BROOKDALE BOULDER CREEK

A relicensure survey with complaint revisit was completed on 5/18/26 for the previous deficiencies cited on 1/29/25. Deficiencies were cited. The deficiencies for event 87K011 were cited prior to the regulation revision that was implemented on 1/7/25 (the date the new regulation set was revised).

Based on observations and interviews, the residence failed to make available a physically safe and sanitary environment, affecting two of five sample residents, #22 and #24. This deficiency was cited previously during a state licensure survey on 1/29/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings IncludeOn 5/18/26 at 8:41 a.m. Resident #22 ' s room was entered. The kitchen floor had dried-up fried rice, and in the dining room, there was smeared food and a dirty spoon on the carpet floor near the dining table. On 5/18/26 at 8:50 a.m., Resident #22 ' s service list on the door for her room, the date/time for housekeeping was blank. On 5/18/26 at 9:40 a.m., Resident #24 ' s room was observed to be clean. The room was entered, and there was a pungent odor that smelled of ammonia/urine. Interviews:On 5/18/26 at 8:20 a.m., Resident #22 stated her room gets cleaned about once a week. She stated that on the evening of 5/28/26, she had dropped food onto the floor and was unable to pick it up. She stated the QMAP was in that morning to provide medications and did not sweep up the food on the floor. On 5/18/26 at 9:40 a.m., Resident #24 stated she was aware of the smell but keeps her room clean. On 5/18/26 at 10:03 a.m., the maintenance director stated Resident #24 ' s room is cleaned weekly, and to get the smell out of the carpet, it would have to be removed, and Resident #24 would have to move out of the room for that to be completed. He acknowledged the room smelled of dog urine and had smelled for a long time, several months. On 5/18/26 at 1:51 p.m., the administrator acknowledged that the food on the kitchen floor and dining room carpet in Resident #22 ' s room should have been cleaned up by the staff and was considered unsanitary. The administrator stated that housekeeping goes in once a week, and staff should help clean throughout the rest of the week. The administrator also acknowledged that Resident #22 ' s room had carpet, the ammonia/urine smell should not be pungent, and maintenance should have shampooed the carpet more frequently.

Based on record review and interview, the residence failed to follow practitioner's orders for five of five sample residents. (#20-24) This deficiency was cited previously during a state licensure survey on 1/29/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:A practitioner's order dated 3/20/26 read in part to administer Kepra 250 mg twice daily for seizures. Resident #23 was admitted to the residence on 3/30/26 with a diagnosis of hemiplegia and hemiparesis following cerebral infarction. A progress note dated 4/29/26 read "Did follow up with [pharmacy] and requested to send the all listed medications. singed (SIC) med-list faxed." A progress note dated 5/1/26 read "Faxed signed med-list to Omnicare. Did follow up, said medication coming tonight."The April and May 2026 medication administration records (MARs) revealed that Resident #23's medication was not administered from 4/30/26 to 5/2/26, both a.m. and p.m. doses. For a total of six missed doses. On 5/18/26 at 12:08 p.m., the resident care provider and the health and wellness coordinator acknowledged that medications for Resident #23 had not been administered because they were awaiting the pharmacy. On 5/18/26 at 3:05 p.m., the administrator stated that he expected medications to be administered as ordered by the practitioner. He stated that he was aware of the medication errors and failure to be in compliance. He stated that they had been working to correct the issue and had recently hired more staff. A review of Residents #20-22 and #24 revealed similar deficient practice.

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 #CO39508, was completed on 5/18/26. A deficiency was cited.

