Willowbrook Place

A licensure complaint, prompted by #CO38599, was completed on 12/24/24. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to ensure the resident care plan met each requirement for each resident in a secure environment, affecting 49 residents residing in a secure unit. Findings include:1. ObservationOn 12/19/24 at 9:00 a.m., the door to Resident #6' s room was locked and he was unable to enter. Resident #7 offered Resident #6 to go through his room because the men had a shared bathroom. Resident #7 had a key for his personal room, unlocked the door and Resident #6 was able to gain access to his room. Resident #8 was also unable to open the door to his room because the door was locked. Staff #9 was walking down hallway when .. Based on observation, record review, and interview, the residence failed to investigate an injury of unknown origin, affecting three of five sample residents (#1, #3 and #5).Findings include:1. Record ReviewResident #1 was admitted to the residence on 5/31/24, with diagnoses including dementia, anxiety and restlessness and agitation. A progress note, dated 10/15/24 at 12:30 p.m., read Resident #1 had an abrasion above her left eyebrow and Resident #1 spent a lot of time in the common outdoor courtyard in the trees and bushes digging around. A progress note, dated 10/15/24 at 12:58 p.m., read Skin Condition Change: Resident #1 had a skin tear on her left upper forehead.A progress note, date.. Based on record review and interview, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting three of five sample residents (#2-#4). Specifically, the care plan for Resident #4, dated 8/7/24, read Resident #4 required fall risk safety checks with an expected outcome of Resident #4 remaining in a safe environment. The resident sustained a fall in September 2024. The residence subsequently failed to implement and document fall interventions in the care plan. The resident fell on 12/7/24, which resulted in a broken arm and b.. Based on record review and interview, the residence failed to evaluate whether a resident could be assisted in a safe manner and provided lift assistance to a resident who was experiencing pain, had a change in their physical baseline status, and requested that staff call 911, affecting 49 current residents living in the secure environment. Specifically, on 11/29/24, Staff found Resident #2 lying on the floor of her room asking for help getting up, requesting to be transported to the emergency department, and had an abrasion on her right forearm. The resident verbalized pain when staff attempted to move her. Staff #2 notified the power of attorney (POA), who instructed Staff #2 to await hi.. Based on record review and interview, the residence' s personnel files failed include first aid certifications for two of three sample staff (#4, #7). On 12/18/24 at 3:07 p.m., a request was made to the administrator or verification of first aid certification for Staff #4, #6 and #7.At 4:07 p.m., the administrator provided a first aid certification for #6 and said human resources was retrieving the remaining two. On 12/19/24 at 9:00 a.m., the administrator said the residence did not have first aid certifications for Staff #4 and #7 and was in the process of obtaining certifications directly from Staff #4 and #7. The administrator added they were aware personnel files were required to include this..

A revisit survey was completed on 12/18/23 for all previous deficiencies cited on 9/28/23. 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 revisit survey was completed on 12/18/23 for all previous deficiencies cited on 9/28/23. 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 licensure revisit was completed on 9/28/23 for all previous deficiencies cited on 10/5/22. Deficiencies were cited. Based on record review and interview, the residence failed to ensure a name-based criminal history record check that was conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective employee prior to staff hire, for three of three sample staff (#8-#10), affecting 41 current residents.This deficiency was cited previously during a state licensure survey 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: Review of the personnel file for Staff #8 revealed a hire date of 7/26/23; however, the file contained no evidence a name-based criminal background check had been completed.Review of the personnel file for Staff #9 revealed a hire date of 8/29.. Based on record review and interview, the residence failed to ensure each personnel file included orientation and training and results of background checks, for three of three sample staff (#8-#10), affecting 41 current residents.This deficiency was cited previously during a state licensure survey 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:The residence' s personnel files for Staff #8 and Contracted Staff #10 revealed no documentation of training as required.On 9/28/23 at approximately 11:00 a.m., the staff development director was requested to provide the completed training for Contracted Staff #10; however, he was unable to provide the docum.. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents along with a diagram showing room locations, affecting 41 current residents.This deficiency was cited previously during a state licensure survey 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 9/28/23 at 8:07 a.m., a resident roster was requested. On 9/28/23 at 8:28 a.m., the administrator provided a list of residents, their room numbers and emergency contact information. However, there was no diagram that showed room locations. On 9/28/23 at approximately 4:30 p.m., the administrator stated she was not aware that a residence diagr.. 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 #CO33334 was completed on 9/28/23. Deficiencies were cited. Based on interview and record review the residence failed to, either directly or indirectly, through a resident agreement, provide personal services, affecting one of seven sample residents (#16).Findings include:1. Reference and Residence Policiesa. Chapter VII regulations governing assisted living residences, in part two, defines "Personal Servic.. Based on observation and interview, the residence failed to place in a visible on-site location the residence' s internal process for raising and addressing grievances and complaints, along with full contact information for required agencies, affecting 41 current residents. Findings include:The residence consisted of a main lobby area with two sep.. Based on observation and interview, the residence failed to place notices of planned resident engagement offerings in a central location readily accessible to residents, affecting 41 current residents.Findings include:The residence had two separate secure environments; East and West side. On 9/28/23 from approximately 7:30 a.m. to 5:30 p.m., ther.. Based on observation, record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) followed national recognized protocols for basic infection control and prevention when preparing and administering medications, affecting three of three sample residents (#14, #21,#22) during medication pass. Findings.. Based on record review and interview, the residence failed to arrange discharge to a resident who posed a danger to self and the assisted living residence was unable to sufficiently address those issues through therapeutic approach and needed more services than could be routinely provided by the assisted living residence or an external service provide.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of six sample residents (#14, #17, #20).Findings include:1. Residence PolicyThe residence' s Basic Care Services policy, dated May 2017, read in part, "Medications are to be given accordin.. Based on record review and interview, the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring one of three sample staff (#33) who provided direct care to at-risk residents, for one of three sample staff (#8), affecting 41 current residents. Findings include:1. .. Based on record review and interview, the residence failed to ensure a name-based criminal history record check that was conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective employee prior to staff hire, for three of three sample staff (#8-#10), affecting 41 current residents.Findings include: Review of t.. Based on record review and interview, the residence failed to ensure each personnel file included orientation and training and results of background checks, for three of three sample staff (#8-#10), affecting 41 current residents.Findings include:The residence' s personnel files for Staff #8 and Contracted Staff #10 revealed no documen.. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents along with a diagram showing room locations, affecting 41 current residents.This deficiency was cited previously during a state licensure survey 10/5/22. Although the residence corrected the deficiency, based on the fin.. 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..