LEGEND OF BROOMFIELD ASSISTED LIVING & MEMORY CARE

A licensure complaint, prompted by #CO42013, was completed on 4/15/26. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter 7.21.2 The assisted living residence grounds shall be maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction. 25.14 Before a staff member is allowed to work independently in the secure environment, the assisted living residence shall provide each staff member with training and education on the provision of care and services for the specific population in the assisted living residence. (A) At a minimum, the individual shall be trained on the care plan for each resident to which the individual could provide care given the staff member's assigned duties and responsibilities. Such training shall be documented. 25.26 A secure environment shall meet the following criteria: (F) There shall be a secure outdoor area that is available for resident use year-round that: (4) Has one or more areas that provides protection from weather elements.

A licensure complaint, prompted by #CO39684, was completed on 01/06/2026. No deficiencies were cited.

A revisit survey was completed on 1/23/25 for all previous deficiencies cited on 8/14/24. 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 relicensure survey with complaint #CO37103 was completed on 8/14/24. 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 93 current residents. Findings include:On 8/13/24 at 7:49 a.m., the residence's resident roster for emergency preparedness was requested. On 8/13/24 at 9:10 a.m., the residence's resident roster was provided. However, the resident roster did not include a diagram of the residence that showed room locations or the emergency contact information for each resident. On 8/14/24 at 1:10 p.m., the administrator stated she did not have a resident roster that had a diagram of the residence as part of it; however, she had a diagram in a separate binder. The administrator further stated that the residence did not have a resident roster that contained emergency contact information.

Based on record review and interview, the residence failed to ensure its emergency policies addressed written instructions for when to evacuate the premises and the procedure for doing so, written instructions for each identified risk that included persons to be notified and steps to be taken, and, in the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies, affecting 93 current residents. Findings include: 1. Residence PolicyThe residence's Evacuation Under Imminent Danger policy, dated 2/12/2020, read in part: "If emergency shelter is needed, see the emergency handbook for facilities that have agreed to temporarily house residents and the corresponding emergency and housing agreement. The first choice of receiving facility should always be another residence managed by (the management company) in the area." The residence's Evacuation Preparedness policy, dated 4/1/14, read in part that "maps to potential relocation residences can be downloaded on the internet. Download them and make copies of these maps. Keep them in several areas."The residence's Associate Training - Emergency Preparedness policy, dated 4/30/19, read in part that "an agreement should be set up in advance with a receiving facility for temporary living arrangements. This agreement addresses key factors such as location, sleeping and associating arrangements and should be updated annually to ensure that the host facility remains in agreement." The residence emergency binder did not contain a written agreement with a receiving facility for temporary living arrangements or have maps to potential relocation residences. The residence emergency binder contained a resident contact list dated 2/21/23. The resident contact list did not include the emergency contacts for 61 of the 93 current residents. The resident emergency binder did not include resident face sheets with emergency contacts. 2. InterviewsOn 8/14/24 at 9:45 a.m., the maintenance director stated the residence had no documented written agreement with other facilities and acknowledged there should have been a written agreement in case of an emergency. He also stated he did not realize the emergency contact list was outdated and did not include all current residents. On 8/14/24 at 1:10 p.m., the administrator stated she expected the residence to have an updated emergency preparedness plan. The administrator acknowledged the emergency contact list was not current. She also stated she was not aware of the requirement to have a written agreement with another facility.

Based on record review, and interview, the residence failed to update resident care plans that reflected the most current assessment information, affecting two of eight sample residents (#1 and #6). Findings include:1. Record ReviewA functional capacity screening, dated 2/7/24, read in part that Resident #1 required staff supervision for walking and mobility, as well as risk of falls and the use of a walker or cane. A care plan, dated 5/14/24, read in part:"Safety: [Resident #1] requires that staff assist her with mobility and ambulation. She can walk with a walker and staff assistance for short distances. She requires the use of a wheelchair outside of her apartment.""Social: [Resident #1] can choose what activities and events she would like to participate in. She can walk to and from them with her walker. The community will provide her with a monthly calendar and daily reminders" "Mobility: [Resident #1] requires that staff assist her with mobility and ambulation. She can walk with a walker and staff assistance for short distances. She requires the use of a wheelchair outside of her apartment."A staff note dated 8/1/24 read "fall, Resident [#1] encouraged to use only her wheelchair with staff assistance and not use her walker at all. Walker stored away."The care plan was not consistent with the use of a walker or wheelchair and was not updated to reflect the need for the use of a wheelchair with staff assistance instead of a walker. 2. InterviewOn 8/14/24 at 1:10 p.m. the administrator stated she expected the care plans to be reviewed when they are updated. She stated they should be accurate and match. The administrator acknowledged the residence did not update the care plan to reflect the most current assessment information for Resident #1. 3. Record review and interview revealed similar deficient practice for Resident #6.

