Brookdale Highlands Ranch

A licensure complaint, prompted by #CO39496, #CO40480, #CO40651, and #CO41537 was completed on 2/5/26. Deficiencies were cited. A change of ownership occurred on 9/3/25. Based on observations and interviews, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the diagnosis of dementia throughout the entire building, affecting 76 current residents.Findings include:On 2/4/26 from approximately 8:00 a.m. to 10:00 a.m., an environmental tour of the residence revealed the following:The residence activity rooms had a small saw, large sewing needles, loose nails and screws in drawers, and fishhooks. Several residents were observed sitting in the dining room, near where many of these items were displayed. On 2/4/26 at 1:30 p.m., the administrator stated she was shocked to learn that a real saw with serrated edges was on display in the activities room. An unname.. Based on record review and interview, the residence failed to comply with the authorized practitioner' s orders associated with medication administration, affecting three of three sample residents whose medications were reviewed (#2-#4). Findings include:1. Resident #2 was admitted to the residence on 8/15/25.a. acetaminophenA written practitioner' s order dated 1/26/26 directed the residence to administer two 325 mg tablets of acetaminophen by mouth three times a day; however, the January 2026 medication administration record (MAR) read that the residence failed to have the medication in stock on 1/6/26 for the afternoon and evening doses. b. diclofenacA written practitioner' s order dated 1/20/26 directed the residence to administer one gram of diclofenac to the right k.. Based on record review and interview, the residence failed to provide an enhanced care plan (ECP) affecting 76 residents who resided in the secured environment. Findings include:1. Record ReviewResident #2 was admitted to the residence on 8/15/25 with a diagnosis of unspecified dementia, anxiety, hallucinations, and psychotic disturbance. A progress note, dated 2/1/26, read in part that Resident #2 was exit seeking after seeing things in her room that did not exist, accused staff of things that were not true, agitated, was not able to be redirected or calmed down by staff or her power of attorney, and threw a "heavy decor item" at a window and broke it in attempt to leave the building.A service (care) plan dated 2/2/26 read in part that Resident #2 had a history, before moving in, of wandering. Howev.. 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 7.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident' s room location, any known allergies, and the name and telephone number of the resident' s authorized practitioner. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident-reported responses t..

A revisit survey was completed on 2/26/25 for all previous deficiencies cited on 10/10/24. 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 complaints #CO37749 and #CO37836 was completed on 10/10/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each care plan was updated to reflect changes in the staff approach to meet resident needs and when observations indicated the resident' s care needs have changed, affecting two of four sample residents (#15, #16). (Cross-reference S1110, S2230)Findings include:1. Resident #16 wa.. Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affects a resident' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident' s changing needs,.. Based on interview and record review, the residence failed to have at least one staff member onsite who had certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization at all times, affecting 41 current residents. (Cross-reference S0732 and S0736)The staff schedule from 10/1-10/19/24 revealed there were .. Based on interview and record review, the residence failed to have at least one staff member onsite who had certification in first aid from a nationally recognized organization, affecting 41 current residents. (Cross-reference S0734 and S0736)Record Review:A review of staff first aid certifications on 10/8/24 revealed that ten out of ten sam.. Based on observation and interview, the residence failed to have, in a visible location, a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR), affecting 41 current residents. (Cross-reference S0732 and S0734)On 10/9/24, a list of current staff members certified in CPR and first aid was not i.. Based on observation and interview, the residence failed to make available, either directly or indirectly through a resident agreement, personal services including but not limited to a system for identifying and reporting resident concerns that require an immediate individualized approach or on-going monitoring and possible re-assessment and p.. Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of four sample residents (#15-#17). (Cross-reference S1604)Findings include:1. Resident #16 was admitted to the residence on 9/10/24 with diagnoses including dementia .. Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin affecting two of four sample residents (#15, #17). (Cross-reference S2230)A shift report dated 9/4/24 read in part: Resident #17 had a skin tear on her left leg th.. Based on record review, observation and interview, the administrator and the qualified medication administration persons (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affectin.. 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 7.7.14 If the employee or volunteer is a qualified medication administration person, the follo..

