aid and cardiopulmonary resuscitation (CPR) in a visible location and readily available at all times, affecting 49 current residents. Findings include:An environmental tour on 8/7/24 from approximately 7:00 a.m. to 12.. Based on record review and interview the residence failed to have written documentation of first aid and cardiopulmonary resuscitation (CPR) certification in staff personnel files, affecting nine of 11 staff members (#5-#7, #9, and #11-#15).Findings include:On 8/7/24 at approximately 8:00 a.m., first aid certifications for all staff were req.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting three of five sample residents whose medications were reviewed (#14, #16 and #17).Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated 7/15/24, read i.. Based on record review and interview, the residence failed to develop and implement a visitation policy which described any restriction or limitation necessary to ensure the health and safety of residents, staff and visitors, affecting 49 current residents.Findings include:On 8/7/24 at approximately 8:00 a.m., the residence' s visitation polic.. Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 49 current residents.Findings include:On 8/7/24 at approximately 8:00 a.m., the residence' s involuntary discharge grievance policy was requested but not pro.. Based on record review and interview, the residence failed to develop and implement defined procedures to prevent the spread of influenza, affecting 49 current residents.Findings include:On 8/7/24 at approximately 8:00 a.m., the residence' s policy and procedure to prevent the spread of influenza was requested, but not provided.On 8/8/24 at 9:.. Based on record review and interview, the residence failed to, on a quarterly basis, audit the controlled substance list, medication error reports and medication disposal records, affecting 49 current residents. Findings include:On 8/7/24 at 9:11 a.m., the administrator provided medication audits of electronic medication administration records (.. Based on record review, observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting three of seven sample residents (#15, #18, .. 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 2.12.2.2 Each facility shall assign at least one (1) staff member responsible for the site manag..

A relicensure survey was completed on 9/20/23. Deficiencies were cited. Based on interviews and record review, the residence failed to hold regular family council meetings at least quarterly, affecting 42 current residents in the secure environment.Findings include:On 9/20/23 at 7:15 a.m., the last three quarters of family council meetings were requested. However, no such documentation was provided.On 9/20/23 at 9:59 a.m., the memory care director (MCD) stated family council meetings were not provided because they were conducted by the former life enrichment director (LED) and she was unable to obtain access to the documentation she had for the meetings. The MCD further stated the meetings had not been quarterly since she could not remember that last time one was held. On 9/20/23 at 4:55 p.m., the legal representative for Resident #9 stated she had never recei.. Based on observation, record review and interview, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting one of two sample residents who fell in the secure environment (#9).Specifically, Resident #9 had a fall on 7/17/23 and sustained a cut on his forehead. On 8/6/23 Resident #9 sustained a fall with a cut over his right eyebrow and bruising to his left side. On 8/17 and 8/19 Resident #9 fell again without injury. However, the residence failed to update Resident #9' s care plan (which was the same as the residence' s assessment) to include individualized approaches necessary to address the resident' s fall risk after Resident #9' s first .. Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid and/or cardiopulmonary resuscitation (CPR), so that the information was readily available to staff at all times, affecting 42 current residents. Findings include:On 9/20/23 at approximately 7:30 a.m., an environmental tour of the residence revealed there was no list of all staff who had current certification in first aid and/or CPR in a visible location so the information was readily available to staff at all times. On 9/20/23 at approximately 9:34 a.m., the business office manager (BOM) stated he had a list of CPR and first aid certified staff on his computer. The BOM acknowledged there was not a list of CPR and first aid certified staff posted in the residence... 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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident ' s condition changes from baseline status.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mod..