Village at Belmar

A licensure complaint, prompted by #CO41277, was completed on 12/17/25. Deficiencies were cited. Based on observation and interview, the residence failed to have a secure outdoor area that was independently accessible without staff assistance, affecting 23 residents in the secure environment. Findings include:1. ObservationOn 12/17/25 at approximately 9:00 a.m., a tour of the secured environment revealed that all exterior doors were locked, preventing residents from accessing the secure outdoor area independently without staff assistance. Additionally, one door leading to the outdoor environment was obstructed by a large plant terrarium.On 12/17/25 at approximately 9:00 a.m. to 2:00 p.m., all of the doors that led to the secure outdoor area remained locked; therefore, prohibiting independent access for the residents who attempted to go outside.2. InterviewsOn 12/17/25 at approximately 9:23 a.m., Staff #1 stated that, in the memory care environment, the doors were locked at all times and residents did not have independent access to the outdoor area, requiring them to request staff assistance to go outside. She further stated that some residents enjoyed the outdoor area and frequently asked to go outside.On 12/17/25 at approximately 2:15 p.m., the executive director stated that he was unaware that the doors in the secured environment leading to the outdoor area were locked and that one of the doors was obstructed by a larg.. Based on record review, observation and interview the residence failed to have documentation of routine monthly testing of all equipment and devices used to secure the environment, affecting 23 current residents in the secure environment.Findings include:1. Record ReviewOn 12/17/25 at approximately 1:30 p.m., the maintenance director provided a work order history in response to a request for documentation of routine monthly testing of all equipment and devices used to secure the memory care environment. The work order history did not show that routine monthly testing had been conducted.2. ObservationOn 12/17/25 at 9:23 a.m., during an environmental tour, the Health Services Director (HSD) attempted to exit the memory care unit; however, the fob and access system did not function properly. The only way to exit the unit was for a person to manually open the door from the outside of the memory care unit.3. InterviewOn 12/17/25 at approximately 1:47 p.m., the maintenance director stated that the residence did not have documentation demonstrating that monthly testing of all equipment and devices used to secure the environment had been routinely conducted.On 12/17/25 at approximately 2:00 p.m., the executive director acknowledged that the residence did not have documentation of monthly device checks in the memory care unit and ..

A relicensure survey with complaint #CO39721 and #CO41017 was completed on 10/8/25. 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 7.7.12 Personnel files for current employees and volunteers shall be readily available onsite for Department review.7.13 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 service and date duties commenced;(C) Orientation and training, including, but not limited to the following, as applicable:(1) Frst aid and CPR certification,(2) Proof of portable training(s) accepted by the assisted living residence, including documentation of the acceptance conditions at Part 7.9(D) being met.(D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable;(E) Results of background checks and follow up, as applicable; and(F) Tuberculin test results or proof of a portable test compliant with Part 7.7, if applicable.(G) Documentation of initial dementia training and continuing education for direct-care staff members:(1) The residence shall maintain documentation of each employee ' s completion of initial dementia training and continuing education. Such records shall be available for inspection by representatives of the Department.(2) Completion shall be demonstrated by a certificate, attendance roster, or other documentation.(3) Documentation shall include the number of hours of training, the date on which it was received, and the name of the instructor and/or training entity.(4) Documentation of the satisfactory completion of an equivalent training as defined in sub-part 7.9(B)(2)(b) and as required in the criteria for an exception discussed in sub-part 7.9(B)(4), shall include the information required in this sub-part 7.13 (G)(2) and (3).(5) After the completion of training and upon request, s..

A licensure complaint, prompted by #CO35238, #CO36931, #CO36982 and #CO37384, was completed on 9/26/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure staff observed a resident' s right to be free of physical and emotional abuse and intimidation, affecting one of six sample residents (#7) and one former resident (#9). (Cross-reference S1410, S3030)Specifically, Former Resident #9 was assaulted, emotionally abused, and intimidated by Former Resident #10 and Resident #1 in December 2023, March, June and July 2024. As a result of the assaults, emotional abuse and intimidation, Former Resident #9 expressed fear and pain.Findings include:1. Resident.. Based on interview and record review, the residence failed to investigate allegation of abuse of residents, document the investigation process and protect the resident from future abuse, affecting one former resident (#9). (Cross-reference S1322)Findings include:1. Residence PolicyThe residence' s Abuse, Neglect and Exploitation policy, dated 2/26/24 read, in part, "Mistreat is defined in Colorado as an act or omission which threatens the health, safety, or welfare of an at-risk adult or which exposes the adult to a situation or condition that poses ... bodily injury.. Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment, affecting two of four residents sampled in the secure environment (#1, #4) and one of two former residents sampled in the secure environment (#10).Findings include:1. Resident #1 was admitted to the residence on 11/30/21.An Evaluation for a Secure Environment form in Resident #1' s record, dated 12/7/21, approximately one week after Resident #1 moved into the residence revealed the following:The document .. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of three sample residents (#7).Findings include:1. References and Residence Policya. According to the Occurrence Reporting Manual, dated May 2018, "Any occurrence involving physical...abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility.Section 25-1-124(2)(d), C.R.S. Two elements needed: Intent OR Knowingly OR Reck.. Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment affecting one of four current residents sampled in the secure environment (#1) and two of two former residents sampled in the secure environment (#9, #10). (Cross-reference S1322, S1410)Findings include:1. Resident #1 was admitted to the residence on 11/30/21.An assessment for Resident #1, dated 7/24/24 did not include documentation to support that a re-assessment was completed on Resident #1 for his continued need for a secure en.. 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 7.13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minim..