Bethesda Gardens Thornton

A licensure complaint, prompted by #CO41425 and #CO41603 was completed on 2/12/26. Deficiencies were cited. Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of seven sample residents (#7-#10). (Cross-reference U1600)Findings include:1. Resident #7 was admitted on 8/8/19. A practitioner' s order, dated 7/17/25, directed the residence to administer biotin 5,000 mcg once daily. However, the January and February 2026 medication administration records (MAR), read that Resident #17 did not receive their biotin 5,000 mcg from 1/30-2/11/26 for a total of 13 missed doses.On 2/12/26 at approximately 1:51 p.m., the administrator acknowledged that the residence was ultimately in charge of ensuring each resident under their care received their ordered medication to comply with the practitioner' s order. 2. During the onsite visits on 2/11 and 2/12/26, similar deficient practice was found for Resident #8-#10. Based on observation, record review, and interviews, the residence administered stock medication and failed to properly label over-the-counter medications with the residents' full names, affecting one of seven sample residents (#3).Findings include:1. Residence PolicyThe residence Medication System policy, dated 12/27/25, read in part: No stock or over-the-counter medication for resident use shall be kept in stock or bulk quantities. No medications are accepted for donation. 2. ObservationOn 2/11/26 at 8:30 a.m., an observation of the medication cart in the secure environment (SE) revealed a bottle of acetaminophen was not labeled with Resident #3' s full name. Further observation of the medication storage room in the SE revealed two plastic bins labelled "overstock" contained medications, including but not limited to, vitamin B-12, zinc ointment, nystatin powder, acetaminophen, Pepto bismol, omega-3, D3, and multivitamin. An observation of the medication storage room of the assisted living reveale.. Based on records review and interviews, the residence failed to ensure staff accurately documented each medication administration event at the time the event was completed for two of seven sample residents (#7 and #10). (Cross-reference U1568)Findings Include:1. Resident #10 was admitted to the residence on 3/21/19.A practitioner' s order dated 12/9/25 directed the residence to administer 110 mcg of fluticasone by inhaling two puffs a day. However, the February 2026 MAR read the medication was not available on 2/6-2/7/26 and from 2/9-2/11/26; however, read the medication was administered on 2/8/26. On 2/12/26 at approximately 10:40 a.m., the resident care coordinator (RCC) noted a staff error in recording the medication as administered on 2/8/26 and reported that she had confirmed this with the two staff members who documented it on the MAR, that it was not administered. On 2/12/26 at 1:59 p.m., the administrator acknowledged that she would expect staff to accurately document before th..

A licensure complaint, prompted by #CO40128 was completed on 5/29/25. A deficiency was cited. Based on record review and interview, the residence failed to ensure a resident had the right to be free from neglect, affecting one former resident (#1) who resided in the secure environment.Specifically, the residence failed to provide, in a timely manner, physical care and medical care for Resident #1. On 9/29/24, Resident #1 fell and sustained a closed fracture of multiple ribs of the left side. On 10/2/24 at 4:30 a.m., staff found Resident #1 on the floor on top of her walker, redness and bruising on the right side of her jaw, bruising on her right elbow, and a skin tear on her left hand. Resident #1 reported no current pain, but pain from a previous fall. The residence failed to provide adequate physical care and medical care for Resident #1 after her fall on 10/2/24 and was found by a family member about six hours after the fall with a bruise on her face, dried red residue on her face and clothing, along with a band-aid partially covering a wound on their left thumb. Resident #1 required wound care to be provided by an external service provider to properly care for the skin tear on her left hand twice a week.Specifically, the residence failed to provide, in a timely manner, physical care and medical care for Resident #1. Resident #1 attempted to elope from the residence on 4/30/25 around 4:03 a.m., became aggressive, and started swinging her luggage at staff. The staff atte.. 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 7.18.8 Resident records shall contain, but not be limited to, the following items: (D) 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; (1) 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.

A revisit survey was completed on 5/1/25 for all previous deficiencies cited on 2/5/25. 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 complaint revisit was completed on 2/5/25 for the previous deficiencies cited on 4/29/24. The residence/facility is in compliance with all regulations surveyed. 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