Gardens at Collinwood, the

A licensure complaint, prompted by #CO38874, was completed on 1/14/25. A deficiency was cited. Based on interview and record review, the residence failed to thoroughly investigate the abuse of a resident in accordance with its written policy, affecting one sample resident (#5).Findings include:1. Reference and PolicyChapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" as any of the following acts or omissions: (B) Confinement or restraint that is unreasonable under generally accepted caretaking standards.The residence' s abuse and neglect policy, dated January 2013, read: "(The residence) will prohibit neglect, mental or physical abuse, including involuntary seclusion, and the misappropriation of the property of residents. (The residence) will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property and will provide notification of information to the proper authorities according to state and federal regulations. Management of the Abuse, Neglect, and Misappropriation of Property Policy will be under the leadership of the (administrator) and/or the health services director (HSD)."2. Record ReviewThe residence provided their investigations of abuse, dated 11/14/24-1/14/24; however, the residence did not include an investigation involving Residents #3 or #5.Resident #3 was admitted on 1/26/23 with a diagnosis of Alzheimer' s Disease. Resident #5 was admitted on 8/21/24 with diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, restlessness, and agitation.A progress note, dated 12/28/24 at 6:45 p.m., read in part that a staff member was directed to Resident #3' s room after he locked himself and Resident #5 inside of his room against her will. Resident #3 refused entrance to staff. The staff member continued to attempt to gain access and free Resident #5. The staff member contacted the memory care director (MCD) for assistance, who recommended calling a family member of Resident #3 for assistance. The note contained no further information about the outcome of the incident or the residence' s investigation of Resident #3' s i..

A licensure complaint, prompted by #CO37444 was completed on 9/12/24. Deficiencies were cited Based on interview and record review, the residence failed to notify a resident' s representative when a resident experienced a change in baseline status, affecting one of five sample residents (#2).Findings include:Resident #2 was admitted to the residence on 3/8/22 with a diagnosis of frontotemporal dementia.An incident report, dated 9/8/24, read in part that on 9/7/24 at 5:00 p.m., the resident was found outside in the courtyard under a tree seeking shade and was suspected to have been outside for two hours.An undated document titled Notification of Primary Contact Person revealed that the residence was required to notify the primary contact person in the event of serious injury, i.. Based on interview, and record review, the residence failed to ensure residents had the right to be free from neglect, affecting one sample resident (#2). Specifically, staff failed to monitor Resident #2 who was outside in the secure courtyard. After the resident spent approximately two hours in extremely hot temperature, staff found her on the ground of the courtyard, hot to the touch, her skin red with sunburn.Findings include:1. Record ReviewResident #2 was admitted to the residence on 3/8/2022 with a diagnosis of frontotemporal dementia.A care plan, dated 8/5/24, read in part Resident #2 required staff to conduct frequent safety checks and limit the time she spent outside during .. Based on observation, interview, and record review the residence failed to have a secure outdoor area that was directly supervised by staff, was independently accessible without staff assistance, had an area of protection from weather elements, and had an enclosure that was at least six feet in height, affecting 32 residents in the secure environment.Specifically, the residence' s secure outdoor area did not meet regulatory requirements which resulted in Resident #2 sustaining sun burn from being outside for approximately two hours because staff failed to directly supervise the secure outdoor area. Additionally, this failure resulted in Residents #1 and #2 eloping from the residen.. Based on observation, record review, and interview, the residence failed to, either directly or indirectly through a resident agreement, provide protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach, affecting 32 current residents.Specifically, the residence had two residents who had a history of eloping, Resident #1 and Resident #2. On 9/11/24, staff failed to close and secure a gate that exited the secure courtyard in the secure environment.Findings include:1. Referencesa. .. Based on record review and interview, the residence failed to contact a resident' s primary practitioner when the resident sustained an injury or accident or experienced a significant change in their baseline status, affecting one of five sample residents (#2). (Cross-reference 1310)Findings include:Resident #2 was admitted to the residence on 3/8/2022 with a diagnosis of frontotemporal dementia.An incident report, dated 9/8/24, read in part that on 9/7/24 at 5:00 p.m., the resident was found outside in the courtyard under a tree seeking shade and was suspected to have been outside for two hours.An undated document titled Notification of Primary Contact Person revealed that the resi..

A revisit survey was completed on 4/17/24 for all previous deficiencies cited on 9/19/23. 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 relicensure survey with complaints #CO32338, and #CO33484 was completed on 9/19/23. Deficiencies were cited.The residence was comprised of three individual sections identified as Building A, Building B, Building C, and Building D. Based on interview and record review, the residence failed to ensure that residents were treated with respect and dignity, affecting 63 residents who resided in the non-secure environment.Findings include:1. Residence PolicyThe residence' s resident agreement, dated May 2019, read in part that the residents had the right to be accepted and treated with respect and dignity. 2. InterviewsOn 9/19/23 at 7:52 a.m., Staff #6 stated that approximately three weeks prior to the on site investigation a resident with cognitive impairment was eating spaghetti at a dining room table. He stated that a kitchen staff member (KSM) took her fork from her hand, placed it on her plate, and took her food from her when she was only halfway finished. He stated that the KSM said, "You' re not eating this, I' ll get you something else, " adding that she sounded angry, demanding, and harsh. Staff #6 stated he witnessed the KSM firmly and loudly tell residents to sit down, to not walk around the dining room, and to wait their turn when ordering. Staff.. Based on observation, interview, and record review, the residence failed to observe a resident' s right to privacy, affecting 21 of 21 residents who resided in building D. Findings include: 1. Residence policyThe residence' s resident agreement, dated May 2019, read in part that the residents had the right to reasonable privacy, including privacy of self and possessions and in personal affairs. The residence maintained resident records, which may contain medical and other personal information. The residents' information and records were confidential and were not released without written consent from the resident or their responsible party.2. ObservationsOn 9/19/23 at 8:26 a.m., a medication cart was against a wall adjacent to the main entry/exit door to building D. On top of the cart was a clipboard, facing outward and leaning against the wall. A paper attached to the clipboard, titled Daily Communication Log, read in part: "(Resident initials) tramadol was given early. (Resident initials) had a rough night last night; he cou.. 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 10 CCR 2505-10 8.400.7.13 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee' s or volunteer' s personnel file: (A) Documentation that the individual' s name appears on the Department' s list of individuals who have successfully completed the medication administration competency evaluation; and (B) A signed disclosure that the individual has not had a professional medical, nursing, or pharmacy license revoked in this or any other state for reasons directly related to the administration of medications.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents:(C) Personal services including, but ..