Brookdale Fort Collins Al (co)

“Based on record review and interview, the residence failed to report an occurrence affecting one former resident (#10).Findings include:1. Reference and Residence Policiesa. Chapter II regulations governing assisted living residences, part 4.2.2, requires that the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (A) Any occurrence that results in the death of a client of the facility or agency and is required to be reported to the coroner pursuant to section 30-10-606, C.R.S., as arising from an unexplained cause or under suspicious circumstances.b. According to the Occurrence Reporting Manual, dated May 2018, the residence must report an occurrence to the Department when: "Any occurrence that results in the death of a patient or resident of the facility and is required to be reported to the coroner pursuant to Section 30-10-606, C.R.S., as arising from an unexplained cause or under suspicious circumstances." Section 25-1-124 (2)(a), C.R.S."c. The residence's "Reportable Events" policy, dated April 2022, read in part that this policy sets out the reporting time frames within Brookdale Senior Living. In addition to the time frames and reporting requirements stated in this policy, the community/agency must adhere to all state-specific, statutory and regulatory reporting requirements and time frames, including, but not limited to, abuse and neglect reporting, reports of hospitalization or death.2. Record ReviewFormer Resident #10 was admitted to the residence on 1/9/24 with diagnoses including dementia, mood disturbance, and atherosclerotic heart disease. The resident's death investigation regarding Former Resident #10, dated 10/22/25, read in part that "resident (Resident #10) passed away on 10/22/25 at 10:32 a.m." Former Resident #10 "was found in room bedside on the floor unresponsive by QMAP (Staff #3) at 9:40 a.m."An emergency medical services (EMS) report dated 10/22/25 at 9:45 a.m., read in part that Former Resident #10's time of death was 10:32 a.m. On 10/28/25, a review of the Department's occurrence database revealed the residence had not submitted an occurrence for Former Resident #10's death.3. InterviewOn 10/28/25 at 2:36 p.m., the administrator stated he did not know he was obligated to report the unexpected, unexplained death of Former Resident #10 to the Department; therefore, he did not report the occurrence. Additionally, he was instructed by the area health and wellness director that he did not have to report Former Resident #10's death as an occurrence.”

“Based on interviews and record reviews, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting two of seven sample residents (#4, #5).(Cross-reference U1600)Findings include:1. Record ReviewResident #5 was admitted to the residence on 2/14/2023 with a diagnosis including hyperlipidemia.Atorvastatin 80 mgA practitioner's order, dated 7/23/24, directed the residence to administer 80 mg of atorvastatin by mouth daily. The August 2025 medication administration record (MAR) showed a "20 code" for the scheduled medication doses on 8/7, 8/8, 8/10, 8/11, 8/12, and 8/13/25, that indicated the medication was missing and not administered to Resident #5.Aspirin 81 mgA practitioner's order, dated 4/26/23, directed the residence to administer 81 mg of Aspirin by mouth daily to Resident #5. The August 2025 MAR showed a "20 code" for the scheduled doses on 8/12, 8/13, 8/14, and 8/15/25 that indicated the medication was missing and not administered to Resident #5.Magnesium Oxide 400 mgA practitioner's order, dated 4/26/23, directed the residence to administer 400 mg of magnesium oxide bymouth daily to Resident #5. The October 2025 MAR showed a "20 code" for the scheduled dose on 10/1-10/2/25 that indicated the medication was missing and not administered to Resident #5.2. InterviewsOn 10/14/25, at approximately 2:00 p.m., the health and wellness director stated when a resident's MAR showed a "20 code," it indicated the medication for that resident was missing and therefore not administered. The wellness director went on to state that this code would trigger an alert to file an incident report, as it was a medication error when medication was missing for a resident. He went on to state there have been multiple times in September 2025 that the residence did not have internet, and at those times, the qualified medication administration persons (QMAPs) have used paper MARs to document medication administration. Paper MARs provided by the residence on 10/14/25 for the months of August, September, and October 2025, in addition to the residence's electronic MAR, indicated Resident #4 and Resident #5 did not receive scheduled medications per the practitioner's order. The wellness director acknowledged that residents not receiving scheduled medication per the practitioner's order was non-compliant with 1568 6 CCR 1011-10-09 Chapter 7, 14.21.On 10/14/25, at approximately 4:50 p.m., the residence's regional nurse acknowledged that there were discrepancies when looking into resident MARs and stated that the residence was in the process of reconciling medication administration challenges. The regional nurse acknowledged that Resident #4 and Resident #5 did not receive medications per practitioner's orders. The regional nurse further acknowledged that residents not receiving scheduled medication per the practitioner's order was non-compliant with 1568 6 CCR 1011-10-09 Chapter 7, 14.21.On 10/14/25, at approximately 4:50 p.m., the administrator acknowledged that Resident #4 and Resident #5 did not receive medication per the practitioner's order. The administrator also acknowledged the residence was still in the process of reconciling medication administration challenges. The administrator further acknowledged that residents not receiving scheduled medication per the practitioner's order was not in compliance with 1568 6 CCR 1011-10-09 Chapter 7, 14.21. 3. Similar deficient practice was found for Resident #4.”

