BROOKDALE LITTLETON

An administrative relicensure survey was completed on 4/23/26. No deficiencies were cited. A change of ownership occurred on 9/11/25.

A revisit survey was completed on 9/15/25 for all previous deficiencies cited on 3/19/25. The facility is in compliance with all deficiencies that were cited.

A relicensure survey with complaint #CO34236 was completed on 3/19/25. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed for one of seven sample staff (#1) who provided direct care to at-risk residents, affecting 31 current residents. Findings include:A review of the personnel file for Staff #1 revealed no evidence of CAPS checks being completed. The residence's January 2025 staff schedule revealed Staff #1 worked from 2:00 p.m. to 6:00 a.m., on 1/3, 1/4, 1/10, 1/11, 1/17, 1/18, and 1/25. Staff #1 worked from 2:00 p.m. to 10:00 p.m. on 1/19 and 1/26. Staff #1 worked from 10:00 p.m. to 6:00 a.m. on 1/31. A total of ten shifts worked in January 2025. The residence's February 2025 staff schedule revealed Staff #1 worked from 2:00 p.m. to 6:00 a.m. on 2/1, 2/8, and 2/22. Staff #1 worked from 2:00 p.m. to 10:00 p.m. on 2/2, 2/9, 2/15, and 2/23. Staff #1 worked from 10:00 p.m. to 6:00 a.m. on 2/7, 2/14, 2/16, and 2/21. Staff #1 worked from 6:00 a.m. to 2:00 p.m. on 2/11 and 2/18. A total of 13 shifts were worked in February 2025. The residence's March 2025 staff schedule revealed Staff #1 worked from 2:00 p.m. to 6:00 a.m. on 3/1, 3/8, and 3/15. Staff #1 worked from 2:00 p.m. to 10:00 p.m. on 3/2, 3/9, and 3/16. Staff #1 worked from 10:00 p.m. to 6:00 a.m. on 3/7 and 3/14. A total of 8 shifts worked in March 2025. On 3/19/25 at 11:45 a.m., the business office manager (BOM) stated that Staff #1 was transferred from a sister residence and the CAPS check could be pulled from the digital system. On 3/19/25 at 12:58 p.m., the administrator stated that Staff #1 did not have a CAPS check completed because the sister residence did not complete one and one was not completed when the staff member transferred. The administrator acknowledged deficient practice.

Based on record review and interviews, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 31 current residents. Findings include:A review of the personnel file for former Staff #7 revealed a first-aid certification not from a nationally recognized organization. A review of the personnel file for Staff #6 revealed a first-aid certification not from a nationally recognized organization. A review of the personnel file for Staff #2 revealed a first-aid certification not from a nationally recognized organization. The residence's January 2025 staff schedule revealed former Staff #7 worked while no other first-aid certified staff were present from 2:00 p.m. to 10:00 p.m. on 1/5, 1/6, 1/12, 1/13, 1/20, 1/27, and 1/31. The residence's February 2025 staff schedule revealed former Staff #7 worked while no other first-aid certified staff were present from 2:00 p.m. to 10:00 p.m. on 2/3, 2/10, and 2/24. The residence's March 2025 staff schedule revealed former Staff #7 worked while no other first-aid certified staff were present from 2:00 p.m. to 10:00 p.m. on 3/3, 3/5, and 3/10. The residence's March 2025 staff schedule revealed Staff #6 worked while no other first-aid certified staff were present from 2:00 p.m. to 10:00 p.m. on 3/6, 3/10, 3/11, and 3/12. The residence's February 2025 staff schedule revealed Staff #2 worked while no other first-aid certified staff were present from 10:00 p.m. to 6:00 a.m. on 2/28. On 3/19/25 at 1:26 p.m., the administrator stated that he was aware that Staff #2 did not have a certification from a nationally recognized organization. He stated that he was not aware of Staff #6 or former Staff #7. He stated that if those staff worked without anyone else who was not first-aid certified from a nationally recognized organization it would be deficient practice.

Based on record review and interviews the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization which included the skills assessment observed and evaluated by an instructor, affecting 31 current residents. Findings include:A review of the personnel file for former Staff #7 revealed a CPR certification not from a nationally recognized organization, which did not include a skills assessment observed and evaluated by an instructor. A review of the personnel file for Staff #6 revealed a CPR certification not from a nationally recognized organization which did not include a skills assessment observed and evaluated by an instructor. A review of the personnel file for Staff #2 revealed a CPR certification not from a nationally recognized organization which did not include a skills assessment observed and evaluated by an instructor. The residence's January 2025 staff schedule revealed former Staff #7 worked while no other CPR-certified staff were present from 2:00 p.m. to 10:00 p.m. on 1/5, 1/6, 1/12, 1/13, 1/20, 1/27, and 1/31. The residence's February 2025 staff schedule revealed former Staff #7 worked while no other CPR-certified staff were present from 2:00 p.m. to 10:00 p.m. on 2/3, 2/10, and 2/24. The residence's March 2025 staff schedule revealed former Staff #7 worked while no other CPR-certified staff were present from 2:00 p.m. to 10:00 p.m. on 3/3, 3/5, and 3/10. The residence's March 2025 staff schedule revealed Staff #6 worked while no other CPR-certified staff were present from 2:00 p.m. to 10:00 p.m. on 3/6, 3/10, 3/11, and 3/12. The residence's February 2025 staff schedule revealed Staff #2 worked while no other CPR-certified staff were present from 10:00 p.m. to 6:00 a.m. on 2/28. On 3/19/25 at 1:26 p.m., the administrator stated that he was aware that Staff #2 did not have a certification from a nationally recognized organization. He stated that he was not aware of Staff #6 or former Staff #7. He stated that if those staff worked without anyone else who was not CPR-certified from a nationally recognized organization which included a skills assessment observed and evaluated by an instructor, it would be deficient practice.

