BROOKDALE MERIDIAN ENGLEWOOD

An administrative relicensure survey was completed on 6/26/26. No deficiencies were cited.

A revisit survey was completed on 3/18/25 for all previous deficiencies cited on 7/10/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO37161 and #CO37134, was completed on 8/19/24. No deficiencies were cited.

A relicensure survey was completed on 7/10/24. Deficiencies were cited.

Based on interview and record review, the residence failed to provide access upon request to staffing records affecting 32 current residents. (Cross-reference tags S0732 and S0734)Based on interview and record review, the residence failed to provide access upon request to staffing records affecting 32 current residents. (Cross-reference tags S0732 and S0734)Findings include:1. ReferenceChapter VII regulations governing assisted living residences require in part 7.13 that each personnel file shall include, but not be limited to, written documentation regarding the following items: (C) Orientation and training, including first aid and cardiopulmonary resuscitation (CPR) certification, if applicable. 2. RequestsOn 7/10/24 at 9:40 a.m., CPR and first aid certifications were requested from the administrator. On 7/10/24 at 12:55 p.m., five CPR/first aid certifications were received. On 7/10/24 at 1:40 p.m., further requests for CPR/first aid certifications were requested from the administrator. On 7/10/24 at 3:14 p.m., three CPR/first aid certifications were received. On 7/10/24 at 4:47 p.m., further requests for CPR/first aid certifications were requested from the administrator. On 7/10/24 at 4:49 p.m., one CPR/first aid certification was received. 3. InterviewsOn 7/10/24 at 1:40 p.m., the administrator stated the human resources representative was in the process of gathering more CPR certifications. On 7/10/24 at 4:47 p.m., the administrator stated she understood the reasons behind the citations for the timely delivery of requested documentation.

Based on observation, interview, and record review the residence failed to ensure there was at least one staff member onsite at all times with current certification from a nationally recognized organization certified in first aid affecting 32 current residents. (Cross-reference tags B290, S0734, S0736) 1. Residence PolicyThe residence ' s policy titled First Aid Certification, dated November 2022, read in part: There shall be one associate onsite at all times with current certification in first aid specific to adults. The first aid certification shall show that it meets the standards of the American Red Cross, American Heart Association, or other nationally recognized organization. The first aid certification training will be completed prior to providing direct care to residents and this first aid certification should be maintained in the associate's personnel file. 2. ObservationDuring an environmental tour of the residence on 7/10/24 at 8:37 a.m. there was no evidence of a posting that included which residence staff was first aid certified. 3. Staff Schedule and First Aid CertificationsThe staff schedule from 6/30 to 7/10/24 and first aid certifications revealed the following 31 shifts had no one onsite with current first aid certification:On 6/23 first, and third shifts; 6/24 third shift; 6/25 first and third shifts; 6/26 third shift; 6/27 second and third shift; 6/28 first and third shifts; 6/29 first and third shifts; 6/30 first and third shifts; 7/1 second shift; 7/2 first and second shifts; 7/3 second and third shifts; 7/4 second and third shift; 7/5 first and third shifts; 7/6 the first and third shifts; 7/7 first and third shifts; 7/8 third shift; 7/9 third shift; and 7/10/24 second and third shifts. Additionally, the schedule and first aid certifications revealed the following seven shifts had no staff onsite with certification from a nationally recognized organization:On 6/23, 6/28, 6/29, 6/30, 7/5, 7/6, and 7/7/24 the second shift. 3. InterviewOn 7/10/24 at 6:02 p.m., the administrator stated that she was unaware some of the staff's first aid certifications were not from nationally recognized organizations and that some staff were only CPR certified and not first aid certified.

