Peakview Assisted Living and Memory Care

A revisit survey was completed on 5/6/25 for previous deficiencies cited on 3/5/25. The agency is in compliance with all regulations surveyed. 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 3/5/25 for all previous deficiencies cited on 9/20/23. A deficiency was cited. Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting one of four sample residents (#38) and one former resident (#45). This deficiency was cited previously during a licensure revisit 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: 1. Residence PolicyThe residence' s undated Medication Administration policy read in part that the residence administered medications per the practitioner' s order. 2. Resident #38 was admitted to the residence on 6/19/23 with a diagnosis including chronic gastroesophageal reflux disease and absence of other specified parts of the digestive tract, postnasal drip, hyperlipidemia, and hypertension.A written practitioner' s order, dated 11/24/24, directed the residence to administer pantoprazole sodium 40 mg tablet once daily. However, a January and February 2025 medication administration record (MAR) for Resident #38 read that the residence failed to administer the medication because it was unavailable on 1/28, 1/29, 1/30, 1/31, and 2/1/2025 for a total of five missed doses. The January and February 2024 MAR revealed the residence failed to administer the following medications as well:Cetirizine HCIVancomycinLosartanAlpha lipoic acidMetronidazole3. Evidence revealed similar deficient practice for Former Resident #45. 4. InterviewsOn 3/5/25 at 8:20 a.m., Staff #31 stated it was the job of the qualified medication administration person (QMAP) to reorder the medication via fax. She stated that the practitioners failed to sign orders, and the pharmacy would not fill them. She stated that the residence failed to have all medications available for all residents. On 3/5/25 at approximately 3:00 p.m., the administrator, director of nursing (DON), and regional operations director acknowledged failure to have medications available for all residents...

A licensure complaint, prompted by #CO35829, #CO36043, #CO37352, #CO38645 and #CO39294, was completed on 3/5/25. Deficiencies were cited. Based on interview and record review the residence failed to ensure the care plan for each resident in a secure environment included a description of the resident ' s known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, affecting one former resident (#45) and one current resident (#41). (Cross-Reference S1318)Findings include:1. Residence policyThe residence' s posted Resident Rights read, in part: Residents had the right to privacy and confidentiality, including the right to have visitors anytime and the right to private, consensual sexual activity. 2. Resident #41 was admitted to the residence on 10/11/24 with a diagnosis including dementia. A progress note dated 2/4/25 for Resident #41 read "Memory Care Manager (MCM) spoke with daughter regarding sexual behavior, daughter state to not inform resident' s wife. MCM did educate daughter that due to resident' s wife being Power of Attorney (P.. Based on record review and interview, the residence failed to observe residents' right to private, consensual sexual activity, affecting one current resident (#41) and one former resident (#45). (Cross-Reference S3060) Findings include:1. Residence PolicyThe residence' s posted Resident Rights read, in part: Residents had the right to privacy and confidentiality, including the right to have visitors anytime and the right to private, consensual sexual activity. 2. Former Resident #45 was admitted to the residence on 12/14/24 with a diagnosis including dementia.A progress note dated 2/4/25 for Former Resident #45 read, "POA (power of attorney) was also notified of the resident having sexual relations with another resident that were consensual. Reviewed the situation that happened and what the staff did at the time the situation was witnessed. Reviewed the care plan interventions that will be put into place to continue monitoring the situation. POA reported that she did not feel comfortable with the relations and asked to be kept upd.. 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 7.14.29 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.16.5 Staff preparing or serving food shall complete recognized food safety training and maintain evidence of completion on site. Food safety training shall be provided by recognized food safety experts or agencies, such as the Department' s Division of Environmental Health and Sustainability, local public health agencies, or Colorado State University Extension Services. At a minimum, a certificate of completion of the available online modules is sufficient to comply ..