Village of Bear Creek, the

A revisit survey was completed on 2/26/25 for all previous deficiencies cited on 10/30/24. 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 revisit was completed on 10/30/24 for the previous deficiencies cited on 6/13/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.The residence consisted of four seperate buildings. Building one through four had current residents. Building four was a secure environment. Based on interview and record review, the residence failed to update comprehensive assessments whenever a resident' s condition changed from baseline status, affecting one sample resident (#32). (Cross-reference S0861)This deficiency was cited previously during a state licensure survey on 6/13/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #32 was admitted to the residence on 5/16/23 with diagnoses including chronic personality disorder and cognitive communication deficit. Progress notes dated 10/12/24-10/16/24, read in part:On 10/12, Resident #32 expressed suicidal thoughts, that she was hallucinating, and demonstrated aggressive behaviors.On 10/14, the resident was admitted to the hospital yesterday. The health and wellness director (HWD) spoke to the hospital, and the hospital plans to discharge the resident today. The hospital completed lab work and a psychiatric evaluation and determined the resident was safe to return to the residence. On 10/15, the resident entered other residents' rooms without permission and became verbally aggressive when staff asked her to exit the rooms. On 10/16, the resident reported seeing people in her apartment. The hospital determin.. Based on record review and interview, the residence failed to request, prior to hire, a named-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for three of three sample staff (#37-#39), affecting 67 current residents. Findings include:On 10/29/24 and 10/30/24, Staff #37-#39 worked at the residence, providing care and services to residents. Personnel records for Staff #37-#39 read in part as follows:Staff #37 was hired on 2/13/24.Staff #38 was hired on 11/5/03.Staff #39 was hired on 1/23/23. The national and state background check records did not contain a criminal history record check conducted by the CBI for Staff #37-#39. On 10/30/24 at 10:36 a.m., the administrator stated that the residence could not provide evidence that the background check company conducted a criminal history record check by CBI. She added that the residence' s background check company conducted state and national background checks but did not stipulate the checks for Staff #37-#39 were conducted by CBI. The administrator could not state why this deficiency was not corrected, as she affirmed she did not work at the residence during the last visit.

12.2.b-12.2.2 Infection Control Officer Each facility shall assign at least one (1) staff member responsible for the site management of the facility' s Infection Prevention and Control Program and training. This individual shall be responsible for the following: 4-Ensuring the facility complies with Department reporting requirements related to inf.. A relicensure survey with complaint #CO36858 was completed on 10/30/24. Deficiencies were cited. The residence consisted of four seperate buildings. Building one through four had current residents. Building four was a secure environment. Based on interview and record review, the residence failed to update comprehensive assessments whenever a resident' s condition changed from baseline status, affecting one sample resident (#32). (Cross-reference S0861)Findings include:1. Resident #32 was admitted to the residence on 5/16/23 with diagnoses including chronic p.. Based on observation, interviews, and record review, the residence failed to ensure that food handlers always washed their hands, affecting 18 current residents who resided in building three. (Cross-reference S001)Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 16.6, requires staff t.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting two of six sample residents (#31, #33).Findings include:1. Resident #33 was admitted to the residence on 12/30/22 with a diagnosis of Alzheimer' s disease with late onset.a. Zenpep A written pr.. 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 resident' s stay, affecting two former residents (#40, #41). Findings include:The residence' s Documentation Retention policy, dated 6/1/24, read in part that the res.. Based on record review and interview, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, affecting two of three sample residents (#32, #35).Findings include:1. Resident #32 was admitted to the residence on 5/16/23. The Resident Activity Report dated September 29.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 67 current residents. (Cross-reference S1146)Findings include:The Resident Agreement, dated 10/24/22, read in part that the residence may terminate the agreement upon thirty days' .. Based on record review and interview, the residence failed to hold quarterly family meetings in the residence' s secure environment (SE), affecting 17 current residents. Findings include:On 10/29/24 and 10/30/24, documented evidence that family council meetings were scheduled and communicated with families was requested; however, the residenc.. Based on record review and interview, the residence failed to request, prior to hire, a named-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for three of three sample staff (#37-#39), affecting 67 current residents. Findings include:On 10/29/24 and 10/30/24, Staff #37-#39 worked at the residence, p.. 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 2.2.9.6 Each licensee shall submit to the Department a letter of intent of any change in the in..

