Belleview Senior Living, the

A licensure complaint, prompted by #CO40818, was completed on 1/28/26. Deficiencies were cited. Based on interview and record review, the residence failed to provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities, affecting 88 current residents. Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(J) Complying with all applicable federal, state, and local laws concerning licensure and certification.b. Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records shall contain, but not be limited to, the following items:(B) Practitioner order;(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 physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.(E) Medica.. Based on record review and interview, 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 (MAR) contained accurate information, affecting one of two sample residents (#10) and one former resident (#8). Findings include:Resident #10 was admitted to the residence on 7/10/23.A written practitioner' s order dated 1/16/26 directed the residence to administer sertraline 50 mg once daily. However, the January 2026 electronic medication administration record (eMAR) for Resident #10 read sertraline 25 mg once daily. On 1/27/26 at approximately 3:15 p.m., Staff #9 said the sertraline 50 mg signed practitioner' s order was not uploaded to Resident #10' s eMAR. Staff #9 said she believed that Resident #10 had only been given 25 mg of sertraline from 1/16/26 to 1/19.26. Staff #9 said the director of nursing (DON) was responsible for updating resident eMAR' s when new orders were received. On 1/28/26 at 11:48 a.m., the DON said that the sertraline 50 mg signed practitioner' s order was received on 1/16/26, but was not uploaded into Resident #10' s eMAR until 1/20/26 because the residence did not have a nurse working the weekend. She added only nurses were allowed to enter new medication orders in residents' eMARs. The DON said if t..

A relicensure survey with complaint #CO40136 was completed on 5/21/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each care plan was updated to reflect changes in the staff approach to meet resident needs, affecting one of four sample residents (#3) in a secure environment. Specifically, Resident #3 fell approximately nine times from 2/21 to 5/13/25. Five of the falls resulted in either pain or injury. Three of the falls on 3/8, 4/26 and 5/12/25 resulted in Resident #3 being sent to the emergency departme.. Based on interview and record review, the residence shall evaluate a resident when the resident expresses the desire to move out of a secure environment, and contact the practitioner and local ombudsman, affecting one of one resident who expressed the desire to move out of the secure environment (#1). (Cross-reference T3050)Findings include:Resident #1 moved directly into the secure environment portion of the residence on 6/10/24.The care plan f.. Based on observation, record review and interview, the residence failed to ensure all shower floors had proper safety features to prevent slips and falls, affecting three of four resident bathroom shower floors in the secure environment (#2, #3, #4). Specifically, on 5/8/25 Resident #4 slipped in the shower, landed on his tailbone and expressed pain. Staff #1, who witnessed the fall, said Resident #4 fell in the shower and there were no proper safety features to prev.. Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment that included an evaluation by a licensed practitioner that described the resident' s cognitive deficits that contributed to wandering, compromised safety awareness and detailed information from the resident' s family that revealed a history and pattern of reduced safety awareness and wanderin.. Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment, affecting three of four sample residents (#1, #3, #4). (Cross-reference T3044)Findings include:Resident #1 was admitted directly to the secure environment portion of the residence on 6/10/24. There was no evidence provided that determined the residence re-assessed Resident #1 every six months for her cont.. Based on record review, observations, and interview, the residence failed to document and implement effective actions that were to be taken by staff to prevent reoccurrence of falls for two of two sample residents who fell (#5, #8). Specifically, Resident #8 was admitted to the residence on 12/16/24 with diagnoses including generalized idiopathic epilepsy and epileptic syndromes, a personal history of transient ischemic attack and cerebral infarction w.. 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. 12..

A licensure complaint, prompted by #CO33431, #CO34114, and #CO35388, was completed on 4/29/24. Deficiencies were cited.A change of ownership occurred on 10/12/22. Based on interview and record review, the residence failed to ensure personnel files included written documentation of orientation and training and results of background checks and follow up for four of five staff (#1, #3-#4, #6), affecting all current residents.Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or suppleme.. Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed or was reported to them, affecting two of six current sample residents (#4 and #5).Findings include:1. Resident #5 was admitted to the residence on 1/31/23, with diagnoses that included Alzheimer' s disease and osteoporosis.A late-entry progress note .. Based on observation, interview and record review, the residence failed to ensure each staff member completed fall prevention and lift assistance training for two of four sample staff (#3 and #4) affecting 78 current residents. Findings include:1. ObservationOn 4/25/24 from 2:00 p.m. to 5:00 p.m., Staff #3 was observed working with residents in the secure environment. 2. Record ReviewThe personnel file for Staff #3 revealed she was hired as a qualified medicatio.. Based on observation, interview and record review, the residence failed to ensure each staff member completed the required orientation and training competencies for two of four sample staff (#3 and #4) affecting 78 current residents. Findings include:1. ObservationOn 4/25/24 from 2:00 p.m. to 5:00 p.m., Staff #3 was observed working with residents in the secure environment. 2. Record ReviewThe personnel file for Staff #3 revealed she was hired as a qualified med.. Based on observation, interviews and record review, the residence failed to implement a fall management program detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance and providing staff training related to fall prevention, affecting one of six sample residents (#5).Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences.. Based on observation, record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for five of five sample staff (#1-#4, #6), affecting all current residents.Findings include:1. References a. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees wh.. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents for five of five sample staff (#1-#4, #6), affecting six of seven sample residents (#1-#7). Findings include: 1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code, " ... individuals receiving care and services from p..