Brookdale Pinehurst Park

A revisit survey was completed on 6/17/25 for all previous deficiencies cited on 3/18/25. 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 #CO37274 was completed on 3/18/25. Deficiencies were cited. Based on interview and record review, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting two of three sample residents (#1 and #2). Findings include:1. Residence PolicyThe residence' s Injuries of Unknown Sources policy, dated September 2024, read in part: "When an injury of unknown origin is identified it should be reported to the (administrator) and an investigation should be conducted along with the appropriate follow-up and/or implementation of steps to prevent or mitigate future injuries. Definition of unknown injuries: the injury was not observed or otherwise known. Cannot exp.. 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 61 current residents. (Cross-reference S1568)Findings include:On 3/18/25, documentation of quarterly medication audits were requested from the administrator and provided. However, the documentation revealed that only the administrator participated in the medication audits and did not include a QMAP supervisor. On 3/18/25, the administrator said that either she, the health and wellness coordinator, .. Based on observation and interview, the residence failed to maintain a physically safe and sanitary environment, affecting 61 current residents.Findings include:1. ObservationsOn 3/18/25 during an environmental tour, the following was observed:Strong urine and other identifiable odors throughout the residence' s common hallways and in residents' rooms.Crumbs on the counter and billiard table along with unswept floors that contained dust and other particles in the activities room.The residence' s common bathroom had brown particles and liquid on the toilet bowl and rim, brown particles on the toilet seat, unswept floors, and a strong urine odor. Staff #1 used a brush on a resident' s hair .. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting three of seven sample residents (#5-#7).Findings include:Resident #5 was admitted to the residence on 5/31/22 with diagnoses of Alzheimer' s disease, chronic obstructive pulmonary disease, and diabetes mellitus.A written practitioner order, dated 1/31/25, directed the residence to administer sertraline HCl 25 mg daily. However, the March 2025 medication administration record (MAR) revealed the residence failed to administer the medication on 3/17-3/18/25 due to being out of stock. The February and March 2025 MARs revealed t.. 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 VII. 7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (A) The assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics:10.1 The assisted living residence shall have readi..