BROOKDALE HIGHLANDS RANCH

A licensure complaint, prompted by #CO39496, #CO40480, #CO40651, and #CO41537 was completed on 2/5/26. Deficiencies were cited. A change of ownership occurred on 9/3/25.

Based on observations and interviews, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the diagnosis of dementia throughout the entire building, affecting 76 current residents. Findings include:On 2/4/26 from approximately 8:00 a.m. to 10:00 a.m., an environmental tour of the residence revealed the following:The residence activity rooms had a small saw, large sewing needles, loose nails and screws in drawers, and fishhooks. Several residents were observed sitting in the dining room, near where many of these items were displayed. On 2/4/26 at 1:30 p.m., the administrator stated she was shocked to learn that a real saw with serrated edges was on display in the activities room. An unnamed program manager next to the administrator stated she was unaware of a saw being out on display. The program manager was also unaware of the potential hazard posed by having a saw, large sewing needles, nails, and fishhooks readily available to residents with dementia. On 2/5/26 at 11:05 a.m., the administrator acknowledged the potential hazard posed by having those items readily available in the residence. She also stated that she expected those items to be locked away and taken out at appropriate times, based on the activity of the residents present.

Based on record review and interview, the residence failed to comply with the authorized practitioner's orders associated with medication administration, affecting three of three sample residents whose medications were reviewed (#2-#4). Findings include:1. Resident #2 was admitted to the residence on 8/15/25.a. acetaminophenA written practitioner's order dated 1/26/26 directed the residence to administer two 325 mg tablets of acetaminophen by mouth three times a day; however, the January 2026 medication administration record (MAR) read that the residence failed to have the medication in stock on 1/6/26 for the afternoon and evening doses. b. diclofenacA written practitioner's order dated 1/20/26 directed the residence to administer one gram of diclofenac to the right knee and right shoulder externally three times a day; however, the January 2026 MAR failed to have the medication in stock on 1/20/26.2. InterviewOn 2/5/26 at 11:08 a.m., the administrator stated that she would expect medications ordered by a practitioner to be available for the residents and acknowledged that not having the medications available or onsite was not following the practitioner's orders. 3. Similar deficient practice was found for Residents #3 and #4.

Based on record review and interview, the residence failed to provide an enhanced care plan (ECP) affecting 76 residents who resided in the secured environment. Findings include:1. Record ReviewResident #2 was admitted to the residence on 8/15/25 with a diagnosis of unspecified dementia, anxiety, hallucinations, and psychotic disturbance. A progress note, dated 2/1/26, read in part that Resident #2 was exit seeking after seeing things in her room that did not exist, accused staff of things that were not true, agitated, was not able to be redirected or calmed down by staff or her power of attorney, and threw a "heavy decor item" at a window and broke it in attempt to leave the building. A service (care) plan dated 2/2/26 read in part that Resident #2 had a history, before moving in, of wandering. However, the care plan failed to provide a description of the resident ' s current wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact. 2. InterviewOn 2/5/26 at 11:09 a.m., the administrator acknowledged that the residence did not have ECP, and that the current care plans in place did not include all the required elements in the regulations. The missing elements included a description of wandering patterns for each resident, a description of how each resident will have continuous access to their room and be protected from unwanted visitors, identifying the level of staff supervision needed for each resident, and documenting if hygiene items are safe for the resident to have and how to prevent others from gaining access to them. 3. Evidence revealed similar deficient practice for 75 other residents residing in the secured environment.

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 7.14.29 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. (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.

A revisit survey was completed on 2/26/25 for all previous deficiencies cited on 10/10/24. 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 revisit survey was completed on 2/26/25 for all previous deficiencies cited on 10/10/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 2/26/25 for all previous deficiencies cited on 10/10/24. The facility is in compliance with all deficiencies that were cited.

A relicensure survey with complaints #CO37749 and #CO37836 was completed on 10/10/24. Deficiencies were cited.

