Gardens at Viewpointe, the

A revisit survey was completed on 12/1/25 for all previous deficiencies cited on 5/13/25. 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 licensure complaint, prompted by #CO40320 was completed on 6/11/25. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to provide a physically safe environment, either directly or indirectly, per the resident agreement, affecting 51 current residents. (Cross-reference T0914, T0920)Specifically, the residence failed to have procedures in place for safe evacuation from floors two and three for non-ambulatory residents in the event that the residence required a complete evacuation. Further, the residence failed to have a plan to ensure residents had continuous access to oxygen in the event of a power outage for those who utilized oxygen. The residence experienced a power outage on 5/24/25 wherein the residence was unable to ensure residents' access to oxygen without emergency medical services (EMS). On 6/5/25, the residence experienced a fire in a room on the third floor. The residence failed to update their policies and procedures or educate staff regarding what to do in the event of a fire or power outage. This created an immediate jeopardy risk of harm or deat.. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 121 current residents. (Cross-reference T1110)Findings include:The residence' s June 2019 Emergency Manual failed to contain the required elements, including circumstances procedure for evacuating the premises; an established means of communicating with families, staff, and other providers; a plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; a plan to store and preserve medications; assignment of specific tasks and responsibilities to current staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; a procedure to protect and transfer of health information as needed to meet the care needs of residents; and written agreements with other health facilities in the event of an e.. Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following an emergency, including, but not limited to, a long-term power failure, affecting 121 current residents. (Cross-reference T1110)On 6/11/25, during the onsite visit, the residence' s 72-hour continuation of care policy and procedure was requested but was not provided.On 6/11/25 at 1:16 p.m., the maintenance director stated he was not aware that the residence was required to have a 72-hour policy or procedure. He added that it made sense, given the recent power outage and the number of residents who required oxygen.On 6/11/25 at 2:33 p.m., the administrator stated that, prior to the onsite visit, the residence did not have a 72-hour continuation of care policy or procedure; however, during the onsite visit, the residence began working on the policy and procedure to ensure residents had access to power when required. He affirmed the residence experienced a pow..

A complaint, prompted by #CO40359, was completed on 6/18/2025. Three deficiencies were cited.The facility is a three floor of a Type V (111) structure and licensed for twenty three (162) beds. The facility is protected by a complete National Fire Protectin Association (NFPA) 13 automatic fire suppression system. Based on observation, record reviews, and interviews, the facility failed to maintain a facility constructed in conformity with the applicable standards adopted by the Division of Fire Prevention and Control (DFPC) related to existing residential board and care occupancies. Specifically, the facility failed to comply with requirements for fireevacuation procedures during a fire event, and the facility did not meet requirements for utilizing defend-in-place procedures. The facility failures had the potential to affect all occupants of the building.Findings include:Cross-reference to A0001 for observation, interviews, and record review related to failures to evacuate to a safe area resident that was in the smoke compartment where a fire event was occurring.Cross-reference to A0002 for observation, interview, and record review related to failures to have a building constructed board and care occupancy that met the requirements for defend-in-place procedures for a building, occupants, and staffing that rat.. Based on observations, interviews and record reviews, the facility failed to evacuate to a safe location, one resident that resided in room #306A, during a fire event that occurred on 6/04/2025. The failure impacted one resident and had the potential to impact all other residents that required the same or higher level of assistance during a fire oremergency evacuation event.Findings include:Regulatory reference2012 NFPA 101 Life Safety Code, Section 4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.At a minimum, the smoke compartment of origin shall be evacuated. ObservationsRoom 307 was observed with the facility administrator on 6/05/2025 at 08:19 a.m. The oxygen concentrator, which was reported by the local fire authority to be the source of a fire on 6/04/2025 at 11:44 p.m, had visual evidence of having been on fire.Room 306A was observed to be next to and with the same smo.. Based on observations, interviews, and record review, the facility did not meet requirements for a defend-in-place procedure in the event of a fire. Specifically, staff of the facility, classified as an existing board and care occupancy, could not provide evidence that the facility can be used as a defend-in-place facility. This failure had the potential to to affect all residents and occupants of the facility.Findings include:Regulatory Reference2012 NFPA 101, Section 33.3.1.2.2* Impractical. Large facilities classified as impractical evacuation capability shall meet the requirements of Section 33.3 for impractical evacuation capability, or the requirements for limited care facilities in Chapter 19, unless the authority having jurisdiction has determined equivalent safety is provided in accordance with Section 1.4.The Life Safety Code Handbook, 12th edition in part states the following. Page 1039 states. The Existing large facilities in which residents are classified as impractical to evacuate must comply with the requirements of Chapter ..