A relicensure survey and complaint revisit was completed on 10/30/24 for all previous deficiencies cited on 6/13/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.The residence consisted of four seperate buildings. Building one through four had current residents. Building four was a secure environment. Based on a record review and interview, the residence failed to provide an enhanced care plan for one of three sample residents (#37) who lived in a secure environment (SE). This deficiency was cited previously during a state licensure survey on 6/13/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #37 was admitted to the residence SE on 2/12/24 with a diagnosis of dementia.Progress notes from 10/3- 10/25/24 read as follows:On 10/3, R.. Based on interview and record review, the residence failed to update comprehensive assessments whenever a resident' s condition changed from baseline status, affecting one sample resident (#32). (Cross-reference S0861)This deficiency was cited previously during a state licensure survey on 6/13/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #32 was admitted to the residence on 5/16/23 with diagnoses including chr.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting two of six sample residents (#31, #33).This deficiency was cited previously during a state licensure survey on 6/13/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #33 was admitted to the residence on 12/30/22 with a diagnosis of Alzheimer' s disease with late onset.a. Zenpep A w.. Based on record review and interview, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, affecting two of three sample residents (#32, #35).This deficiency was cited previously during a state licensure survey on 6/13/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #32 was admitted to the residence on 5/16/23. The Resident Activity Repo.. Based on record review and interview, the residence failed to hold quarterly family meetings in the residence' s secure environment (SE), affecting 17 current residents. This deficiency was cited previously during a state licensure survey on 6/13/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 10/29/24 and 10/30/24, documented evidence that family council meetings were scheduled and communicated with families was requested; however, the.. Based on record review and interview, the residence failed to request, prior to hire, a named-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for three of three sample staff (#37-#39), affecting 67 current residents. Findings include:On 10/29/24 and 10/30/24, Staff #37-#39 worked at the residence, providing care and services to residents. Personnel records for Staff #37-#39 read in part as follows:Staff #37 was hired on 2/13/24.Staff #38 was hired on 11/5/03.Staff #39 was hired on 1/23/23. The national and state background check..

A licensure revisit was completed on 6/13/23 for all previous deficiencies cited on 7/28/22. Deficiencies were cited Based on interview and record review the residence failed to investigate allegations of abuse affecting 11 residents in the secure environment. (Cross reference Q1312)Findings include:1. References and Residence Policya. The residence' s Elder Abuse, Neglect and Exploitation policy, dated 1/13/23, read in part: Upon notice of reported, observed, suspected, or at imminent risk of any form of abuse a) appropriate protections for the resident would be immediatel.. Based on interview and record review the residence failed to obtain a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for contracted staff, affecting 67 current residents.Findings include:On 6/8/23, the residence had no evidence a criminal history record check conducted through CBI had been completed for Staff #23-#32 (contracted staff). The residence' s staff schedule, dated 5/28-6/8/23, was reviewed and.. Based on interview and record review, the residence failed to ensure care plans detailed specific person service needs along with staff tasks necessary to meet those needs affecting five of six sample residents (#11,#21-#24). (Cross-reference Q1146)Findings include:1. Residence PolicyThe residence' s undated Resident Care Plan policy read in part: Each resident care plan shall reflect the most current assessment information, promote choice, mobility, indep.. Based on interview and record review, the residence failed to update comprehensive assessments whenever a resident' s condition changed from baseline status affecting two of three sample residents in the secure environment (#11, #21). (Cross-reference Q1150, Q2960)Findings include:1. Residence Policya. The residence' s undated Comprehensive Resident Assessment policy read in part: Information from the comprehensive assessment shall be use.. Based on observation, interview and record review the residence failed to ensure there was sufficient staff in number to help residents in need of assistance, affecting 67 current residents. (Cross-reference tag 2960) Findings include:1. Residence PolicyThe residence' s Staffing Plan and Duties policy, dated 1/13/23, read in part: The residence would maintain a staffing plan to meet the needs of the residents. Staff should have been sufficient in number to hel.. Based on observation, record review and interview, the residence failed to ensure out of the ordinary events and issues were documented in progress notes, affecting two of seven sample residents (#22, #25)This deficiency was cited previously during a licensure complaint completed on 7/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings includ.. Based on record review and interview the residence failed to comply with Colorado Adult Protective Services Data System, affecting seven of seven sample residents (#11, #14, #19, #21, #22, #24 and #25).Findings Include:1. Referencesa. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, "... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse..