BELLEVIEW SENIOR LIVING, THE

A revisit survey was completed on 5/4/26 for all previous deficiencies cited on 1/28/26. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO41896 and #CO41592, was completed on 3/18/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40818, was completed on 1/28/26. Deficiencies were cited.

Based on interview and record review, 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 88 current residents. Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(J) Complying with all applicable federal, state, and local laws concerning licensure and certification.b. Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records shall contain, but not be limited to, the following items:(B) Practitioner order;(C) Individualized resident care plan(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs;(1) The assisted living residence shall 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.(E) Medication Administration Record;(F) Documentation of on-going services provided by external service providers including, but not limited to, caregivers, essential caregivers, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and care providers. 2. Record ReviewOn 1/27/26 at 10:00 a.m., The following records were requested by the department:Resident records for Resident #1, #3, #10-#13, and Former Resident #8. A current staff list with their names, titles, hire dates, and telephone numbers. On 1/27/26 at approximately 4:00 p.m., Former Resident #8's partial record was provided, approximately six hours after the initial request. Still waiting for MARs and external provider documentation. On 1/27/26 at approximately 11:00 a.m., the staff list was provided; however, it was missing hire dates and telephone numbers. On 1/28/26 at 8:15 a.m. the administrator provided a staff list that included hire dates and telephone numbers, approximately 21 hours after the initial request. On 1/28/26 at 10:30 a.m., requested MARs and external provider documentation for Resident #8 were provided, approximately 24 hours after the initial request. On 1/28/26 at approximately 3:15 p.m., the administrator provided the requested secured environment placement form from Resident #13's record, approximately 30 hours after the initial request. 3. InterviewOn 1/28/26 at approximately 12:00 p.m., the administrator stated she was under the impression she had provided all records upon request. 4. There was similar deficient practice for Residents #1, #3, and #10-#12.

Based on record review and interview, the residence failed to ensure all prescribed and PRN (as needed) medication was listed on a medication administration record (MAR) and that the resident's medication administration record (MAR) contained accurate information, affecting one of two sample residents (#10) and one former resident (#8). Findings include:Resident #10 was admitted to the residence on 7/10/23. A written practitioner's order dated 1/16/26 directed the residence to administer sertraline 50 mg once daily. However, the January 2026 electronic medication administration record (eMAR) for Resident #10 read sertraline 25 mg once daily. On 1/27/26 at approximately 3:15 p.m., Staff #9 said the sertraline 50 mg signed practitioner's order was not uploaded to Resident #10's eMAR. Staff #9 said she believed that Resident #10 had only been given 25 mg of sertraline from 1/16/26 to 1/19.26. Staff #9 said the director of nursing (DON) was responsible for updating resident eMAR's when new orders were received. On 1/28/26 at 11:48 a.m., the DON said that the sertraline 50 mg signed practitioner's order was received on 1/16/26, but was not uploaded into Resident #10's eMAR until 1/20/26 because the residence did not have a nurse working the weekend. She added only nurses were allowed to enter new medication orders in residents' eMARs. The DON said if the new medication was not urgent, it could wait until a nurse came in. At approximately 12:15 p.m., the DON acknowledged that Resident #10's family member administered the additional 25 mg of sertraline for a total of 50 mg. On 1/28/26 at approximately 12:15 p.m., the administrator said the DON was responsible for entering medications into eMAR's and that the residence did not have 24-hour nurses. She added that there was no nurse in the building seven days a week. The administrator said that if there was an emergency, the qualified medication administration person would call the DON, and the DON would decide whether the medication was emergent or not. During the onsite visits on 1/27 and 1/28/26, similar deficient practice was found for Former Resident #8.

A relicensure survey with complaint revisit was completed on 1/28/26 for all previous deficiencies cited on 5/21/25. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25.

A relicensure survey with complaint #CO40136 was completed on 5/21/25. Deficiencies were cited.

