Carillon at Belleview Station

A licensure complaint, prompted by #CO39668, was completed on 4/8/25. No deficiencies were cited. 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 7.11.15 In the event a resident is transferred to another health care entity for additional care, the assisted living residence shall arrange to evaluate the resident prior to re-admission or discharge the resident in accordance with the discharge procedures specified below.

A relicensure survey with complaints #CO31375 and #CO32337 was completed on 9/4/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure the medication administration record (MAR) contained accurate information, affecting one of twelve sample residents (#17) and one former resident (#24) whose medications were reviewed.Findings include:1. Residence PolicyThe residence' s Medication Administration policy dated 2/26/24 read in part, medications are to be listed and recorded on medication administrations records as pres.. Based on observation, interview and record review the residence failed to comply with authorized practitioner' s orders affecting one of fifteen sample residents (#17) and one former residents (#24). Findings Include:1. Resident #17 was admitted to the residence on 10/6/24 with a diagnosis of hypertension and unspecified dementia.A written practitioners order dated 8/7/24, directed the residence to administer miralax oral powder every three days for and .. Based on record review and interview, the residence failed to ensure health information records for residents were kept on site for at least three years following the termination of the residents stay, affecting one former resident (#24).Findings include:1. Reference Chapter VII regulations governing assisted living residences, part 18.8, requires resident records shall contain, but not be limited to, the following items: (C) Individualized resident care plan2. Rec.. Based on record review and interview, the residence failed to request, prior to hire, a name-based criminal history record check for each perspective staff member for two of four sample staff, (#4, #6) affecting 110 current residents.1. Record ReviewReview of the personnel files for Staff #6 revealed they were hired on 7/30/24. The personnel file contained signed orientation training documentation dated 7/31/24. However, the personnel file cont.. Based on record review, observation and interview the residence failed to ensure an up to date list of all staff who had a current certification in first aid and cardiopulmonary resuscitation (CPR) was maintained and posted in a visible and readily available at all times, affecting 110 current residents.Findings include:On 9/3/24 at 7:22 a.m., all staff CPR certifications and the list of all CPR certified staff was requested and provided. CPR certifications were provided for .. Based on record review, observation and interview, the residence failed to ensure potentially hazardous chemicals were stored in an area that was inaccessible to residents, affecting 23 current residents residing in the secure environment. Specifically, the residence failed to ensure all chemicals remained locked in the secure environment. On 9/3/24 there were 23 residents who resided in the secure environment of the residence. The kitchen shelves contain.. 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 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sa..

A complaint revisit was completed on 9/4/24 for all previous deficiencies cited on 2/10/22. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on observation, interview and record review the residence failed to comply with authorized practitioner' s orders affecting one of fifteen sample residents (#17) and one former residents (#24). Findings Include:1. Resident #17 was admitted to the residence on 10/6/24 with a diagnosis of hypertension and unspecified dementia.A written practitioners order dated 8/7/24, directed the residence to administer miralax oral powder every three days for and hold for loose stool.However the August and September 2024 MAR detailed staff administered the medication every other day instead of every three days. Staff administered the medication three times a week instead of every three days as directed from 8/7/24 to 9/3/24. 2. Former Resident #24 was admitted to the residence on 4/30/21 with diagnoses including dementia, type two diabetes, sleep apnea, mood disturbance, anxiety, and pulmonary hypertension. On 2/18/23 Resident #24 fell, bumped her head, went to the emergency room and was prescribed acetaminophen for pain.a. AcetaminophenAn emergency room discharge summary dated 2/18/23, revealed Resident #24 had been seen due to the injuries she had after a fall. The summary read in part, "your pain is most likely caused from a muscle strain and concussion from the fall." Further review revealed the practitioner ordered Resident #24 to alternate between 400 mg of ibuprofen and 650 mg of acetaminophen every six hours for optimal pain control. However, from 2/18/23 to 2/28/23 the MAR read the medication was placed on hold. The residence failed to provide a written practitioner order that confirmed the acetaminophen was placed on hold. Further review of the MAR revealed three staff (#15-#17) marked a code nine on the electronic MAR. The key portion of the MAR indicated that code nine meant, "other, see progress note." Further review of the progress notes provided revealed notes that read, "daughter requested that the med should be on hold."On 9/3/24 at 3:52 p.m.,the clinical director stated that she looked every..