Based on record review, observation, and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications that a resident self-administers, affecting two of four sample residents (#2, #4). Findings include:Resident #2 was admitted to the residence on 2/19/25. A practitioner's order for Resident #2, dated 2/19/25, directed the residence to administer olopatadine 0.1% ophthalmic solution, one drop in each eye twice daily. The March 2025 Medication Administration Record (MAR) for Resident #2 revealed the residence failed to administer olopatadine 0.1% ophthalmic solution because the medication was unavailable for the 7:00 a.m. dose on 3/1 and 3/16, both the 7:00 a.m. and 8:00 p.m. doses from 3/2 to 3/13, and the 7:00 a.m. dose on 3/14 for a total of 28 missed doses. On 3/19/25 at 1:26 p.m., the administrator stated that he expected all medications to be available for administration at all times. He stated that he was unaware that Resident #2 had missed 28 doses of his medication. He agreed that when resident medications were unavailable to administer that was a failure to comply with practitioner orders and deficient practice. Similar deficient practice was found related to Resident #4.

Based on record review, observation, and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting two of four sample residents (#2, #4). Findings include:1. ObservationOn 3/19/25 at 10:02 a.m., an environmental tour revealed that a bottle of Nystatin for Resident #4 was on her bathroom countertop. The staff did not store the medication in a locked storage area; therefore, the medication was accessible to the resident. On 3/19/25 at 10:54 a.m., an environmental tour revealed a box for Resident #2 labeled albuterol sulfate HFA inhalation aerosol sitting on his nightstand next to the bed. The staff did not store the medication in a locked storage area; therefore, the medication was accessible to the resident. 2. Record Review Resident #4's assessment dated 11/16/24 read in part that all medication would be managed by the residence. Per the physician's orders, Resident #4 can self-administer her acetaminophen. Resident #2's assessment dated 2/19/25 read in part that Resident #2 and his physician believed that he needed help to manage his medications, that staff attention or physical assistance with taking medications was required, and that his medications were to be stored in the community's medication storage area. 3. InterviewsOn 3/19/25 at approximately 10:20 a.m., Staff #4 stated that the Nystatin was left in Resident #4's bathroom on most days. She further stated that since she was a QMAP, she knew it should be put back in the locked medication cart after the medication is applied to Resident #4. On 3/19/25 at approximately 10:40 a.m., Staff #5 stated that Resident #2 had Albuterol in his room. She further mentioned that she did not take the medication out of Resident #2's room because she didn't know where it came from and she was uninformed on what to do in this situation. On 3/19/25 at approximately 10:45 a.m., Staff #5 stated that Resident #4's Nystatin was always in her bathroom and not locked up in the medication cart where it should be. On 3/19/25 at 1:45 p.m., the administrator stated all medications should be locked up unless the resident had an order from a physician stating that the resident can self-administer medication. He acknowledged that Resident #4's Nystatin and Resident #2's Albuturol should have been locked up. He further stated that the family often provided over-the-counter medications without notifying staff and that this was something he would need to work on with staff and families.

Based on observations, interviews, and record reviews, the residence failed to implement a policy and procedure for an effective information management system, affecting 31 residents. Findings include:1. ObservationOn 3/19/25 at approximately 10:30 a.m., a shift report log was in the health and wellness director's office as well as unfiled and incomplete paper documents scattered throughout. 2. Record reviewThe shift report log was documented by room numbers, and included short descriptions, such as, "fell out of bed" or "complained of chest pain". It was unclear whether the documents were reviewed, followed up on, or tracked in the residence's electronic filing system due to the lack of detailed information. A review of the residence's shift report log revealed that from 3/13 - 3/14/25, three resident rooms had cold water in their bathrooms and went without taking a shower; furthermore, another resident's room flooded "again". The shift report log further included documentation from 3/13-3/16/25, that read Resident #3 complained about pain, diarrhea, and throwing up. There was no follow up documentation of the above concerns. 3. InterviewsOn 3/18/25 at approximately 8:00 a.m., the regional compliance nurse (RCN) stated that the residence was currently using electronic records and paper-based records. On 3/19/25 at approximately 9:40 a.m., Staff #5 stated that staff communicated from shift to shift through a shift report log. She said that staff were expected to write down anything out of the ordinary of a resident or tasks that were completed during the shift. Furthermore, she stated that the log was kept in the HWD office. On 3/19/25 at approximately 10:15 a.m., the RCN stated that the expectation for the shift report log was for the executive director (ED) and the HWD to review the shift report log and find a process to follow up or make changes as needed. He further stated that this should have been communicated to the staff. The RCN stated that he saw a disconnect with the current process. On 3/19/25 at approximately 11:00 a.m., the maintenance manager stated that he was not made aware that over the past week, more than one resident's room did not have hot water for the resident to shower. He further mentioned that he was unaware of a shift report log that mentioned maintenance issues. On 3/19/25 at 2:00 p.m., the ED acknowledged that the current communication process throughout the residence was not effective. He also stated that he planned to create a policy to improve the process.

A revisit survey was completed on 4/27/23 for all previous deficiencies cited on 11/17/22. The facility is in compliance with all deficiencies 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