BROOKDALE FORT COLLINS MC (CO)

An administrative relicensure survey was completed on 7/13/26. No deficiencies were cited.

A licensure complaint, prompted by #CO41427, was completed on 4/29/26. No deficiencies were cited.

A revisit survey was completed on 4/21/26 for all previous deficiencies cited on 12/22/25. 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 licensure complaint, prompted by #CO39386 and #CO39439, was completed on 12/30/25. Deficiencies were cited.

Based on observations and interviews, the residence failed to make available a physically safe and sanitary environment, affecting 46 current residents. Findings Include:On 12/30/25 at 8:00 a.m., during an environmental tour of the residence, a strong odor of urine was present throughout the dining room. There were food crumbs, empty medication cups, shoes, and snake wrappers on the ground and in the hallways. On 12/30/25 at approximately 10:00 a.m., during a tour of Resident #2's room, the bathroom had an odor of urine, the toilet had an old urine stain on the seat, and there was toilet paper on the ground. On 12/30/25 at 4:16 p.m., the administrator stated care staff were expected to ensure the day-to-day cleaning was completed, common areas were free of debris, resident rooms and bathrooms were clean, and there was a housekeeper who thoroughly cleaned the building once a week. The administrator further expected the residence to be physically safe and sanitary, and acknowledged that the residence was unclean. The administrator stated that the conditions were due to the lack of staff.

Based on observation, record review and interview, the residence failed to ensure the rights and responsibilities of its residents were observed in the care, treatment and services received in accordance with the resident agreement and the care plan, affecting three of five sample residents (#1-#3) whose care plans were reviewed. Findings include:Resident #2 was admitted to the residence on 8/5/24 with a diagnosis of Alzheimer's disease. A care plan dated 12/11/25 read in pertinent part, Resident #2 requires direct staff attention or direct physical assistance while eating. On 12/30/25 at approximately 8:00 a.m., Resident #2 was observed in her wheelchair in front of the dining table for breakfast. Resident #2 began chewing on the yellow napkin in front of her instead of eating the bowl of cereal. She then dropped the napkin and leaned over to her side, unable to sit up straight. Resident #2 could not grab any of the silverware and did not eat her breakfast in front of her. Later, she was provided with an omelet, fruit, and juice; however could not eat independently. The breakfast was taken away by kitchen staff before Resident #2 consumed her breakfast. There were no care staff observed assisting or attending to Resident #2 during her meal. After breakfast was taken, Resident #2 was seen sleeping in her wheelchair from 9:00 a.m., to approximately 9:20 a.m. The Resident Care Coordinator (RCC) then walked past Resident #2 and attempted to wake her around 9:20 a.m., and Resident #2 was unable to sit up independently. The RCC then instructed Staff #1 to take Resident #2 to her room, Staff #1 attempted to transfer Resident #2 to her bed yet was not successful because she had not transferred her before and insisted on having a second staff member there, so she moved Resident #2 to the common television area where Resident #2 was observed to lean all the way forward in her wheelchair and fell asleep. On 12/30/25 at approximately 10:00 a.m., Staff #1 stated that staff were familiar with resident care plans; however, was unaware Resident #2 required feeding assistance for meals. On 12/30/25 at 4:16 p.m., the administrator stated staff were expected to review resident care plans and ensure care plans were followed. The administrator stated if a resident's care plan read the resident requires direct staff attention or direct physical assistance while eating, staff were expected to sit at the table with the residents and ensure they were provided the appropriate assistance during every meal time. The administrator stated Resident #2 was not provided the appropriate assistance due to the staff turn over and lack of staff available. The administrator acknowledged that residents who required assistance with dining were not receiving the service in accordance with their care plans. Similar deficient practice was found with Residents #1 and #3.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. 25.21 Residents who indicate a desire to go outside the secured area shall be permitted to do so with staff supervision except in those situations where it would be detrimental to the resident's health, safety or welfare.

A licensure complaint prompted by #CO37361, #CO39182, and #CO39250 was completed on 2/18/25. No deficiencies were cited.