Based on record review, observations, and interview, the residence failed to document and implement effective actions that were to be taken by staff to prevent reoccurrence of falls for two of two sample residents who fell (#5, #8). Specifically, Resident #8 was admitted to the residence on 12/16/24 with diagnoses including generalized idiopathic epilepsy and epileptic syndromes, a personal history of transient ischemic attack and cerebral infarction without residual deficits, memory deficit following other cerebrovascular disease, and Refsum's disease. On 4/20/25, 4/30/25, and 5/19/25, Resident #8 experienced falls that resulted in injury and required transport to the emergency department. The resident ' s care plan, dated 4/11/25 read in part, Resident #8 had a history of falls. Interventions included assisting with maintaining a clutter-free environment, encouraging the resident to wear proper footwear, and reminding the resident to request assistance as needed. However, there was no documentation in the record showing what effective actions were taken by staff to prevent the reoccurrence of falls. 1. Record reviewResident #8 was admitted to the residence on 12/16/24 with a diagnosis of generalized idiopathic epilepsy and epileptic syndromes, personal history of transient ischemic attack and cerebral infarction without residual deficits, memory deficit following other cerebrovascular disease, and refsum's (vision loss) disease. A progress note dated 4/20/25 read in part, Resident #8 had a fall in her apartment while trying to do their laundry. Soon after being transferred into their wheelchair, Resident #8 experienced a seizure, and emergency medical services (EMS) were telephoned. Resident #8 was transported to the emergency department. The progress note failed to include effective actions taken by staff to prevent the reoccurrence of falls. A progress note dated 4/22/25 read in part, Resident #8 returned from the emergency department with antibiotics for pneumonia and a urinary tract infection. A progress note dated 4/22/25 read in part, Resident #8 had a large bruise above her left eye and a bruise above her lip from a fall she had when she had two seizures. The appearance of a black eye on the left side was noted. A progress note dated 4/30/25 read in part, Resident #8 was observed on the floor lying on her back with her arms folded across her chest. Resident #8 reported doing her laundry and then fell. EMS was telephoned, and when they arrived, Resident #8 had a seizure. Resident #8 was transported to the emergency department. Resident #8 may have hit their head on the corner of the washer due to a seizure, and had a left eyelid/ eyebrow bruise. Resident #8 was diagnosed with pneumonia and a urinary tract infection. The progress note failed to include effective actions taken by staff to prevent the reoccurrence of falls. An incident report dated 5/19/25 read in part, Staff #3 heard yelling coming from Resident #8's room and found her on the floor lying on her left side with blood next to her. Resident #8's left eye was swollen shut and had blood coming from what looked like her left eye, and blood over her hands. Resident #8 was yelling in pain, complaining of right knee pain, experiencing difficulty breathing from her left nostril, and was unsure how they fell. Resident #8 could not remember that she had fallen. The incident report confirmed pain, bruising, blood, hitting head, difficulty noting all injuries due to the amount of blood, and that Resident #8 appeared to have had a seizure, fell forward, and landed on her face. The progress note failed to include effective actions taken by staff to prevent the reoccurrence of fallsA progress note dated 5/19/25 read in part, Resident #8 was observed on the floor in the bathroom this morning. She did not remember the fall at all and denies that she fell. She was awake and disoriented. Her face was swollen and covered in blood. She appeared to have injured her nose, the left eye was swollen shut, and she had a small laceration on her upper lip on the left side. She complained of pain in her left knee. No blood was noted on the cabinet tops or sink. Resident #8's care plan dated 4/11/25 read in part, Resident #8 had a history of falls. Staff were to assist in keeping a clutter-free apartment, encourage resident to wear proper footwear, and remind resident to ask for assistance as needed. The residence failed to document additional effective actions taken by staff to prevent recurrence after Resident #8 fell two more times after 4/11/25. On 5/19/25 at 10:33 a.m., 1:09 p.m., and 1:40 p.m., any incident reports for Resident #8 were requested, however, only one incident report dated 5/19/25 was provided. 2. ObservationsOn 5/19/25 at approximately 9:30 a.m., Resident #8 was being wheeled on a stretcher by emergency medical services (EMS) to be transported to the emergency department. Resident #8 had a swollen shut left eye, swollen lip, and blood on her face. On 5/20/25 at approximately 12:08 p.m., Resident #8 was in their room and had black, blue, and red bruising around their left eye and mouth, a red left eyeball, and stitches on the left part of their lip. Resident #8 was barefoot and was unsteady while using a walker to ambulate independently from the bathroom to the bedroom. They attempted to transfer into bed independently but had difficulty due to weakness, improper foot placement, feet sliding on the carpet, the height of the bed, and nearly sliding off the bed because of the blanket material. 3. InterviewsOn 5/19/25 at 1:19 p.m., the director of nursing reported reassessments of residents are completed yearly, when residents are out of the building for more than 24 hours, or have a change in condition. She stated either herself or the assistant director of nursing would complete the reassessments. Reassessments were expected to be completed as soon as possible. On 5/19/25 at 4:10 p.m., Staff #7 reported being unsure of the interventions to prevent falls for Resident #8 and how to access their care plan to reference fall prevention interventions. Staff were not aware of any other effective actions to prevent the recurrence of falls after 4/11/25. On 5/20/25 at 11:52 a.m., Staff #8 reported that Resident #8 had grab bars, a transfer poll, and was encouraged to use their emergency pendant when they needed help with anything to prevent falls. Staff #8 stated that after Resident #8 fell on 5/19/25, hourly checks by staff were implemented. Staff were not aware of any other effective actions to prevent the recurrence of falls after 4/11/25. On 5/20/25 at 12:08 p.m., Resident #8 reported that they were supposed to use their emergency pendant when they needed help, but tried to be as independent as possible. She stated after falling on 5/19/25, staff began completing hourly checks. 4. Similar deficient practice of not implementing effective actions that were to be taken by staff to prevent reoccurrence of falls occurred with Resident #5, who experienced recurring falls.