Based on interview and record review, the residence failed to provide residents with lift assistance when determinedappropriate instead of relying on emergency medical responders, affecting one of one sample resident (#21) and one former resident (#25). Findings include:1. Resident #21 was admitted to the residence on 9/17/24 with diagnoses including hypertension, atrial fibrillation, and hypertensive heart disease. Progress notes in Resident #21's record for March, April and May 2026 revealed the following:On 3/9/26 at 12:50 p.m., Resident #21 had an unwitnessed fall in the parking lot; he was uninjured and did not express pain. A staff member contacted emergency services for lift assistance. On 4/8/26 at 4:48 a.m., Resident #21 had an unwitnessed fall by his bedside while transferring from his bed to an unlocked chair. Resident #21 did not report any pain or injuries. A staff member contacted emergency services for lift assistance. On 5/3/26 at 12:00 a.m., Resident #21 fell in his bedroom and had no pain or injury. Staff contacted emergency services for lift assistance. 2. Interviews On 5/18/26 at 8:20 a.m., Staff #10 said when residents were unable to be lifted by staff she notified non-emergency lift assistance, even if they were uninjured and expressed no pain but were hard to lift. On 5/18/26 at 12:56 p.m., Resident Care Provider (RCP) stated staff called emergency services for non-emergency lift assistance when Resident #21 fell by his car. On 5/18/26 at 1:18 p.m., Resident #21 said when he fell in April and May 2026 he was uninjured and had no pain. He added staff were unable to lift him, so emergency services were notified to provide him lift assistance. On 5/18/26 at 3:06 p.m., the administrator confirmed that staff were notifying non-emergency lift assistance in April and May 2026 when Resident #21 fell and was unable to get up despite not being in any pain or having any injuries. He added staff were unable to lift him during the night and Resident #21 was working with external therapy services to improve his strength so he could assist in lifting himself. 3. Similar deficient practice occurred with Former Resident #25.

A relicensure survey with a complaints revisit was completed on 5/18/26 for the previous deficiency cited on 1/29/25. Deficiencies were cited. The deficiency for event X26B12 was cited prior to the regulation revision that was implemented on 1/7/25 (the date the new regulation set was revised).

Based on record review and interview, the residence failed to follow practitioner's orders for five of five sample residents. (#20-24) This deficiency was cited previously during a state licensure survey on 1/29/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include: A practitioner's order dated 3/20/26 read in part to administer Kepra 250 mg twice daily for seizures. Resident #23 was admitted to the residence on 3/30/26 with a diagnosis of hemiplegia and hemiparesis following cerebral infarction. A progress note dated 4/29/26 read "Did follow up with [pharmacy] and requested to send the all listed medications. singed (SIC) med-list faxed." A progress note dated 5/1/26 read "Faxed signed med-list to Omnicare. Did follow up, said medication coming tonight." The April and May 2026 medication administration records (MARs) revealed that Resident #23's medication was not administered from 4/30/26 to 5/2/26, both a.m. and p.m. doses. For a total of six missed doses. On 5/18/26 at 12:08 p.m., the resident care provider and the health and wellness coordinator acknowledged that medications for Resident #23 had not been administered because they were awaiting the pharmacy. On 5/18/26 at 3:05 p.m., the administrator stated that he expected medications to be administered as ordered by the practitioner. He stated that he was aware of the medication errors and failure to be in compliance. He stated that they had been working to correct the issue and had recently hired more staff. A review of Residents #20-22 and #24 revealed similar deficient practice.

