Brookdale Brighton

A complaint revisit was completed on 10/1/24 for all previous deficiencies cited on 4/18/24. Deficiencies were cited. Based on interview and record review, the residence failed to establish a fall management program 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 two of five sample residents (#9 and #11).This deficiency was cited previously during a state licensure survey on 4/18/24. Although the residence 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 fall management policy, dated October 2013, read in part, "a post-fall evaluation is completed after a resident fall, individualized interventions are considered, and the evaluation is part of the resident record. When a fall occurs service plan is reviewed for potential fall interventions and updated as necessary."2. Resident #11 was admitted to the residence on 1/1/22 with diagnoses of hypothyroidism and hypertension.A progress note, dated 7/10/24, read in part: Resident #11 had an unwitnessed fall on 7/9/24 at 11:15 p.m., the fall happened at the bedside. A temporary service plan-non injury fall note read a start date of 7/10/24 and had no specific interventions. The discontinuation date was 7/13/24.A progress note, dated 8/12/24, read in part: Resident #11 had an unwitnesse.. Based on interviews and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications that a resident self-administers, affecting one of five sample residents whose medications were reviewed (#11).This deficiency was cited previously during a state licensure survey on 4/18/24. Although the residence 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 Medication and Treatment policy, dated November 2011, read in part: "trained and/or licensed associates may administer or assist the resident with medication management or medication administration and treatments per physician/healthcare provider (HCP) order and as per state regulation."2. Resident #11 was admitted to the residence on 1/1/22 with diagnoses of hypothyroidism and hypertension.A practitioner' s order, dated 9/8/24, directed the residence to administer Bactrim DS 800-160 mg two times a day for three days. However, the September 2024 medication administration record revealed the residence failed to administer the medication on 9/9 and 9/10/24, for a total of four missed doses.4. InterviewsOn 10/1/24 at 1:32 p.m., the health and wellness director..

A recertification and complaint revisit was completed on 10/1/24 for all previous deficiencies cited on 4/18/24. A deficieny was cited. Based on interviews and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting two of five sample members (residents) (#10, #11).This deficiency was cited previously during a state licensure survey on 4/18/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Chapter VII regulations governing assisted living residences, part 14.20, requires that the assisted living residence contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.Resident #10 was admitted to the residence on 10/13/21.A care plan which was the same document as the residence' s assessment, dated 9/17/24, read in part the residence managed all of Resident #10' s medications. A practitioner' s order, dated 7/24/24, directed the residence to administer 0.25 mL of scheduled morphine every six hours for pain, and 0.25 mL every hour pro re nata (PRN). The most recent order in Resident #10' s record, dated 9/11/24, directed the residence to "hold morphine orders until (a) new order (was) received." However, the September and October 2024 electronic medication administration records (eMARs) revealed staff administered morphine as written in the 7/24/24 practitioner' s order without any new orders in the morning, afternoon and evening of 9/12/24, all four doses 9/13-9/30, and two morning doses on 10/1/24. On 10/1/24 at 1:22 p.m., the health and wellness director (HWD) stated he had asked Resident #1' s practitioner for an order to hold morphine until the residence received the medication, because the pharmacy had not delivered the refill to the residence on 9/11/24. The HWD stated he did not understand why he should have requested written clarification of the practitioner' s order since he had "an understanding between himself and the resident' s (external) hospice provide..

A recertification survey with complaint #CO35589 was completed on 4/18/24. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to provide all residents with regular opportunities to participate in structured engagement and support the pursuit of each resident' s interests, affecting 37 current residents.Findings include: 1. Reference and Residence Policy a. The residence' s Resident Agreement, dated April, 2021, read in part: "The residence will provide social and recreational services ..."b. According to the National Institue on Aging, "Being lonely or socially isolated is not good for your overall health. For example, it can increase feelings of depression or anxiety, which can have a negative impact on many other aspects of your health ... Research has shown that older adults with an active lifestyle:Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer.Have a longer lifespan. Studies looking at people ' s outlo.. Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting three of five sample participants (residents) (#1, #2, #5).Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.21, requires 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. Specifically, a written practitioner' s order, dated 4/10/24, directed the residence to administer acetaminophen 325 mg two tablets three times daily for pain relief from her injuries following falls on 4/6 and 4/8/24. However, residence staff transcribed the medication on the electronic medication administration record (eMAR) to be administered on an pro re nata (PRN) basis, although the resident was.. Based on record review and interview, the residence failed to ensure an informed consent for rights modification, was documented in resident records, affecting one of five sample residents (#1).Findings include:1. Residence PolicyThe residence' s electronic monitoring policy, dated October 2023, read in order for residents or their legal representatives to have electronic monitoring in a resident' s room, the electronic monitoring form must be completed.2. Resident #1 was admitted to the residence on 5/3/21 with a diagnosis of dementia. Medical durable power of attorney (MDPOA) paperwork dated 2/5/19, revealed Resident #1' s family member was her MDPOA.A "request for electronic monitoring" form dated 8/8/24 filled out by Resident #1' s family member and signed by the former administrator, read in part: "the (family member) on behalf of (Resident #1) wish(es) to conduct authorized electronic monitoring in accordance with (the residence' s) electronic monitoring policy. (The family member) released (the residence) from any civil liabi..

A relicensure survey with complaint #CO35588 was completed on 4/18/24. Deficiencies were cited. Based on interview and record review, the residence failed to establish a fall management program 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 two sample residents who sustained injuries from falls (#1 and #2). (Cross reference .. Based on observation and interview, the residence failed to provide at least three meals in accordance of the resident' s needs, affecting one of five sample residents (#1). (Cross reference S1324)Findings include: 1. Residence Policy The signed Resident Agreement for Resident #1, dated 4/30/21, read in part; "Unless otherwise not.. Based on observation, interview and record review, the residence failed to ensure residents had the right to be free from neglect, affecting one of five sample residents (#1). (Cross reference S1180, S1410 and S1600)Specifically, Resident #1 sustained a fall with injury on 2/18/24. A care plan updated 2/20/24 read the resident used a walker, w.. Based on observation, interview and record review, the residence failed to ensure the administrator was responsible for managing the overall day-to-day operations of the assisted living residence as described in the resident agreement, affecting 36 current residents. (Cross reference S1410)Findings include:Chapter VII regulations governing assisted livi.. Based on observation, interview, and record review, the administrator failed to designate one staff member to be responsible for organizing, conducting, and evaluating resident engagement, affecting 37 current residents. (Cross-Reference S1202)Findings include:Throughout the onsite visit from 4/16/24 to 4/17/24, an April 2024 activity .. Based on observation, interview, and record review, the residence failed to provide all residents with regular opportunities to participate in structured engagement and support the pursuit of each resident' s interests, affecting 37 current residents. (Cross-Reference S1230)Findings include: 1. Reference and Residence Policy a. The residenc.. Based on observation, interviews and record review, the residence failed to ensure resident' s medication administration record contained accurate information, affecting two of four sample residents (#2 and #5). (Cross reference S1568)Findings include:1. Resident #2 was admitted to the residence on 12/18/22.A written practitioner' s .. Based on observation, record review and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting two of four sample residents whose medications were reviewed (#1 and #2). (Cro.. Based on observations, record review and interviews, the residence failed to investigate all allegations of abuse in accordance with regulation and their written policy, affecting 36 current residents. (Cross reference S540, S1180 and S1324)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residen.. Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting five of five sample residents (#1-#5).Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 18.8 requires that Resident records shall contain, but not be lim.. 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 7.6.5 Each administrator shall have completed 40 hours of administrator training before assu..