Based on observation, interview, and record review the residence failed to ensure there was at least one staff member onsite at all times with current certification from a nationally recognized organization certified in CPR affecting 32 current residents. (Cross-reference tags B290, S0732, S0736) 1. ObservationDuring an environmental tour on 7/10/24 at 8:37 a.m. there was no evidence of a posting that included which residence staff was CPR certified. 2. Staff Schedule and CPR CertificationsThe staff schedule from 6/30to 7/10/24 and CPR certifications revealed the following 36 shifts had no one onsite with certification from a nationally recognized organization:On 6/23 first, second, and third shifts; 6/24 third shift; 6/24 first and third shifts; 2/25 first and third shift; 6/26 third shift; 6/27 second and third shifts; 6/28 first, second, and third shifts; 6/29 first, second, and third shifts; 6/30 first, second, and third shifts; 7/1/24 the third shift; 7/2 first and third shifts; 7/3 third shift; 7/4 second and third shifts; 7/5 first, second, and third shifts; 7/6 first, second, and third shifts; 7/7 first, second, and third shifts; 7/8 third shift; 7/9 the third shift; and 7/10 third shift. 3. InterviewOn 7/10/24 at 6:02 p.m., the administrator stated that she was unaware some of the staff's CPR Certifications were not from nationally recognized organizations.

Based on observation, interview, and record review, the residence failed to place in a visible location a list of all staff who had current certification in CPR and first aid affecting 32 current residents. (Cross-reference tags B290, S0732, S0734). Findings include:During an environmental tour on 7/10/24 at 8:37 a.m. there was no evidence of a posting that included which residence staff was CPR/first aid certified. A review of first aid and CPR certifications revealed that 10 staff were CPR certified and two staff were first aid certified. At 4:01 p.m., the administrator stated she was not aware the residence did not have a posting of certified staff and stated she would have the health and wellness director (HWD) post one. At 4:47 p.m., the administrator sent a picture of the posting that the HWD had posted on the medication room door the day of the onsite visit; however, the posting was not accurate as it included staff that were certified through an organization that was not nationally recognized and did not specify which staff had first aid, CPR or both.

Based on interview and record review, the residence failed to develop written policies and procedures regarding visitation affecting 32 current residents. Findings include:The residences Visitor/Vendor/Third Party Provider Sign In-Out Policy, dated 08/17, read in part: The policy identified the processes for visitor entry which included maintaining a log book for recording entries and issuing visitor badges. However, the residence's policy failed to contain the following elements: The residence may impose limitations on visitation rights. During a period when the risk of transmission of a communicable disease is heightened, an assisted living residence may: Require visitors to sign a document acknowledging: (a) (b) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and That menacing and physical assaults on health-care workers and other employees of the residence will not be tolerated; Prohibiting the presence of visitors during aerosol-generating procedures or during collection of respiratory specimens. On 7/10/24 at 4:01 p.m., the administrator stated she was not aware the visitor policy was missing the required elements.

Based on interview and record review, the residence failed to develop an involuntary discharge grievance policy affecting 32 current residents. Findings include:The residence's Grievance Procedure- Resident, dated 01/17, read in part: The member should first discuss the complaint with the associate and administrator, and if they are unable to resolve then the grievance should be put into writing to the administrator who will respond within 14 days. If the grievance cannot be resolved on a district level, members were advised to contact the residence's main office. A list of ombudsman, adult protective services, area on aging, and the department was listed as places to file a grievanceHowever, the residence's policy failed to contain the following elements: "A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) (2) (3) (F) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. The written response shall include the following statement regarding the filing of an appeal."On 7/10/24 at 4:01 p.m., the administrator stated she was not aware of the changes to the regulation.

Based on interview and record review, the residence failed to complete a risk assessment of all hazard and preparedness measures to address natural and human-caused crises affecting 32 current residents. Findings include:The residence's emergency response manual contained the following elementsHurricane preparedness, Cold Inclement Weather, Evacuation plans related to transportation vendors and lodging vendors, However, the emergency response manual failed to contain any risk assessments of preparedness that address the aforementioned potential crises while containing template risk assessments intended to be used to assess resident support needs in a crisis situation. On 7/10/24 at 6:02 p.m., the administrator stated she understood the emergency policies needed to be updated and was in the process of going through them.