Based on interview and record review, the residence failed to implement a fall management program which included providing fall management education and materials to residence and family members, detailing in the resident's care plan the individualized approaches necessary to address fall risk, and providing staff training related to fall prevention, affecting 93 current residents. Findings include:1. Residence Policy The residence's fall management policy, dated 7/1/2012, read in part: "All residents will be assessed for the potential for falls using the Fall Risk Assessment. The assessment is to be completed by the Healthcare Coordinator or licensed nurse designee upon admission, upon change of condition and at least annually."2. Failure to develop a policy and procedure that included all required elementsOn 8/13/24 at 7:49 a.m., the administrator was asked to provide the residences fall management policy. The provided policy was missing the following elements:(A) Providing fall management education and materials to residents and family members;(E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6). 3. Resident #9 was admitted to the residence on 5/11/23 with diagnoses of protein calorie malnutrition and dementia. An incident report, dated 3/16/24, read in part, "[Resident #9] was observed sitting on her buttocks on the floor near her bathroom door. Staff report that she was not using her walker or wheelchair at the time of her fall and she was barefooted, the resident was instructed to call the staff for assistance when she needed to use the toilet"..A care plan dated 4/29/24 read in part,"[Resident #9] is a high fall risk and uses her wheelchair for mobility. She is able to stand and transfer with one person's assistance." A care plan, dated 5/1/24, Resident #9 ' s mobility needs read, "[Resident #9] is a high fall risk and uses her wheelchair for mobility. She is able to stand and transfer with one person's assistance. Staff to report any changes to the HCD (healthcare director)." An incident report, dated 6/27/24, read in part, Resident #9 was walking her husband (Resident #11) to the door in her apartment, and she turned around to walk back to her bed and fell. The resident pushed her husband in his wheelchair to the door and after falling stated, "I forgot that I cannot walk."A progress note, dated 6/28/24, instructed Resident #9 to not walk without her walker and not push her husband in the wheelchair. 3. InterviewsOn 8/13/24 at approximately 7:15 a.m., Staff #2 stated she received a series of online training before providing care and services to residents; however, she stated she did not receive fall management training. On 8/13/24 at approximately 2:15 p.m., Staff #6 and Staff #8 stated when a resident falls they let the healthcare director know and she documented in the resident chart about the fall. Staff did not know how to access a resident care plan when it had been updated after a fall. Staff #6 stated she did not receive fall management training. On 8/13/24 at 2:38 p.m., Staff #7 stated she received some training before working; however, she did not receive fall management training. She stated when a resident fell, staff let the healthcare director know. She also stated she did not know how to access a residents care plan when it had been updated. On 8/14/24 at 1:12 p.m., the administrator stated all staff had gone through a list of training and it was documented on their individual training sheets. She acknowledged that the training checklist did not include fall management and that staff stated they did not receive fall management training. The administrator stated she expected staff to notify the HD and evaluate the resident after they fell. She stated she expected staff to assist the resident up and document the fall in a "task sheet" after each shift.. The HD looked at all the task sheets daily and the assistant resident director looked at the task sheets weekly. She statedthe residence should have documented any assistance required from staff in the resident care plan. The administrator stated she expected all required elements to be included in the fall management policy and acknowledged the fall management policy was missing these specific components.

