Gardens Care Homes - Coyote Creek Memory Care, the

A licensure revisit was completed on 3/24/25 for all previous deficiencies cited on 8/27/24. The residence is in compliance with all regulations surveyed. 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 and complaint revisit was completed on 3/24/25 for all previous deficiencies cited on 8/27/24. A deficiency was cited. Based on record review and interview, the residence failed to report and investigate an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations, affecting two of seven sample residents (#6 and #11).This deficiency was cited previously during a state licensure survey on 8/27/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewAccording to the Occurrence Reporting Manual, dated May 2018, the residence must report an occurrence to the Department when: "Any occurrence involving physical...abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility. Two elements (were) needed: Intent OR Knowingly OR Recklessly AND Bodily injury."Resident #11 was admitted to the residence on 2/19/25 with diagnoses of type II diabetes mellitus with diabetic chronic kidney disease, low back pain, and dysphagia. A progress note, dated 3/2/25, read in part that Resident #11 was outside with two other residents (both unidentified); when she came into the residence, she stated that one of those residents attacked her.A progress note, dated 3/8/25, read in part that an incident report was created for Resident #11 due to a resident-to-resident altercation.An incident report, dated 3/8/25, read in part that Resident #11 was in another (unidentified) resident' s room and they began to argue. The (unidentified) resident had dug their nails into Resident #11' s arm and it began to bleed from a previous scab. Staff did not provide first aid. Resident #11 reported a pain level of 10 and requested a practitioner examine their arm.On 3/24/25 at approximately 9:18 a.m., occurrence reports for the incidents that occurred in the month of March were requested, however, none were provided. Additionally, a review of the depart..

A relicensure survey with complaint #CO37233 was completed on 8/27/24. Deficiencies were cited. Based on record review and interview the residence failed to comply with occurrence reporting required by state law, and to submit its final report to the department within five business days after the initial report, affecting one (#9) of three sample residents.Findings include:1. Residence PolicyThe residence ' s undated policy and procedure read in part, allegations and/or incidents of abuse or neglect were reported to the Health Facilities Division of the Colorado Department of Health by the administrator or designee, as indicated by regulations. According to this document, the administrator would be responsible to notify adult protective services (APS) as soon as possible or within 24 hours of the occurrence. 2. Record ReviewAn incident report (IR), dated 8/18/24 read in part, the house manager (HM) noted in the follow up section of the report that Resident #9 sat outside in the sun for 90 minutes in 96 degree Fahrenheit weather. The report read the incident was "not reportable". Additionally it read that APS was not notified.. Based on record review and interview the residence failed to provide protective oversight including but not limited to, taking appropriate measures when confronted with an unanticipated situation and the identification of urgent issues or concerns that require an immediate and individualized approach, affecting one of three sample residents (#9).Specifically, on 8/18/24, Resident #9 was in the outside courtyard for 90 minutes in 96 degree Fahrenheit weather. The resident was sent to the emergency department with a 102 degree temperature and was at risk for a heat stroke. It took four staff to get the resident into the residence because the resident was slumped over and resisting care. Findings include:1. Residence PoliciesThe residence ' s undated residence policies, titled residents rights, read in part, the resident has the right to be treated with dignity and respect and the right to be free from neglect.The residence ' s undated residence policies, titled caregiver definitions read in part, caretaker .. Based on record review and interview, the residence failed to report suspected physical or sexual abuse, exploitation and/or caretaker neglect of an at-risk person to law enforcement within 24 hours of observation or discovery affecting one (#9) of three sample residents.Findings include:1. Residence policyThe residence ' s undated quality management program read in part staff engaged in care of at-risk persons shall report physical abuse or caretaker neglect to law enforcement (LE) within 24 hours.On 8/21/24 at approximately 9:40 a.m., the undated policy and procedure read, any actual or suspected acts of abuse would be reported to the appropriate authorities and a thorough investigation would take place.The residence ' s undated policy titled mandatory reporting, read in part the administrator would notify as soon as possible or within 24 hours of the occurrence; the residents family, the police department, the department of social services, adult protective services, and the occurrence reporting line. 2. Record reviewAn incident report (IR),..

A licensure revisit was completed on 8/27/24 for the previous deficiencies cited on 9/1/22. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on record review and interview the residence failed to provide protective oversight including but not limited to, taking appropriate measures when confronted with an unanticipated situation and the identification of urgent issues or concerns that require an immediate and individualized approach, affecting one of three sample residents (#9).This deficiency was cited previously during a state licensure survey 9/1/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Specifically, on 8/18/24, Resident #9 was in the outside courtyard for 90 minutes in 96 degree Fahrenheit weather. The resident was sent to the emergency department with a 102 degree temperature and was at risk for a heat stroke. It took four staff to get the resident into the residence because the resident was slumped over and resisting care. Findings include:1. Residence PoliciesThe residence ' s undated residence policies, titled residents rights, read in part, the resident has the right to be treated with dignity and respect and the right to be free from neglect.The residence ' s undated residence policies, titled caregiver definitions read in part, caretaker neglect means neglect that occurs when adequate clothing, shelter, physical care, medical care, supervision, or any .. 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