Based on interview and record review, the residence failed to have emergency policies and procedures that were tailored to the geographic location of the assisted living residence affecting 32 current residents. Findings include:The residence's policy 2024 Emergency Manual, dated 1/2024, included policies and procedures related to:Preparing for an emergency with advanced warning, approaching hurricane/emergency preparation, emergency evacuation buses, generators, water/fluid management, as well as a significant amount of information unrelated to emergency preparedness including but not limited to daily diet modification summary reports, weekly meal plans, and a template resident to hospital transfer agreement. However, the policy manual failed to contain procedures tailored to the geographic location such as wildfires, high temperatures, and tornados. On 7/10/24 at 6:02 p.m., the administrator stated she understood the emergency policies needed to be updated and was in the process of going through them.

Based on interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration affecting three of four sample residents (#1, #2, #4). Findings include:1. Residence PolicyThe residence's policy titled, How To Order Medications, dated March 2019, read in part: The practitioner ordered or prescriptions were required for all medications and treatments, including over-the-counter medications for all residents whose medications were managed by the community. Routine medications were placed on a "cycle" refill, so they were automatically refilled by the pharmacy. If "cycle" refill was not available, when the resident ' s medication supply reached seven days, to were to fax a refill request to the pharmacy. Staff were directed to contact the pharmacy by phone if the newly ordered/refilled medications did not arrive in a timely manner. Staff were to notify the resident, family or contact the practitioner for a new order/prescription when routine medication refill orders were depleted. The residence ' s policy titled, Medication & Treatment - General Guide-lines for Medication Administration/Assistance, dated July 2024 read in part: Trained or licensed associates administering or assisting with medications should follow the "7 Rights of Medication Administration: right medication, right dose right time, right route, right resident, right documentation, and right to refuse. Follow the medication label, pharmacy, and manufacturer directions for each individual medication prescribed. Expiration dates should be checked on medications or treatments before administration."2. Resident #1 was admitted to the residence on 7/5/23 with diagnoses consisting of Chronic Fatigue and Repeated Falls.a. Midodrine A written practitioner's order, dated 3/26/24, directed the residence to administer midodrine HCI 7.5 mg three times a day hold for systolic over 140 related to orthostatic hypotension. However, the June and July 2024 medication administration records (MARs) read the medication was not administered for the morning dose on 6/1-6/16 and 6/18/24 as the medication was out of stock or the resident was sleeping; was not administered at noon on 6/1, 6/4, 6/7, 6/9, 6/11,6/13, 6/15, 6/18 as it was out of stock; was not administered for the evening dose on 6/2 as the medication was outside of parameters; however, the parameters read systolic was under 140 at 112; was not administered the evening dose on 6/4, 6/6, 6/11, 6/12. On 6/2, 6/16 at noon was administered in which there were no vitals administered. On 6/2, 6/18, 6/28-6/30, 7/4, and 7/7/24 p.m., the medication was not administered as it was outside of the parameters, however, there was no evidence of parameters taken.b. AcetaminophenA written practitioner ' s order, dated 3/13/24, directed the residence to administer acetaminophen 650 mg by mouth three times a day. However, the June 2024 MAR read the medication was not administered on 6/1 at 8:00 a.m. and 2:00 p.m., and 6/4/24 at 2:00 p.m. as the medication was out of stock.c. Zinc OxideA written practitioner ' s order, dated 6/5/24, directed the residence to administer Zinc Oxide Cream, 13%, 1 application twice daily. However, the June 2024 MAR read the medication administered was not administered on 6/8 a.m., 6/11 both doses, 6/13-6/15 a.m., 6/17 a.m., 6/18 both doses, 6/19-6/21 a.m., 6/24 and 6/25/24 a.m., doses. 3. Resident #2 was admitted to the residence on 10/22/20.a. Magnesium CitrateA written practitioner ' s order, dated 8/23/23, directed the residence to administer magnesium citrate 250 mg one capsule by mouth in the afternoon. However, the June 2024 MAR read magnesium oxide 250 mg two tablets was administered daily from 6/1-6/30/24. During a medication audit on 7/10/24 magnesium oxide 250 mg was discovered in the medication cart. b. Vitamin DA written practitioner ' s order, dated 10/22/20, directed the residence to administer Vitamin D 50 mcg (2000 units) by mouth one time a day. However, during a medication audit vitamin D-3 50 mcg was discovered in the medication cart. 4. There was similar deficient practice identified for Resident #4.5. InterviewsOn 7/10/24 at 1:42 p.m., the heath and wellness director (HWD) stated Resident #1's significant other ordered medications of getting medications and that was why some went out of stock. She stated in regards to the zinc oxide, he went through it quickly and the zinc oxide was out of stock. Acetaminophen the 6/4 MAR entry was inaccurate and the other two were a failure to comply. She stated if the resident's blood pressure was not taken the medication was not administered and if it was not listed as administered on the MAR report it was not administered. On 7/10/24 at 1:42 p.m., the HWD stated She thought she had a change order for Resident#2; however, she was unable to find the change order. On 7/10/24 at 1:42 p.m., the HWD stated in regards to Resident #4, the residence in general would wake residents up for medication administration; however the family and husband of the resident requested to not enter their room before 9:30 a.m. or after 10:00 p.m. and 9:30 am. She stated the plan was to change the medication administration time to evenings and had not done that yet.