Based on interview and record review, the residence failed to have at least one staff member onsite who had certification in first aid from a nationally recognized organization, affecting 41 current residents. (Cross-reference S0734 and S0736)Record Review:A review of staff first aid certifications on 10/8/24 revealed that ten out of ten sample staff did not have first aid certifications from a nationally recognized organization. The staff schedule from 10/1-10/19/24 revealed there were no staff with first aid certification from a nationally recognized organization for 57 of 57 shifts. Interviews:On 10/9/24 at 11:28 a.m., the wellness director stated that she was not aware that the residence was required to have at least one staff member onsite at all times who was certified in first aid from a nationally recognized organization. On 10/9/24 at 2:42 p.m., the administrator stated that she was aware that the residence was required to ensure that a staff member certified in first aid was onsite at all times.

Based on interview and record review, the residence failed to have at least one staff member onsite who had certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization at all times, affecting 41 current residents. (Cross-reference S0732 and S0736)The staff schedule from 10/1-10/19/24 revealed there were no staff with CPR certification from a nationally recognized organization for three of 57 shifts. In an interview, dated 10/9/24 at 2:43 p.m., the administrator stated that she was aware that the residence was required to ensure at least one staff member with current CPR certification was onsite at all times.

Based on observation and interview, the residence failed to have, in a visible location, a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR), affecting 41 current residents. (Cross-reference S0732 and S0734)On 10/9/24, a list of current staff members certified in CPR and first aid was not in a visible location throughout the residence. On 10/8/24 at 11:00 a.m., Staff #11 stated that there was no list of staff with current CPR or first aid certifications at the front desk. On 10/9/24 at approximately 9:31 a.m., Staff #7 stated that he was not aware of where to look for a list with CPR or first aid certified staff and that if an emergency situation arose that required him to find someone certified in CPR or first aid he would radio the qualified medication administration personnel (QMAP) on shift to assist. On 10/9/24 at 2:44 p.m., the administrator stated that she was aware that the residence was required to have a list of staff currently certified in CPR and first aid in a visible location.

