Gardens at Columbine, the

A relicensure survey was completed on 4/2/25. Deficiencies were cited. Based on interview and record review, the administrator failed to routinely complete audits of the accuracy and completeness of medication administration records (MARs), medication error reports, and medication disposal records affecting all residents whose medications were managed by the residence.Findings include:The residence' s MARs audi.. Based on observation and interview the residence failed to place in a visible location a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR), affecting 127 current residents. Findings include: On 4/1/25 at approximately 7:30 a.m., a posted list of staff with current first aid and CPR certificatio.. Based on observation, interview, and record review, the residence failed to ensure that at all times, at least one staff member who had current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization was onsite, which affected 127 current residents. Findings include 1. Residence policy The residence' s m.. Based on observation, interview, and record review, the residence failed to provide each staff member with initial orientation prior to providing any care or services to a resident for two sample staff (#1, #2) and one former staff (#4), affecting 127 current residents. (Cross-reference S0648 and S0664)Findings include: Chapter VII regulations governing.. Based on observation, interview, and record review, the residence failed to provide each staff member with training relevant to their specific duties and responsibilities for one sample staff (#2), affecting 127 current residents. (Cross-reference S0640 and S0664)Findings include: Chapter VII regulations governing assisted living residences, part .. Based on observation, record review, and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 127 current residents.Findings include: 1. Residence PolicyThe residences Required Certifications policy dated 7/1/24, rea.. Based on record review and interview the residence failed to ensure qualified medication administration persons (QMAPs) did not assess residents or make decisions regarding administering medications pro re nata (PRN), affecting three of three sample resident (#1-#3) residing in the secure environment.Findings include:Resident #2 was admitted.. Based on record review and interview, the residence failed to evaluate the resident who had fallen and safely provide lift assistance when the resident had no pain, affecting one resident (#4) of 10 sample residents.Specifically, Resident #4 was admitted to the residence on 7/24/21 with diagnoses of Alzheimer' s disease, eye disorder, macular degenerat.. Based on record review and interview, the residence failed to have a policy and procedure regarding the training of staff providing services in secure environment, which includes information on the appropriate staff response and procedure for the distribution of staff when a resident is deemed missing, ensuring continued supervision for all othe.. Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 127 current residents.Findings include:On 4/1/25 at 8:07 a.m., the following records were requested from the administrator:All current staff cardiopulmonary resuscitation (CPR) and first aid cer.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.9 The comprehensive assessment shall be updated for each resident at least an..

A licensure complaint, prompted by #CO31981 was completed on 5/8/23. Deficiencies were cited. Based on interview and record review, the residence failed to have a roster of current residents that included their emergency contact information, along with a residence diagram showing room locations, affecting 118 current residents. Findings include:On 5/8/23 at approximately 7:00 a.m. the resident roster was requested and provided. However, the resident roster did not include the residents' emergency contact information, along with a residence diagram showing room locations.On 5/8/23 at approximately 7:15 a.m., the receptionist stated the provided resident roster, in addition to individual face sheets, was what emergency services would have been provided.On 5/8/23 at approximately 12:37 p.m., the administrator stated he was not aware that residents' emergency contact information or a residence diagram showing room locations was required to be included with the resident roster. He stated that when emergency services entered the residence, they were provided with individual face sheets for each resident. Based on observation, interview and record review, the residence failed to provide residents with protective oversight, affecting one of three sample residents (#1).Specifically, Resident #1 was admitted to the residence on 12/18/22 with diagnoses including arthritis. A care plan, dated 4/14/23, directed the staff to provide the resident with two person transfer assistance. However, on 4/26/23, Staff #1 improperly transferred the resident alone, which resulted in a skin laceration to the resident' s left shin that required 11 stitches.Findings include:The undated sample resident agreement, read in part; the residence would provide protective oversight to all residents.Chapter VII regulations governing assisted living residences, part 2.38, defined "Protective oversight" as guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (A) Being aware of a resident' s general whereabouts, although the resident may travel independently in the community; and (B) Monitoring the activities of the resident while on the premises to ensure the resident' s health, safety and well-being, including monitoring the resident' s needs and ensuring that the resident receives the services and care necessary to protect the resident' s health, safety, and well-being. Resident #1 was admitted to the residence on 12/18/22 with di..