A complaint revisit was completed on 5/13/25 for all previous deficiencies cited on 1/22/25. Deficiencies were cited. Based on record review and interview the residence failed to on a quarterly basis audit the accuracy and completeness of medication administration records affecting four of six sample residents (#4,#9,#17-#20).This deficiency was cited previously during a state licensure survey. Although the residence corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:On 5/12/25 at approximately 9:30 a.m., the last two quarterly medication audits were requested from the administrator and provided. However, the audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the medication administration records (MAR), medication error reports, and medication disposal records.On 5/12/25 at approximately 11:30 a.m., the administrator provided an additional medication audit tool titled "Medication Exception Report," dated April 2025. However, the secured environment section of the report indicated that the holes in the M.. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioners' orders associated with medication administration, affecting two (#9, #17) of six sample residents.This deficiency was cited previously during a state licensure survey. Although the residence corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Resident #9 was admitted to the residence on 3/30/24 with diagnoses including dementia. Gabapentin A written practitioner' s order, dated 10/22/24, directed the residence to administer gabapentin 300 mg capsule twice a day orally. However, the April 2025 medication administration record for Resident #9 read the medication was not in stock and not administered on 4/13 through 4/15/25 twice a day, for a total of six missed doses.LidocaineA written practitioner' s order, dated 9/25/24, directed the residence to apply topically a thin layer of lidocaine on the right kn..

A relicensure survey with complaints #CO36009, #CO34198, #CO34057, and #CO33058 was completed on 1/22/25. Deficiencies were cited. Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting six of 10 sample residents (#1, #5, #6, #9, #11 and #12). Findings include:On 1/21/25 at 8:04 a.m., quarterly medication audits were requested from the administrator. .. Based on observation, interview and record review, the residence failed to develop and implement a fall management program detailing in each resident care plan the individualized approach necessary to address fall risks related to deficits in strength and balance and provide staff with training related to fall prevention affecting three of five samp.. Based on observations and interviews, the residence failed to properly label over-the-counter medications for five of 10 sample residents (#2, #4, #9, #11, #12).Findings include:1. ObservationsOn 1/22/25 at 1:30 p.m., a medication cart audit in the non-secure environment revealed over-the-counter medications for Residents #2, #4, #11, and #12 in a d.. Based on observations, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration affecting six of 10 sample residents (#1, #5, #6, #9, #11 and #12). (Cross-reference S1530)Findings include:1. Resident #9 was admitted to the residence on 3/30/24 with diagnoses incl.. Based on record review and interview, the residence failed to ensure residents had the right to be treated with respect and dignity, affecting one of twelve sample residents (Confidential Resident #13).Specifically, Confidential Resident #13 reported staff intimidated them and did not treat them respectfully and with dignity. Staff told Confide.. Based on record review and interview, the residence failed to include the resident' s attending practitioner during six month reassessments or when the resident' s condition changed from baseline status to determine the continued need for a secure environment, affecting five of five sample residents (#1, #6-#9) in the secure environment. Findings incl.. Based on record review and interview, the residence failed to prepare or administer only medication that had been ordered by an authorized practitioner, affecting three of ten sample residents (#5, #10, and #11). (Cross-reference S1568)Findings include:1. Record ReviewResident #5 was admitted to the residence on 5/29/23 with diagnoses of chr.. Based on record review and interview, the residence failed to provide an enhanced care plan for five of five sample residents (#1, #6-#9) in the secure environment. Findings include:1. Resident #9 was admitted to the residence on 3/30/24 with a diagnosis including dementia. Progress notes from 10/8/24 to 11/29/24 read Resident #9 was speakin.. Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 144 current residents. (Cross-reference S1530, S1604)Findings include: On 1/21/25 at 8:04 a.m., staff cardiopulmonary resuscitation (CPR) and first aid certifications were requested. The CPR .. 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 7.7.13 Each personnel file shall include, but not be limited to, written documentation regardi..

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 1/12/23. 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