A complaint revisit was completed on 8/8/24 for all previous deficiencies cited on 12/27/22. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on observations and interviews, the residence failed to have staff sufficient in number to help residents needing or potentially needing assistance, affecting 39 current residents.This deficiency was cited previously during a state licensure survey 12/27/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Reference and Residence Policy a. The residence' s staffing policy, dated November 2022, read in part: " The community shall have sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled resident needs, as required by the residents' assessments and service plans on a 24-hour per day basis."b. The residence ' s resident agreement, dated February 2024, read in part, "(Staff) are available 24 hours a day, seven days a week."2. Record ReviewAn incident investigation summary, dated 7/30/24, read in part: "It has been substantiated that two [staff], [Staff #5], caregiver, and [Staff #4] did not check on [Former Resident #14] during her time in the courtyard."2. Interviews On 8/7/24 at 9:53 a.m., Staff #2 stated with insufficient staff it was hard to keep up with resident care needs and he had been working longer hours due to the lack of staff. He stated that staff were cleaning resident rooms and common living and dining areas due to the lack of housekeeping staff. On 8/7/24 at approximately 2:15 p.m., the maintenance director stated due to insufficient staff, he had been at the residence for the past two days with only a total of six hours to go home, take a break and then come back to help care for the residents. He also stated that the residence needed to hire more staff and it had become difficult to keep up with resident care needs. He stated he was the only staff member in maintenance for the residence, and there was one housekeeper to clean all resident rooms and the residence. On 8/7/24 at 3:50 p.m., the health and wellness director (HWD) acknowledged res..

A licensure complaint, prompted by #CO37022 and #CO37023, was completed on 8/8/24. Deficiencies were cited. Based on record review and interview, the residence failed to document the investigation process to evidence the required reporting and that a thorough investigation was conducted including the documentation of appropriate measures to prevent similar future situations of neglect, affecting 39 current residents. Findings include:1. Residence PolicyThe residence' s How to Conduct Internal and External Investigations policy, dated October 2018, read in part: "The investigator should draft an investigation using the investigation notes form ... The notes should contain the date, time, name of each person questioned, their title and an impartial report of the facts ... The legal department should be contacted if there are any questions regarding the documentation of the facts gathered or the.. Based on record review and interview, the residence failed to ensure the resident right to be free from neglect affecting one current former resident (#14). Findings include:1. Residence Policya. The residence' s Secure Environment Policy, dated August 2021, read in part: "There shall be a secure outdoor area that is available for resident use year-round that is directly supervised by [staff]."b. The residence' s Resident Meal Check Policy, dated January 2023, read in part: "[Staff] should conduct routine resident checks for each meal; [staff] should indicate the resident' s status at each meal check by marking the box next to the resident' s name on the resident meal check record; if the resident is not attending the meal and there is no indication the resident is in the hospital, or out of th.. Based on record review and interview, the residence failed to have readily available a roster of current residents along with a residence diagram showing room locations and the emergency contacts for each resident, affecting 39 current residents.Findings include:On 8/7/24 at 8:00 a.m., the residence' s resident roster was provided but did not include a diagram of the residence that showed room locations or the emergency contact information for each resident. The resident roster was not accurate; it included a deceased resident and was missing one new resident. 2. InterviewOn 8/8/24 at 12:15 p.m., the district director of clinical services stated the residence was expected to update the resident roster upon resident admissions, discharges, and with a change in baseline status. He acknowledged that the.. Based on record review and interview, the residence failed to implement policies and procedures for the delivery of resident care and services including a system or method of accounting for the whereabouts of each resident affecting one former resident (#14). Findings include:Residence Policies a. The residence' s Resident Meal Check policy, dated January 2023, read in part: "[Staff] should complete a Resident Meal Check Record verifying the presence of residents for each meal."b. The residence' s resident agreement, dated February 2024, read in part: "[Staff] are available 24 hours a day, seven days a week."2. Record Review Former Resident #14 was admitted to the residence on 2/28/24 with a diagnosis of dementia. An incident investigation summary, dated 7/30/24, read: " On 7/30/24 resident, [Form..