Garden Plaza of Aurora

A revisit survey was completed on 6/16/25 for all previous deficiencies cited on 1/28/25. 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

12.2.2 Infection Control Officer (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility' s Infection Prevention and Control Program and training. This individual shall be responsible for the following: (2) Completing a minimum of 1.5 hours of continuing education in infection prevention .. A relicensure survey with complaint #CO35350 was completed on 1/28/25. Deficiencies were cited. Based on interview and record review, the residence failed to have at least one staff member onsite who had certification in first aid from a nationally recognized organization, affecting 55 current residents. Findings include:A review of staff first aid certifications and staff schedules from 1/1/25-1/31/25 revealed the following 28 shifts did n.. Based on observation and interview, the residence failed to place in a visible location a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR) so that the information is readily available to staff at all times, affecting 55 current residents.During the onsite visit on 1/28/25, the residence placed no list of st.. Based on record review and interview the residence failed to define procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting 55 current residents.Findings include:On 1/28/25 the residence had a posted sign on the entrance door of the residence that indicated the residence was currently in an active influenza o.. Based on record review and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire for two of three sample staff (#1, #2), affecting 55 current residents.Findings include:1. Referencesa. Chapter VII regula.. Based on record review and interview, the residence failed to ensure qualified medication administration persons (QMAP) had documentation that the individual ' s name appears on the Department' s list of individuals who have successfully completed the medication administration competency evaluation, for three of three staff (#1-#3), affect.. 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 55 current residents. Findings include:A review of staff CPR certificatio.. Based on record review and interview, the residence failed to have the administrator and the QMAP (qualified medication administration person) supervisor, on a quarterly basis, audit the accuracy and completeness of the medication administration records, affecting 55 current residents.Findings include:1. Record reviewA weekly .. Based on record review and interview, the residence failed to report suspected caretaker neglect to law enforcement within 24 hours of observation or discovery, affecting 55 current residents.Findings include:Former Resident #8 was admitted to the residence on 10/31/24 with diagnoses including respiratory failure with hypoxia, femur and left hip f.. Based on record review, observation and interview, the residence failed to comply with practitioners orders associated with medication administration, affecting three out of six sample residents (#2-#4).Findings include:1. Record reviewA physician order dated 1/9/25, read that the residence was required to administer prednisone 30 mg (3 tablets) three.. 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 7.12.1 The assisted living residence shall make available, either directly or indirectly through ..

A licensure complaint, prompted by #CO35159 was completed on 3/4/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that all residence personnel engaged in the care and treatment of at-risk persons, affecting 43 current residents. (Cross-Reference S640)Findings include:1. Residence Policiesa. The residence' s Resident Abuse Policy, dated 1/4/22, read in part that each of the residence' s staff was a mandated reporter and had the duty as an individual to report any actual/known, alleged, suspected incident of physical abuse, neglect, exploitation, financial abuse, abandonment, or isolation to local law enforcement within 24 hours of suspicion or allegation. b. The residence' s Staff Training Policy, dated 8/25/22, read in part that staff traini.. 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 43 current residents. (Cross-Reference S1146)Findings Include: 1. References and Residence Policya. The residence' s undated fall management policy read in part that residence staff reviewed the Fall Intervention sheet and the Environmental Screen: Resident Room section for interventions, and added the interventi.. Based on interview and record review, the residence failed to 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, affecting two of four current sample residents (#3, #4).Findings include:Residence PolicyThe residence' s Progress Notes policy, dated 8/22/22, read in part that staff recorded observations and changes regarding a resident in the progress notes of the residence' s electronic information management system. Designated individuals, including qualified medication administration persons and care staff, documented in the progress notes. The policy further rea.. Based on interview and record review, the residence failed to update a comprehensive assessment whenever a resident' s condition changed from baseline status, affecting one of four current sample residents (#3). Findings include:Residence policyThe residence' s Evaluations policy, dated 8/25/22, read in part that the residence reviewed and updated comprehensive assessments every six months or as needed for changes in baseline status.Record ReviewA comprehensive assessment, dated 12/18/23, read in part that the resident required stand-by assistance with mobility and transfers and reminders to use her ambulatory device. It read that Resident #3 had sustained two falls: on 12/11.. Based on observation, interview, and record review, the residence failed to ensure that each staff member received initial orientation prior to providing any care or services to a resident, affecting five of five sample staff (#1-#5). (Cross-Reference S410)Findings include:Residence PolicyThe residence' s Staff Training Policy, dated 8/25/22, read in part that the residence provided initial orientation to staff based on state regulations and the needs of the residents being served in the residence. All training was documented and retained in the staff files.ObservationOn 3/4/24, from approximately 7:15 a.m. to approximately 2:00 p.m., Staff #2 was observed providing care and services to residents...