A revisit survey was completed on 1/28/25 for all previous deficiencies cited on 7/24/24. 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 relicensure survey with complaint #CO30120 was completed on 7/24/24. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to update a resident care plan that reflected the most current assessment information, promote resident mobility and safety and detail specific service needs along with the staff tasks necessary to meet those needs affecting one sample residents (#3) who experienced falls. Resident #3 fell on 5/11/24, 6/8/24 which resulted in a scrape on his forehead and nose, 6/12/24 which resulted in bruising under the resident's right eye, 6/14/24, 7/1/24 which resulted in a skin tear, 7/6/24 and 7/16/24 for a total of seven falls in about nine weeks. The residence failed to update the resident's care plan with information to promote safety. Findings include:1. Residence PolicyThe residence's Fall Management Policy dated January 2024 read in part: Resident falls were to be noted in the incident reports and resident record and that a post fall evaluation should be noted in the resident record after a fall, individualized interventions are considered. 2. Resident #3 was admitted to the residence on 1/19/24, with diagnoses including alzheimer's disease and type two diabetes mellitus. Progress notes dated 5/13/24-7/11/24 read in part:On 5/11/24, Resident #3 fell and there were no signs of a head injury. On 6/8/24, Resident #3 fell in the tv room which resulted in a head injury and a scrape to the forehead and nose. On 6/12/24, Resident #3 fell in the hallway and there were signs of bruising under the right eye. On 6/14/24, Resident #3 fell in his apartment. On 7/1/24 Resident #3 fell in living room left eye and nose had abrasions. On 7/6/24, Resident #3 fell in his apartment. On 7/16/24, Resident #3 fell at the end of a hall. Incident Reports dated 5/11/24-7/11/24 read in part:On 5/11/24, Resident #3 fell. The residence added follow-up approaches to the incident report; however, the information was added on 7/24/24, the date of the onsite survey. On 6/8/24, Resident #3 fell in the dining room. It read, "resident observed lying in TV room with scrape to forehead and nose, areas cleansed (external hospice provider [EHP]) notified and came to evaluate. The residence added follow-up approaches to the incident report; however, the information was added on 7/24/24, the date of the onsite survey. On 6/12/24, Resident fell in the hallway. It read, "resident found in hallway lying on his side, no complaints of pain, small abrasions on right eye." The residence added follow-up approaches to the incident report; however, the information was added on 7/24/24, the date of the onsite survey. On 6/14/24, Resident #3 fell unwitnessed in his apartment. It read, "found on the floor no injuries." The residence added follow-up approaches to the incident report; however, the information was added on 7/24/24, the date of the onsite survey. On 7/6/24, Resident #3 fell, no apparent injury. Resident was in another resident's room yelling and not able to understand the problem. The residence added follow-up approaches to the incident report; however, the information was added on 7/24/24, the date of the onsite survey. On 7/16/24, Resident #3 fell with no apparent harm/injury. The residence added follow-up approaches to the incident report; however, the information was added on 7/24/24, the date of the onsite survey. Fall Risk Assessments dated 5/13/24-7/11/24 read in part:On 5/13/24 the resident had an increased risk for falls after he fell on 5/11/24. On 6/8/24 the resident had an increased risk for falls after he fell on 6/8/24. On 6/13/24 the resident had an increased risk for falls after he fell on 6/12/24. On 6/14/24 the resident had an increased risk for falls after he fell on 6/14/24. On 7/11/24 the resident had an increased risk for falls after he fell on 7/6/24. On 7/16/24 the resident had an increased risk for falls after he fell on 7/16/24. The care plan, dated 2/23/24, did not include updated information that promoted the resident's independence and safety, detail specific needs along with the staff tasks necessary to meet those needs, or reflect the most recent assessments after the resident sustained falls on 5/11/24, 6/8/24, 6/12/24, 6/14/24, 7/6/24 and 7/11/24. 3. Interviews On 7/24/24 at 1:20 p.m., the regional manager stated that the residence's policy was to write an incident report when a fall occurred and that took the place of the investigation. On 7/24/24 at 1:50 p.m., the administrator stated that the expectation was to input fall mitigations in care plans. The administrator stated that the residence had meetings with the external camera monitoring system team about fall interventions. She stated items discussed were not documented and the administrator was unsure why there were no fall interventions in place for Resident #3. On 7/24/24 at 2:17 p.m., the health and wellness director stated plans and interventions had "fallen through" with Resident #3 over the last month since she had been working on the floor more.