“Based on record review and interviews, the residence failed to accurately document each medication administration or monitoring event at the time the event was completed for each resident, affecting three of seven sample residents (#3, #4). (Cross-reference U1568)Findings include:1. Record Review Resident #4 was admitted to the residence on 9/19/24 with a diagnosis including heart failure, hyperlipidemia, obstructive and reflux uropathy.Quetiapine Fumarate 25mgA written practitioner's order, dated 7/24/25, directed the residence to administer one tablet of 25mg quetiapine fumarate by mouth two times daily. The September 2025 medication administration record (MAR) indicated that the staff had failed to document the medication as administered the evening of 9/12/25. 2. Interview On 10/14/25 at 1:55 p.m., the health and wellness director stated that a blank space on the MAR meant the medication had not been signed as administered. He stated that he was unsure if the medication had been administered. He acknowledged that the staff failed to accurately record the medication at the time of administration. On 10/14/25 at 2:00 p.m., the regional nurse acknowledged that the medication record had blank spaces on the MAR. She stated that the residence had internet issues and staff had been required to use paper MAR's on the evening of 9/16 and all shifts on 9/17/25, but could not state why other dates were not accurately documented by staff. Similar deficient practice was found for Resident #3.”

“Based on record review and interview, the residence failed to have a roster of current residents readily available, affecting 56 current residents. Findings include:On 10/14/25 at 7:10 a.m., an outdated resident roster was observed in an emergency binder. On 10/14/25 at 7:15 a.m., a current resident roster was requested from the residence. The roster included Former Residents #8-#10; however, the residents no longer resided at the residence. A date at the bottom of the roster read it was updated on 8/18/25. On 10/14/25 at 8:30 a.m., the administrator stated that the staff member responsible for updating the roster had not worked at the residence in over three weeks as of 10/14/25. He acknowledged that the roster was not up to date and that it had not been updated for several weeks. He also stated that Former Resident #8-#10 had moved out or no longer resided at the residence.”

“Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of four current sample residents (#5, #7, and #8).Findings include:1. Resident #7 was admitted to the residence on 1/5/24.a. AtorvastatinA written practitioner's order, dated 1/20/24, directed the residence to administer atorvastatin tablet 81 mg nightly. However, June 2024 medication administration record (MAR) read that the residence failed to administer the medication from 6/6-6/9/24 for a total of three missed doses due to the medication being unavailable. The July 2024 MAR read that the residence failed to administer the medication from 7/1-7/3/24, for a total of three missed doses due to the resident being asleep.b. Tamsulosin HCL A written practitioner's order, dated 1/20/24, directed the residence to administer Tamsulosin HCL 0.4 mg nightly. However, June 2024 MAR read that the residence failed to administer the medication from 6/6-6/9/24 for a total of three missed doses due to the medication being unavailable. The July 2024 MAR read that the residence failed to administer the medication from 7/1-7/3/24, for a total of three missed doses due to the resident being asleep. 2. InterviewsOn 7/23/24 at 7:31 a.m., Staff #4 stated that the residence was out of medication for a resident almost everyday. Staff #4 stated when the residence had medication that was out of stock she attempted to call the pharmacy to get it delivered as soon as possible.On 7/24/24 at 2:12 p.m., the administrator said she was unaware the residents had gone without medication due to the residence not having the medication available. She stated the residence had coding issues with their electronic medication administration record (eMAR) and staff had documented incorrectly as not administered or refused. However, the administrator confirmed the dates listed for the missed medications for Residents #5, #7, and #8 were due to the residence's failure to comply with practitioner's orders. The administrator stated she expected the residence to have all medications in stock to provide to the residents.On 7/24/24 at 2:45 p.m., the nurse coordinator stated that the residence was unable to administer medications as ordered by the practitioner because they were out of stock. She was made aware at the end of each day the medications were not given and staff ordered the medications immediately. The nurse coordinator stated she expected the residence to be in stock with all medications to be administered to the residents. She also stated that she expected the qualified medication administration person to wake a resident when they were asleep during evening medication administration and ask if the resident wanted their medications. 3. Record Review and interview revealed similar deficient practice for Resident #5 and Resident #8.”

“Based on record review, observation, and interview, the residence failed to implement their policy and procedure regarding the timeline of destruction and disposal of outdated, unused, and discontinued and/or expired medications that were not returned to the representative or legal guardian, affecting two of four current sample residents who received medication administration services (#5 and #8).Findings include:The residence's Drug Destruction/Disposal of Medications policy, dated October 2022, read in part that the residence disposed of expired or discontinued medication within 30 days.A written practitioner's order, dated 6/14/24, read in part: "discontinue famotidine 10 mg tablet by mouth once daily" for Resident #5.Resident #10 was admitted on 12/22/22 with a self administration order. On 3/1/24 the residence took over medication administration for Resident #10. The residence did not have a physician's order to administer phenazopyridine hydrochloride.On 7/24/24 from approximately 8:30 a.m. to 9:00 a.m., a medication cart audit revealed phenazopyridine hydrochloride for Resident #8 was stored with other medications in the medication cart. The audit also revealed famotidine, that was discontinued on 6/14/24 for Resident #5, was stored with other medications in the medication cart.On 7/24/24 at 9:07 a.m. the nurse coordinator stated that either herself or a QMAP can receive a discontinue order and would expect the medication to be pulled immediately and placed for destruction. If the medication was not pulled when the discontinue order was placed then the medication would be removed during our medication audits. The nurse coordinator explained they review the medication cart during their medication audits and remove any expired or discontinued medications at that time.On 7/24/24 at 2:12 p.m., the administrator stated she expected staff to remove discontinued medications from the medication cart and place them in the disposal bin immediately after the practitioner discontinued them.”

