3
Inspections
1
Deficiencies
0
Actual Harm or Above
2
Occurrences
May 6, 2026
Last Inspection
S/S B Minimal potential
The most recent inspection of BROOKDALE UNIVERSITY PARK on record is dated May 6, 2026. Across 3 published inspections, state surveyors cited 1 deficiency, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Assisted Living Residence (Licensed Only)
Administrator
DAY, CHERESE
Owner
ARC HERITAGE CLUB INC
Phone
(303) 757-1404
Payor Source
Private Pay
City
DENVER
ZIP
80210
Inspections & Citations
3 inspections · 1 deficiencies5/6/2026Licensure (Re-licensure) · ID EWO611No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 5/6/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/17/2024Revisit: Licensure and Licensure Complaint (Combined) · ID 93IY12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/17/24 for all previous deficiencies cited on 9/3/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9/3/2024Licensure and Licensure Complaint (Combined) · ID 93IY111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO35408 was completed on 9/3/24. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on record review, observation, and interview, the residence failed to make a sanitary environment available, either directly or indirectly through a resident agreement, affecting four of four sample residents. Findings include
1. References The residence's September 2024 resident agreement read in part, the residence will in good effort provide the care and services indicated in the resident's care plan. 2. Record Review Resident #1 was admitted to the residence on 1/20/22 with diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and dementia. A care plan, dated 4/29/24, read in part the resident was incontinent of bladder and bowel. Resident #1 required assistance with incontinence products and toileting needs. According to the incontinence product instructions on the package, wearing multiple incontinence products at one time could cause leaks and skin damage. There was similar deficient practice for Resident #3, #5 and #7.3. Interviews On 9/3/24 at 9:26 a.m., Staff #1 stated she often saw that Resident #1 had two incontinence products on him. She stated some staff place two incontinence products on residents who had higher care needs such as Residents #3 and #5. On 9/3/24 at 11:36 a.m., Resident #3 stated staff usually placed two incontinence products on her every time they assisted her with toileting. On 9/3/24 at 11:45 a.m., Resident #5 stated when staff assisted her with toileting, they always put two incontinence products on at a time except for the morning of 9/3/24. On 9/3/24 at approximately 12:00 p.m., Staff #5 stated she often saw that staff had placed two incontinence products on Resident #1 and Resident #3 at 6:00 a.m., the beginning of her shift. She also stated that throughout the day when she went to check on the residents, they had more than one incontinence product on them. She acknowledged that placing two incontinence products on residents was unsafe. On 9/3/24 at 2:02 p.m., the health and wellness director (HWD) stated she was unaware staff placed more than one incontinence product on Residents #1, #3, and #5. She stated most residents at the residence wore incontinence products and she suspected staff placed more than one incontinence product on the other residents. The HWD stated she had frequent meetings with staff about only placing one incontinence product on residents at a time and stated it was unsanitary to have more than one incontinence product on. On 9/3/24 at 2:22 p.m., the administrator designee stated he was unaware staff were placing two incontinence products on residents; however, he acknowledged that it was unsanitary to do so.
Plan of correction · submitted by the facility
On 9/4/24 an in-Service was completed with all Assisted Living staff on the Urinary Incontinence Clinical Guidelines and placing only one incontinence product at a time on resident. Staff are now placing only one incontinence product at a time on residents 1, 3, and 5. To monitor for ongoing compliance, for a period of 3 months, the Health and Wellness Director or designee will audit twice weekly on random days, times, and residents that only one incontinence product is being placed at a time. The Health and Wellness Director will provide re-education to all care staff by 10/11/24 to include Bathroom/toileting assistance and incontinence care, and following resident care plans. Resident care plans will be made readily available to staff for review if they have questions about a resident’s bathroom/toileting or incontinence care needs. This re-education will be documented on an in-service with signatures of all staff in attendance. Resident #1 - Toileting assessment for care needs was completed on 9/6/2024 and care plan updated. Care plan was updated to include current toileting needs and staff to check, change, and reposition approximately every 2 hours and as needed. Resident $#1 sadly passed away on 9/28/2024. Resident #3, #5 - Toileting assessments for care needs was completed on 9/6/2024 and 9/10/2024 and care plans updated. They were assessed for size of incontinence product needed and frequency that assistance is needed. Both residents are capable of calling and asking for bathroom assistance when needed. Updated care plan information was added to the PCC POC task lists for staff. To monitor for ongoing compliance, for a period of 3 months, the Health and Wellness Director or designee will audit twice weekly that Bathroom/toileting assistance and incontinence care is being provided as care planned, including only one incontinence product is being placed at a time. This monitoring will be performed by observation of cares being provided by staff and visiting with residents to discuss any incontinence or toileting need changes and update care plans as needed. This monitoring will be documented on an audit sheet and will be included in the community’s QAPI process.
Reportable Occurrences
2 records4/18/2025Misappropriation of Property · ID 25230490002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/18/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. A family member alleged there was $1000 transaction from Client (A)’s bank account in staff #1’s name. During the course of the investigation the healthcare entity conducted a search, and interviews. The police were notified. Staff #1 denied the allegation and was unaware of any transaction. The family member was able to to provide documentation of the transaction in Staff #1’s name. Staff #1’s employment was terminated on 4/25/25. The family member with the clients permission took possession of the client’s checks book to prevent future occurrences. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 8/18/2025 · released to the public 8/25/2025.
7/25/2024Diverted Drugs · ID 24230490001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/8/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported diverted drugs. During the course of the investigation the healthcare entity was notified by staff member (1) they took a syringe of Morphine Sulfate home with them and did not administer it to Client (A) as documented. The client was on hospice services and had since passed away. Staff member (1) resigned immediately. All staff were educated on Medication Diversion policies. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/20/2025 · released to the public 4/29/2025.