Based on observation and interview, the residence failed to make available, either directly or indirectly through a resident agreement, personal services including but not limited to a system for identifying and reporting resident concerns that require an immediate individualized approach or on-going monitoring and possible re-assessment and protective oversight including but not limited to taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach, affecting three of four sample residents (#15-#17). (Cross-reference S3062)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 12, requires the assisted living residence to be responsible for the coordination of resident care services with known external service providersb. Chapter VII regulations governing assisted living residences, part 2, defines external services as personal services and protective oversight services provided to a resident by family members or healthcare professionals who are not employees, contractors, or volunteers of the facility. External service providers include, but are not limited to, home health, hospice, private pay care providers, caregivers as defined in Part 2.11, and essential caregivers as defined in Part 2.25.2. Protective Oversight and Coordination of Care with External Service Providers (ESPs)a. Resident #15 was admitted to the residence on 9/10/24 with diagnoses including Alzheimer's disease and senile degeneration. Record ReviewESP notes for Resident #15 in September and October 2024 revealed the following:On 9/13/24, Resident #15 was not changed at all during the night. The private caregiver (PCG) provided care and services to Resident #15 throughout her shift. On 9/15/24, the PCG provided care and services to Resident #15. On 9/17/24, the PCG provided care and services to Resident #15. On 9/18/24, the PCG provided care and services to Resident #15 because the residence staff were busy attending to a flood in the residence. On 9/19/24, the PCG and residence staff assisted Resident #15 into his bed. On 9/20/24, the PCG requested assistance from residence staff to change Resident #15. Residence staff did not respond to the PCG's request for assistance so the PCG provided care and services to Resident #15. On 9/25/24 at approximately 7:30 p.m., Resident #15 wanted to go to bed. The PCG provided care and services to Resident #15 because she did not want to wait for the residence staff. On 9/26/24, the PCG assisted Resident #15 into bed with the assistance of residence staff. The PCG also helped Resident #15 to lunch. At approximately 4:30 p.m., the residence staff and the PCG took Resident #15 to the bathroom and cleaned him up before dinner. On 9/27/24, the PCG provided care and services to Resident #15. On 9/28/24, Resident #15's incontinence product was saturated with bowel movement. On 9/30/24, the PCG provided care and services to Resident #15.b. Resident #16 was admitted to the residence on 9/10/24 with diagnoses including Alzheimer's disease, anxiety and dementia with psychotic disturbance. A care plan in Resident #16's record, dated 9/13/24, read Resident #16 did not require grooming, showering, bathroom, mobility and dressing assistance. The care plan read Resident #16 had a private caregiver (PCG) but did not indicate what services were provided or when the PCG was expected to provide assistance. A care plan in Resident #16's record, dated 9/24/24, read Resident #16 did not require grooming, bathroom, mobility, dressing or showering assistance. Resident #16's personal services (dressing, grooming, showers, mobility and bathroom) were to be provided by the PCG. The care plan did not include what was expected of the residence care in the event the PCG did not show up. Additionally, the care plan did not include how often the PCG would provide assistance. ESP notes for Resident #16's PCG in September and October 2024 revealed the following:On 9/11/24 Resident #16's PCG provided care and services to Resident #15 and Resident #16. On 9/13/24 Resident #16 did not get changed throughout the night and had two incontinence pull ups on that were soiled with urine. On 9/15/24 the residence staff showered Resident #16. On 9/17/24 the PCG provided care and services to Resident #16. On 9/18/24 the PCG provided care and services to Resident #16. On 9/19/24 the PCG provided care and services to Resident #16. On 9/28/24 Resident #16 was wearing Resident #15's incontinence product so urine leaked.c. Interviews for Resident #15 and Resident #16On 10/8/24 at 9:51 a.m., Staff #10 said the PCG provided all care and services to Resident #16 and the residence was responsible for providing care and services to Resident #15 since she moved in. On 10/8/24 at approximately 2:00 p.m., the administrator said when Resident #16 was admitted, the PCG was not providing any care; a week and a half later, the residence informed Resident #16's family member what care would cost if the residence provided it. The administrator stated that the family member said the PCG would provide care and services to Resident #16. On 10/8/24 at 2:14 p.m., an ESP representative for Resident #16 said that since Resident #16 was admitted to the residence, the PCG provided all care and services to her. She added the PCG was required to act as an advocate for Resident #15, and when he required help the PCG pulled the cord for staff assistance. She added, sometimes staff took too long to respond or did not respond at all so the PCG provided care and services to Resident #15. On 10/8/24 at 4:05 p.m., the ESP representative said when Resident #16 was admitted, the residence staff provided care and services to Resident #16 and approximately one week later, the PCG was responsible for care and services for Resident #16 with the exception of bathing assistance, which was provided by residence staff. On 10/9/24 at 8:40 a.m., the ESP representative said the PCG was responsible for providing care and services to Resident #16 from 8:00 a.m. to 8:00 p.m. and the residence staff provided the care and services from 8:00 p.m. to 8:00 a.m. when the resident was admitted to the residence. On 10/9/24 at 8:45 a.m., Staff #7 said when Resident #16 moved into the residence the PCG was required to provide all care and services to Resident #16 during the day. Staff #7 stated she was not aware who provided the care during the overnight hours. On 10/9/24 at 11:33 a.m., the health and wellness director said the residence was responsible for providing care and services to Resident #16 when she moved in and the PCG was responsible for companionship only; the residence was required to provide all care and services to Resident #15 when he moved in. The HWD said that on 9/24/24 the PCG was required to take over all care and services for Resident #16 and the residence staff helped with transfers. The HWD said the communication between the PCG company and the residence could have been better. The HWD said the first time she spoke with management at the PCG company was 9/28/24, 18 days after Residents #15 and #16 were admitted. On 10/9/24 at 12:00 p.m., the HWD said when Resident #15 was admitted to the residence, staff provided all care and services to him. She added that when Resident #15 required assistance the PCG was required to pull the cord in the room so the residence staff could provide care. On 10/9/24 at 12:18 p.m., the family member of Residents #15 and #16 said the residence was required to assist Resident #16 to meals, provide bathing assistance twice weekly, and bring her to activities. She added the residence did not provide any care or services when she was admitted and that only the PCGs did. The family member said the residence changed the care plan for Resident #16 to reflect that the PCG provided all care and services on 9/24/24. Sheadded that for the first 14 days of Resident #16's admission, the residence did not know what care and services were to be provided. On 10/9/24 at approximately 3:00 p.m., Staff #9 stated that the PCG was to provide care for both Residents #15 and #16. He stated he was not sure of the care that the PCGs were meant to provide because he was told sometimes that they were only companionship and at other times they were meant to provide care for both Residents #15 and #16. Staff #9 stated that the issue was that when Residents #15 and #16 were admitted he was told they were independent with all care.d. Evidence obtained during the onsite investigation revealed deficient practice for Resident #17.

Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin affecting two of four sample residents (#15, #17). (Cross-reference S2230)A shift report dated 9/4/24 read in part: Resident #17 had a skin tear on her left leg that a band aid was placed on, and the health and wellness director was notified. However, staff did not document the incident in a progress note for Resident #17. Additionally, the residence was unable to provide records of an investigation performed to determine the cause of the skin tear found on 9/4/24. On 10/9/24 at 2:13 p.m., the health and wellness director stated that she was not aware of a skin tear on 9/4/24, and the external care provider reported it so the residence did not complete an investigation. On 10/9/24 at 2:47 p.m., the administrator stated that she expected an investigation to be performed when staff discovered an injury of unknown origin. Similar deficient practice was found with Resident #15.

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of four sample residents (#15-#17). (Cross-reference S1604)Findings include:1. Resident #16 was admitted to the residence on 9/10/24 with diagnoses including dementia with psychotic disturbance.a. ClonazepamA written practitioner's order, dated 9/4/24, directed the residence to administer clonazepam 0.5 mg twice daily. However, the September 2024 medication administration record for Resident #16 read the medication was not administered because Resident #16 was sleeping on 9/10 morning dose, 9/21 evening dose, for a total of two missed doses. b. SimvastatinA written practitioner's order, dated 9/4/24, directed the residence to administer simvastatin 40 mg daily. However, the September and October 2024 medication administration records (MARs) revealed the residence failed to administer the medication because Resident #16 was asleep on 9/10, 9/21, 10/3 and 10/6/24, for a total of four missed doses.c. TrazodoneA written practitioner's order, dated 9/26/24, directed the residence to administer trazodone 100 mg daily. However, the October 2024 MAR read the residence failed to administer the medication because Resident #16 was asleep on 10/3 and 10/6/24 for a total of two missed doses.d. SeroquelA written practitioner's order, dated 9/4/24, directed the residence to administer seroquel 25 mg daily. However, the September 2024 MAR revealed the residence failed to administer the medication on 9/10/24 because Resident #16 was asleep. 2. InterviewsOn 10/9/24 at 8:22 a.m., the practitioner for Resident #16 said she did not write an order for staff to hold medication when the resident was asleep. She added she expected staff to administer Resident #16's clonazepam to remain consistent with the therapeutic medication. On 10/9/24 at approximately 11:28 a.m., the health and wellness director (HWD) said she did not have an order to hold the medication that staff did not administer. The HWD acknowledged that the medications that were coded as sleeping meant staff did not administer the medications. The HWD said she expected the residence to administer resident medications, as ordered and not run out of stock. On 10/9/24 at approximately 2:45 p.m., the administrator said she expected the residence to administer medications according to their practitioner's orders and not run out of stock. 3. During the onsite visits on 10/8 and 10/9/24, similar deficient practice was found for Residents #15 and #17.

Based on record review, observation and interview, the administrator and the qualified medication administration persons (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting three of four sample residents (#15-#17). (Cross-reference S1568)Findings include:A medication audit record, dated September 2024, had no documentation that the QMAP supervisor and the administrator investigated nor resolved any medication administration irregularities. On 10/9/24 at 11:15 a.m., the health and wellness director (HWD) stated that she was the QMAP supervisor and that she did not participate in medication cart audits. On 10/9/24 at 2:58 p.m., the administrator stated that she was aware that she and the HWD were required to investigate all irregularities found during a quarterly medication audit.

Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs, affecting three of four sample residents (#15-#17). (Cross-reference S1412)Findings include:1. Resident #15 was admitted to the residence on 9/10/24. Incident reports for September 2024 revealed the following:On 9/19/24, Resident #15 fell in his bedroom with no apparent injury. On 9/28/24, Resident #15 had an unwitnessed fall in the bathroom with no apparent injury. There were no documented actions taken by staff to address Resident #15's changing needs. Shift reports for October 2024 revealed the following:On 10/3/24, Resident #15 had a fall. On 10/6/24, Resident #15 had a small skin tear on his right elbow. There were no documented actions taken by staff to address Resident #15's changing needs. External service provider notes (ESP) notes for Resident #15 on 9/15/24 revealed Resident #15 sat up during the night, fell off his bed, and had some bruising on his arms. The residence did not document in Resident #15's record that this event had occurred. Specifically, there were no incident reports or shift reports that indicated this had occurred. 2. Interviews On 10/9/24 at 11:28 a.m., the health and wellness director said she expected staff to write progress notes for residents as soon as an incident occurred. On 10/9/24 at approximately 2:45 p.m., the administrator said she expected staff to document progress notes for any unusual event or issue that involved residents immediately after the event occurred. 3. Evidence obtained during the onsite visit on 10/8 and 10/9/24 revealed similar deficient practice for Residents #16 and #17.

Based on interview and record review, the residence failed to ensure each care plan was updated to reflect changes in the staff approach to meet resident needs and when observations indicated the resident's care needs have changed, affecting two of four sample residents (#15, #16). (Cross-reference S1110, S2230)Findings include:1. Resident #16 was admitted to the residence on 9/10/24. A care plan, dated 9/13/24, read Resident #16 did not require assistance with grooming, bathing, or toileting. Additionally, the care plan read Resident #16 had a private caregiver (PCG), however there was no information in the care plan that detailed what services the PCG provided to Resident #16. Another care plan, dated 9/24/24, read Resident #16 did not require toileting assistance. It read that the resident had a PCG but did not include what care or services they were to provide other than bathing assistance. Progress notes for Resident #16 for September and October 2024 revealed the following:On 9/12/24, Resident #16 expressed suicidal and homicidal ideations. On 9/20/24, Resident #16's practitioner visited Resident #16 and documented Resident #16 was unable to self regulate and should be considered high risk for safety concerns and required a one-on-one PCG. On 10/7/24, Resident #16 had swallowing difficulties and required puree-textured foods and thickened liquids. Practitioner progress notes for Resident #16 on 9/19 and 9/30/24 read in part that the resident had worsening agitation, mood changes, and decline in her cognition. Additionally, Resident #16 had increased agitation and dependence on care assistance. She was walking and transferring well and was now completely dependent on staff for care. Neither care plan on 9/13 and 9/24/24 addressed behavioral concerns related to staff approach to meet Resident #16's needs. The care plans did not address the change in diet and liquid texture. On 10/9/24 at approximately 8:30 a.m., Staff #2 said he was not aware Resident #16 had suicidal ideations nor what to watch out for. On 9/10/24 at approximately 8:45 a.m., Staff #7 said she was not aware of Resident #16's suicidal thoughts and that she was only told Resident #16 yelled throughout the night. On 10/9/24 at approximately 2:45 p.m., the administrator said she expected the residence to update care plans to reflect changes in residents and the staff approaches necessary to meet those needs when appraisals or observations indicated the residents' care needs had changed. The administrator acknowledged Resident #16's care needs had changed and said there was no documentation of the services that residence care staff were providing versus those of the PCG.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.14 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee's or volunteer's personnel file:(A) Documentation that the individual's name appears on the Department's list of individuals who have successfully completed the medication administration competency evaluation;14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 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.(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. 17.14 Staff who assist feeding a resident shall be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist, or registered dietitian. 18.9. The face sheet shall be updated at least annually and contain the following information: (F) Name, contact information, and mailing address, if available, for family members, legal representatives, and/or other persons to be notified specifically in case of emergency.