A relicensure survey with complaint #CO30614 was completed on 1/29/25. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state regulations to help prevent the possible development and transmission of gastrointestinal illness (GI) caused by suspected Norovirus, affecting 70 current residents. (Cross-reference S1130)Findings include: 1 . References and Residence PolicyThe U.S. Centers for Disease Control and Prevention (CDC) defined a Norovirus outbreak as an occurrence of two or more similar illnesses that were either suspected or confirmed Norovirus. CDC (2025) Norovirus Outbreaks, retrieved from: https://www.cdc.gov/norovirus/outbreak-basics/index.htmlThe Summary of Guidelines for Investigation and Management of Norovirus Outbreaks in Healthcare and Residential Facilities requires residences to:-Notify the department or the local public health agency within four hours.-Collect three to five stool specimens from different ill individuals during the first 48 hours of illness while stool is still liquid and submit them to a commercial laboratory or the department for norovirus testing and bacterial culture.-Implement outbreak control measures while waiting for test results.-Collect and document the following information for each illresident and staff member: illness onset date and time, symptoms, duration of illness, hospitalizations/deaths, resident apartment number, and staff job duties, locations, and dates worked. The residence Communicable Disease policy, dated April 2024, read in part that the residence identified an outbreak as one or more cases of infectious disease at the residence. Residence staff were required to report all signs and symptoms experienced by staff and residents to the administrator or health and wellness director (HWD). The HWD was required to contact local public health (LPH) for directions regarding the management of the infectious disease. Further, testing for communicable diseases was conducted per the direction of LPH.2. ObservationsPosted signs on the front entrance and at the dining area, dated 1/17/25, read in part, "Several residents have experienced GI distress symptoms in past two weeks."3. Record ReviewA progress note for Resident #16, dated 1/27/25, read that the resident had GI symptoms for ten days. Progress notes for Resident #14, read:On 1/10/25, the resident had uncontrolled loose stool on the surfaces of his bathroom. On 1/11/25, the resident was feeling unwell. Electronic communications (EC) between a local public health representative (LPHR) and the residence read as follows:On 1/22/25, the LPHR communicated to the administrator that the LPH received notification from a local hospital of a possible increase in GI at the residence. The LPHR requested information regarding the possible illness at the residence and offered assistance with guidance if the residence experienced an increase in GI symptoms. On 1/23/25, the administrator responded that the residence had experienced an increase in GI symptoms in the past week. Further, the residence had 13 residents and five staff with symptoms; however, they had not had new symptoms in the previous 48 hours, and the administrator believed the illness spread from person to person. On 1/23/25, the LPHR requested more information, such as what measures the residence took to mitigate the spread of the symptoms and whether testing was completed. On 1/27/25, the administrator responded to follow-up questions from the LPHR regarding the precautions for Norovirus, such as infection control and testing. The administrator responded that the residence had not conducted testing, and that was a mistake. During the onsite survey on 1/27/25, the residence could not provide a list of residents who had GI symptoms with the date of onset. On 1/28/25, during the onsite survey, the residence created and provided a list of all residents who had GI symptoms, including the date of onset. The list contained 24 current residents; however, the residence did not include Resident #16 despite her progress note which read that she had symptoms for approximately ten days. Further, the list read that the first onset of symptoms occurred on 1/15/25, despite the progress notes for Resident #14 reading that he had GI symptoms on 1/10/25.4. InterviewsOn 1/27/25-1/28/25, during the onsite survey, Staff #7 and #10-#12 stated that there had been GI symptoms throughout the residence for approximately two weeks prior to the onsite visit. On 1/27/25 at 11:27 a.m., the LPHR stated that the residence failed to report suspected Norovirus and should have done so within four hours of the presentation of symptoms of two or more residents or staff. She added that the residence reported thirteen residents had experienced GI symptoms. On 1/27/25 at 12:05 p.m., the health and wellness coordinator (HWC) stated that the residents had been experiencing GI symptoms for approximately two weeks prior to the onsite survey. On 1/27/25 at 12:17 p.m., the HWD stated that approximately thirty residents had GI symptoms. In a later interview on 1/28/25, the HWD stated that the residence should have done a better job of accurately tracking the dates of residents' onset of symptoms to ensure that the residence adequately isolated the residents. On 1/27/25 at 1:22 p.m., the administrator stated that he left a message on the LPH hotline to report the GI outbreak on 1/22/25; however, he did not speak to anyone. He added that the suspected GI outbreak began about one week prior to his call. The administrator added he understood that he was responsible for reporting the GI outbreak within four hours of two or more residents or staff presenting with symptoms. He stated he believed that reporting did not apply to assisted living residences but rather to skilled nursing facilities. In a later interview, on 1/28/25, the administrator stated that the residence should have tracked and documented the onset dates of infection better than they did.

Based on observation, record review, and interview, the residence failed to request, prior to staff hire, a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for each prospective staff member for one staff (#7), affecting 70 current residents. Findings include:On 1/28/25 from 6:00 a.m. to 2:00 p.m., Staff #7 worked directly with residents. The personnel file for Staff #7 read she was hired on 5/9/21. The file contained no evidence that the residence requested a criminal history record check conducted by the CBI.On 1/28/25, documentation of CBI criminal history record checks for Staff #7 was requested but not provided. The January 2025 staff schedule revealed Staff #7 worked 1/21-1/25 and 1/28/25. On 1/28/25 at approximately 1:30 p.m., the business office manager stated that the residence failed to conduct a background check that included a CBI check for Staff #3. She added she was not aware that the residence failed to request a background check had not been conducted by CBI prior to Staff #7's hire date until the date of the onsite visit. On 1/29/25 at 11:02 a.m., the administrator stated that he expected the residence to conduct the required name-based background check through CBI prior to hiring the staff. He stated the residence should have completed one for Staff #7 considering she had worked at the residence for an extended period of time and had been rehired several times. The administrator affirmed that all hired staff at the residence should have been reviewed to ensure that the residence conducted all required background checks.

