BROOKDALE LOWRY

An administrative relicensure survey was completed on 4/23/26. No deficiencies were cited. A change of ownership occurred on 4/1/26.

A licensure complaint was completed on 3/24/26, prompted by #CO40742 and #CO41559. Deficiencies were cited.

Based on record review and interviews the residence failed to arrange an evaluation for a resident after transfer and discharge to another health care entity affecting one (#1) of three sampled residents. Findings Include:1. Record ReviewFormer Resident #1 was admitted to the residence on 10/25/25 with diagnosis of Alzheimer's ( a brain disorder), post traumatic stress disorder, and asthma (a respiratory disorder). Progress note dated 11/20/25 read in pertinent part, the resident was transferred to (hospital name) by non-urgent transportation for a neurology evaluation due to increased weakness, difficulty eating and drinking, and a change in cognition. Progress note dated 11/21/25 read the resident was admitted to the hospital. Progress note dated 12/24/25 read the resident would not return to the residence from the hospital due to the higher level of care concerns. Further review failed to reveal documentation the residence arranged for an evaluation for the resident prior to discharge. 2. Interviews:On 3/23/26 at 1:29 p.m. an interview with the executive director (ED) and health and wellness director (HWD) was conducted regarding Resident #1. The HWD said the resident was sent to the hospital due to her change of condition on 11/20/25. The HWD said the hospital case manager called him on 11/25/25 to inform him Resident #1 would be needing a higher level of care. The HWD said he informed the ED of the conversation with the hospital case manager. The ED provided Resident #1 ' s power of attorney (POA) a few options that would allow the resident to return to the community. The POA did not choose the options, instead she decided to move the resident out. The HWD said when he became aware that the resident was not returning, he did not feel an evaluation was necessary. The ED confirmed the residence should have arranged for an evaluation of the resident prior to discharge. She said moving forward necessary evaluations would be arranged.

Based on observation and interview, the residence failed to ensure staff changed gloves in between changing tasks or after touching soiled surfaces, affecting15 residents who resided in the secure environment. Findings include:1..ObservationAn observation was conducted of the residence secure environment unit on 3/18/26 from 10:40 a.m. through 12:20 p.m. The observation included an activity and a meal service (lunch). At 11:31 a.m. the food cart arrived. AA was observed getting a pair of gloves from a dispenser unit in the area of the dining room. No hand hygiene was performed prior to putting the gloves on. AA unlocked the door to a room set up as a meal prep area. She rolled the hot cart over to the door and pulled the plates out. The AA lined the plates up on the countertop and began to cut and prep the food on the plates. When she was finished, she placed the plates onto a black rolling cart. Without changing her gloves. At 11:33 a.m. Staff #1 was observed putting on a pair of gloves she pulled out from her uniform top. No hand hygiene was performed prior to putting the gloves on. Staff #1 was observed serving the residents their beverage by handling the top of the glassware where an individual places their mouth to drink. At 11:38 a.m. AA was observed pulling cloth napkins from a steamer container set on the counter outside the food prep area. The clothes were placed on a tray and then offered to each resident. AA assisted an unknown resident by wiping the resident's hands with her own. Once the resident was able to complete the task independently, AA continued serving the remaining residents with the clothes. The unknown resident was coughing without covering their mouth; The unknown resident was observed trying to wipe the airborne and droplet pathogens from herself and/or her outfit. Staff #1 brought the resident's walker to the seated resident and assisted her to stand up by placing her arm under the resident's arm to cue her up. Staff #1 then placed her own hands on the resident's walker to encourage her to take a few steps forward. Staff #1 assisted the resident to sit down at a table and then continued serving beverages from the beverage cart to the residents. At approximately 11:47 a.m AA was observed collecting clothes from the residents who completed their hand hygiene. She put the clothes onto a tray and then put the tray on the counter near the sink. At 11:49 a.m. AA resumed serving the residents their lunch plates. At 12:05 p.m. AA was observed pouring beverages for the resident room trays. She took the cup by the top and filled it. She then put it back still holding the top where the resident would be drinking from. At 12:07 p.m. observation revealed AA removed the gloves she donned at 11:33 a.m. Staff #1 was observed continuing to assist residents in the dining room with standing up, providing additional beverages or clearing their plates. At 12:10 p.m. observation failed to reveal staff #1 changed gloves in between switching tasks such as serving food, assisting unknown resident(s) with standing up and handling unknown resident(s) adaptive devices including walker and/or wheelchairs. 2. InterviewsAn interview was conducted on 3/24/26 at 9:00 a.m.with the activities assistant (AA). The AA said her department was not specifically trained in proper use of gloves. The AA said she assisted the memory care unit usually daily with tasks outside of activities, including the meal prep. She explained how she would wear gloves and change them only if visibly soiled or if she assisted with personal care tasks. The AA did not know to perform hand hygiene and change gloves when going from a clean surface to a contaminated surface then back to clean. An interview conducted with the health and wellness director (HWD) on 3/24/26 at 9:45 a.m. revealed not every staff was trained in appropriate use of gloves, including when to change them and perform hand hygiene. The HWD said all staff were aware of infection control processes but he agreed additional training was needed for non care staff. The HWD provided the infection control book and explained how training was provided to staff at hire and then annually during the skills lab.

A revisit survey was completed on 4/17/25 for all previous deficiencies cited on 1/23/25. 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 was completed on 1/23/25. A deficiency was cited.

Based on interview and record review, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for a secure environment residency that described the resident's medical condition and any cognitive deficits that contribute to wandering, compromised safety awareness and other types of conduct. Additionally, the residence failed to include detailed information in the pre-admission assessment that included information from the residents' family concerning the resident's recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting or any other types of known conduct, affecting three of three sample residents (#7-#9) who resided in the secure environment. Findings include:Residents #7, #8 and #9 were admitted to the residence on 1/17/25, 4/29/24 and 11/20/24, respectively. Residents #7-#9 had forms in their records titled Evaluation for a Secure Environment. The forms were last revised in February 2009. The forms consisted of six checked boxes for the practitioner to fill out. The last page had an area for recommendations, if the practitioner had any. The forms for Residents #7-#9 did not include detailed information from the resident's practitioners to determine the appropriateness and need for a secure environment residency that described the resident's medical condition and any cognitive deficits that contribute to wandering, compromised safety awareness and other types of conduct. Additionally, the forms failed to include detailed information in the pre-admission assessment that included information from the residents' family concerning the resident's recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting or any other types of known conduct. On 1/23/25 at 11:30 a.m., the administrator said the residence's pre-admission practitioner's assessment did not include the exact reasons why residents were required to be in the secure environment, as required. The health and wellness director (HWD) said the pre-admission assessment should have included the practitioner and family representative signatures and the boxes needed to be checked to show why the resident required a secure environment. The HWD added that he did not know that the residence was required to include medical diagnoses on the assessment, and he was not sure if the form was required to have specific details.

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 7,12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (C) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; Room and board; Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment; 42 6 CCR 1011-1 Chapter 7 CODE OF COLORADO REGULATIONS Health Facilities and Emergency Medical Services Division;(E) 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; and Social care and resident engagement. 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. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status.(A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment.