Brookdale Greenwood Village-alr

“Based on record review and interview, the residence failed to ensure there was at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 83 current residents. (Cross-reference S0540)Findings include:A review of staff CPR certifications and staff schedules from 1/27/25-2/13/25 revealed the following 10 shifts did not have a person onsite certified CPR: Day shifts: 1/28, 2/6, 2/13Afternoon shifts: 1/27, 1/28, 1/30, 2/4, 2/5 -2/10, 2/11 and 2/12.On 2/11/25 at 3:40 p.m., the administrator stated it was her responsibility to ensure there was one staff member onsite at all times with current certification in CPR and she looked at the schedule daily to ensure compliance. She acknowledged discrepancies and there were shifts without a staff member certified in CPR.”

“Based on observation, interview and record review, the residence failed to ensure the administrator managed the day-to-day operations of the assisted living residence, including managing the day-to-day delivery of services to ensure residents received the care that is described in the resident agreement and for complying with all applicable state and local laws concerning licensure and certification, affecting 83 current residents. (Cross reference S0734, S0910, S1604) Findings include:Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1.The department database revealed the administrator was the administrator of record as of 2/11/24. The administrator provided a certificate that indicated she had been qualified to be an administrator since 11/17/22.a. Quarterly Medication Audits The residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records as required. On 2/11/25 at 3:13 p.m., the administrator stated she was unaware of the requirement to participate in quarterly medication audits and had not completed one. b. Cardiopulmonary Resuscitation (CPR) RequirementsThe residence failed to have a CPR certified staff member onsite on from 2:00 p.m., to 10:00 p.m., for 10 days from 1/27/24 to 2/13/25. From 10:00 p.m., to 6:00 a.m., for five days from 1/27/24 to 2/13/25.On 2/11/25 at 3:40 p.m., the administrator stated it was her responsibility to ensure there was one staff member onsite at all times with current certification in CPR and she looked at the schedule daily to ensure compliance. She acknowledged there were shifts without a staff member certified in CPR. c. Resident Roster The residence failed to have an updated, readily available roster containing all requirements, resident name, room number, emergency contact information and a diagram of the residence. On 2/11/25 at 8:45 a.m., the administrator confirmed a resident roster with the resident names and room number was their official resident roster. She stated the residence had an emergency preparedness binder with the roster as well. On 2/11/25 at 9:50 a.m., the administrator presented a second roster from the emergency preparedness binder however, she acknowledged it had not been updated with recent residents who had been admitted and it had not included emergency contact information. On 2/11/25 at 3:40 p.m., the administrator confirmed that she was aware that the residence needed to have an emergency roster readily available at the front desk. Further stating that they were not in compliance with what regulation 10.1 required.On 2/11/25 at 3:41 p.m., the administrator stated she delegated many of the tasks to other members of the team, she understood managing the day to day was her responsibility. However, she stated she was not a nurse and nursing duties were not her responsibility.”

“Based on interview and record review the residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records affecting 83 current residents. (Cross-reference S0540)Findings include:The residence's Medications Systems policy, dated 10/11/23, read in part: Ongoing oversight of medication delivery would be provided through the residence's quality assurance section. The oversight consisted of routine medication administration record (MAR) audits and MAR to medication cart audits which focused on medication availability. On 2/11/25 quarterly medication audits were requested from the administrator and provided. However, the medication audits were not completed by the administrator and the qualified medication administration supervisor, they were completed by the health and wellness director and the resident care coordinator.On 2/11/25 at 9:13 a.m., the health and wellness director stated she had been completing the medication audits with the resident care coordinator monthly, she stated the administrator did not review or complete medication audits with them. On 2/11/25 at 3:13 p.m., the administrator stated she was not aware of the regulation and therefore did not complete the audits.”

“Based on record review, and interview, the residence failed to have a readily available roster of current residents, their room assignments, and emergency contact information, along with a residence diagram showing room locations, affecting 83 current residents. (Cross-reference S0540)Findings include:1. Record ReviewOn 2/11/25 at 8:45 a.m., a resident roster, provided by the administrator (AD), was not readily available and failed to include two current resident names along with their room assignments and emergency contact information (ECI). Additionally, the names on the resident roster did not accurately reflect the current residents, their ECI, their room numbers or the residence diagram showing room locations.On 2/11/25 at 9:39 a.m., a second resident roster, provided by the AD, was not readily available and failed to include two current resident names along with their room assignments and emergency contact information (ECI). Additionally, the names on the resident roster did not accurately reflect the current residents, their ECI, their room numbers or the residence diagram showing room locations.On 2/11/25 at 9:50 a.m., a third resident roster, provided by the administrator,was not readily available and failed to include two current resident names along with their room assignments and emergency contact information (ECI). Additionally, the names on the resident roster did not accurately reflect the current residents, their ECI, their room numbers or the residence diagram showing room locations.2. InterviewsOn 2/11/25 at 8:45 a.m., the AD confirmed that the roster provided was not readily available and was the residence's "official roster". Further stating that the emergency prep roster was located in the emergency book and did not include two current residents.On 2/11/25 at 8:45 a.m., the AD confirmed the roster provided did not include all aspects of the 10.1 regulation.On 2/11/25 at 9:50 a.m., the AD confirmed the residence roster was not in compliance with the 10.1 regulation, the roster was not readily available and did not include the ECI, room number or map of the residence. She further stated, the required information was in her office and not accessible by staff. On 2/11/25 at 3:40 p.m., the AD confirmed to be aware the residence needed an emergency roster readily available. Further stating that the residence roster was not in compliance with the 10.1 regulation.”