Based on observation and interview, the residence failed to provide a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment affecting one of seven sample residents (#15). (Cross-reference S540)Findings include:1. ObservationsOn 1/27/25 at approximately 7:40 a.m., Resident #15's carpet in the front room had approximately 20 dark brown spots that varied in size, shape and color ranging from approximately one to fifteen inches in diameter. The sofa had white stains on the seat, pillows and back cushions that varied in size and shape, from approximately one to five inches in diameter. The seat cushion closest to the patio door had a tan oblong stain that started at the front center of the cushion and extended down the front of the cushion to the carpet beneath. The recliner had white spots on the right and left arms of the chair that varied in sizes from approximately one inch to six inches in diameter. The seat cushion was covered with a disposable protection pad with a pillow covered with brown and orange stains that varied in size, shape and color. The foot rest and front of the recliner had white stains that flowed from underneath the disposable protection pad to the carpet beneath. The frame of the recliner had white and tan food pieces that varied in size approximately one to two inches in diameter on the frame and attached to the front right side of the frame. The carpet in the TV area had a brown spot approximately 10 inches in diameter as well as one inch white spots. An arm chair had a white and tan stain that started on the front center of the seat cushion and extended down the front of the chair to the carpet beneath. The bathroom wall had three brown stains approximately two inches in diameter. The floor had pieces of toilet paper (TP) near the TP holder and a roll of TP on the floor near the sink, as well as a hand towel on the floor in front of the toilet. The front dining area had pieces of TP on the floor. 2. InterviewsOn 1/27/25 at approximately 10:00 a.m., the resident's legal representative (LR) stated that Resident #15 was and always had been a "sloppy man" and he was the reason his apartment was in this condition. On 1/27/25 at 7:30 a.m., Staff #10 stated that Resident #15 had a change in baseline status, becoming weaker after having had the gastrointestinal (GI) symptoms. Staff #10 also stated that Resident #15 had stains on his carpet and furniture because he spilled his food and drinks a lot which was unsanitary .On 1/28/25 at approximately 2:30 p.m., Resident #15's LR stated that the residence sent the carpet cleaners to clean Resident #15's carpet. The LR stated that although the carpet was filthy and unsanitary, she turned them away. On 1/29/25 at 8:15 a.m., the health and wellness director (HWD) stated that when Resident #15 ate, he dropped food on the table, chair and floor. The HWD stated that Resident #15's room had been dirtier than he would have liked it to be. He further stated that Resident #15's room had not met his standard of a physically safe and sanitary environment, especially considering there was a GI outbreak and Resident #15 had symptoms. On 1/29/25 at 9:00 a.m., the administrator designee (AD) stated that he was aware of the unsafe and unsanitary condition of Resident #15's room. The AD further stated that Resident #15's room did not meet the standard of a physically safe and sanitary environment, especially considering there was a GI outbreak and Resident #15 had symptoms.

Based on observation, record review, and interview, the residence failed to contact the resident's primary practitioner when the resident experienced a significant change in their baseline status in accordance with its written policies, affecting three of six sample residents (#14-#16). (Cross-reference S0540)Specifically, on 1/24/25-1/26/25, Resident #16 experienced an increase in back pain that led to an inability to sit up and rise from her bed independently. According to staff members, this was a significant change in her baseline status. The residence failed to contact the resident's practitioner. The practitioner stated that she would have directed the residence to send the resident to the emergency department (ED). Subsequently, Resident #16 was sent to the emergency department on 1/27/25 after experiencing a drop in blood pressure to 80/38, and gastrointestinal illness for ten days. Findings include:1. Residence PolicyThe residence Practitioner Assessment policy, dated 8/4/21, read in part that the residence contacted the resident's practitioner when the resident experienced a significant change in baseline status. 2. ObservationOn 1/27/25 at approximately 11:30 a.m., emergency medical services (EMS) arrived at the residence and transported Resident #16 to the ED.3. Resident #16 was admitted to the residence on 11/7/24 with diagnoses including hypertension and heart failure. The most recent care plan for the resident, dated 11/26/24, read in part that the resident was independent with mobility. A progress note, dated 1/27/25, read in part that the resident went to the ED due to low blood pressure of 80/38 and intestinal symptoms that she had for ten days. 4. InterviewsOn 1/27/25 at 12:05 p.m., the health and wellness coordinator (HWC) stated that the residence last contacted the practitioner for Resident #16 prior to 1/17/25 regarding loose stool. On 1/28/25, during the onsite survey, Staff #12 and #13 stated that Resident #16 had significant back pain from 1/24/25 to 1/26/25 and was unable to sit upright. The staff members reported the concern to the qualified medication administration person (QMAP), who administered pain medication; however, they were unaware whether the QMAP notified the practitioner. The staff members stated that the back pain and inability to sit up were a significant change from Resident #16's baseline status. On 1/28/25 at 11:05 a.m., the practitioner for Resident #16 stated that the residence did not contact her or anyone in her office on 1/24/25-1/26/25 regarding the resident's significant back pain and inability to sit up. She added these symptoms were a significant change from the resident's baseline as the resident was independent with most tasks. The practitioner added that if the residence had notified her, she would have directed the residence to send the resident to the ED. She stated that the ED visit might have mitigated the resident's subsequent symptoms had she been examined before 1/27/25. The practitioner stated that blood pressure as low as Resident #16 experienced could have meant something as significant as sepsis. The practitioner added that the residence did not notify her that the resident had been transported to the ED on 1/27/25. On 1/28/25, at approximately 8:20 a.m., the health and wellness director (HWD) stated that no staff informed him of Resident #16's change in baseline status and that staff should have notified her practitioner of the back pain and the inability to sit up, as they were both significant changes. On 1/28/25, at approximately 9:20 a.m., the administrator stated that when Resident #16 experienced a change in baseline status, staff who were working should have contacted her practitioner. He added that he just became aware, during the onsite visit, that they had not. 5. Additionally, the residence failed to contact residents' primary practitioners when Residents #14 and #15 experienced significant changes in their baseline statuses.

