Brookdale North Loveland

A revisit survey was completed on 4/17/25 for all previous deficiencies cited on 1/22/25. 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 #CO34600 was completed on 1/22/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that at least one staff member onsite at all times was certified in cardiopulmonary resuscitation (CPR) and obstructed airway technique, affecting 44 current residents. On 1/21/25, the residence provided CPR certifications for all certified staff. The residence failed to provide CPR certifications for Staff #4 and #5. The December 2024 and January 2025 staff schedules read in part that Staff #4 and #5 worked at the residence without other CPR-certified staff present from 10:00 p.m. until 6:00 a.m. on the following dates: 12/26-12/28/24, 1/2-1/4, 1/9-1/10, and 1/16-1/18/25. On 1/21/25 at 12:34 p.m., the administrator stated t.. Based on interview and record review, the residence failed to ensure that at least one staff member was onsite at all times with a current certification in first aid, affecting 44 current residents. Findings include:On 1/21/25, the residence provided first aid certifications for all certified staff. The residence failed to provide first aid certifications for Staff #4 and #5. The December 2024 and January 2025 staff schedules read in part that Staff #4 and #5 worked at the residence without other first aid-certified staff present from 10:00 p.m. until 6:00 a.m. on the following dates: 12/26-12/28/24, 1/2-1/4, 1/9-1/10, and 1/16-1/18/25. On 1/21/25 at 12:34 p.m., the administrator stated that Sta.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of five sample residents (#1).Findings include:Resident #1 was admitted to the residence on 3/21/24 with diagnoses of history of anxiety and major depressive disorder.A written practitioner' s order, dated 12/4/24, directed the residence to administer bupropion 100 mg daily. However, the December 2024 medication administration record read that the residence failed to administer the medication on 12/19 to 12/26/24 because the medication was unavailable.On 1/2.. Based on record review and interview, the residence failed to ensure each resident care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting three of four sample residents (#1-#3) and one former resident (#5).Findings include:Resident #1 was admitted to the residence on 3/21/24 with a diagnosis of history of alcohol abuse.A written practitioner' s order, dated 12/4/24, directed the residence to administer disulfiram 250 mg daily to prevent drinking alcohol. Additionally, it directed the residence to administer two alcoholic drinks pro re nata (PRN) daily, and the staff was to keep alcohol on the medication cart.A w.. 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 2.2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities:(A) Individual client records(B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department.

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 2/15/23. 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 9/13/23 for all previous deficiencies cited on 2/15/23. 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 licensure revisit was completed on 2/15/23 for all previous deficiencies cited on 8/4/21. Deficiencies were cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with mediation administration, affecting three of four current sample residents (#15, #16, #17) and one of three former residents (#19).This deficiency was cited previously during a relicensure survey with complaint on 8/4/21. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence Policiesa. The residence' s Medication and Treatments Absence from Community policy, dated October 2019, read, in part: "When a resident is going to be absent from the community for any period of time, the resident' s current medications scheduled during the temporary absence time will be released to the resident/responsible party per state regulation...The nurse will be responsible for reviewing the medication administration orders with the resident and/or responsible party, prior to a .. Based on record review and interview, the residence failed to include all required documentation in each personnel file, affecting three of three sample staff (#3-#5). This deficiency was cited previously during a relicensure survey with complaint on 8/4/21. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewOn 2/15/23 at approximately 1:30 p.m., the business office coordinator (BOC) provided staff files for Staff #3-#5. The staff file for Staff #3 did not include documentation of orientation, results of background checks, nor tuberculin test results.The staff files for Staff #4 and #5 did not include documentation of orientation nor results of background checks.On 2/15/23 at approximately 2:30 p.m., the BOC provided plastic sleeves she had taken from a binder that was kept separate from the staff files, which included additional documentation. However, the documentation still did not inc.. 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 licensure complaint, prompted by #CO29135 and #CO29583, was completed on 2/15/23. Deficiencies were cited. Based on observation, interview and record review, the residence shall ensure that each resident received proper administration and monitoring of medication, affecting one of six sample residents (#15).Findings include:1. Residences and Residence Policiesa. Chapter XXIV regulation governing assisted living residences, section 2.13, defines "monitoring" as (C) Visual observation of the resident to ensure compliance.b. Chapter VII regulations governing assist.. Based on record review and interview, the residence failed to accurately document each medication administration or monitoring event at the time the event was completed for each resident, affecting three of four current sample residents (#15, #16, #17) and two of three former resident (#19, #21).Findings include:1. Residence PolicyThe residence' s medication policy dated 10/1/19, read in part: The qualified medication administration persons (QMAP) .. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with mediation administration, affecting three of four current sample residents (#15, #16, #17) and one of three former residents (#19).This deficiency was cited previously during a relicensure survey with complaint on 8/4/21. Although the residence corrected the deficiency, based on the findings below, the residence h.. Based on record review and interview, the residence failed to clarify with the authorized practitioner an incomplete or unclear order and obtain a new order in writing, affecting one of four sample residents (#16). Findings include:1. Resident #16 was admitted to the residence on 12/5/22 with diagnoses including type I diabetes and renal dialysis.a. Bumetanide (Bumex)A written practitioner' s order, dated 1/6/23, directed the residence to administer Bumex 2 milli.. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) at least quarterly audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting three of four sample residents (#15, #16, #17). Findings include:On 2/25/23 at approximately 12:00 p.m., the reside.. Based on record review and interview, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, assistance from staff when residents summoned staff for assistance, affecting two of eight residents in assisted living, who utilized their call lights to summon staff assistance (#17, #18).Findings include:1. Residence Policy A residence policy, dated April 2021, titled Resident Rights, read in p.. Based on record review and interview, the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting one sample resident (#18).Findings include:The residence' s medication policy, dated 10/1/19, read in part: The medications or treatments brought to the residence by the resident, legally responsible party, or family member must be accompanied by a current practitioner order issued by .. 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 7.7.13 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee' s or volunteer' s personnel file:(B) A signed disclosure that the individ..