Gardens Care Homes - Columbine Acres, the

A licensure complaint, prompted by #CO41367 was completed on 1/13/26. Deficiencies were cited. Based on interviews and record reviews the residence failed to protect residents from physical abuse affecting five of five sample resident (#1-#5) within the secured environment. (Cross-reference U0410 and U1140)Findings include:Resident #3 was admitted to the residence 12/11/25 with a diagnosis of Dementia.A care plan, date unknown read in part, Resident #3 requires supervision and monitoring to help manage/redirect destructive/abusive behaviors. Maintain a low level of abusive or destructive behaviors with supervision/intervention from staff.An incident report dated 12/12/25 read in part, Resident #3 throughout the day had become aggressive towards staff and other residents. While Resident #2 was trying to enter his room to use the restroom, that him and Resident #3 shared, Resident #3 became agitated and aggressive and charged the Resident #2 and hit him in his chest with a closed fist. An incident report dated 12/23/25 read in part, towards the end of shift Resident #3 had grabbed a female resident cau.. Based on record review and interview, the residence failed to comply with occurrence reporting requirements, affecting five of five sample residents from abuse. (#1-#5) (Cross-reference U1322).Findings include:1. References and Policiesa. Chapter II regulations governing assisted living residences, part 4.2.2, requires that the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (D) Any occurrence involving physical, sexual, or verbal abuse of a client, by another client, an employee of the licensee or a visitor to the facility or agency. b. Chapter VII regulations governing assisted living residences, part 2.1, defines"Abuse" means subjection to sexual conduct or contact that is classified as a crime.c. According to the Occurrence Reporting Manual, dated May 2018, the residence must report an occurrence to the Department when: "Any occurrence involving physical...abuse .. Based on records review and interview, the residence failed to complete a comprehensive assessment at the time of move-in for the one of five residents (#3). (Cross Reference-U0410 and U1322)Findings include:The residence Admission policy, read in part, a preadmission assessment is completed on all residents who apply for admission to this residence. The residence administrator and/or his or her designee will complete an in-person, on-site evaluation of each new admission. The facility administrator and/or his or her designee agrees to admit only those residents whose needs can be met by the programs offered at the facility and/or in conjunction with agencies, individuals, and others with which the facility has written contracts or agreements.Resident #3 was admitted to the residence on 12/11/25 with diagnoses including dementia. On 1/13/26, a review of Resident #3' s record revealed the residence had not completed a comprehensive assessment prior to move-in to the current residence. On 1/13/26 at ..

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 4/26/23. 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

The facility failed to provide the final report for Missing Person occurrence event #2323N684001. The facility failed to provide the final report for Missing Person occurrence event #2323N684001.The findings:A.The facility submitted an initial Missing Person occurrence report on 4/20/2023. The facility failed to provide the final report within the required timeframe.1. Department staff sent electronic late final report notices through the COHFI system on 5/2/2023, 5/8/2023 and 9/21/2023.2. On 5/11/2023, department staff sent an external email to a facility representative requesting submission of the final report. 3. On 6/13/2023, department staff phoned the facility representative requesting submission of the final report.Following 9/21/23, the facility has made no attempts to contact the Department regarding the status of the final report. As of 2/20/2024, no final report has been submitted for review.

A relicensure survey with complaint #CO31830 was completed on 4/26/23. Deficiencies were cited. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of three sample residents (#1). (Cross-reference Q1110)Findings include:1. References a. According to the Health Facilities and Emergency Medical Services Division Occurrence Reporting Manual (2018), an occurrence should be reported to the department "Any time that a resident or patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident' s health, safety or welfare at risk or, regardless of whether such circumstances exist, the patient or resident has been missing for eight hours." b. Chapter VII regulations governing assisted living residences, section two.. Based on record review and interview, the residence failed to perform and document routine monthly testing of all equipment and devices used to secure the environment, affecting 16 current residents.Findings include:The residence' s undated Secured Environment Disclosure/Secure Door Checks/Resident Checks policy, read, in part, "The doors and gates that lead to the street and/or parking lot are on a delayed egress locking system ... Door checks are conducted twice weekly. Maintenance will test all doors and alarm systems. They will keep record of any faulty doors, alarms boxes or egress bars ... Administrator will do quarterly audits to ensure all checks are done and done properly."The residence' s undated Restrictive Egress Alert Devices policy, read, in part, "(Residence) will conduct mo.. Based on record review, interview and observation, the residence failed to provide a safe and sanitary environment affecting 16 current residents and protective oversight affecting one sample resident (#1). Findings include:1. Protective oversighta. Chapter VII regulations governing assisted living residences, section two, defines "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 r.. 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 Assisted Living Residence program regulations. 10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.11.5 The assisted living residence shall review its resident agreements annually and update or amend them as necessary. Amendments to the resident agreement shall also be signed and dated by both parties.(A) When a change of ownership occurs, the new owner shall either acknowledge and agree to the terms of each existing resident agreement or estab..