Brookdale Greeley

A revisit survey was completed on 4/2/26 for all previous deficiencies cited on 12/16/25. 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 revisit survey was completed on 4/2/26 for all previous deficiencies cited on 12/16/25. 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 was completed on 12/16/25. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure that each staff member met the dementia training requirements in 7.9 (B), affecting 33 current residents. Findings include:Personnel files for the resident care coordinator and Staff #3, #4 provided by the administrator, revealed no evidence that each staff member had completed the initial four hour dementia training.Review of resident records revealed Resident #1 mild cognitive impairment had a diagnosis of dementia. Resident #2 had a diagnosis of vascular dementia, and Resident #3 had a dia.. Based on observation and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets along with fire resistant waste baskets in the designated smoking area outside the residence, affecting 33 current residents. Findings include: On 12/16/25 at approximately 8:30 a.m., the administrator verbally stated there was one resident who smoked cigarettes at the residence.An environmental tour of the residents' room revealed no fire-resistant wastebasket within the room. The outdoor environment revealed the cigarette wastebaske.. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 33 current residents.Findings include:The residence' s emergency plan failed to include the following: policies that address a pre-determined means of communicating with residents, families, staff and other providers. The emergency plan also failed to include storage and preservation of medications. Lastly, the plan of protection and transfer of health information as needed to meet.. Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 33 current residents.Findings include:On 12/16/25 at 8:00 a.m., a 72-hour Continuation of Care policy and procedure was requested; however, the residence did not have one included in their policy. On 12/16/25 at approximately 4:00 p.m., the administrator stated she was not aware that a 72-hour plan was included in the residence' s emergency policies. She acknowledged the need for th.. Based on record review and interview, the residence failed to identify the highest potential risk for its residence and hold routine drills to facilitate staff and resident response to that risk, affecting 33 current residents. Findings include: The residence' s emergency plan failed to include a plan to identify its highest potential risk for its residence and hold routine drills to facilitate staff and resident response to that risk.On 12/16/25 at 8:00 a.m., emergency drill documentation was requested. However, after review, the drills that were being held were meetings with the staff a.. 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 7.14.33 (U1612) Practitioner and legal representatives notified if: Decline in baseline Resident has pattern of refusal Repetitive requests for PRNs Reaction to medications Emergent medication for angina administered Medication errors that affect the resident14.21 (U1568) Residence complying with orders.14.31 The ad..

A recertification survey was completed on 12/16/25. Deficiencies were cited. Based on interviews and record review, the facility (residence) failed to ensure that each staff member met the dementia training requirements, affecting 33 current members (residents). Findings include:Personnel files for Staff #3, #4 and the resident care coordinator provided by the administrator, revealed no evidence that each staff member had completed the initial four hour dementia training.Review of resident records revealed Resident #1 mild cognitive impairment had a diagnosis of dementia. Resident #2 had a diagnosis of vascular dementia, and Resident #3 had a diagnosis of dementia. On 12/17/25 at approximately 3:20.m., the administrator stated she was unaware of the requ.. Based on record review and interview the facility (residence) failed to identify the highest potential risk for its residence and hold routine drills to facilitate staff and resident response to that risk, affecting 33 current members (residents). Findings include: The residence' s emergency plan failed to include a plan to identify its highest potential risk for its residence and hold routine drills to facilitate staff and resident response to that risk.On 12/16/25 at 8:00 a.m., emergency drill documentation was requested. However, after review, the drills that were being held were meetings with the staff and not simulated drills to track the response to the risk. On 12/6/25 at approximately .. Based on record review and interview, the facility (residence) failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 33 current members (residents).Findings include:The residence' s emergency plan failed to include the following: policies that address a pre-determined means of communicating with residents, families, staff and other providers. The emergency plan also failed to include storage and preservation of medications. Lastly, the plan of protection and transfer of health information as needed to meet the care needs of the residents. The residence' s emergency plan failed to include the .. Based on record review and interview, the facility (residence) failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 33 current members (residents).Findings include:On 12/16/25 at 8:00 a.m., a 72-hour Continuation of Care policy and procedure was requested; however, the residence did not have one included in their policy. On 12/16/25 at approximately 4:00 p.m., the administrator stated she was not aware that a 72-hour plan was included in the residence' s emergency policies. She acknowledged the need for the plan to be in place. 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 10 CCR 2505-10 8.7000.8.7411.AA. Complete the timely reporting, recording, and reviewing of Incidents which shall include, but not be limited to:DeathHospitalizationMedical emergencies above and beyond first aidAllegations of MANEInjury or illnessDamage or theft of personal propertyMed errorsLost or missing personCriminal activityIncidents or reports of unusual actions that require review8.7414.A.1-4Provider Agencies provide sufficient support to Members in..