Garden Square at Westlake

Based on record review and interview the residence failed to individualize resident care plans, require staff members to document any out of the ordinary events or issues, before the end of shift, regarding a resident they personally observed or was reported to them along with actions taken to address the residents changing needs and documentation of on-going services provided by external service providers, affecting two of seven sample residents (#1 and #4).Findings include:Record reviewResident #1 was admitted to the residence initially on 12/21/24 with a diagnosis of bipolar disorder.Resident #1 had a psychiatric hospitalization from 4/9/25 to 4/28/25 for mania. A progress note, created on 4/6/25 with an effective date of 4/1/25, read in part: Resident #1 had not slept for two consecutive nights and reported ' they' told him he could not sleep. Resident #1 was found lingering in front of another resident' s room and when asked to return to his room he mumbled profanity while complying with the request. Resid.. A relicensure survey with complaint #CO37344 was completed on 4/30/25. Deficiencies were cited.A change of ownership occurred on 1/3/25. Based on interview and record review the residence failed to provide, upon request, access to relevant information from requested documents, affecting seven of seven (#1 - #7) sample residents (Cross-reference S2230). On 4/29/25 at 9:46 a.m., the executive director was emailed with a request for 90 days of incident reports, occurrences, investigations of unknown injury, grievances, complaints and investigations. On 4/29/25 at 2:30 p.m., the executive director said the items requested were considered internal documents by the residence' s legal department and they would not be provided to the survey team. The executive director said she informed the legal department only documents for a sample of residents #1 - #7 were being requested, however, she was not permitted to provide the requested documents but she was still working on it. On 4/30/25 at 1:10 p.m., the onsite survey was concluded and the residence had not provided relevant information from documents requested by the department. Based on observation, interview and record review the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#3). Findings include:ObservationOn 4/29/25 at 7:30 a.m., Staff #1 dispensed and crushed all scheduled medications listed on the medication administration record (MAR) except Duloxetine HCL capsule and a multivitamin adult gummies chew for Resident #3. 2. Record reviewResident #3 was admitted on 8/27/2 gastro-esophageal reflux disease (GERD). The record for Resident #3 failed to include a physician' s order to crush medications.On 4/30/25 at 10:01 a.m., during the onsite visit, the executive director retrieved an order from the physician that read in part: Continue to crush medications due to risk of aspiration. 3. InterviewOn 4/30/25 at 7:35 a.m., Staff #1 said her MAR charting screen had displayed instructions to crush meds in the past but was unable to locate those instructions currently. On 4/30/2..