Brookdale Briargate

A revisit survey was completed on 3/6/24 for all previous deficiencies cited on 9/6/23. 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 complaint, prompted by #CO34517, was completed on 12/21/23. 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 7.4.5 The licensee shall appoint an administrator who meets the minimum qualifications set forth in these regulations and delegate to that individual the executive authority and responsibility for the administration of the assisted living residence.(A) If the assisted living residence does not have an administrator, the licensee shall appoint an interim administrator and delegate to that individual the executive authority and responsibility for the administration of the assisted living residence, until such time that the facility has an administrator.(1)The licensee shall notify the department of the interim administrator appointment within 24 hours of the appointment in accordance with 6 CCR 1011-1, Chapter 2 – General Licensure, Part 2.9.6.

A complaint revisit was completed on 12/21/23 for all previous deficiencies cited on 6/27/23. The residence is in compliance with all regulations surveyed. 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 complaint prompted by #CO33298 was completed on 9/6/23. Deficiences were cited. Based on interview and record review, the residence failed to ensure the residents had the right to be free from caretaker neglect, affecting one former resident (#9). (Cross-reference Q1160, Q1180, Q1192 and Q2960)1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.10, defines "Caretaker neglect" as that which occurs when adequate food, clothing, shelter, psychological care, physical care, medical care,.. Based on observation, interview and record review, the residence failed to detail in each resident' s care plan the individualized approach necessary to address fall risk, and staff were not consistent in their understanding of the interventions in place for the residents, affecting one of three sample residents (#8) and one former resident (#9). (Cross-reference Q1160, Q1192, Q1312, Q2130, Q2960)Specifically, Resident #8 was admitted to the residence on 5/1.. Based on observation, interview and record review, the residence failed to reassess residents in the secure environment to determine his or her continued need for a secure environment every six months and whenever the resident' s condition changes from baseline status including consulting with the resident' s attending practitioner, family and/or representative, affecting two of three sample residents (#6, #7) who resided in the secure environment. 1. R.. Based on record review and interview, the residence failed to ensure resident records contained documented progress notes, by staff before the end of their shift, of out of ordinary events or issues that affected a resident' s physical, behavioral, cognitive, and/or functional condition, along with the action taken by staff to address that resident' s changing needs documented, affecting one sample resident (#8) and one former resident (#9). (Cross-reference Q118.. Based on record review and interview, the residence failed to ensure the care plan for each resident in the secure environment included a resident' s known behavioral expressions along with individualized approaches to be implemented, affecting one former resident (#9). (Cross-reference Q1180, Q1312 and Q2130)Findings include:Chapter VII regulations governing assisted living residences, part 12.10, requires that each resident care plan shall:(C) Promot.. Based on record review and interviews, the residence failed to follow their lift assistance policy, affecting one former resident (#9). (Cross-reference Q1180 and Q1312)Findings Include:1. Residence PolicyThe residence' s Lift Assistance Policy, dated February 2022, read in part: The assisted living residence shall ensure to have assisted a resident who fell by following the fall management policy and if a resident were free of pain, the associate would physically perfo.. Based on record review, and interview, the residence failed to be responsible for the coordination of resident care services with known external service providers, affecting one former resident (#9). (Cross-reference Q1180, Q2130, Q2960)Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 2.21, defines "External services" as personal services and protective oversight services provided to a resident by family members or.. 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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident' s condition changes from baseline status.13.1 The assisted living residence shall adopt, and pl..

A licensure complaint, prompted by #CO29696 and #CO31472, were completed on 6/27/23. Deficiencies were cited.A change of ownership occured on 1/13/21. Based on observation, record review, and interview, the residence failed to comply with authorized practitioners orders associated with medication administration, affecting one former resident (#2) and one of three sample residents (#4). Findings include:1. Residence Policy The residence' s Medication and Treatment General Guidelines for Medication Administration Assistance dated 4/2022, read in part,"Trained and/or licensed associates may administer or assist the resident with medication management or medication administration treatment per physician/healthcare provider (HCP) order and as per state regulation."2. Resident #4 was admitted to the residence on 6/20/2022 with a diagnosis including Severe Vascular Dementia with mood disturbance. a. Haloperidol A written practitioners order dated 5/21/23, directed the residence to administer Haloperidol lactate oral concentrate 2 mg/ml. Give 0.25 ml by mouth every six hours. However, the June 2023 Medication Administration Records revealed the medication was not .. Based on observations and interview, the residence failed to ensure the use of the fireplace in the common area of the residence did not present a resident burn risk, affecting 36 current residents.Specifically, the residence was licensed as a secure environment and served residents with cognitive deficits. The residence' s common area, where residents gathered, had a gas burning fireplace. The fireplace emitted heat through the glass and the temperature on the glass measured 394 degrees Fahrenheit. This failure created an immediate jeopardy risk of harm to all 36 residents residing in the residence. On 6/27/23, the department directed the residence to provide written evidence that the risk had been removed..Findings include: 1. References a. According to Children' s Hospital Colorado (2022), "Contact with the glass of gas fireplace doors can result in second or third degree burns. Burns of the hand can result in hand dysfunction causing long term impairment and disability." Retrieved from: https://www.childrenscolorado.org/conditions-and-ad.. 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 7.13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies: (A) The state and local long-term care ombudsman; (B) The Adult Protection Services of the appropriate county Department of Social Services; (C) The advocacy services of the area ' s agency on aging; (D) The Colorado Department of Public Health and Environment; and (E) The Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence i..