Based on observation, record review and interview, the residence failed to ensure the resident record contained documentation of the actions taken by staff and the residence's efforts to prevent the re-occurrence of falls and lift assist training for staff, affecting four of four current residents (#3-#6) and two former residents (#9 and #10) who had repeated falls. Findings include:1. Residence Policy The residence ' s mobility policy, dated 7/1/2012, read in part: "In keeping with our philosophy of encouraging independence and dignity, the residence encourages the use of assistive devices such as walkers, wheelchairs, scooters and lifting equipment, as allowed by state regulation, while offering the kind and amount of assistance needed by the resident. I. Walkers are encouraged for residents who need such assistance in order to ambulate safely. II. Wheelchairs will be used when a resident is no longer physically able to ambulate rather than as a faster method of transporting a resident. A resident may choose an electric wheelchair or scooter. See the policy on Motorized Vehicle Assessment should the resident choose such a method of mobility. Ill. For the safety of the resident and staff, a mechanical lift or other device may be used to facilitate safe transfers. Consult state regulations to determine appropriateness of such use in your residence. IV. Staff will be trained in safe transfers, including the use of gait belts and mechanical lifts where permitted by state regulation."The policy did not include how the residence documented actions taken by staff and ongoing efforts to prevent a recurrence of a resident that had fallen and lift assist training. 2. Interviews On 8/13/24 at 8:52 a.m., the assistant resident director stated the mobility policy was the residence ' s lift assist policy. On 8/14/24 at 1:12 p.m., the administrator stated she expected all interventions to be included in the residence's mobility policy and acknowledged the mobility policy had missing required components.

Based on record review and interview, the residence failed to properly identify the right medication with the right resident, affecting two of two sample residents (#4 and #7) whose medications were reviewed. Specifically, Staff #3 administered Resident #7 ' s medication to Resident #4. Staff #3 did not ensure the identity of the resident prior to giving her the medication. Resident #4 had a documented simvastatin allergy. Staff #3 administered atorvastatin to Resident #4 which resulted in the residence transporting her to the emergency department after the resident became ill. Findings include:1. Residence Policy The residence ' s medication administration policy, dated 4/30/2019, read in part: The person responsible for administering medication shall identify the resident before administration of the drug. 2. Record Review Resident #7 was admitted to the residence on 10/6/22 with diagnoses of molecular degeneration, Charles Bonnet syndrome and an allergy to simvastatin. A practitioner's order, dated 9/25/23, read in part, Resident #4 may self administer all medication without assistance. An incident report, dated 8/9/24, read in part that Staff #3 administered Resident #4 ' s medication to Resident #7 by mistake. An incident note, dated 8/9/24, written by the healthcare director, read in part that Staff #3 contacted her on 8/9/24 at 8:22 p.m. Staff #3 made a medication error and administered Resident #7's medication to Resident #4 which included acetaminophen, tramadol, metoprolol, and atorvastatin. Resident #7 ' s chart was reviewed and revealed she had a statin allergy. Staff #3 was informed to call 911 and send her to the emergency department. 3. InterviewsOn 8/14/24 at 10:19 a.m., Resident #7 stated, staff came into her room on 8/9/24, woke her up, and told her she needed to take medication the doctor prescribed. Resident #7 stated she was scared so she listened to the staff and ingested four pills. She stated that right after she ingested the pills, she contacted her family member who then contacted the residence. She stated she was transported to the emergency department and was feeling very ill. On 8/14/24 at 12:12 p.m., Staff #3 stated she made a mistake; she thought Resident #7 was in the room of Resident #4 and administered the medication to the wrong resident. She stated she did not look at the photograph of the resident whose medications she was administering and did not verify the name of the resident. She stated, "I just told her she has to take the medication. I do not identify the residents before giving them medications." On 8/14/24 at 1:12 p.m., the administrator stated she expected qualified medication administration personnel (QMAPs) to identify every resident prior to administering a medication. She stated was aware that Staff #3 failed to properly identify the right medication with the right resident.

Based on record review and interview, the residence failed to comply with practitioner's orders for three of eight sample residents whose medications were reviewed (#2, #4, #7). Findings include:1. Record ReviewResident #4 was admitted to the residence on 6/6/24. A written practitioners order, dated 7/23/24, directed the residence to administer Protgold 30 ml twice daily. However, the July 2024 medication administration record (MAR) read the residence failed to administer the medication on 7/23-7/26 and 7/28-7/31/24 for a total of 13 missed doses. A written practitioner's order, dated 7/19/24, directed the residence to administer doxycycline mono 100 mg twice daily. However, the July 2024 MAR read the residence failed to administer the medication on 7/19/24 because the medication was out of stock. A written practitioner's order, dated 7/23/24, directed the residence to administer acetaminophen 1000 mg twice daily for pain. However, the July 2024 MAR read the residence failed to administer the medication on 7/23/24 because the medication was out of stock. 2. InterviewsOn 8/14/24 at 10:24 a.m., healthcare director-nurse (HDN), confirmed staff failed to administer medications to Resident #4 on 7/23/24 through 7/26/24 because the medication was out of stock. The HDN stated staff failed to administer the medication to Resident #4 on 7/27-7/31/24 because staff could not find the medication in the cart. On 8/14/24 at 1:12 p.m., the administrator stated she expected staff to order medications in time to be administered to residents as ordered by the practitioner. 3. Record review and interview revealed similar different practice for Residents #2 and #8.

