Crossroads at Lakewood

A complaint investigation, prompted by #CO41580, was completed on 2/11/26. Deficiencies were cited. Based on observation, interviews and record review, the residence failed to complete a reassessment whenever the resident had a change from baseline status, affecting two of three sample residents (Resident #1 and #2).Findings include:ObservationOn 2/11/26, at 8:55 a.m., was observed sitting in a chair at a community dining room table on the west end of the residence. Resident #1 wore a thigh-high support stocking on his left lower extremity; folded at the base of the knee. Resident #1 ' s right ankle appeared slightly larger than the left ankle.On 2/11/26 at approximately 1:10 p.m., Resident #1 was observed getting out of a chair located in the west end community dining room with stand-by assistance from residence staff. Resident #1 was then observed ambulating with a walker and residence staff at his left side. Resident #1 received the direction of residence staff to keep his walker closer to his body as he unsteadily and slowly walked toward the west end hallway. Record ReviewResident #1 was admitted to the residence.. Based on record review and interviews, the residence failed to comply with authorized practitioner ' s orders associated with medication administration, affecting two of three sample residents (#2-#3). Findings include:1.Record ReviewResident #3 was admitted to the residence on 9/17/25 with a diagnosis including diabetes mellitus type 2 with diabetic chronic kidney disease. a. Sulfamethoxazole-TMM SS 400-80mg A written practitioner' s order, dated 1/2/26, directed the residence to administer one table of sulfamethoxazole-TMM SS 400-80mg by mouth twice a day for seven days to treat a urinary tract infection. The January Medication Administration Record (MAR) displayed an "NG"code that indicated the medication was not available and not given to Resident #3 for the morning dose on 1/8/26 and for the scheduled evening dose on 1/9/26.b. Bismuth Subsalicylate 525mg/30mLA written practitioner ' s order dated 2/12/26, directed the residence to administer 30mL of bismuth subsalicylate by mouth twice every 12 hours for diarr.. Based on record review and interviews, the residence failed to ensure each resident had a care plan that detailed specific personal service needs and preferences, reflect the most current assessment and promoted resident safety, affecting two of three sample residents. (#1 and #2). Findings include:1. Record ReviewResident #2 was admitted to the residence on 7/19/2024 with diagnosis including advanced dementia.On 2/10/26, at approximately 8:20 a.m., a full chart including the most recent care plan was requested.A six month care plan was last completed for Resident #1 on 8/15/25, and a fall risk assessment was last completed on 10/24/25 that was added to Resident #2 ' s care plan.A progress note, dated 1/8/26, read nursing staff were following up on an incident occurring 1/7/25, detailing Resident #2 was found on the floor with complaints of foot, ankle, and pain in her tail bone area. The note also read Resident #2 received a scrape on her back, and her ankle appeared minimally swollen. The note explained Resident #2 ' s prov..

A licensure complaint, prompted by #CO40372, was completed on 6/30/25. A deficiency was cited. Based on record review, observation, and interview the residence failed to have two individuals who are either qualified medication administration persons, nurses, or practitioners jointly count all controlled substances at the end of each shift and sign documentation regarding the results of the count at the time it occurs, affecting three of five (#1-#3) sample residents who were administered controlled substances.Findings includeOn 6/30/25 at 7:47 a.m., record review revealed the residence' s west side narcotic shift change count sheet failed to have two signatures on 6/25/25 at 6:00 a.m. and 2:00 p.m., and on 6/30/25 at 6:00 a.m.On 6/30/25 at 7:50 a.m., Staff #2 was observed signing off on the 6:00 a.m. oncoming narcotic shift change count sheet after the surveyor addressed that it had not been signed off on.On 6/30/25 at 7:48 a.m., Staff #2 stated that two staff members would count the narcotics at the beginning and end of each shift. She explained that she counted the narcotics with another staff member, but did not sign off at the time it was completed, and was unsure why. She acknowledged that she should have signed off after completing the narcotic count.On 6/30/25 at 3:52 p.m., the administrator stated that she expected two staff members to sign off on the narcotic count sheet at the beginning and end of their shift. She stated she was unaware that staff were not doing that for each shift.

A relicensure survey with complaints #CO39312 and #CO40141 was completed on 6/3/25. No deficiencies were cited. 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 7.14.9 No medication shall be administered by a qualified medication administration person on a pro re nata (PRN) or "as needed" basis except:(B) Where the resident understands the purpose of the medication, is capable of voluntarily requesting the medication, and the assisted living residence has documentation from an authorized practitioner that the use of such medication in this manner is appropriate.25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following:(A) A description of the resident ' s wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact.

A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 6/3/24. 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