Brookdale Arvada

A revisit survey was completed on 3/13/25 for all previous deficiencies cited on 9/9/24. 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 relicensure survey with complaints #CO35265 and #CO35487 and #CO37252 was completed on 9/9/24. Deficiencies were cited. Based on interview and record review, the residence failed to have a sufficient number of staff to help residents needing or potentially needing assistance, affecting one of 31 days in July 2024 (7/31/24) in the unsecure portion of .. Based on interview and record review, the residence failed to provide a resident the right to receive services in accordance with their care plan, affecting one of seven sample residents (#1). (Cross-reference S1324)Findings includ.. Based on interview and record review, the residence failed to request an updated criminal history and adult protective service record check for a staff member who could pose a risk to the health, safety and welfare of the residents, inv.. Based on observation and interview, the assisted living residence failed to place in a visible location a list of all staff who have current certification in first aid or CPR (cardiopulmonary resuscitation), affecting 56 current residents. Fin.. Based on observation, record review, and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, aff.. Based on observation, record review, and interview, the residence failed to observe resident rights in the care, treatment and oversight of residents and their right to be free from neglect, affecting two of seven sample residents.. 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 compl.. Based on record review and interview, the residence failed to ensure that no medication was administered by a qualified medication administration person (QMAP) on a pro re nata (PRN) or "as needed" basis, affecting one sample .. Based on record review and interview, the residence failed to have at least one staff member on shift at all times with a current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization, affecting 56.. Based on record review and interview, the residence failed to have at least one staff member on shift at all times with a current certification in first aid from a nationally recognized organization, affecting 56 current residents.Finding in.. Based on record review and interview, the residence failed to include current cardiopulmonary resuscitation (CPR) certifications along with first aid certifications in personnel files, affecting 56 current residents. Findings include:1. .. Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment affecting two of four sample residents (#3, #5).Findings include:1. Resident #3 was admitted to t.. Based on record review, interview and observation, 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 56 curre.. 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 a..

A licensure complaint, prompted by #CO34774 and #CO34887, was completed on 2/22/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting one of five sample residents (#6) and one former resident (#10). (Cross reference Q1568)Findings include:1. Residence policyThe residence' s Medication and Medication Administration policy, dated 3/31/22 read in part: "follow the 7 rights of medication administration ... right documentation ... document medicatio.. Based on observations, interviews and record review, the residence failed to implement a fall management which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting three of three sample residents who fell (#1, #6 and #7). (Cross reference Q1146)Specifically, Resident #1 sustained a fall on 1/29/24 which resulted in a hip fracture. However, the residence failed to update Resident #1' s care plan with individualized interventions following the fall and the resident' s return f.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting five of five sample residents (#1-#4, #6) and one former resident (#10). (Cross reference Q1600)Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated 3/31/22, read in part: "medication administration/assistance and treatment shall be provided in a safe and timely manner, and as prescribed by the resident' s (practitioner)."2. Resident #1 was admitted to the residence on 5.. Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated at least annually or whenever the residents' conditions changed from baseline status, affecting one of two sample residents (#1) who experienced a change in condition. (Cross reference Q1180)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items: (J) History and circumstances of recent falls and any.. Based on record review and interview, the residence failed to implement a policy for an effective information management system that allowed effective continuity of care which included a method of integration for both paper-based and electronic records in the effective management for storing and retrieving care/service data and information, affecting nine of nine sample residents (#1-#9) and one former resident (#10). (Cross reference Q1530)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 9.1, .. Based on record review and interview, the residence failed to prepare or administer only medication that had been ordered by an authorized practitioner, affecting four of five sample residents (#2-#4, #6). (Cross reference Q2114)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 14.17, requires the assisted living residence shall ensure that each authorized practitioner' s order for medication includes ... the signature of the practitioner.b. The residence' s Medication Administration policy, dated 3..

A revisit survey was completed on 9/1/23 for all previous deficiencies cited on 3/2/23. 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 3/2/23 for all previous deficiencies cited on 4/21/22. Deficiencies were cited. Based on observation, interview and record review, the residence failed to ensure oxygen tanks were secured upright at all times in a manner that prevented tanks from falling over, being dropped or striking each other, affecting one current resident (#13).This deficiency was cited previously during a state licensure survey 4/21/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 14.8, requires that The assisted living residence shall be responsible for ensuring compliance with all safety requirements regarding oxygen use, handling, and storage as set forth in Parts 22.29 throu.. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records, affecting six of six current sample residents (#6, #13, and #16-#19).This deficiency was previously cited during a state licensure survey on 4/21/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewOn 3/2/23 at 7:27 a.m., documentation of the residence' s last two audits (prior to the onsite visit) were requested. At 7:56 a.m., the health and wellness director (HWD) brought documentation of a medication audit that .. Based on record review and interview, the residence failed to include written documentation of a description of job duties, date of hire and date duties commenced, orientation and training, background checks, and tuberculin test results in each personnel file affecting three of three sample staff (#6-#8).This deficiency was previously cited during a state licensure survey on 4/21/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. ReferenceChapter 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 individual.. 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