Brookdale Meridian Englewood

A relicensure survey was completed on 7/10/24. Deficiencies were cited. Based on interview and record review the residence failed to comply with authorized practitioner' s orders associated with medication administration affecting three of four sample residents (#1, #2, #4).Findings include:1. Residence PolicyThe residence' s policy titled, How To Order Medications, dated March 2019, read in part: The practitioner orde.. Based on interview and record review the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis audited the accuracy and completeness of the medication administration records (MARs) affecting four of four sample residents (#1, #2, #3,#4). (Cross-reference S1.. Based on interview and record review the residence failed to ensure the medication administration record was accurate affecting two of four sample residents (#1, #4).Findings include:1. Residence Policy:The residences policy titled, Medication & Treatment-General Guidelines for Medication Administration/Assistance), dated 11/11, Rev.. Based on interview and record review, the residence failed to complete a risk assessment of all hazard and preparedness measures to address natural and human-caused crises affecting 32 current residents.Findings include:The residence' s emergency response manual contained the following elementsHurricane preparedness, Cold Inclement W.. Based on interview and record review, the residence failed to develop an involuntary discharge grievance policy affecting 32 current residents. Findings include:The residence' s Grievance Procedure- Resident, dated 01/17, read in part: The member should first discuss the complaint with the associate and administrator, and if they are unable to r.. Based on interview and record review, the residence failed to develop written policies and procedures regarding visitation affecting 32 current residents.Findings include:The residences Visitor/Vendor/Third Party Provider Sign In-Out Policy, dated 08/17, read in part: The policy identified the processes for visitor entry which included maintain.. Based on interview and record review, the residence failed to have emergency policies and procedures that were tailored to the geographic location of the assisted living residence affecting 32 current residents.Findings include:The residence' s policy 2024 Emergency Manual, dated 1/2024, included policies and procedures related to:Preparing for a.. Based on interview and record review, the residence failed to provide access upon request to staffing records affecting 32 current residents. (Cross-reference tags S0732 and S0734)Based on interview and record review, the residence failed to provide access upon request to staffing records affecting 32 current residents. (Cross-reference t.. Based on observation, interview, and record review the residence failed to ensure there was at least one staff member onsite at all times with current certification from a nationally recognized organization certified in CPR affecting 32 current residents. (Cross-reference tags B290, S0732, S0736)1. ObservationDuring an environmental tour on 7/10/24 .. Based on observation, interview, and record review the residence failed to ensure there was at least one staff member onsite at all times with current certification from a nationally recognized organization certified in first aid affecting 32 current residents. (Cross-reference tags B290, S0734, S0736)1. Residence PolicyThe residence ' s policy titled First Ai.. Based on observation, interview, and record review, the residence failed to place in a visible location a list of all staff who had current certification in CPR and first aid affecting 32 current residents. (Cross-reference tags B290, S0732, S0734).Findings include:During an environmental tour on 7/10/24 at 8:37 a.m. there was no evidence of a posting th..