Based on observation, record review, and interview, the residence failed to place notices of planned resident engagement offerings in a central location readily accessible to residents, relatives, and the public and failed to retain copies of the offerings for six months, affecting 26 current residents. Findings include: The Residency Agreement, dated December 2023, read that the residence provided planned social and recreational activities. On 7/23/24, between approximately 7:25 a.m. and 2:00 p.m., the activity director (AD) worked as a qualified medication administration person (QMAP) and sole staff member in the lower acuity area of the secure environment. On 7/23/24 and 7/24/24, between approximately 7:15 a.m. and 4:00 p.m., the residence posted no notices of planned resident engagement offerings in the residence. Further, the residence did not conduct any planned engagement activities with residents. On 7/24/24, at approximately 10:30 a.m., Resident #6 wandered throughout the residence and took the hand of any person passing to engage with her. On 7/24/24 at 10:15 a.m., the AD stated that she had been working as a QMAP with residents for approximately two months and had not created or posted a July 2024 activity calendar. She stated that when she conducted an activity in the higher acuity area, she told the residents about it. She added that the residents generally remembered but had no calendar to reference or plan around. The AD stated that she worked alone in the lower acuity area of the secure environment (SE) and completed engagement activities when she was able. She added that she had not completed consistent activities in the higher acuity area of the SE for July 2024. She stated that there had been a specific AD for the higher acuity area of the SE; however, the AD left approximately two or three months prior to the onsite survey. On 7/24/24 at 10:20 a.m., Resident #5 stated that she went to an offsite external service provider (ESP) and participated in activities there as the residence did not have consistent activities. She added that she often observed that other residents had nothing to do and that they appeared bored to her. She affirmed that the residence had not created a calendar for activities and that it was not posted. On 7/24/24 at 10:24, a family member of Resident #7 stated that the residence provided no engagement activities for the residents in the higher acuity area of the SE since the residence lost the AD for that area in May 2024. She added that Resident #7 was often agitated with nothing to do, and she observed that other residents were not engaged and wandered. She affirmed that the residence had not created a calendar for activities, and they had not posted anything about activities. On 7/24/24, at approximately 10:30 a.m., Resident #8 stated that he never knew what engagement activities the residence offered because no calendar was posted. He added that he was often bored and looking for something to do. On 7/24/24 at approximately 10:40 a.m., Staff #2 and the health and wellness coordinator (HWC) stated that the residence had not consistently provided planned engagement activities since approximately May 2024, when the higher acuity area of the SE former AD left. They affirmed that the residence had not created a calendar for activities and that it was not posted. On 7/24/24 at 2:03 p.m., the administrator stated that the SE had two areas: one area was a lower acuity area, and the other was a higher acuity area. She stated that the higher acuity area AD left the residence in May 2024, and since then, the staff had done their best, but the residence offered no planned engagement activities. She stated that the AD had been working as a QMAP recently and conducted activities when she was able; however, the residence had not created or posted an activity calendar for July 2024. She added that the residence had not created a calendar nor posted it, as the residence had the AD working as a QMAP.

Based on observation, record review, and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and identification of injuries of unknown origin, affecting 26 current residents. Findings include:1. Residence Policy and Incident Report ExampleThe residence provided the residence's January 2024 Incident Reporting Policy as the residence's policy of investigation of identification, reporting, and investigation of injuries of unknown origin. The policy read in part that the residence entered preliminary information regarding the incident into their incident reporting system and completed the incident the same day or no more than three days after the residence initiated the incident. The residence notified the resident's responsible party and practitioner. The policy failed to include several required elements, such as the process that the residence details of any interviews or records used in the investigation, implemented related staff training, or any required modification of the residence's policies, or a case a summary of the investigation and how the residence included the steps taken in the resident's care plan and progress notes. Further, the policy did not contain reporting requirements. An undated residence example of an Incident Report did not include areas to document several elements of investigation of injury of unknown origin, such as an area to include details of any interviews or records used in the investigation, related staff training, or any required modification of the residence's policies, or a case a summary of the investigation and how the residence included the steps taken in the resident's care plan and progress notes. 2. ObservationOn 7/23/24 at approximately 7:41 a.m., Resident #2 had a purple baseball-sized bruise around her left eye. 3. Record ReviewResident #2 was admitted to the residence on 3/23/24 with a diagnosis of dementia. A progress note for Resident #2, dated 7/20/24, read in part the resident sustained an unwitnessed fall without injury. An incident report for Resident #2, dated 7/20/24, read in part that the resident was found on the floor at the bedside without pain or injury, and the practitioner was notified. Further, the reported follow-up was conducted on 7/23/24 and included the residence's request to the external hospice provider (EHP) for a new mattress, bolster sheet, and assessment. However, the residence did not have an incident report that investigated the black eye sustained by Resident #2. 4. InterviewsOn 7/24/24 at approximately 1:30 p.m., the regional director of nursing (RDN) stated that the residence's Incident Reporting Policy was the residence's investigation of injury of unknown origin. She affirmed that the policy itself was not specific to the residence's investigation of unknown origin and was not sure it contained all of the elements. The RDN affirmed that no incident report for Resident #2 indicated she sustained a black eye. On 7/24/24 at 1:53 p.m., the administrator stated that she expected the health and wellness (HWD) to talk with staff and find out the circumstances that may have caused the injury. She added that the residence required that the investigation and outcome be documented. She added that there was no documented investigation of injury of unknown origin for Resident #2 as required. She added that the residence policy for investigation of injury of unknown origin was the policy that the RDN provided. She was not aware if it met all of the elements or not. On 7/24/24 at 2:19 p.m., the health and HWD stated that the residence was required to document all investigations of injury of unknown origin. She added that the residence did not complete a documented investigation of a black eye sustained by Resident #2 and should have. She added that she became aware of the black eye sustained by Resident #2 one to two days after it was first observed by staff. She added that she was not sure whether the black eye sustained by Resident #2 was first observed by staff one, two, or three days prior to the onsite survey. She affirmed that no incident report for Resident #2 indicated she sustained a black eye. 5. Additionally, the residence failed to investigate an injury of unknown origin for Resident #2; however, the residence's failure to have a policy with all required elements affected all 26 current residents.

