Assisted Living on Broadway

A relicensure survey was completed on 1/20/26. 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.(U1180) 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following:(A) Providing fall management education and materials to residents and family members;(B) Detailing in each resident ' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment.

A licensure complaint, prompted by #CO37921, was completed on 10/16/24. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to ensure that each staff member received initial orientation for four of five sample staff (#7-#10), affecting 11 current residents.Findings include: 1. Record ReviewOn 10/16/24, staff files for Staff #7-#9 contained no evidence that the residence conducted orientation before working with residents. An email correspondence with a contract staffing agency, dated 10/16/24, read in part that Staff #7-#10 worked at the residence on the following dates and times: On 9/30/24, Staff #7 worked from 2:00 p.m. to 10:00 p.m. On 9/22/24, Staff #8 worked from 6:00 a.m. to 8:00 a.m.On 9/24/24, Staff #9 worked from 10:00 p.m. to 6:15 a.m.On 9/27/24 and 9/28/2024, Staff #10 worked from 2:00 p.m. to 10:00 p.m.On 10/16/24, at approximately .. Based on record review and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each staff member prior to staff hire for four sample staff (#7-#10), affecting 11 current residents.Findings include:1. Record Review On 10/16/24, staff files for Staff #7-#9 contained no evidence that the residence obtained documentation of a name-based criminal history check conducted by the CBI before working with residents. An email correspondence with a contract staffing agency, dated 10/16/24, read in part that Staff #7-#10 worked at the residence on the following dates and times: On 9/30/24, Staff #7 worked from 2:00 p.m. to 10:00 p.m. On 9/22/24, Staff #8 worked from 6:00 a.m. to 8:00 a.m.On 9/24/24, Staff #9 worked .. Based on record review and interview, the residence failed to ensure two individuals who are qualified medication administration persons, nurses, or practitioners jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting four current residents with controlled medications (#1, #2, #4, #5) Findings include:1. Record ReviewA controlled substance sheet, dated 10/15/24, read Staff #1 signed in and Staff #5 signed out.A review of the staff file for Staff #1 revealed no documentation that Staff #1 was a qualified medication administration personnel (QMAP). 2. InterviewsOn 10/16/24 at 1:01 p.m., the nursing consultant stated that she told the residence that a staff member who was not a QMAP could s.. Based on record review and interview, the residence failed to have a readily available updated and current roster, which affected two current residents (#2, #3).Findings include:1. Record Review On 10/16/24 at 7:35 a.m., a roster of current residents for emergency preparedness was requested. On 10/8/24 at 7:36 a.m., the roster that was provided included three former residents (#12-#14) and did not include Residents #2 and #3. 2. InterviewOn 10/16/24 at 7:45 a.m., the interim administrator stated that she was aware the resident roster did not have current resident information prior to the on-site visit and that if there was an emergency, the list was incorrect and could have caused issues for emergency responders.On 10/16/24 at 9:38 a.m., the administrator stated she failed to update the residen..

A revisit survey was completed on 8/29/24 for all previous deficiencies cited on 6/3/24. 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 6/3/24 for all previous deficiencies cited on 3/8/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 1/14/24. Based on interview and record review, the residence failed to ensure that each qualified medication administration person (QMAP) documented accurate information in the medication administration record (MAR), including any medication omissions; the residence additionally failed to ensure that, as part of the MAR, the residence maintained a legible list of the names of the persons utilizing the MAR, along with their signatures and initials, affecting three of three sample residents whose medications were reviewed (#1-#3).This deficiency was cited previously during a state licensure survey on 3/8/23. Although the residence corrected the deficiency, based on the findings below, the reside.. Based on observation, record review and interview, the residence failed to ensure that only medication ordered by an authorized practitioner was prepared for or administered to residents, affecting two of three sample residents (#5 and #9). This deficiency was cited previously during a state licensure survey on 3/8/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: Resident #5 was admitted to the residence on 8/17/22.The May 2024 medication administration record (MAR) read the residence administered K-Y pearls in the evenings of 5/1-5/31/24 for a total of .. Based on observation, record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 12 current residents. This deficiency was cited previously during a state licensure survey on 3/8/23. Although the facility 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 first aid policy, dated October 2023, read in part: "at least one staff member is on duty at all times that is professionally trained by an approved provider for fi.. Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration affecting two of three sample residents whose medications were reviewed (#5 and #13). This deficiency was cited previously during a state licensure survey on 3/8/23. 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 #13 was admitted to the residence on 5/20/24 with a diagnosis of dementia.a. SertralineA written practitioner' s order, dated 5/17/24, directed the residence to administer sertraline .. 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 7.14.17 The assisted living residence shall ensure that each authorized practitioner' s order for medication includes the correct name of the resident, date of the order, medication name, strength of medication, dosage to administer, route of administration along with timing and/or frequency of administration, any specific considerations, if substitutions are allowed or restricted, and the signature of the practitioner.