Based on observation, record review and interview, the residence failed to ensure all shower floors had proper safety features to prevent slips and falls, affecting three of four resident bathroom shower floors in the secure environment (#2, #3, #4). Specifically, on 5/8/25 Resident #4 slipped in the shower, landed on his tailbone and expressed pain. Staff #1, who witnessed the fall, said Resident #4 fell in the shower and there were no proper safety features to prevent slips on the floor of Resident #4's shower. The assistant director of nursing (ADON) said she was called on the evening of 5/8/25 and said staff reported Resident #4 was in pain from his fall earlier in the day. Findings include:1. Record ReviewResident #4 was admitted to the residence on 5/31/22 and subsequently into the secure environment on 11/26/24 with diagnoses including fusion of spine, chronic fatigue and restless leg syndrome. An incident report in Resident #4's record, dated 5/8/25 read Resident #5 slipped on the shower floor while getting into the shower. He fell on his backbone, broke his glasses and complained of pain on his tailbone. An external ambulance report for Resident #4, dated 5/10/25 read, "Staff state they found Pt (Resident #4) on the floor in front of his recliner. Pt (Resident #4) states he remembers falling and denies LOC. Pt (Resident #4) complains of pain in his left knee and lower back. Pt (Resident #4) also complains of pain in his left ribs from a separate fall several days ago for which he has not been seen."2. ObservationOn 5/21 and 5/22/25, shower floors for Resident #2, #3, #4 revealed no safety features to prevent slips and falls. 3. InterviewsOn 5/19/25 at 12:50 p.m., Staff #1 said she was assisting Resident #4 with his shower and the shower floor was slippery and as a result Resident #4 fell in the shower. She added there were no proper safety features to prevent slips and falls on the floor of Resident #4's shower. On 5/20/25 at 12:45 p.m., the ADON said she had reached out to Resident #4's family member after his fall on 5/8/25 to see if she could provide something to prevent him from slipping or falling on the shower floor. She added, shower floors in resident bathrooms did not have safety features unless their families provided them. On 5/21/25 at approximately 10:30 a.m., the administrator said she was aware the residence was required to have safety features on shower floors for residents to prevent slips and falls. 4. Similar deficient practice was found and revealed that the shower floors for Resident #2 and #3 did not have safety features to prevent slips or falls.

Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment that included an evaluation by a licensed practitioner that described the resident's cognitive deficits that contributed to wandering, compromised safety awareness and detailed information from the resident's family that revealed a history and pattern of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, affecting three of four residents (#1, #3, #4) who resided in a secure environment. Findings include:Resident #1 was admitted directly to the secure environment portion of the residence on 6/10/24. There was no pre-admission assessment to determine Resident #1's appropriateness and need for a secure environment. Resident #3 was admitted to the residence on 10/31/20 and then transferred to the secure environment on 1/8/25. Resident #3's pre-admission assessment to determine his appropriateness and need for the secure environment was dated on the second day of the onsite visit on 5/20/25, four months after Resident #3 moved into a secure environment. Resident #4 was admitted to the residence on 5/31/22 and then transferred to the secure environment on 11/26/24. Resident #4's pre-admission assessment to determine his appropriateness and need for the secure environment was dated on 3/13/25, four months after his admission to the secure environment. Additionally, the evaluation for secure environment form listed another residence and not the secure environment Resident #4 actually transferred to. On 5/19/25 at 2:05 p.m., the assistant director of nursing (ADON) acknowledged that the pre-admission assessment for Resident #4 was filled out after his admission to the secure environment and acknowledged that the form listed an incorrect residence and not the current residence. The ADON said she expected there to be a pre-admission practitioner's assessment in Resident #1's record but could not find one. Lastly, the ADON said there was no other pre-admission assessment completed prior to 5/20/25 in Resident #3's record. On 5/20/25 at 1:50 p.m., Resident #1's practitioner said she reviewed Resident #1's records and confirmed that no pre-admission practitioner's assessment was completed at all and that the residence had asked her to fill one out on the day of the onsite visit on 5/20/25. On 5/21/25 at approximately 10:30 a.m., the administrator said she expected the residents who were going to live in a secure environment to have an evaluation completed by a licensed practitioner prior to move-in. She added she was aware that Resident #1, #3, and #4's evaluation forms were either not completed or were completed after move-in.