Based on record review and interview, the residence failed to promptly notify the residents' responsible parties regarding the residents' potential exposure to a communicable gastrointestinal illness (GI) affecting 70 current residents. (Cross-reference S0540)Findings include: Posted signs, dated 1/17/25, on the front entrance and in the dining room read: "Several residents have experienced GI distress symptoms in the past two weeks."An electronic communication to residents' responsible parties, dated 1/20/25, read that the residence had ten residents and three staff members who experienced a GI virus; however, the residence did not include the dates of onset of symptoms. On 1/28/25, during the onsite survey, the residence created and provided a list of all residents who had GI symptoms, including the dates of onset. The list contained 24 current residents. On 1/27/25-1/28/25, during the onsite survey, Staff #7 and #10-#12 stated that there had been GI symptoms throughout the residence for approximately the last two weeks prior to the onsite visit. On 1/27/25 at 12:17 p.m., the health and wellness director (HWD) stated that approximately thirty residents had GI symptoms. In a later interview on 1/28/25, the HWD stated he was not aware when the administrator notified the residents' responsible parties of the GI virus exposure. On 1/27/25 at 1:22 p.m., the administrator stated that the GI virus began on approximately 1/13/25 or 1/17/25. He added that whether it was 1/13/25 or 1/17/25, he should have notified the responsible parties regarding the GI virus more promptly than he did.

