BROOKDALE PINEHURST PARK

A licensure complaint, prompted by #CO39685, was completed on 3/3/26. No deficiencies were cited.

An administrative relicensure survey was completed on 2/18/26. No deficiencies were cited.

A revisit survey was completed on 6/17/25 for all previous deficiencies cited on 3/18/25. 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 relicensure survey with complaint #CO37274 was completed on 3/18/25. Deficiencies were cited.

Based on observation and interview, the residence failed to maintain a physically safe and sanitary environment, affecting 61 current residents. Findings include:1. ObservationsOn 3/18/25 during an environmental tour, the following was observed:Strong urine and other identifiable odors throughout the residence's common hallways and in residents' rooms. Crumbs on the counter and billiard table along with unswept floors that contained dust and other particles in the activities room. The residence's common bathroom had brown particles and liquid on the toilet bowl and rim, brown particles on the toilet seat, unswept floors, and a strong urine odor. Staff #1 used a brush on a resident's hair that was identified to be a shared brush between the residents. 2. InterviewsOn 3/18/25 at 7:43 a.m., Staff #5 reported that housekeeping for residents' rooms occurred once per week, and staff assisted with cleaning daily. Staff #5 reported that Resident #6's room odors were caused by urine and open wounds. On 3/18/25 at 11:36 a.m., Staff #1 reported the residence had a bathroom caddy with hair tools, combs, and brushes that were shared between the residents. She explained that residents commonly misplaced their hygiene items, so they had a shared bathroom caddy with items to provide hair hygiene. Staff #1 reported she cleaned and sanitized the items by taking the hair out and rinsing the items under hot water. Staff #1 acknowledged she did not clean and sanitize the hairbrush after using it on a resident before putting it back in the bathroom caddy. On 3/18/25 at 4:32 p.m., the administrator reported the observations during the environmental tour were not safe and sanitary. She reported being unaware staff were sharing hygiene products between residents and expected them not to. She reported all staff were responsible for keeping the environment clean and would expect the residence to be free from odors.

Based on interview and record review, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting two of three sample residents (#1 and #2). Findings include:1. Residence PolicyThe residence's Injuries of Unknown Sources policy, dated September 2024, read in part: "When an injury of unknown origin is identified it should be reported to the (administrator) and an investigation should be conducted along with the appropriate follow-up and/or implementation of steps to prevent or mitigate future injuries. Definition of unknown injuries: the injury was not observed or otherwise known. Cannot explain how the injury occurred or can explain the source of the injury, but the source could be addressed to prevent further injury. An identified injury should be documented in the resident record when it was not observed by or otherwise known by an associate. Follow reportable event grid guidance and notification flow if the injury requires medical intervention (such as a fracture or head trauma) or constitutes suspected resident abuse. Perform an incident investigation for injuries identified to determine source/origin."2. Resident #1 was admitted to the residence on 12/22/21 with a diagnosis of dementia. A progress note, dated 7/30/24, read in part that Resident #1 was found lying in his bed with blood in his hair. Staff called emergency medical services and Resident #1 was transported to the emergency department. A progress note, dated 8/1/24, read in part that Resident #1 returned from the hospital with eight staples to the crown of his head. A hospital note, dated 7/30/24, read in part that Resident #1 was seen for a head injury and lacerations to the scalp. Resident #1 had a scalp contusion (bruise). Resident #1 had eight staples to close a wound on his scalp. On 3/18/25 at 12:56 p.m., Resident #1's family member said Resident #1 had staples put in his head but staff did not know what had caused the injury. On 3/18/25 at approximately 4:20 p.m., the administrator said when staff found injuries and did not know what happened, she expected them to report it to her. She said someone from the management team would have conducted interviews with the staff and witnesses, evaluated the environment, and investigated the incident. The administrator stated that management staff should have documented an investigation. She said it was important to investigate injuries of unknown origins so they could protect all residents. The administrator stated that staff should have completed an investigation when they found a resident with a laceration on their head. She said she did not know what happened to Resident #1 on 7/31/24 but staff did not conduct an investigation. On 3/18/25 at approximately 4:20 p.m., the district director of clinical services (DDCS) said staff should conduct an investigation anytime a resident was found with an injury of unknown origin to determine if the resident had fallen or if there was possible abuse. He said investigating injuries of unknown origin was important to determine the cause and prevent it from happening again, adding it protected all residents if the investigation revealed abuse. The DDCS stated staff were required to document all investigations. He stated staff should have completed an investigation when they found a resident with a laceration to the head. 3. The investigation revealed evidence for similar deficient practice for Resident #2.

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting three of seven sample residents (#5-#7). Findings include:Resident #5 was admitted to the residence on 5/31/22 with diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and diabetes mellitus. A written practitioner order, dated 1/31/25, directed the residence to administer sertraline HCl 25 mg daily. However, the March 2025 medication administration record (MAR) revealed the residence failed to administer the medication on 3/17-3/18/25 due to being out of stock. The February and March 2025 MARs revealed the residence failed to follow the practitioner's orders and administer these medications due to being out of stock:Symbicort inhalation aerosol DonepezilBupropion HCIEvidence revealed similar deficient practice for Residents #6 and #7 in February and March 2025.3. InterviewsOn 3/18/25 at 4:30 p.m., the administrator reported the residence ensured medications were in stock by having the medications on monthly automatic refills with the pharmacy and completing medication audits. She explained she was unsure why the residence did not have the above medications in stock. She reported she expected the residence to have all medications in stock and to administer the medications with no delay. On 3/18/25 at 4:33 p.m., the health and wellness coordinator reported they ensured medications were in stock by having the medications on monthly automatic refills with the pharmacy. She explained the residence was out of medications when there was a change in the practitioner's order for the medication, the family did not provide over-the-counter medications, or the QMAP was unaware of the back stock of the medications. The health and wellness coordinator reported she was responsible for training the QMAPs and expected them to administer all medications in accordance with practitioners orders.

Based on interview and record review, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis audited the accuracy and completeness of the medication administration records (MARs), affecting 61 current residents. (Cross-reference S1568)Findings include:On 3/18/25, documentation of quarterly medication audits were requested from the administrator and provided. However, the documentation revealed that only the administrator participated in the medication audits and did not include a QMAP supervisor. On 3/18/25, the administrator said that either she, the health and wellness coordinator, or the QMAP completed medication audits. She said she was aware that a QMAP supervisor was required to complete medication audits with her, and she acknowledged that there was only one staff member currently doing them.

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 VII. 7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (A) The assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics:10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 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. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications. 22.37 Designated outdoor smoking areas shall have fire resistant waste disposal containers.