Gardens Care Homes - Indian Tree, the

A licensure complaint, prompted by #CO41596, was completed on 2/25/26. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to have one functioning bathroom for every six residents, affecting nine current residents. (Cross-reference U1110)Findings include:1. ObservationOn 2/25/26, from 7:30 a.m. to 3:30 p.m., during an environmental tour of the residence, one full bathroom had a sign reading "out of service, do not use." There were two more bathrooms down the main hallway of the residence; however, only one toilet was fully functional. The other toilet was not flushing properly. Resident #7 was seen using that bathroom and was unable to flush the toilet. Staff had to remove the toilet tank lid and pull the metal string to flush the toilet for the residents. 2. Record ReviewA maintenance form, dated 2/24/26, read the toilet in the middle of the house still d.. Based on observations, record review, and interviews, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment, including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, and personal services, affecting nine residents. (Cross-reference U2670)Findings include:1. ObservationsOn 2/25/26 at approximately 7:30 a.m., during an environmental tour of the residence, a strong sewage odor was detected. The fully accessible bathroom located in the northwest wing had a sign taped to the outside of the door stating "out of service." The door to the left, leading to the laundry room, was blocked by a box of copy paper c.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four residents whose medication was reviewed (#1-#4). Findings include:1. Resident #1 was admitted to the residence on 3/16/25 with a diagnosis consisting of preglaucoma, dry eye syndrome, and hypertension with inflammation to the left lower extremity and dermatitis. a. LatanoprostA written practitioner' s order, dated 1/15/26, directed the residence to administer Latanoprost 0.005%, one drop into both eyes once daily at bedtime. However, the February 2026 Medication Administration Record (MAR) indicated it was not administered on 2/15/26 due to the medication being unavailable.b. LidocaineA written practiti.. 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 7.7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (C) The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training, and shall include, but is not limited to, the following topics: (1) Overview of state regulatory ove..

A relicensure revisit was completed on 1/7/25 for the previous deficiencies cited on 10/2/24. 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 survey was completed on 10/2/24. Deficiencies were cited. Based on observation and interview, the residence failed to keep the residence grounds free of garbage and rubbish, affecting 10 current residents.Findings include:On 10/1/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m, the backyard of the residence had a broken plastic container, tipped-over flower pots, an upside table with no surface, other broken furniture, and plastic wrapping under the overgrown trees. The backyard of the residence also had a used medical gloves, metal sheet material, leaves, sticks, large branches and an abundant amount of apples on the ground that were attracting wasps. The backyard patio of the residence had a used disposable medical gloves on the ground, leaves and sticks scattered, an open package of snow melt ice in a planter bag, a full f.. Based on observation and interview, the residence failed to keep the residence porches in good repair, affecting 10 current residents.1. ObservationOn 10/1/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m, the backyard patio was observed to have chipped and broken tile flooring at the edge of the patio on the left hand side. On 10/2/24 throughout the onsite visit from approximately 7:00 a.m. to 5:00 p.m, the front porch was observed to have unsecured tile as the floor that shifted when being walked on.2. InterviewOn 10/2/24 at approximately 4:00 p.m., the operations compliance officer confirmed that the residence' s front porch and backyard patio was not in good repair and could be a tripping hazard for residents. The operations compliance officer stated she submitted a work o.. Based on record review, observation, and interview, the residence failed to detail in a resident' s care plan with the individualized approach necessary to address fall risk related to deficits, affecting one of three sample residents (#2).Findings include:Specifically, Resident #2 with a diagnosis of osteoporosis, osteoarthritis, chronic obstructive pulmonary disease, and a seizure disorder had three falls within 22 days. On 8/22/24, Resident #2 had an unwitnessed fall that resulted in injuring her arm on the edge of a dresser. On 8/23/24, Resident #2 had an unwitnessed fall that resulted in a bruise on her knees. On 9/13/24, Resident #2 had an unwitnessed fall that resulted in hitting her head on the wall, a skin tear on her left knee, and a small puncture wound near her right rib. The fall on 9/13/24 resulted in .. 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 VII6.8 The administrator, or individual appointed as an interim administrator, shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (A) Managing the day-to-day delivery of services to ensure residents receive the care that is described in the resident agreement, the comprehensive resident assessment, and the resident care plan; (B) Organizing and directing the assisted living residence ' s ongoing functions including physical maintenance; (C) Ensuring that resident..

A licensure complaint, prompted by #CO30797, was completed on 8/11/23. A deficiency was cited. Based on interview and record review, the residence failed to implement the required process pending discharge of reassessing the resident to be discharged; revision of their care plan to identify current resident needs and what services to provide to meet those needs; and, ensure staff were aware of new directives and properly trained, affecting one sample resident (#1). Findings include:1. Residence Policya. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as any person who is 70 years of age or older.b. The residence' s undated discharge policy read in part that a resident may be discharged from the residence when the residence could not protect the resident from harming themselves or others.c. The residence' s undated resident agreement read in part that the resident may be discharged when the resident posed a danger to self or others. 2. Resident #1 was admitted to the residence on 5/9/15, with diagnoses including dementia.A face sheet for Resident #1 read that her date of birth was 4/14/47, which meant she was 76 years old on 8/3/23.A local law enforcement report, dated 2/3/23, read in part that on 2/3/23 at 11:11 p.m., local law enforcement responded to a welfare check after concerned employees at a local supermarket reported an elderly customer who could not secure a ride home. At 11:20 p.m. local law enforcement provided Resident #1 a courtesy ride to the residence. An assessment, dated 2/7/23, read in part Resident #1 was a wandering risk, elopement risk, had poor safety awareness, and had behaviors. Resident #1 required supervision on outings, would need redirection to prevent elopement, and was cognitively unable to safely manage affairs independently. A progress note, dated 2/12/23, written by the former administrator designee (AD), read in part Resident #1 left the residence on 2/4/23 at 8:00 p.m. by taxi. She was returned to the residence by local law enforcement. A care plan, dated 2/16/22, read in part that Resident #1 displayed independence with shopp..