Based on observation, interview and record review, the residence failed to ensure that qualified medication administration persons applied nationally recognized protocols for basic infection control when preparing and administering medications affecting one sample resident (#3) and five residents (#9-#13). Findings include:The residence's handwashing/hand hygiene in secured/memory care policy, dated June of 2022, read in part that, "Associates should carry hand sanitizer bottles in their waist aprons to assist with resident hand hygiene and for personal use. Associates should be trained on this policy and regularly in serviced on the importance of hand hygiene in preventing the transmission of healthcare- associated infections ...to residents." On 7/23/24 at 8:03 a.m., Staff #2 administered six resident's medications without washing or sanitizing hands. Staff #2 handed Resident #12 several pills in a small medication cup. Resident #12 attempted to pour the medication cup in her mouth but a few pills fell out and landed on her shirt. Staff #2 grabbed the pills with her bare hands gave it back to Resident #12 and Resident #12 swallowed them. Staff #2 continued to administer medication without washing or sanitizing hands, at 8:15 a.m. Staff #12 administered crushed pills in yogurt to Resident #10. Staff #12 spoonfed the yogurt into Resident #10's mouth and encouraged her to swallow, however, Resident #10 spat the yogurt on the table. Staff #12 cleaned the yogurt from the table and continued on with medication administration. Staff #12 administered medication to Resident #3 at 8:21 a.m. and did not wear gloves, sanitize or wash hands. This practiced continued as medication was administered to Residents #9, #11 and #13. On 7/24/24 at 2:08 p.m., the administrator stated the expectation for administering medication was to sanitize hands, wash hands or wear gloves when medication was administered. On 7/24/24 at 2:26 p.m., the health and wellness director was shocked to hear that a staff member would pick medications up by bare hands and echoed that her expectation is that the staff used proper hand sanitizing protocols.

Based on observations, record review, and interview, the residence failed to give residents the opportunity to choose where and with whom to sit, affecting 26 current residents. On 7/23/24 and 7/24/24, all residents sat in the same seat for all meals. Care plans for Residents #1-#4 read in part that the residents had assigned seats as follows:Resident #1, dated 1/27/24, at table one in the dining room. Resident #3 care plan, dated 2/23/24, at table 10 in the dining room. Resident #2 care plan, dated 4/30/24, at table four in the dining room. Resident #4 care plan, dated 7/20/24, at table one in the dining room. On 7/24/24 at 10:20 a.m., Resident #5 stated that the residence assigned seats, and she had no choice where she sat at meals. She added this practice led to her sitting alone at meals with no one to talk to. She stated the residence had not allowed her to move to another table in the dining room as needed. She added that she used to enjoy her table mates; however, they did not come to all meals or were away from the residence. On 7/24/24 at 10:24, a family member of Resident #7 stated that the residents all had assigned seats and did not choose the seats. She added that the residents were not permitted to move in the moment if they so chose. She added that Resident #7 was not happy at her table. On 7/24/24 at 1:56 p.m., the administrator stated that the residence had assigned seating in the secure environment (SE) dining room. She stated that she was not aware that the residence was required to ensure the residents had the opportunity to choose with whom to sit at mealtimes. She stated that the residence care plans listed the seat assignment, which may have led staff to believe that the rule was inflexible. On 7/24/24 at 2:21 p.m., the health and wellness director (HWD) stated that all residents in the SE had assigned seating. She added she was unaware of the requirement that the residence must offer the opportunity for the resident to choose where and with whom they sit. She stated that staff typically followed the care plan.

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 7.14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualifiedmedication administration person to perform any of the following tasks: (I) Masking or deceiving administration of medication including, but not limited to, concealingin food or liquid. 14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence ' s Quality Management Program assessment and review.