Brookdale Greenwood Village-Alr

A revisit survey was completed on 6/16/25 for all previous deficiencies cited on 2/11/25. 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 with complaint #CO34897 was completed on 2/11/25. Deficiencies were cited. Based on interview and record review the residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records affecting 83 current residents. (Cross-reference S0540)Findings include:The residence' s Medications Systems policy, dated 10/11/23, read in part: Ongoing oversight of medication delivery would be provided through the residence' s quality assurance section. The oversight consisted of routine medication administration record (MAR) audits and MAR to medication cart audits which focused on medication availability. On 2/11/25 quarterly medication audits wer.. Based on observation, interview and record review, the residence failed to ensure the administrator managed the day-to-day operations of the assisted living residence, including managing the day-to-day delivery of services to ensure residents received the care that is described in the resident agreement and for complying with all applicable state and local laws concerning licensure and certification, affecting 83 current residents. (Cross reference S0734, S0910, S1604) Findings include:Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assist.. Based on record review and interview, the residence failed to ensure health information records for residents were kept on site for at least three years following the termination of the resident' s stay, affecting one of two former residents (#10). Findings include:Former resident #17 was admitted to the residence on 1/18/22 and discharged on 12/29/23.Records were requested for Former resident #17; however, the residence could not provide the resident' s complete record as the residence could not find the paper records the former administrator had kept. The residence did not have recent care plans, recent assessments, or provide medication administration records (MARs) at the end .. Based on record review and interview, the residence failed to ensure there was at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 83 current residents. (Cross-reference S0540)Findings include:A review of staff CPR certifications and staff schedules from 1/27/25-2/13/25 revealed the following 10 shifts did not have a person onsite certified CPR: Day shifts: 1/28, 2/6, 2/13Afternoon shifts: 1/27, 1/28, 1/30, 2/4, 2/5 -2/10, 2/11 and 2/12.On 2/11/25 at 3:40 p.m., the administrator stated it was her responsibility to ensure there was one staff memb.. Based on record review, and interview, the residence failed to have a readily available roster of current residents, their room assignments, and emergency contact information, along with a residence diagram showing room locations, affecting 83 current residents. (Cross-reference S0540)Findings include:1. Record ReviewOn 2/11/25 at 8:45 a.m., a resident roster, provided by the administrator (AD), was not readily available and failed to include two current resident names along with their room assignments and emergency contact information (ECI). Additionally, the names on the resident roster did not accurately reflect the current residents, their ECI, their room numbers or the residenc..

A licensure complaint revisit was completed on 2/11/25 for all previous deficiencies cited on 8/23/22. Tag 1604 was not cited in the previous event; however, the deficiency was included in the previous event' s informational 999 tag. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/24. Based on interview and record review the residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records affecting 83 current residents. (Cross Reference S0540)This deficiency was cited previously during a state relicensure and complaint survey on 8/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:The residence' s Medications Systems policy, dated 10/11/23, read in part: Ongoing oversight of medication delivery would be provided through the residence' s quality assurance section. The oversight consisted of routine medication administration record (MAR) audits and MAR to medication cart audits which focused on medication availability. On 2/11/25 quarterly medication audits were requested from the administrator and provided. However, the medication audits were not co.. Based on observation, interview and record review, the residence failed to ensure the administrator managed the day-to-day operations of the assisted living residence, including managing the day-to-day delivery of services to ensure residents received the care that is described in the resident agreement and for complying with all applicable state and local laws concerning licensure and certification, affecting 83 current residents. (Cross reference S0734, S0910, S1604) This deficiency was cited previously during a state relicensure and complaint survey on 8/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is .. 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