Based on interview and record review, the residence shall evaluate a resident when the resident expresses the desire to move out of a secure environment, and contact the practitioner and local ombudsman, affecting one of one resident who expressed the desire to move out of the secure environment (#1). (Cross-reference T3050)Findings include:Resident #1 moved directly into the secure environment portion of the residence on 6/10/24. The care plan for Resident #1, dated 5/19/25, read Resident #1 did not have a current or history of wandering. On 5/19/25 at 7:53 a.m., Resident #1 said she was a prisoner in the current residence. On 5/20/25 at 7:40 a.m., the assistant director of nursing (ADON) said she was aware of Resident #1's desire to move out of the residence and was in communication with her family member to hire a private care giver to bring her to activities since she was required to have an escort since she lived in a secure environment. She added she had not notified the practitioner of Resident #1's desire to move. On 5/20/25 at 1:50 p.m., Resident #1's practitioner said the residence never reached out to her about Resident #1's desire to move out and said, "I had questioned whether or not she needed the secure environment." She added she had reached out to the director of nursing in February 2025 about re-evaluating Resident #1 for her need for a secure environment because she felt she did not qualify. On 5/21/25 at approximately 9:00 a.m., Resident #1 said she had first spoken with the former director of nursing about her desire to move and about a month or so prior to the onsite visit she said she spoke with the ADON. On 5/21/25 at approximately 10:30 a.m., the administrator said she was not aware that residents who expressed the desire to move out of the secure environment the practitioner must be notified and evaluated and then notify the ombudsman. She added she was just made aware of Resident #1's desire to want to move out of the secure environment.

Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment, affecting three of four sample residents (#1, #3, #4). (Cross-reference T3044)Findings include:Resident #1 was admitted directly to the secure environment portion of the residence on 6/10/24. There was no evidence provided that determined the residence re-assessed Resident #1 every six months for her continued need for a secure environment. Resident #3 was admitted to the residence on 10/31/20 and then transferred to the secure environment on 1/8/25. There was no evidence provided that determined the residence re-assessed Resident #3 every six months for his continued need for a secure environment. Resident #4 was admitted to the residence on 5/31/22 and then transferred to the secure environment on 11/26/24. There was no evidence provided that determined the residence re-assessed Resident #4 every six months for his continued need for a secure environment. On 5/21/25 at approximately 10:30 a.m., the administrator said she was aware that each resident shall be re-assessed to determine his or her continued need for a secure environment every six months. She added she was aware the documentation she did provide for Resident #1, #3, and #4 did not meet the requirements.