Based on observation, interview, and record review, the residence failed to ensure devices, such as a bed rail, were only used if the device supported the resident's well-being or independence, the resident was able to remove the bed rail, it was ordered by a practitioner, and the practitioner and a therapist documented the benefits and hazards associated with the bed rail, affecting one sample resident (#19). Specifically, Resident #19 had two full-length bedrails attached to the sides of her bed. On 1/28/25 at 10:52 a.m., the resident had one bedrail up and was resting her head on it, which posed a serious risk of injuries from falls, entrapment, or death by asphyxiation. Due to weakness, a recent fracture, and a high risk of falls, the resident was unable to lower the bed rail. The residence did not ensure the resident was assessed by a practitioner and therapist describing the hazards associated with the bedrails. Subsequently, this failure created an immediate jeopardy risk of injury or death from entrapment or asphyxiation. On 1/28/25, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policy a. Chapter VII regulations governing assisted living residences, part 2.53, defines "Restraint" as any method or device used to involuntarily limit freedom of movement, including, but not limited to, bodily physical force, mechanical devices, chemicals, or confinement.b. According to the Consumer Product Safety Commission (CPSC), "there are risks involved in using adult portable bedrails ... including injuries from falls or entrapment, or death by asphyxiation. CPSC data show that 92% of fatalities associated with adult portable bedrails are from entrapment, usually of the head or neck." CPSC (2024) Consumer Safety Alert: CPSC Issues Urgent Warning About Adult Portable Bedrails; 9 Recalls in 3 Years; 18 Deaths Reported Since 2021, retrieved from: https://www.cpsc.gov/Newsroom/News-Releases/2025/Consumer-Safety-Alert-CPSC-Issues-Urgent-Warning-About-Adult-Portable-Bed-Rails-9-Recalls-in-3-Years-18-Deaths-Reported-Since-2021c. According to the National Consumer Voice (NCV), "Bedrails pose a risk of strangulation or asphyxiation or severe injury. Older adults can get trapped in the gap between the bed rail and the mattress. The individual can roll into that gap and be too weak, frail or confused to change position. The mattress may press against the individual's chest, preventing the individual from breathing. This can quickly result in death. Older adults can also get trapped between the rails and suffocate. Individuals who have cognitive impairment and bedrails block their way from getting out of bed frequently try to climb over the rails. This can lead to a fall, hitting their heads, and a serious injury. Injuries such as cuts, abrasions, and bruises can also result when an older adult becomes entrapped." NCV (2024), Protecting Long-Term Care Consumers from the Dangers of Bedrails, retrieved from: https://theconsumervoice.org/bed-rails/ d. The residence Restraint policy, dated February 2020, read that the residence prohibited the use of restraints such as full or half-side bedrails. 2. Resident #19 was admitted to the residence on 1/23/25 with diagnoses including severe cognitive impairment, age-related osteoporosis, and current pathological fracture of vertebrae.a. Observation On 1/27/25-1/28/25, during the onsite survey, Resident #19 remained in bed with full-sided bedrails on the bed. There was no evidence regarding whether or not the bedrails allowed the resident to participate in activities that would otherwise have been difficult or impossible. On 1/28/25 at approximately 10:52 a.m., Resident #19 was resting her head against a full-length bed rail that was in the raised position. A second full-length bed rail was lowered on the other side of the bed.b. Record ReviewThe resident record for Resident #19 did not include a practitioner's order for the use of bedrails. A comprehensive assessment for Resident #19, dated 1/23/25, did not address or document the use of bedrails. A care plan for Resident #19, dated 1/24/25, read in part that the resident required stand-by assistance with most care tasks and utilized a wheelchair or walker to transport. The care plan did not address or document the use of bedrails.c. InterviewsOn 1/28/25 at 9:33 a.m., Staff #12 stated that Resident #19 had bedrails on her bed since she moved into the residence the week prior to the onsite survey. She added that bedrails were considered a restraint. On 1/28/25 at 12:41 p.m., the health and wellness director (HWD), the administrator, and the district director of clinical services (DDCS) stated that they were unaware that Resident #19 had full-length bedrails on her bed. They stated that bedrails were not permitted at the residence or in the state, and they affirmed the bedrails posed a serious risk of injury or death to Resident #19. The HWD stated that the resident's family ordered the bed and it arrived prior to the resident's admission on 1/23/25. The HWD and administrator stated that the issue would have been resolved had they visited the resident after her admission to the residence. On 1/29/25 at approximately 8:30 a.m., the HWD stated that bedrails were not permitted in the assisted living residence and that he was unaware that the resident had them on her bed. On 1/29/25 at approximately 9:20 a.m., the administrator stated that bedrails were not permitted at the residence and that had he been aware, the bedrails would not have been in place. 3. Immediate Jeopardy Risk-Written Evidence, Immediate CorrectionThe survey established that the findings above placed the resident at immediate jeopardy risk for serious injury or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 1/29/25 at 2:20 p.m., the administrator submitted written evidence that read in pertinent part: "Resident sample 19 has had bedrail removed from bed on 1.28.25. (Residence) team made rounds in every apartment to look for any other bedrails on 1.28.25. Issues identified were corrected immediately with follow-up to resident/family and (practitioner) as indicated. Retraining held with community associates on 1.28.25 by (DDCS) on approved bedside mobility device policy which included why bedrails are not allowed, what they look like, and what to do if they find one. (Administrator) will communicate with residents and families about the usage of bedrails in assisted living by 2.07.25. Moving forward all new residents and families will be educated on appropriate and approved bed mobility devices at the time of move-in and during care plan review as indicated. (Administrator) or designee will conduct room rounds for 10 resident rooms weekly for the next (three) months to look for bedrails and present results during quarterly (quality assurance and performance improvement) QAPI. (Administrator) is responsible for compliance with this plan."However, the written evidence did not indicate the risk had been removed because the plan did not contain how the residence would ensure that residents did not have bedrails immediately after admission. On 1/29/25 at 3:00 p.m., the administrator submitted written evidence that read in pertinent part that the administrator would visit all newly admitted residents' apartments for three months to ensure that the residents had no bedrails.