A complaint revisit was completed on 8/8/24 for all previous deficiencies cited on 12/27/22. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on observations and interviews, the residence failed to have staff sufficient in number to help residents needing or potentially needing assistance, affecting 39 current residents. This deficiency was cited previously during a state licensure survey 12/27/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence Policy a. The residence's staffing policy, dated November 2022, read in part: " The community shall have sufficient staffing at all times to meet the scheduled and reasonably foreseeable unscheduled resident needs, as required by the residents' assessments and service plans on a 24-hour per day basis."b. The residence ' s resident agreement, dated February 2024, read in part, "(Staff) are available 24 hours a day, seven days a week."2. Record ReviewAn incident investigation summary, dated 7/30/24, read in part: "It has been substantiated that two [staff], [Staff #5], caregiver, and [Staff #4] did not check on [Former Resident #14] during her time in the courtyard."2. Interviews On 8/7/24 at 9:53 a.m., Staff #2 stated with insufficient staff it was hard to keep up with resident care needs and he had been working longer hours due to the lack of staff. He stated that staff were cleaning resident rooms and common living and dining areas due to the lack of housekeeping staff. On 8/7/24 at approximately 2:15 p.m., the maintenance director stated due to insufficient staff, he had been at the residence for the past two days with only a total of six hours to go home, take a break and then come back to help care for the residents. He also stated that the residence needed to hire more staff and it had become difficult to keep up with resident care needs. He stated he was the only staff member in maintenance for the residence, and there was one housekeeper to clean all resident rooms and the residence. On 8/7/24 at 3:50 p.m., the health and wellness director (HWD) acknowledged resident care needs were not being met and that staffing had become an issue with staff not working their scheduled shifts. The HWD stated this deficiency that was previously cited had not been fixed because some of the staff were not reliable, and she acknowledged the importance of sufficient staffing and correcting deficiencies.

A licensure complaint, prompted by #CO37022 and #CO37023, was completed on 8/8/24. Deficiencies were cited.

Based on record review and interview, the residence failed to have readily available a roster of current residents along with a residence diagram showing room locations and the emergency contacts for each resident, affecting 39 current residents. Findings include:On 8/7/24 at 8:00 a.m., the residence's resident roster was provided but did not include a diagram of the residence that showed room locations or the emergency contact information for each resident. The resident roster was not accurate; it included a deceased resident and was missing one new resident. 2. InterviewOn 8/8/24 at 12:15 p.m., the district director of clinical services stated the residence was expected to update the resident roster upon resident admissions, discharges, and with a change in baseline status. He acknowledged that the residence failed to update the resident roster and include all the required components.