Based on interview and record review, the residence failed to ensure each care plan was updated to reflect changes in the staff approach to meet resident needs, affecting one of four sample residents (#3) in a secure environment. Specifically, Resident #3 fell approximately nine times from 2/21 to 5/13/25. Five of the falls resulted in either pain or injury. Three of the falls on 3/8, 4/26 and 5/12/25 resulted in Resident #3 being sent to the emergency department (ED) for evaluation. Findings include:1. Record ReviewResident #3 was admitted to the residence on 10/31/20 and transferred to the secure environment on 1/8/25 after he returned from rehab after breaking his hip, which required surgery. Resident #3's diagnoses include Parkinson's, difficulty in walking, delusions, restlessness and agitation, unspecified fall and visual hallucinations. Progress notes and incident reports in Resident #3's record from February to May 2025 revealed the following:On 2/21/25 Resident #3 was on the floor lying on his left side and had a small gash on his left knee. On 3/7/25 Resident #3 was on the floor between the chair and the television. On 3/8/25 Resident #3 was on the floor between the chair and the nightstand. He complained of pain in his right arm and hip. He was sent to the ED for evaluation. On 3/22/25 Resident #3 was on the floor. On 3/24/25 Resident #3 was on the floor in the hallway. On 4/14/25 Resident #3 lost his balance and was lying on the floor in his room. On 4/26/25 Resident #3 was on the floor in his bathroom. He complained of right hip and head pain and was sent to the ED for evaluation. On 5/5/25 Resident #3 stood up from the dining room table without his walker and tripped and fell to his knees. On 5/5/25 Resident #3 was found kneeling on the floor and said his knees were sore. Staff were unable to lift him so they contacted lift assistance. On 5/12/25 Resident #3 was on the floor on his stomach. He said he hit his head and was in pain when he was moved. He was sent to the ED for evaluation. On 5/13/25 Resident #3 tripped over his feet while trying to stand up from the dining room table. He fell on his left side, scraped his left knee and complained of left knee pain. A care plan for Resident #3, dated 1/20/25 revealed he was a fall risk and staff were required to keep his room free of clutter and to provide encouragement to wear proper footwear and reminders to ask for assistance. Staff were to also remind him to use his walker. However, the care plan was not updated to reflect changes in the staff approach to meet Resident #3's needs after he fell approximately nine times between 2/21 and 5/13/25. Practitioner progress notes for Resident #3 for January through April 2025 revealed the following:On 1/9/25 Resident #3 was seen by his practitioner after he was discharged from rehab after sustaining a fall which resulted in a right hip/femur fracture that required surgery to repair. Resident #3 was listed as a high fall risk. On 2/11/25 Resident #3 was seen due to multiple falls at the residence. The practitioner indicated Resident #3 was a high risk for catastrophic falls. Resident #3 was working with therapy services with little improvement. On 3/10/24 Resident #3 was seen by his practitioner after he returned from the ED from a fall. Gait unsteady, shuffled and small laceration to his left knee. "...had a fall on 3/7/25 ... high risk for falls ... is high risk for decline and sudden events, continue to monitor closely."On 3/19/25 Resident #3 was seen by his practitioner because of an abrasion to his left knee. "...multiple recent falls, small round abrasion to left knee ... has home health, home health inquiring about need for skilled nursing services."On 3/26/25 Resident #3 was seen by his practitioner to evaluate him after a fall. "...had a fall over the weekend, unwitnessed, he was found in the hallway. Not clear if he hit his head ... he often forgets his walker ... Mechanical fall. Mild back pain."On 4/28/25 Resident #3 was seen by his practitioner after being discharged from the ED after falling at the residence. "...high risk for falls ... dependent on the following assistive device: walker" Resident #3 was a high risk for exacerbations and a high risk for decline. 2. InterviewsOn 5/19/25 at 12:50 p.m., Staff #1 said Resident #3 was at risk for falling and the approaches she was told to help mitigate future falls were to remind him to use his walker. On 5/19/25 at 3:40 p.m., Staff #3 and #4 said they were directed to check Resident #3 often and when he stood up to remind him to use his walker. On 5/20/25 at 7:45 a.m., Staff #5 said she was directed to keep an eye on Resident #3 and directed him to use his walker. She added it was hard to keep an eye on him when he was in his room. On 5/20/25 at 9:55 a.m., Staff #6 said she was directed to remind Resident #3 to use his walker when walking. On 5/20/25 at 10:40 a.m., Staff #2 said Resident #3 was "just recently a fall risk ... just started falling a week or so ago."On 5/21/25 at approximately 10:30 a.m., the administrator said she expected the enhanced care plans for residents in the secure environment to reflect changes in staff approach to meet resident needs. She added she expected there to be a fall care plan and approaches addressed in the incident reports. The administrator said staff were expected to be educated on the care plan changes and implement the changes.

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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. 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. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. 18.8 Resident records shall contain, but not be limited to, the following items: (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall 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. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact;(B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR's plan to protect the resident from unwanted visitation by other residents; (C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and (D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.

A revisit survey was completed on 7/30/24 for all previous deficiencies cited on 4/29/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO33431, #CO34114, and #CO35388, was completed on 4/29/24. Deficiencies were cited. A change of ownership occurred on 10/12/22.

Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents for five of five sample staff (#1-#4, #6), affecting six of seven sample residents (#1-#7). Findings include: 1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult." Justia US Law (2018), 2018 Colorado Revised Statutes Title 26 - Human Services Code Article 3.1 - Protective Services for Adults at Risk of Mistreatment or Self-Neglect Part 1 - Protective Services for At-Risk Adults § 26-3.1-111. Access to CAPS - employment checks - confidentiality - fees - rules - legislative declaration - definitions, retrieved from: https://law.justia.com/codes/colorado/2018/title-26/article-3.1/part-1/section-26-3.1-111/b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. 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 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Observations On 4/25/24 from 7:30 a.m. to 2:00 p.m., Staff #2 was observed working at the residence. On 4/25/24 from 2:00 p.m. to 5:00 p.m., Staff #3 was observed working at the residence. 3. Record Review The personnel files for staff #1-#4 and former Staff #6 revealed they were hired on 12/13/22, 2/8/22, 1/9/24, 8/11/23, and 12/15/23 respectively. Review of the March and April 2024 staff schedule revealed Staff #1 worked the following dates:3/1-3/5/243/8-3/12/243/17-3/19/243/21-3/26/243/39-4/2/244/4-4/9/244/11-4/16/244/18-4/23/244/25/24Review of the March and April 2024 staff schedule revealed Staff #2 worked the following dates:3/3-3/6/243/10/243/14/243/17-3/21/244/14-4/18/244/21-4/22/244/24-4/25/24Review of the March and April 2024 staff schedule revealed Staff #3 worked the following dates:3/1-3/2/243/5/243/8-3/9/243/11/243/15-3/19/243/22-3/23/243/24-3/25/243/29-3/31/244/2-4/4/244/7-4/11/244/15/244/18/244/21-4/25/24Review of the March and April 2024 staff schedule revealed Staff #4 worked the following dates:3/3-3/7/243/10-3/13/243/17-3/21/243/24-3/28/243/31/244/2-4/4/244/7-4/11/244/14-4/18/244/21-4/25/24Review of the March and April 2024 staff schedule revealed former Staff #6 was no longer on the schedule. 4. InterviewsOn 4/29/24 at 9:45 a.m., the administrator stated he was aware that CAPs checks were required to be completed for all new employees; however, was unaware they had not been completed for Staff #1-#4 and former Staff #6. He stated the business director was responsible for conducting the CAPs checks, and as far as he had known, they had been completed.