Based on observation, interview, and record review, the residence failed to comply with practitioner orders, affecting four of six sample residents (#15-#17, #19). Findings include:1. Resident #19 was admitted to the residence on 1/23/25 with diagnoses including severe cognitive impairment, atrial fibrillation, a urinary tract infection, edema, anxiety, age-related osteoporosis, and current pathological fracture of the vertebrae.a. Record ReviewA signed practitioner order, dated 1/22/25, directed the residence to administer levofloxacin 750 mg daily for seven days. However, the January 2025 medication administration record (MAR) revealed the residence failed to administer the medication on 1/24-1/28/25 due to being out of stock. A signed practitioner order, dated 1/24/25, directed the residence to administer apixaban 2.5 mg twice daily. However, the January 2025 MAR revealed the residence failed to administer one dose of the medication on 1/24/25 due to being out of stock .A signed practitioner order, dated 1/23/25, directed the residence to administer furosemide 20 gm daily. However, the January 2025 MAR revealed the residence failed to administer the medication on 1/23-1/26/25 due to being out of stock. A signed practitioner order, dated 1/24/25, directed the residence to administer olanzapine 2.5 mg daily at bedtime. However, the January 2025 MAR revealed the residence failed to administer the medication on 1/24-1/27/25 due to being out of stock. Record review revealed the residence additionally failed to comply with practitioner's orders for Resident #19's acetaminophen, mirtazapine, cyanocobalamin, multivitamin, sennosides, and psyllium husk powder. 3. InterviewsOn 1/29/25 at 8:08 a.m., the health and wellness director stated it was the responsibility of the residence to ensure levofloxacin was administered to Resident #19 and that they were not compliant per the practitioner's order. He added that a family member of Resident #19 advised they would bring the missing medications to the residence but failed to do so. On 1/29/25 at a.m., the administrator could not explain why levofloxacin was not administered to Resident #19 on 1/24-1/27/25. He added that the residence was not compliant with practitioner's orders when the residence did not administer the medications. 4. Similar deficient practice was found with Residents #15-#17.

Based on interview and record review, the residence failed to notify the practitioner of the resident's pattern of refusals, affecting three of seven sample residents (#14, #16, #18). Findings include:Resident #14 was admitted to the residence on 3/8/23 with a diagnosis of idiopathic peripheral autonomic neuropathy. A written practitioner's order, dated 8/8/23, directed the residence to administer gabapentin 300 mg three times a day related to idiopathic peripheral autonomic neuropathy. However, the January 2025 medication administration record (MAR) read the resident refused the morning dose on 1/3, 1/11, 1/12, 1/26/25, the afternoon dose on 1/2, 1/3, 1/7, 1/10-1/12, 1/26/25, and the evening dose on 1/10/25, for a total of 12 refused doses. The January 2025 progress notes revealed no documentation that staff had any communication with the practitioner about Resident #14's pattern of refusal. On 1/29/25 at 8:15 a.m., the health and wellness director (HWD) stated that he was not aware that Resident #14 was refusing medication that often and that the residence should have notified the physician about the refusals. He further stated that Resident #14 had issues in July 2024 with nerve pain so the practitioner changed the order to a scheduled dose to control his pain. On 1/29/25 at 9:00 a.m., the administrator stated that he was not aware of Resident #14's pattern of refusals and that the residence should have notified the practitioner. Additionally, the residence failed to notify Residents #16 and #18's practitioners of their patterns of refusal.

Based on record review and interview, the residence failed to ensure that staff members documented in progress notes before the end of their shifts any out-of-the-ordinary events or issues regarding a resident's wellbeing that they observed or reported to them, affecting five of seven sample residents (#14-#16, #18, #19). (Cross-reference S1130)Findings include: 1. Resident #14 was admitted to the residence on 3/8/23 with diagnoses including idiopathic peripheral autonomic neuropathy, hypertension, venous insufficiency, and chronic obstructive pulmonary disease. Progress notes, dated 1/10-1/11/25, read in part as follows:On 1/10: The resident had diarrhea. He refused his bedtime medication, and he refused to allow staff to take his vitals. On 1/11: "The resident was upset this morning and throughout the day because he was feeling sick and did not sleep well. He refused his medication, he was angry, aggressive and yelling loudly."2. Interviews On 1/29/25 at 8:15 a.m., the health and wellness director (HWD) stated that he was not fully aware as to when staff were required to document progress notes. The HWD stated that the residence was not compliant with progress notes and were not documenting the actions taken by staff when there were out of the ordinary events. On 1/29/25 at 9:00 a.m., the administrator (AD) stated that the residence was not compliant with progress notes. The AD stated that if all staff would have documented all any out of the ordinary events for Resident #14 in relation to his GI symptoms, the residence would have known dates of isolation, and it would have helped them to figure out where the GI symptoms started. 3. The residence additionally failed to ensure staff members documented, before the end of their shift, events or issues regarding a resident that they observed or was reported to them for Residents #15, #16, #18 and #19.

