Gardens at Broadmoor Court, the

A licensure complaint, prompted by #CO40909 and #CO36636, was completed on 12/4/25. Deficiencies were cited. Based on observation and interview, the residence failed to ensure that each resident received proper monitoring of medications, affecting three of four sample residents (#1-#3).Findings include:1. Residence Policy The residence' s medication administration policy dated 5/16/2019 read in part: "It is the policy of the residence that Residents receive medications as ordered by the physician in a safe, efficient and systematic manner. 2. ObservationOn 12/4/25 at 7:58 a.m., Staff #1 brought a small clear plastic cup with medications to the dining room, placed them on the table in front of Resident #1 next to her breakfast plate, and walked out of the dining room. At approximately 8:05 a.m. Resident #1 ingested the medications that were in the clear plastic cup. There were no other staff in the dining room at this time.On 12/4/25, throughout the morning meal service, Staff #1 additionally failed to observe ingestion when she administered medications to Residents #2-#3.3. InterviewsOn 12/4/25 at approximately 8:00 a.m., Resident #1 stated that Staff #1 consistently left her medications on the dining room table while she ate her breakfast, allowing her to take them without supervision. On 12/4/25 at 8:12 a.m., Staff #1 stated she was aware that she was required to observe the residents ingest their medication as part of the medication administration process. On 12/4/25 at 10:19 .. Based on observation, interview, and record review, the residence failed to ensure qualified medication administration personnel (QMAP) did not pre-pour medication, affecting three of four sample residents (#1-#3).Findings Include:On 12/4/25 at 7:46 a.m., Staff #1 held a stack of small clear cups, labeled with various numbers, each contained multiple medications. Staff #1, stated that the cups contained medications for residents #1-#3, corresponding to room numbers. Staff #1 admitted to pre-pouring the medications and acknowledged that this practice is not permitted. On 12/4 /25 at 9:30 a.m., the administrator said it was not acceptable for QMAPS to pre-pour any medications and that staff were aware. Similar deficient practice was found for Resident #2-3.

A revisit survey was completed on 4/26/24 for all previous deficiencies cited on 2/1/24. 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 revisit survey was completed on 4/26/24 for all previous deficiencies cited on 2/1/24. 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 recertification survey was completed on 2/1/24. A deficiency was cited. Based on observation, interview, and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting six of eight sample participants (residents) (#1, #2, #6-#9).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence comply with authorized practitioner' s orders associated with medication administration except for those medications which a resident self-administers.a. Residence PolicyThe residence' s medication administration policy, dated 1/1/23, read in part that the residence administered medication upon the order of the practitioner in a safe, efficient, and systematic manner. The residence ordered medications ordered by the practitioner from the pharmacy.The residence' s resident agreement, dated March 2023, read in part that when the residence provided medication administration services to residents, they followed their current medication system and medication policies and followed applicable state regulations.b. Resident #7 was admitted to the residence on 11/2/21 with diagnoses including a history of pulmonary embolism, constipation, and neuropathic pain. WarfarinA practitioner' s order, dated 1/8/24, directed the .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.495.2(B)1. An assessment will be conducted prior to admission, annually, and whenever there is a significant change in physical, cognitive, or behavioral needs, or as requested by the participant. The annual assessment must be completed by the team outlined in , Sections2. The assessment will document that the facility is able to support the participant and their needs. The assessment will also document the participant' s physical, behavioral and social needs, so that supports can be identified to enable them to lead as independent a life as possible. The assessment will be used to develop the participant' s Care Plan.8.495.6(F)(1) The following information must be documented in the Care Plan:b. Social and recreational engagement:i. The participant' s preferences and current relationships; andii. Any restrictions on social and/or recreational activities identified by a physician.c. Any other special health or behavioral management needs that supports the participant' s individual needs.

A relicensure survey was completed on 2/1/24. Deficiencies were cited. Based on interview and observation, the residence failed to place in a visible location a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR) so that the information is readily available to staff at all times, affecting 60 current residents.Findings include:1. ObservationsThroughout the onsite visit on 1/31/23 at 12:15 p.m. to 2/1/24 at 3:45 p.m., there was no list of staff who had current certification in first aid and.. Based on interview and record review, the residence failed to have at least one staff member on site who had current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization such as the American Red Cross, the American Heart Association, National Safety Council, or American Safety and Health Institute, affecting 60 current residents.Findings include:1. References and Residence Policya. According to Mayo Clinic, "Cardiopulmona.. Based on interview and record review, the residence failed to have at least one staff member on site who had current certification in first aid from a nationally recognized organization such as the AmericanRed Cross, the American Heart Association, National Safety Council, or American Safety andHealth Institute, affecting 60 current residents.Findings include:1. Reference and Residence Policya. According to VeryWell Health, "First aid is the emergency care a sick or .. Based on record review and interview, the administrator and the qualified medication administration person (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, affecting four of six sample residents (#1, #2, #6. #7). (Cross-Reference Q11468, Q1496, Q1510)Findings include:The residence' s medicati.. Based on record review and interview, the residence failed to comply authorized practitioner orders associated with medication administration, affecting three of six sample residents (#1, #2, #7). (Cross-Reference Q1514)Findings include:1. Residence Policya. The residence' s medication administration policy, dated 1/1/23, read in part that the residence administered medication upon the order of the practitioner in a safe, efficient, and systematic manner. Th.. Based on record review and interview, the residence failed to ensure that each qualified medication administration person, nurse, or practitioner accurately documented each medication or monitoring event at the time the event was completed for each resident, affecting three of six sample residents (#1, #2, #6). (Cross-Reference Q1514)Findings include:1. Residence Policya. The residence' s medication administration policy, dated 1/1/23, read i.. Based on record review and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting three of three sample residents (#1, #8, #9) observed during evening medication administration. (Cross-Reference Q1514)Findings include:1. Residence Policya. The residence' s m.. 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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident' s condition changes from baseline status.12.10 Each resident care plan shall:(B) Reflect the m..