Based on observation, record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for five of five sample staff (#1-#4, #6), affecting all current residents. Findings include:1. References a. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following items:(E) Results of background checks and follow up, as applicable. 2. ObservationsOn 4/25/24 from 7:30 a.m. to 2:00 p.m., Staff #2 was observed working at the residence. On 4/25/24 from 2:00 p.m. to 5:00 p.m., Staff #3 was observed working at the residence. 3. Record Review The personnel files for staff #1-#4 and former Staff #6 revealed they were hired on 12/13/22, 2/8/22, 1/9/24, 8/11/23, and 12/15/23 respectively. The personnel files for staff #1-#4 and #6 contained evidence of background checks; however, the background checks had been run through an outside agency which did not include the Colorado Bureau of Investigations (CBI) as required by state regulations. Review of the March and April 2024 staff schedule revealed Staff #1 worked the following dates:3/1-3/5/243/8-3/12/243/17-3/19/243/21-3/26/243/39-4/2/244/4-4/9/244/11-4/16/244/18-4/23/244/25/24Review of the March and April 2024 staff schedule revealed Staff #2 worked the following dates:3/3-3/6/243/10/243/14/243/17-3/21/244/14-4/18/244/21-4/22/244/24-4/25/24Review of the March and April 2024 staff schedule revealed Staff #3 worked the following dates:3/1-3/2/243/5/243/8-3/9/243/11/243/15-3/19/243/22-3/23/243/24-3/25/243/29-3/31/244/2-4/4/244/7-4/11/244/15/244/18/244/21-4/25/24Review of the March and April 2024 staff schedule revealed Staff #4 worked the following dates:3/3-3/7/243/10-3/13/243/17-3/21/243/24-3/28/243/31/244/2-4/4/244/7-4/11/244/14-4/18/244/21-4/25/24Review of the March and April 2024 staff schedule revealed former Staff #6 was no longer on the schedule. 4. Interview On 4/29/24 at 9:45 a.m., the administrator stated he was aware that employee background checks were required to be conducted by the CBI. However, he stated he was unaware the background checks for staff #1-#4 and former Staff #6 had been conducted by an outside agency that did not include CBI background checks. He stated the business director was responsible for completing the background checks for new employees. The administrator stated the BOM was already in place when he started working at the residence, and was unaware the CBI background checks were not being done properly.

Based on observation, interview and record review, the residence failed to ensure each staff member completed the required orientation and training competencies for two of four sample staff (#3 and #4) affecting 78 current residents. Findings include:1. ObservationOn 4/25/24 from 2:00 p.m. to 5:00 p.m., Staff #3 was observed working with residents in the secure environment. 2. Record ReviewThe personnel file for Staff #3 revealed she was hired as a qualified medication administration person (QMAP) on 1/9/24. There was no evidence in her personnel file of having completed training on practitioner's assessment, serious illness or injury, reporting requirements, or where to locate advance directives. The personnel file for Staff #4 revealed she was hired as a caregiver on 8/11/23. There was no evidence in her personnel file of having completed training on practitioner's assessment, serious illness or injury, reporting requirements, or where to locate advance directives. March and April 2024 staff schedules revealed as follows:Staff #3 worked at the residence from 2:00 p.m. to 10:00 p.m. on 3/5, 3/8, 3/9, 3/11, 3/15 and 3/16/24. Staff #4 worked at the residence from 2:00 p.m. to 10:00 p.m. on 3/3-3/7, 3/10-3/13, 3/17-3/21, 3/24-3/28, 3/31, 4/2-4/4, 4/7-4/11, 4/14-4/18 and 4/21-4/25/24. 3. InterviewsOn 4/25/24 at 4:43 p.m., Staff #3 stated she was not trained by the residence when she was hired in January 2024 on practitioner's assessment, serious illness or injury, reporting requirements other than to make a progress note, or where to locate advance directives. On 4/25/24 at 1:54 p.m., the regional health services manager stated most staff have not had orientation and training since the business director (BD) was unaware what all was required or that it needed to be documented. On 4/29/24 at approximately 9:46 a.m., the administrator stated the BD was responsible for orientation and training. The administrator acknowledged he was aware that practitioner's assessment, serious illness or injury, reporting requirements, or where to locate advance directives were required competencies and would have expected it to have been completed and in the personnel files. The administrator stated there to have been training issues with the BD where she was unclear what the requirements were.