Based on record review and interview, the residence failed to ensure the resident right to be free from neglect affecting one current former resident (#14). Findings include:1. Residence Policya. The residence's Secure Environment Policy, dated August 2021, read in part: "There shall be a secure outdoor area that is available for resident use year-round that is directly supervised by [staff]."b. The residence's Resident Meal Check Policy, dated January 2023, read in part: "[Staff] should conduct routine resident checks for each meal; [staff] should indicate the resident's status at each meal check by marking the box next to the resident's name on the resident meal check record; if the resident is not attending the meal and there is no indication the resident is in the hospital, or out of the community, and a [staff] should check the community and the resident sign in/out log."c. The residence's Resident Bill of Rights, dated January 2020, read in part that residents had "the right to be free from neglect."d. The residence's Secure Environment Policy, dated August 2021, read in part: "There shall be a secure outdoor area that is available for resident use year-round that is directly supervised by [staff]."2. Record ReviewAn incident investigation summary, dated 7/30/24, read in part: "On 7/30/24 Former Resident [#14] entered the courtyard at approximately 2:20 p.m. At approximately 5:50 p.m. three residents went out to the courtyard after dinner. [The residents] called the QMAP (qualified medication administration person) on shift, [Staff #4], stating someone needed help. [Staff #4] responded to the courtyard to find Former Resident [#14] who appeared to be deceased ... It has been substantiated that two [staff] (#4 and #5) did not check on [Former Resident #14] during her time in the courtyard." The resident meal check record for the week of 7/28/24 revealed that staff did not document that they checked on the residents for the dinner meal on 7/30/24. The resident sign out sheet, dated 7/23/24 to 7/31/24, revealed that Former Resident #14 did not sign out of the residence on 7/30/24. 3. ObservationA photo, taken on 7/30/24 between 7:00 p.m. and 8:00 p.m., provided by an anonymous person, revealed a human body in a chair covered in a sheet, facing west; there was an umbrella behind the body to the east, raised approximately seven feet high, that did not provide shade in the afternoon hours. An electronic message from the anonymous person confirmed it was Former Resident #14 in the photo. 4. InterviewsOn 8/7/24 at 8:10 a.m., Anonymous Staff #7 stated Staff #5 was working as the caregiver for Former Resident #14 on the afternoon of 7/30/24 and thought Former Resident #14 was out of the residence with her family. On 8/7/24 at 11:30 a.m., Former Resident #14's family member stated she had arrived to visit her mother at 6:01 p.m.; about ten minutes after she arrived, staff found Former Resident #14 in the courtyard deceased. She stated that the outdoor temperature was 98 degrees fahrenheit that afternoon, and Former Resident #14 was found with her socks and shoes off and her pant legs rolled up. Former Resident #14's family member also stated that when she touched Former Resident #14 upon her arrival, her skin was very hot. She stated staff reported to her that they did not look for Former Resident #14 for dinner and that no one had seen her from 2:20 p.m. until 5:50 p.m. On 8/7/24 at 2:53 p.m. the health and wellness director (HWD) stated that the residence served dinner at 5:30 p.m., and staff should have checked on all of the residents. On 8/7 at 3:41 p.m., Anonymous Staff #8 who spoke directly following the incident with Staff #5, said they had not seen Former Resident #14 at all on 7/30/24, adding that they had checked on the residents at 3:00 p.m. S/he stated that when they did not see Former Resident #14, s/he presumed s/he was out with her family and did not look for her. On 8/8/24 at 12:15 p.m., the district director ofclinical services stated the residence did not set a specific time for staff to check the courtyard and the staff were trained to check it several times per shift. On 8/8/24 at 12:34 p.m., the HWD stated that staff were trained to check the whereabouts of residents a few times per shift and acknowledged the staff did not do so on 7/30/24.

Based on record review and interview, the residence failed to document the investigation process to evidence the required reporting and that a thorough investigation was conducted including the documentation of appropriate measures to prevent similar future situations of neglect, affecting 39 current residents. Findings include:1. Residence PolicyThe residence's How to Conduct Internal and External Investigations policy, dated October 2018, read in part: "The investigator should draft an investigation using the investigation notes form ... The notes should contain the date, time, name of each person questioned, their title and an impartial report of the facts ... The legal department should be contacted if there are any questions regarding the documentation of the facts gathered or the investigation process." An incident investigation summary, dated 7/30/24, summarized the facts of the incident; however, the residence did not document any interviews related to the investigation or measures to prevent similar situations. On 8/8/24 at 8:15 a.m., additional documentation of the incident that occurred on 7/30/24 was requested, however none was received. The residence Abuse, Neglect and Exploitation Policy, dated November 2021 read in part: "Upon learning of alleged abuse, neglect or exploitation, the executive director or supervisor on duty should attempt to take necessary steps to ensure that residents are protected from subsequent episodes of abuse, neglect or exploitation while a determination on the matter is pending."2. Record ReviewA photo, dated 8/1/24, provided by an anonymous person, revealed two large chairs on the interior of the building that were blocking the doors to the courtyard. A staff training document, dated 8/6/24, revealed a courtyard yard check training to ensure hourly monitoring of the courtyard to seven out of 46 staff members, seven days after the incident occurred. The residence provided documentation of courtyard checks, however they were not implemented until 8/4/24. A staff training document, dated 8/6/24 (seven days after the incident), revealed the residence provided training to eight out of 46 total staff on documenting whether residents were present at meal times and (when they were not present) their whereabouts. 3. InterviewsOn 8/8/24 at 12:15 p.m., the district director of clinical services (DDCS) stated the residence had no other documentation regarding the incident on 7/30/24 other than the incident investigation summary. He also stated there were no new documents or policies related to the investigation. The DDCS stated the residence had procedures in place, but the staff failed to follow the procedures. The DDCS also stated the residence implemented courtyard checklists on 8/5/2024 and following the occurrence on 7/30/24, staff kept the courtyard doors closed due to excessive smoke from a nearby fire and discouraged residents from going to the courtyard. On 8/8/24 at 12:34 p.m. the health and wellness director (HWD) stated that she was unaware of any documentation of appropriate measures to prevent similar future situations. She also stated that she did not know of other documentation of the incident, since the executive director at the time, was suspended pending the investigation of the incident.

