Palisades at Broadmoor Park, the

A licensure complaint, prompted by #CO38417, was completed on 2/19/25. Deficiencies were cited. Based on record review and interview the residence failed to ensure residents were free from abuse affecting one of four sample residents (#1). (Cross-reference S1400, S1410, S3050, and S3076)Specifically, Former Staff #6 was terminated from her position after an incident which she was involved in, where Resident #1 was found with the skin of her left hand pulled back from her wrist to her knuckles.Findings include:Resident #1 was admitted to the residence on 4/30/23 with a diagnosis of dementia.A progress note dated 9/14/24 read that Former Staff #6 was suspected of abuse when she reported that Resident #1 had a skin tear on her hand. Other staff at the time reported that they did.. Based on record review and interview the residence failed to have an internal process to ensure the prompt handling of grievances and complaints recorded in a visible on-site location, affecting 21 current residents in the secured environment. (Cross-reference S1322, S1410, S3050, and S3076)Findings include:On 2/18/25 at approximately 10:30 a.m., the grievances and complaints that the residence received in the last 90 days, and their resolutions, were requested and not provided. On 2/18/25 at approximately 8:30 a.m., Confidential Staff #1 stated that s/he informed her supervision on multiple occasions about the misconduct of Former Staff #6, but there was no resolution and s/he .. Based on record review and interview the residence failed to investigate allegations of abuse affecting 21 current residents in the secured environment. (Cross-reference S1322, S1400, S3050, and S3076)Findings include:A team member action plan document dated 9/13/23 read that Former Staff #6 was reprimanded for unprofessional and disrespectful behavior towards residents. A record of conversation document dated 3/18/24 read that Former Staff #6 was talked to about respecting residents and not rushing residents during medication pass. On 2/18/25 at approximately 8:30 a.m., Confidential Staff #1 stated that s/he informed the director that Former Staff #6 was disre.. Based on record review and interview the residence failed to provide each staff member with a minimum of six hours of dementia/cognitive impairment training, affecting 21 current residents in the secured environment. (Cross-reference S1322, S1400, S1410, and S3050)Findings include:Personnel files revealed Staff #2 was hired on 11/26/24. On 2/18/25 at approximately 11:00 a.m., personnel files were reviewed. There was no training for dementia in Staff #2' s file.On 2/18/25 at approximately 1:02 p.m., the administrator stated that she was aware of the requirements for dementia training and she was aware that Staff #2 was missing this training and that the residence .. Based on record review and interview the residence failed to re-asses residents in the secured environment every six months affecting two of four sample residents (#1, #2). (Cross-reference S1322, S1400, S1410, and S3076)Findings include:Resident #2 was admitted to the residence on 8/31/22 with a diagnosis of dementia.On 2/18/25 at approximately 8:30 a.m., Staff #4 stated that Resident #2 was usually very aware.On 2/18/25 at 8:40 a.m., Resident #2 stated that she did not belong in a secure environment and that she told the administrator this and felt alone.On 2/18/25 at approximately 1:30 p.m., the administrator stated that she was aware that Resident #2 did not believe th..