“Based on observation, record review, and interview, the residence failed to provide all residents with regular opportunities to participate in structured engagement and support the pursuit of each resident's interests, affecting 52 current residents.Findings include:1. Residency AgreementThe Residency Agreement, dated December 2023, read in part that the residence provided planned social and recreational programs.2. ObservationsOn 7/23/24 from 7:00 a.m. to 4:00 p.m., the residence did not provide planned social or recreational activities for the residents. Also, on 7/24/24 from 7:00 a.m. to 4:00 p.m., the residence did not provide planned social or recreational activities for the residents.3. Interviews On 7/23/24, at 1:46 p.m., Resident #5 stated that she often became bored and wished that they had more opportunities to be in the community. She also stated that staff often canceled scheduled activities.On 7/24/24, at 1:30 p.m., the activities director (AD) stated that in the past two months she had to cancel activities and outings because she was required to provide care and services to residents due to a lack of staff. Furthermore, the AD said that she rarely was able to conduct activities because of this.On 7/24/24, at approximately 2:15 p.m., the nurse coordinator stated that the residence was not conducting social and recreational activities as they should.”

“Based on observation and interview, the residence failed to ensure that residents had the right to privacy and confidentiality, affecting six of six residents residing in double occupancy rooms (#5 and #9).Findings include:1. ObservationsOn 7/23/24, from approximately 2:30 p.m. to 2:50 p.m., an environmental tour revealed Resident #5 occupied a double occupancy room with Resident #10. The was laid out to have a small bedroom area to the right for Resident #10 and straight ahead was another area for Resident #5; the rooms were divided by a curtain. The curtain partition was in the middle of the room dividing the room in half for the two occupants. However, the curtain divided the room in a way that Resident #5 could not leave or enter the bedroom or utilize the shared kitchenette without walking through Resident #10's private sleeping area. Resident #10 had to walk through Resident #5's private sleeping area to access the shared bathroom. 2. InterviewsOn 7/16/24 at 12:16 p.m., the nurse coordinator stated Residents #5 and #10 who occupied double occupancy rooms reserved for an alternative pay provider.On 7/23/24 at 1:46 p.m., Resident #5 stated she wished to have more privacy. She said due to the lack of privacy she often left the room to talk on the phone. Resident #5 stated that her roommate who occupied the front bedroom had to enter the private space of her room to use the shared restroom and this has made her uncomfortable at times.On 7/23/24 at 2:13 p.m., Resident #9 stated she was concerned about how her roommate maintained privacy because she was in the front area of the room. She stated that the other resident who occupied the shared bedroom had to enter her portion of the room to access the shared bathroom. Resident #9 stated she thought the rooms were too small to ensure that two residents were comfortable and achieved sufficient privacy.On 7/24/24 at 2:12 p.m., the administrator stated she was unaware that the residence was required to provide residents access to their personal space privately in a double occupancy room.3. Observation and interview revealed similar deficient practice for Residents #9-#13.”

“Based on interview and record review, the residence failed to ensure the residents right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence, affecting four of four sample residents (#5-#8).Findings include:1. Residence PolicyThe Residency Agreement, dated December 2023, read in part that the residence provided services to residents that were detailed in the care plans.The residence's Resident Rights policy, dated June 2004, read in part that residents rights included the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit.2. Resident #6 was admitted to the residence on 07/21/24.A care plan for Resident #6, dated 07/21/24, read in part that she had a call light pendant to request assistance from the residence. Resident #6 had a history of falls and a urethral catheterization.A document of July 2024 response times for when Resident #6 used her call light read as follows:07/21/24: 30 minutes07/22/24: 1 hour07/22/24: 41 minutes07/22/24: 40 minutes07/23/24: 19 minutes7/23/24: 17 minutes7/24/24: 24 minutes3. InterviewsOn 7/23/24 at 10:43 a.m., Resident #7 stated he had to wait over 30 minutes for staff to come and assist him after he pushed his call button.On 07/24/24 at 2:12 p.m., the nurse coordinator stated that staff were trained to answer resident call lights within ten minutes and staff should respond in the order they were received. She further stated that sometimes it took staff up to 20 minutes to respond to resident call lights due to staff working in other areas of the residence.On 07/24/24 at approximately 2:30 P.M., the administrator stated that staff were required to respond to resident call lights within ten minutes.4. Additionally, the residence failed to ensure the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the residence for Residents #5, #7, and #8.”