Based on interview and record review the residence failed to ensure the medication administration record was accurate affecting two of four sample residents (#1, #4). Findings include:1. Residence Policy:The residences policy titled, Medication & Treatment-General Guidelines for Medication Administration/Assistance), dated 11/11, Revised 7/24 read in part: 1. A. Follow the 7 rights of Medication Administration: Right medication, right dose, right time, right route, right resident, right documentation, and right to refuse. 1. E. Document medications administered or assisted with on the Medication Administration Record (MAR)/ Medication Assistance Record/Medication Observation Record (MOR)/Treatment Administration Record (TAR) with their full signature/title and initial each medication administered/assisted or follow the electronic MAR procedure as required. 25. Medications and treatments should be administered within the parameters of the physician/Health Care Provider (HCP) orders. 1. Resident #1 was admitted to the residence on 7/5/23 with a diagnosis consisting of Parkinson's disease, constipation, neuropathy and hypokalemi. Zinc OxideA written practitioner's order, dated 6/5/24, directed the department to administer Zinc Oxide 13% 1 application twice daily. However, the June 2024 medication administration record (MAR) read see progress notes on 6/7 both doses, 6/8 p.m., 6/9 both doses, 6/10 a.m., 6/13-6/16 p.m., 6/21 p.m.-6/23, 6/24 p.m., 6/25 p.m., 6/26, a.m., 6/27 a.m., and 6/28/24 both doses. Review of the progress notes revealed no evidence of documentation regarding the lack of administration for zinc oxide on the above dates. 2. There was similar deficient practice for Resident #4.3. InterviewOn 7/10/24 at 1:42 PM, the health and wellness director stated if a staff wrote see progress notes, the reason for the notation should have been in the progress notes. The health and wellness director confirmed the MARs were not accurate for both residents.

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 four of four sample residents (#1, #2, #3,#4). (Cross-reference S1568, S1600)Findings include:On 7/10/24 at 8:46 a.m., the last three quarterly medication audits were requested from the administrator. However, the medication audits that were provided revealed no evidence of an audit completed to ensure the accuracy and completeness of the MARs. Additionally, the audit had no evidence that they were completed by the QMAP supervisor and the administrator. On 7/10/24 at approximately 4:47 p.m., the health and wellness director stated that neither she nor the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. She stated they were unaware of the requirement.

A revisit survey was completed on 12/15/2023 for all previous deficiencies cited on 11/21/2022. The facility is in compliance with all deficiencies that were cited.