Based on observation, interview and record review, the residence failed to ensure each staff member completed fall prevention and lift assistance training for two of four sample staff (#3 and #4) affecting 78 current residents. Findings include:1. ObservationOn 4/25/24 from 2:00 p.m. to 5:00 p.m., Staff #3 was observed working with residents in the secure environment. 2. Record ReviewThe personnel file for Staff #3 revealed she was hired as a qualified medication administration person (QMAP) on 1/9/24. There was no evidence in her personnel file of having completed fall prevention or lift assistance training. The personnel file for Staff #4 revealed she was hired as a caregiver on 8/11/23. There was no evidence in her personnel file of having completed fall prevention or lift assistance training. March and April 2024 staff schedules revealed as follows:Staff #3 worked at the residence from 2:00 p.m. to 10:00 p.m. on 3/5, 3/8, 3/9, 3/11, 3/15 and 3/16/24. Staff #4 worked at the residence from 2:00 p.m. to 10:00 p.m. on 3/3-3/7, 3/10-3/13, 3/17-3/21, 3/24-3/28, 3/31, 4/2-4/4, 4/7-4/11, 4/14-4/18 and 4/21-4/25/24. 3. InterviewsOn 4/25/24 at 4:43 p.m., Staff #3 stated she was not trained by the residence when she was hired in January 2024 on fall management or prevention or lift assistance. On 4/25/24 at 1:54 p.m., the regional health services manager stated most staff have not had orientation and training since the business director (BD) was unaware what all was required or that it needed to be documented. On 4/29/24 at approximately 9:46 a.m., the administrator stated the business director (BD) was responsible for fall prevention and lift assist training and was aware of the requirement. The administrator stated there to have been training issues with the BD where she was unclear what the requirements were.

Based on interview and record review, the residence failed to ensure personnel files included written documentation of orientation and training and results of background checks and follow up for four of five staff (#1, #3-#4, #6), affecting all current residents. Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff' does not include individuals providing external services, as defined herein.b. Chapter VII regulations governing assisted living residences, part 7.12, requires each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable; (E) Results of background checks and follow up, as applicable 2. Record ReviewThe personnel files for staff #1, #3-#4, and former Staff #6 were reviewed and revealed they were hired on 12/13/22, 1/9/24, 8/11/23, and 12/15/23, respectively. However, there was no evidence of orientation, training or CBI background checks as required by state regulations. 3. Interview On 4/29/24 at 9:45 a.m., the administrator stated he was aware that personnel files were required to contain evidence of completion of employee orientation, training, and background checks. He stated all new employees were expected to to complete orientation and training prior to working with residents; however, could not explain why there was no documentation for Staff #1, #3-#4, and former Staff #6. Additionally, the administrator stated he was aware that personnel files were required to contain background check documentation.

Based on observation, interviews and record review, the residence failed to implement a fall management program detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance and providing staff training related to fall prevention, affecting one of six sample residents (#5). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.10, defines "care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. b. The residence's Fall Management Policy, dated February 2024, read in part: "service/care plans for each resident will include the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, use of the walker or other assistance devices ... staff orientation will include fall management and prevention and will be reviewed no less than annually ... the training will also include resident fall procedures including responding to falls, incident reporting, and post fall interventions and service/care planning."2. Resident #5 was admitted to the residence on 1/31/23, with diagnoses that included Alzheimer's disease and osteoporosis.a. ObservationOn 4/25/24 at 12:08 p.m., a fall mat was observed underneath Resident #5's hospital bed. b. Record ReviewA progress note, dated 2/29/24 read Resident #5 sustained a fall and was found on the floor by her bed. Redness was observed on the resident's back. A progress note written by Staff #2, dated 4/25/24, read on 4/21/24 Resident #5 sustained a fall and was found on the floor next to her bed. The residence's most recent care plan for Resident #5, dated 1/2/24, read the resident required up to two person transfer assistance, used a walker and wheelchair for mobility and required two hour safety checks. The care plan further read the resident was a fall risk and required proper footwear, a decluttered apartment and reminders to notify staff for assistance. There were no other care plans in Resident #5's record, detailing the individualized approaches necessary to address fall risk, after Resident #5's falls on 2/29 or 4/21/24. Further, the care plan did not include the resident had a fall mat or a hospital bed.c. InterviewsOn 4/25/24 at 7:59 a.m., Staff #6 stated she heard from other staff members that Resident #5 sustained a fall on 4/21/24. Staff #6 stated she was unaware what fall interventions were. After the surveyor explained to Staff #6 the meaning of fall interventions, the staff member stated Resident #5 required two hour checks and up to two person assistance with transfers; however, was unaware of any other fall interventions in place for the resident. On 4/25/24 at 8:14 a.m., Staff #2 stated he was also the wellness coordinator for the secured environment. The staff member stated Resident #5 required two person assistance with transfers and checks every 30 minutes to an hour. Staff #2 stated the resident had a wheelchair and a fall mat that was put in place by Resident #5's external hospice provider; however, was unaware of any fall interventions in place for the resident. On 4/25/24 at 12:07 p.m., the regional health services manager (RHSM) stated Resident #5 had a "high-low hospital bed," wheelchair and fall mat for fall interventions. The RHSM stated Resident #5 had sustained falls on 2/29 and 4/21/24. On 4/25/24 at 12:28 p.m., the external hospice provider for Resident #5 stated they had put in place two fall mats for Resident #5 following Resident #5's fall out of bed on 2/29/24. The external hospice provider stated he would expectresidence personnel to ensure fall mats were placed on both sides of Resident #5's bed. The external hospice provider stated the instructions for fall mats was communicated to Staff #2. On 4/25/24 at 4:43 p.m., Staff #3 stated she was not trained on fall prevention when she was hired and was unaware of any fall interventions in place for Resident #5. On 4/29/24 at 8:53 a.m., the RHSM stated the director of nursing (DON) was responsible for the majority of the care plan updates. The RHSM stated care plans should have included individualized fall interventions and believed there to be a "gap" in education, since the RHSM was new to assisted living residences. On 4/29/24 at 9:24 a.m., the DON stated she was responsible for updating care plans as of November 2023. The DON stated she was not familiar with assisted living regulations, and was unaware care plans needed to be updated with individualized fall interventions, which was why Resident #5's care plan had not been updated since 1/2/24. On 4/29/24 at approximately 9:46 a.m., the administrator stated the DON was responsible for updating care plans and should be updated following resident falls as part of the residence's assessment. The administrator stated he would have expected Resident #5's care plan to have been updated with individualized interventions, and for personnel to have been trained by the business director on fall prevention.

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 of six current sample residents (#4 and #5). Findings include:1. Resident #5 was admitted to the residence on 1/31/23, with diagnoses that included Alzheimer's disease and osteoporosis. A late-entry progress note written by Staff #2, dated 4/25/24, read on 4/21/24 Resident #5 sustained a fall and was found on the floor next to her bed. However, there was no evidence of a progress note having been documented by residence personnel before the end of their shift, on 4/21/24. On 4/25/24 at 12:09 p.m., Staff #2 stated Resident #5 had fallen on 4/21/24 and had informed Staff #3 who had found Resident #5 on the floor, to make a progress note. Staff #2 stated he was not aware a progress note had not been documented for Resident #5, and stated he was unsure Staff #3 was aware how to make progress notes since she was newly hired. Staff #2 stated he thought he had made a follow up progress note on 4/22/24; however, noticed it was not documented in the residence's electronic health record, and acknowledged it should have been. On 4/25/24 at 4:43 p.m., Staff #3 stated she was hired in January 2024 and she knew how to document a progress note; however, she would not consider falls to be out of the ordinary and did not think she needed to make a progress note for Resident #5's fall on 4/21/24. Contrary to Staff #3's previous statement, she stated progress notes should be made for when a resident falls; however, she was still learning the residence's electronic health system. On 4/29/24 at approximately 9:46 a.m., the administrator stated the director of nursing and Staff #2 were mainly responsible for making progress notes. The administrator stated he believed other staff members also had the ability to make progress notes. He further stated progress notes should be documented whenever a resident goes to the hospital or when there is a fall. The administrator stated he would consider falls an out of the ordinary event and acknowledged a progress note should have been documented before the end of shift for Resident #5 and all actions taken should have been documented. 2. There was similar deficient practice for Resident #4.