Based on record review and interview, the residence failed to ensure residents' medication administration records contained accurate information, affecting two of 10 current residents (#2, #4) and one former resident (#10) whose medications were reviewed. Findings include:1. Resident #4 was admitted to the residence on 6/6/24.a. Potassium ChlorideA written practitioner's order, dated 7/25/24, directed the residence to administer potassium chloride 10 mEq daily. However, the August 2024 electronic medication administration record (eMAR) contained an exception code "other" with no notes as to why the staff did not administer the medication on 8/9 - 8/11/24.b. Furosemide A written practitioner's order, dated 7/25/24, directed the residence to administer furosemide 20 mg once daily at bedtime. However, the August 2024 electronic medication administration record (eMAR), contained an exception code "other" with no notes as to why the medication was not administered on 8/9 and 8/11.2. Former Resident #10 was admitted to the residence on 12/26/23.a. MorphineA written practitioner's order, dated 7/19/24, directed the residence to administer morphine 0.5 mL every four hours. However, the July 2024 eMAR, contained an exception code "other" with no notes as to why the medication was not administered on 7/21 for the 8:00 p.m. dose and 7/22 for the 8:00 a.m. dose and a blank space on 7/22/24 for the 4:00 a.m. dose, for a total of three inaccurately documented doses. b. ErythromycinA written practitioner's order, dated 7/25/24, directed the residence to administer erythromycin 2% to the resident's left foot twice daily. However, the July 2024 eMAR, contained an exception code "other" with no notes as to why the medication was not administered on 7/27 and 7/28/24 for the morning dose, and contained a blank space on 7/27/24 for the evening doses, for a total of three inaccurately documented doses.c. HaloperidolA written practitioner's order, dated 8/1/24, directed the residence to administer haloperidol 0.25 ml twice daily. However, the August 2024 eMAR, contained an exception code "other" with no notes as to why the medication was not administered on 8/1/24 for the evening dose, for a total of one inaccurately documented dose. Additionally, the residence failed to ensure the resident's July and August 2024 eMARs contained accurate information for the following medications:In July 2024:Haloperidol 0.5 mg twice dailyAcetaminophen 500 mg twice dailyNystatin 100,000 grams twice dailyBaza Protect 2% three time dailyIn August 2024:Atropine Sulfate 1% every two hours 3. InterviewsOn 8/14/24 at 8:48 a.m., the health director stated She would have expected staff to document, or have informed her so she could document any medication exceptions that read "other" in July and August 2024. The health director stated the residence switched in the middle of July 2024 to a new electronic medication record system and believed staff were unsure how to make a note when there was a medication exception.

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 7.7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items: A description of the employee or volunteer duties; Date of hire or acceptance of volunteer service and date duties commenced; Orientation and training, including first aid and CPR certification, if applicable; Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable; Results of background checks and follow up, as applicable; and Tuberculin test results, if applicable. Documentation of initial dementia training and continuing education for direct-care staff members. 18.8 Resident records shall contain, but not be limited to, the following items: Progress notes which shall include information on resident status and wellbeing, as well as 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; The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: A description of the resident ' s 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.

A licensure complaint, prompted by #CO34846 was completed on 2/13/24. No deficiencies were cited.

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 7.25.5 Before an individual moves in, the assisted living residence shall complete a pre-admission assessment to determine the appropriateness and need for secure environment residency. The pre-admission assessment shall include all the items required for the comprehensive assessment in Part 12.7(A) through (M), plus the following:(A) An evaluation by a licensed practitioner which has occurred within the previous ninety (90) calendar days and which describes the resident ' s medical condition and any cognitive deficits that contribute to wandering, compromised safety awareness, and other types of conduct; and(B) Detailed information from the resident ' s family and/or representative 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, and any other known types of conduct.

A licensure revisit was completed on 3/8/23 for all previous deficiencies cited on 7/26/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 3/8/23 for all previous deficiencies cited on 4/11/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 3/8/23 for the previous deficiency cited on 4/11/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 3/8/23 for all previous deficiencies cited on 6/8/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 3/8/23 for all previous deficiencies cited on 4/11/22. The residence is in compliance with all regulations surveyed.