Based on record review and interview, the residence failed to implement policies and procedures for the delivery of resident care and services including a system or method of accounting for the whereabouts of each resident affecting one former resident (#14). Findings include:Residence Policies a. The residence's Resident Meal Check policy, dated January 2023, read in part: "[Staff] should complete a Resident Meal Check Record verifying the presence of residents for each meal."b. The residence's resident agreement, dated February 2024, read in part: "[Staff] are available 24 hours a day, seven days a week."2. Record Review Former Resident #14 was admitted to the residence on 2/28/24 with a diagnosis of dementia. An incident investigation summary, dated 7/30/24, read: " On 7/30/24 resident, [Former Resident #14] entered the courtyard at approximately 2:20 p.m. At approximately 5:50 p.m., three residents went out to the courtyard after dinner. They called the QMAP [qualified medication administration person] on shift, [Staff #4], stating that someone needed help. [Staff #4] responded to courtyard to find resident, [former Resident #14], who appeared to [Staff #4] to be deceased. [Staff #4] notified another QMAP, [Staff #3], who called 911 at approximately 6:00 p.m. EMS [Emergency Medical Services] arrived shortly after 6:00 p.m. [The] coroner arrived at approximately 8:00 p.m. The executive director received a call on 7/31/24 that the body was being released back to the coroner to investigate as a potential accident. An autopsy was done, no cause of death has been determined at this time. It has been substantiated that two [staff], [Staff #5], caregiver, and [Staff #4], did not check on [Former Resident #14] during her time in the courtyard."3. Interviews On 8/7/24 at 2:05 p.m., Staff #2 stated the residence did not require staff to check on residents on an hourly basis until 8/5/24. He stated that prior to 8/5/24, the residence required staff to check on residents at mealtimes to determine if they were at the residence or out with family; however, he stated that staff frequently failed to do so. On 8/7/24 at 3:41 p.m., Anonymous Staff #8 stated s/he arrived for her shift on 7/30/24 at approximately 5:53 p.m., when Staff #5 told him/her no one had seen Resident #14 during his/her shift and assumed Former Resident #14 was with her family. Anonymous Staff #8 stated communication between staff was lacking and often they were not aware of which residents were in the residence or who had left. S/he stated that when a resident left with their family member, the family entered information on a resident sign out form located out at the receptionist desk. Staff #2 added, however, that staff did not have a way of keeping track of residents' whereabouts. On 8/8/24 at 12:15 p.m., the district director of clinical services stated the residence did not have any documentation for when staff monitored resident safety and whereabouts except for the resident meal checks and sign out sheet prior to 8/5/24, after the incident. He acknowledged that resident meal checks were not being done and there was no documentation of resident whereabouts. On 8/8/24 at 12:34 p.m., the health and wellness director stated staff were expected to check on residents every four hours and periodically throughout the day. She stated that meal checks were the only documentation to account for the whereabouts of residents; however, she stated that staff had not been doing the meal checks according to the residence's requirement.