“Based on record review and interview, the residence failed to ensure health information records for residents were kept on site for at least three years following the termination of the resident's stay, affecting one of two former residents (#10). Findings include:Former resident #17 was admitted to the residence on 1/18/22 and discharged on 12/29/23.Records were requested for Former resident #17; however, the residence could not provide the resident's complete record as the residence could not find the paper records the former administrator had kept. The residence did not have recent care plans, recent assessments, or provide medication administration records (MARs) at the end of the onsite visit for Former resident #17.On 2/11/25 at 11:25 a.m., the health and wellness director stated the previous administrator had stored resident records in disorganized boxes.. She added Former resident #17 had been discharged from the residence prior to her hire date and could not find the record. On 2/11/25 at 3:13 p.m., the administrator stated the residence did not have the complete record for many residents as the previous administrator had not left the residence with complete files. She stated she did not have the record for Former resident #17.”

“Based on observation, interview and record review, the residence failed to ensure the administrator managed the day-to-day operations of the assisted living residence, including managing the day-to-day delivery of services to ensure residents received the care that is described in the resident agreement and for complying with all applicable state and local laws concerning licensure and certification, affecting 83 current residents. (Cross reference S0734, S0910, S1604) This deficiency was cited previously during a state relicensure and complaint survey on 8/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1.The department database revealed the administrator was the administrator of record as of 2/11/24. The administrator provided a certificate that indicated she had been qualified to be an administrator since 11/17/22.a. Quarterly Medication Audits The residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records as required. On 2/11/25 at 3:13 p.m., the administrator stated she was unaware of the requirement to participate in quarterly medication audits and had not completed one. b. Cardiopulmonary Resuscitation (CPR) RequirementsThe residence failed to have a CPR certified staff member onsite on from 2:00 p.m., to 10:00 p.m., for 10 days from 1/27/24 to 2/13/25. From 10:00 p.m., to 6:00 a.m., for five days from 1/27/24 to 2/13/25.On 2/11/25 at 3:40 p.m., the administrator stated it was her responsibility to ensure there was one staff member onsite at all times with current certification in CPR and she looked at the schedule daily to ensure compliance. She acknowledged there were shifts without a staff member certified in CPR. c. Resident Roster The residence failed to have an updated, readily available roster containing all requirements, resident name, room number, emergency contact information and a diagram of the residence. On 2/11/25 at 8:45 a.m., the administrator confirmed a resident roster with the resident names and room number was their official resident roster. She stated the residence had an emergency preparedness binder with the roster as well. On 2/11/25 at 9:50 a.m., the administrator presented a second roster from the emergency preparedness binder however, she acknowledged it had not been updated with recent residents who had been admitted and it had not included emergency contact information. On 2/11/25 at 3:40 p.m., the administrator confirmed that she was aware that the residence needed to have an emergency roster readily available at the front desk. Further stating that they were not in compliance with what regulation 10.1 required.On 2/11/25 at 3:41 p.m., the administrator stated she delegated many of the tasks to other members of the team, she understood managing the day to day was her responsibility. However, she stated she was not a nurse and nursing duties were not her responsibility.”

“Based on interview and record review the residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records affecting 83 current residents. (Cross Reference S0540)This deficiency was cited previously during a state relicensure and complaint survey on 8/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:The residence's Medications Systems policy, dated 10/11/23, read in part: Ongoing oversight of medication delivery would be provided through the residence's quality assurance section. The oversight consisted of routine medication administration record (MAR) audits and MAR to medication cart audits which focused on medication availability. On 2/11/25 quarterly medication audits were requested from the administrator and provided. However, the medication audits were not completed by the administrator and the qualified medication administration supervisor, they were completed by the health and wellness director and the resident care coordinator.On 2/11/25 at 9:13 a.m., the health and wellness director stated she had been completing the medication audits with the resident care coordinator monthly, she stated the administrator did not review or complete medication audits with them. On 2/11/25 at 3:13 p.m., the administrator stated she was not aware of the regulation and therefore did not complete the audits.”