Retreat at Sunny Vista, the

A licensure complaint, prompted by #CO40666 was completed on 2/24/26. One deficiency was cited. Based on interview, investigation, and record review, the residence failed to ensure residents had a right to live free from restraint and involuntary confinement, affecting 28 current residents who resided in the residence' s memory support unit.Specifically, Resident #6 stated she was in the memory support unit from November 2023 to May 2025 against her will. She stated her daughter was her power of attorney and signed off on paperwork that read the resident required a secure environment due to wandering and exit seeking. She stated being confined in the memory support area behind an alarmed door made her have suicidal ideations and feel mentally distraught.Findings include:An environmental tour on 2/24/26 from 10:30 to 4:00 p.m. revealed the first floor of the residence had a memory support unit. Anytime the door leading from assisted living to the memory support unit was opened from either side, an alarm would sound until staff turned it off. The alarm sounded more than 10 times in the first hour of being onsite and continued to sound throughout the onsite.Resident #6 was admitted to the residence on 11/29/23 with diagnoses including frontal lobe dementia.On 2/24/26 at 10:41 a.m., Resident #6 stated during her residency in the memory support her movement was restricted; she felt could not leave the memory support which resulted in her feeling she was in a prison, confined and mentally distraught. She also stated she was aware of her surroundings and understood that "she did not fit in with the other residents" in the section of memory support due to her cognition.. She also stated that this sitution caused her to develop a sever depression along with suicidal ideation.A psychiatric assessment was completed twice in May 2025 for 12 hours each that revealed the resident was of sound mind and did not require a secure environment or memory support. Resident #2 was admitted to the residence on 3/31/23 with diagnoses including dementia and Alzheimer' s disease. A care plan dated 4/28/25, read in part "Monitor me for signs ..

A revisit survey was completed on 2/26/25 for all previous deficiencies cited on 9/27/24. 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 complaint, prompted by #CO37125, #CO37339 and #CO37543, was completed on 9/27/24. Deficiencies were cited. Based on interview and record review the residence failed to have a roster readily available affecting 25 current residents.Findings include:On 9/18/24 at approximately 8:30 a.m., the resident care coordinator (RCC) provided the resident roster with the resident names and room numbers; however, it failed to include a diagram showing the room locations and emergency contacts.On 9/18/24 at approximately 9:45 a.m., the RCC provided another version of the r.. 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 former residents (#6, #7). (Cross-reference S1410)Findings include:1. Record ReviewFormer Resident #7 was admitted to the residence on 6/14/24 with diagnosis of dementia, bacteremia including unstaged ski.. Based on observation, record review and interview, the residence failed to ensure a correct name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire for four current sample staff (#1-#4) affecting 25 current residents and three former residents (#5-#7). Findings include:1. ObservationsOn 9/18/24 from 7:00 a.m. to 10:00 a.m., Staff #1 and #2 was obs.. Based on record review and interview , the residence failed to ensure that each staff member met the dementia training requirements in 7.9(B), affecting 25 current residents and three former residents (#5-#7). Findings include:On 9/18/24 at approximately 1:59 p.m., personnel files for Staff #1-#3 provided by the executive director revealed no evidence that the direct care staff members met the dementia training requirements in part 7.9(B).On 9/19/24 at ap.. Based on record review and interview, the residence failed to ensure Resident #5' s record contained documentation of the actions taken by staff and the residence' s efforts to prevent the re-occurrence of falls and lift assist training for staff, affecting 25 current residents and one former resident (#1). (Cross-reference S1192, S3072)Findings include:1. Residence Policy a. The residence' s Falls policy, dated December 2022, read in part: "Falls will have follow-up docum.. Based on record review and interview, the residence failed to ensure staff were trained to provide lift assistance when appropriate instead of relying on emergency medical responders, specifically the failure to do an evaluation post fall caused harm, affecting one former resident (#5). (Cross-reference S3072)Specifically, Former Resident #5 fell on 9/7/24 and sustained a hip fracture. However, the residence failed to evaluate the resident prior to requesting the l.. Based on record review and interview, 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 25 current residents. Findings include:On 9/18/24 at 8:20 a.m., 9:35 a.m., 11:00 a.m., 12:00 p.m., 2:00 p.m., and 4:53 p.m., the staff schedule, last three months of call light response times, incident reports, the communication log in the residen.. 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 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties;(B) Date of hire or acceptance of volunteer..

A licensure complaint, prompted by ##CO34081, #CO34813, #CO34821, was completed on 2/7/24. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure the residents were observed the right to be treated with dignity and respect, affecting of one of seven sample residents (#1). (Cross reference Q410 and Q1360). Findings include:1. Reference and Residence Policya. According to Depend Care, "depends are briefs that are designed for both bladder and bowel incontinence" Depend Care, retrieved from: https://www.dependcare.com.au/.. Based on interviews and record review, the residence personnel failed to report suspected sexual abuse of at-risk residents to law enforcement within 24 hours of discovery, affecting 64 current residents. (Cross reference Q1312 and Q1360)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as any person who is 70 years of age or older, or any person who is 1.. Based on observation, interview and record review the residence failed to either directly or indirectly through a resident agreement provide personal services and a safe and sanitary environment, affecting 64 current residents. (Cross reference Q1620)Findings include:1. Residence Policy and Referencesa. Chapter VII regulations governing assisted living residences, defines personal services as those services that an assisted living residence and its staff pr.. Based on observation, record review and interview, the residence failed to ensure bed linens were cleaned at least weekly to meet individual resident needs, affecting one of seven sample residents (#5). (Cross reference Q1110)Findings include:The residence' s Resident Agreement, dated March 2022, read in part, "we will launder your personal clothing, bed linens and bath linens on a weekly basis in accordance with the laundry schedule ... we.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of five sample residents (#3, #4, #5) whose medications were reviewed, and one former resident (#9). (Cross reference Q1510 and Q1522)Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated November 2023, read in part, "the community provides medicatio.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was completed for each resident along with each of their signatures and, if used, their initials, affecting two of five sample residents (#1, #3) whose medications were reviewed and one former resident (#9). (Cross reference Q1468 an.. Based on record review and interview, the residence failed to ensure that the resident' s legal representative was promptly notified of a resident' s pattern of refusal, affecting one of five sample residents (#3). (Cross reference Q1468 and Q1510)Findings include: Resident #3 was admitted to the residence on 11/29/23 with diagnoses that included frontotemporal dementia, hypothyroidism and chronic kidney disease.Power of attorney (POA) paperwork signed 9/1.. Based on record review and interview, the residence failed to investigate all allegations of abuse in accordance with regulation and their written policy, affecting 64 current residents. (Cross-reference Q410 and Q1312)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of resi..