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 7.5.1 Assisted living residence personnel engaged in the admission, care or treatment of at-risk persons shall report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement within 24 hours of observation or discovery pursuant to Section 18-6.5-108, C.R.S.5.3 An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR 1011-1, Chapter 2, Part 4.2.(A) An assisted living residence shall investigate an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations.(1) Documentation regarding the investigation, including the appropriate measures to be instituted, shall be made available to the Department, upon request.(B) An assisted living residence shall submit its final investigation report to the Department within five business days after the initial report of the occurrence.(C) Nothing in this Part 5.3 shall be construed to limit or modify any statutory or common law right, privilege, confidentiality, or immunity."12.18 The assisted living residence's policy shall also require documentation of the action taken by staff and ongoing efforts to prevent a reoccurrence of the situation in the future. 13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation;(C) The process for investigating such allegations;(D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted;(E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted;(F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and(G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. 13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:(A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either:(1) The resident cannot explain how the injury occurred; or(2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries.(B) The assisted living residence shall document the following:(1) The investigation and identification of any injury identified in (A), above.(2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin:(a) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or (b) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse, neglect, or exploitation. Such steps may include, but not be limited to:(i) Staff or volunteer corrective action and/or additional training; or(ii) Modification of the assisted living residence's policies, procedures or physical environment.(3) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries.(C) All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request.(1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes.(D) The assisted living residence shall notify the resident's representative of the outcome of the investigation and steps taken. 22.9 Hot water shall not measure more than 120 degrees Fahrenheit at taps which are accessible by residents.

A relicensure survey and complaint revisit was completed on 1/29/25 for the previous deficiencies cited on 12/30/21. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The Chapter 7 regulations were implemented on 7/1/24.

Based on observation, interview, and record review, the residence failed to comply with practitioner orders, affecting four of six sample residents (#15-#17, #19). This deficiency was cited previously during a relicensure survey with complaint on 12/30/21. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #19 was admitted to the residence on 1/23/25 with diagnoses including severe cognitive impairment, atrial fibrillation, a urinary tract infection, edema, anxiety, age-related osteoporosis, and current pathological fracture of the vertebrae.a. Record ReviewA signed practitioner order, dated 1/22/25, directed the residence to administer levofloxacin 750 mg daily for seven days. However, the January 2025 medication administration record (MAR) revealed the residence failed to administer the medication on 1/24-1/28/25 due to being out of stock. A signed practitioner order, dated 1/24/25, directed the residence to administer apixaban 2.5 mg twice daily. However, the January 2025 MAR revealed the residence failed to administer one dose of the medication on 1/24/25 due to being out of stock .A signed practitioner order, dated 1/23/25, directed the residence to administer furosemide 20 gm daily. However, the January 2025 MAR revealed the residence failed to administer the medication on 1/23-1/26/25 due to being out of stock. A signed practitioner order, dated 1/24/25, directed the residence to administer olanzapine 2.5 mg daily at bedtime. However, the January 2025 MAR revealed the residence failed to administer the medication on 1/24-1/27/25 due to being out of stock. Record review revealed the residence additionally failed to comply with practitioner's orders for Resident #19's acetaminophen, mirtazapine, cyanocobalamin, multivitamin, sennosides, and psyllium husk powder for the same reason. 3. InterviewsOn 1/29/25 at 8:08 a.m., the health and wellness director stated it was the responsibility of the residence to ensure levofloxacin was administered to Resident #19 and that they were not compliant per the practitioner's order. He added that a family member of Resident #19 advised they would bring the missing medications to the residence but failed to do so. On 1/29/25 at a.m., the administrator could not explain why levofloxacin was not administered to Resident #19 on 1/24-1/27/25. He added that the residence was not compliant with practitioner's orders when the residence did not administer the medications. The administrator stated that he could not explain the reason the deficiency was not corrected as he thought it had been. 4. Similar deficient practice was found with Residents #15-#17.