Springbrooke Retirement and Assisted Living

A relicensure survey with complaint #CO40312 and #CO40034 was completed on 2/4/26. Deficiencies were cited. Based on observations and interviews, the residence failed to only allow resident access to appliances with staff supervision, affecting 15 current residents who reside in the secure environment.Findings Include:An environmental tour of the secure environment on 2/3/26 at 7:35 a.m. revealed that the kitchen island had a steam table. The steam table was turned on high, and steam was visible coming from the water basin. The steam table was accessible to 13 r.. Based on observations, record review, and interviews, the residence failed to provide all residents in the secure environment with regular opportunities to participate in structured engagement, affecting 15 current residents.Findings Include:An interview with Resident #2 and her husband on 2/3/26 at 8:15 a.m. revealed that minimal structured activities were provided regularly. Resident #2 stated that last week, there were no activities off.. Based on observations, records review, and interviews, the residence failed to ensure care plans were updated to include specific care-planned needs and unique approaches. Staff members were not familiar with each resident' s specific care-planned needs and the unique approaches for assisting with care and safety, affecting three of five sample residents who live in the secure environment (#1, #3, #4).Specifically, Resident #3, who sustained eight falls .. Based on records review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting two of five sample residents (#2 and #6).Findings Include:Resident #2 was admitted to the residence on 10/24/23 with diagnoses including dementia and bipolar disorder.A written practitioner ' s order, dated 1/19/26, directed the residence to administer metronidazole 500 mg twice daily for seven days. Howe.. Based on records review and interviews, the residence failed to have complete employee files readily available onsite for Department review for all employees with current cardiopulmonary resuscitation (CPR) certification, affecting 43 current residents.Findings Include:On 2/3/26 at 2:25 p.m., the residence' s personnel files that included CPR certification were requested by the administrator.On 2/3/26 at 4:25 p.m., a second request was made for the reside.. Based on records review and interviews, the residence failed to reassess to determine the continued need for a secure environment every six months, affecting two of five sample residents who reside in the secure environment (#4, #5).Findings Include:Record review revealed the following; Resident #4, admitted to the residence on 2/12/24, and Resident #5, admitted to the residence on 6/30/25, revealed the most recent assessments to determine continued n.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter VII.7.10 The assisted living residence shall develop and maintain written personnel policies, job descriptions and other requirements regarding the conditions of employment, management of staff and resident care..

A licensure complaint, prompted by #CO36488, was completed on 3/31/25. Deficiencies were cited. Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed or was reported to them, affecting two of four current sample residents (#1, #2).Findings include:Resident #2 was admitted to the residence on 2/3/25 with a diagnosis of multiple fractures of her pelvis without disruption of pelvic ring, and retention of urine. A care plan, dated 2/3/25 read Resident #2 required bathing needs twice a week and dressing needs twice a day. Skin checks were required to be performed during bathing and report any reddening to the nurse. The task sheet for Resident #2 from 2/27-3/25 read, a shower and skin check had been done on 2/27/25 and 3/21/25. Not applicable had been checked off three times and that she refused three times. A progress note from 3/22/25 read in part that a qualified medication administration personnel (QMAP) checked on Resident #2 at 10:30 p.m. and noticed .. Based on record review and interview, the residence failed to follow the residence' s policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one resident (#2).Findings include:1. Residence policyThe residence' s Investigation of Abuse and Neglect and Exploitation Allegations and Occurrence Reporting policy, dated February 2025, read in part, the residence will investigate all allegations of abuse or neglect, if the allegation is against a staff member of the community, the staff member will be suspended until the outcome of the investigation.2. Record Review A written investigation of injury of an unknown origin, dated 3/23/25, read in part, on 3/23/25 at 7:28 a.m., Staff #5 notified the Executive Director (ED) that Resident #2 had sustained a dark purple bruise to her left upper arm. The resident care coordinator (RCC) and ED conducted interviews with Resident #2, Staff #1 and Staff #2. However the investigation did not include any immediate action against the staff .. Based on record review, observation and interview, the residence failed to provide a resident the right to receive services in accordance with their care plan, affecting two of four sample residents (#1, #2). (Cross-reference S2230)Findings include:1. Record ReviewA care plan, dated 2/3/25 read Resident #2 required bathing needs twice a week and dressing needs twice a day. Skin checks were required to be performed during bathing and report any reddening to the nurse. A task sheet read, Resident #2 was assisted with dressing, personal hygiene and grooming twice a day from 3/16-3/23/25.A task sheet read, Resident #2 was assisted with bathing/showering two times, she refused three times and staff documented "not applicable" four times from 2/27-3/25/25.2. ObservationOn 3/26/25 at 10:40 a.m., during an environmental tour, staff members sat at the desk on the third floor while using their phones.3. InterviewOn 3/27/25 at 9:10 a.m., the residential care coordinator (RCC) stated that staff were expected to docume..

A revisit survey was completed on 7/20/23 for all previous deficiencies cited on 5/11/23. No deficiencies 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 #CO28594 was completed on 5/11/23. Deficiencies were cited. Based on observation, record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting one resident (#1) who was not administered four out of six medications, as ordered.Findings include:1. Residence PolicyThe residence' s Pharmacy Services policy, dated February 2019, read in part: "The goal of the community is to consistently provide safe, efficient, timely and quality medication service as prescribed by the resident' s physician and in partnership with the dispensing pharmacy."2. Resident #1 was admitted to the residence on 3/13/23 with a diagnosis of dementia.On 5/11/23 at 7:28 a.m., Staff #5 stated the residence was out of stock of multiple medications for Resident #1. A. Quetiapine FumarateA written practitioner' s o.. Based on observation, record review and interview, the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting 14 current residents in the secure environment.Findings include:The residence' s undated Resident Agreement, read in part: "Sliding patio doors are not locked and allow residents free passage to the secure courtyard which has a magnetic lock on the gate and is monitored by staff. Staff may engage the locks on the sliding patio doors at times of inclement weather or unsafe temperatures."On 5/11/23, from approximately 7:30 a.m. until 1:00 p.m., the sliding door to the secure outdoor area of the residence remained locked.On 5/11/23 at 7:25 a.m., a couch, foot rest, side table, and c.. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records, affecting 57 current residents.Findings include:On 5/11/23 at 8:40 a.m., the residence' s medication audits were requested from the administrator.On 5/11/23 at 12:20 p.m., the resident care coordinator (RCC) stated she was responsible for conducting medication audits for the residence. She stated she completed medication audits for the residence; however, she did not document the audits. Further, she added the administrator completed audits with her; however, there was no documentation medication audits had been complet.. 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 7.7.8 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: (1) The care and services provided by the assisted living residence; (2) Assignment of duties and responsibilities, specific to the staff member or volunteer; (3) Hand Hy..