Brookdale Broadmoor

A relicensure survey with complaint #CO37375 was completed on 2/26/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure residents had the right to be free from neglect, affecting one former resident (#8). (Cross-reference S430)Specifically, Former Resident #8 was readmitted to the res.. Based on observation and interview the residence failed to ensure that qualified medication administration persons (QMAP) are trained in and apply nationally recognized protocols for basic infection control and prevention when prep.. Based on observation and interview, the residence failed to ensure the residence grounds were maintained to protect residents from slopes and hazards, affecting six of six residents who used the designated smoking area. Findings inclu.. Based on observation and interview, the residence failed to have a secure outdoor area that was independently accessible without staff assistance, affecting 26 residents in the secure environment. Findings include: 1. Observatio.. Based on observation and interview, the residence failed to provide toilet paper in a dispenser, liquid soap, and paper towels or hand drying devices in the secure environment common bathroom, affecting 26 current residents in the sec.. Based on observation, record review, and interview, the residence failed to provide residents who resided in the secure environment with regular opportunities to participate in structured engagement and support the pursuit of ea.. Based on observations and interviews the residence failed to provide a sanitary environment, affecting 64 current residents.Findings include:On 2/25/25 to 2/26/25 during an onsite environmental tour, the following was observed:T.. Based on observations and interviews the residence failed to provide residents with the opportunity to choose where and with whom they were able to sit during dining times, affecting 26 current residents in the secured environment. .. Based on record review and interview the residence failed to comply with all occurrence reporting required by state law and investigate an occurrence to determine the circumstances of the event and institute appropriate measures t.. Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting three of three sample residents (#1-#3).Findi.. Based on record review and interview the residence failed to provide staff training related to fall prevention affecting two of eight sample residents (#1, #2).Specifically, Resident #1 had an unwitnessed fall on 12/28/24 that resulted in .. 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.. 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 #CO31893 was completed on 5/11/23. Deficiencies were cited. Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting five of five sample residents (#14, #24, #27, #29, #30).Findings include:1. Referencea. Chapter VII regulations governing assisted living residences, part 6.8, requi.. Based on observation, interview, and record review, the residence failed to comply with authorized practitioner orders associated with medication administration affecting four of four sample residents (#24, #27, #29, #30). (Cross-reference Q1160, and Q1430).1. Residence PolicyThe residence' s medication administration policy, updated M.. Based on observation, record review and interview, the residence failed to ensure each residents' care plan identified all external service providers and care coordination, promoted residence choice, mobility, independence and safety, and detailed specific personal service needs and preferences along with staff tasks necessary to meet those needs, af.. 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 three of four sample residents (#24, #27, and #30). (Cross-reference Q1468 and Q1160)Findings include: 1. Residence Policya. The residence' s Medication .. Based on record review and interview the residence failed to coordinate care with known external service providers affecting two of two sample residents (#27 and #29). (Cross-reference Q1468, Q1430, Q1146, and Q1150).Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residence defines, in p.. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one sample resident (#30).Findings include:1. References a. According to the Occurrence Reporting Manual, dated May 2018, "Any time that a resident or patient of the facility cannot be located following a search of the facili.. Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' condition changed from baseline status, affecting two of five sample residents (#24 and #27). (Cross-reference Q1150, and Q2130).Findings include:1. Residence Policy The residence' s Fall Management Poli.. Based on record review and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue 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, affecting three o.. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration supervisor (QMAP) conducted quarterly audits of medication administration records, controlled substance lists, medication error reports, and medication disposal records for completeness and accuracy, affecting f.. Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 66 current residents.Findings include:The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and..

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 PLEASE NOTE: The Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response has been discontinued. A revisit to determine compliance with the cited deficiency can no longer be completed.

A licensure revisit was completed on 5/11/23 for all previous deficiencies cited on 12/19/22. Deficiences were cited. Based on record review and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue 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, affecting three of five sample residents (#24, #27, and #29). (Cross-reference Q1146 and Q1150).Findings include:1. Residence PolicyThe residence' s Change in Condition Policy, updated February 2021, read in part: "any change in condition should be evaluated and documented for residents who exhibit deviation in physician or mental status ... and update the resident record as needed."2. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including primary hypertension, hyperlipidemia and hyperglycemia.On 1/10/23 a hospital discharge note read that Resident #27 was admitted with acute chest pain.A hospital discharge summary, dated 2/17/23, read Resident #27 was admitted with "slurred speech, dysarthria and ataxia was noted- was admitted to the hospital with a diagnosis of cerebrovascular accident unspecified- likely chronic right thalamic stroke." On 5/11/23 at approximately 12:50 p.m., the administrator stated that Resident #27 was admitted to hospice and had experienced a decline the week prior to .. Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 66 current residents.Findings include:The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/22/23, required residences to: -Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month) and (period two, defined as days 15-31 of each month). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods.The residence' s resident roster read the residence had 66 current residents. On 5/11/23 at 2:00 p.m., a review of the residence' s EMResource details revealed the last date the residence reported updated information was 4/17/23, the last update to the number of residents being on 12/5/22, which read that there were 60 current residents. Therefore, EMResource was not updated bi-monthly, or to reflect the residence' s 66 current residents.On 5/11/23 at 5:05 p.m., the administrator acknowledged that he was aware he had..