Gardens Care Homes - Memorial Park Assisted Living 1, the

A recertification survey with complaint #CO39532 was completed on 7/29/25. A deficiency was cited. Based on observations, records review, and interviews, the facility (residence) failed to meet a minimum of one staff to 10 members (residents) during daytime, affecting 12 current members.Findings include:1. ObservationsOn 7/29/25 from 7:00 a.m. to 3:00 p.m., two staff members were present from 7:00 a.m. until approximately 10:00 a.m., when the support staff ' s shift ended. The administrator designee (AD) arrived at approximately 8:00 a.m. and floated between the assisted living residence and a sister residence (SR). The AD floated between the residence and the SR approximately every hour, alerting Staff #1 each time she was leaving the residence.2. Record Reviewa. Resident Agreement and CensusThe residence template resident agreement, undated, read in part: The residence employed sufficient staff to ensure the provision of services necessary to meet the needs of the residents. This included trained staff members for both the assisted living and memory care secured environments. Staffing considerations included: services to meet the residents' needs, services to be provided under the care plan, and services to be provided under the resident agreement.A resident roster, dated 7/16/25, revealed that 12 residents resided in the residence.b. Staff ScheduleA staff schedule for 7/27/25 through 8/2/25 revealed the following staffing pattern:On 7/27/25, from 6:00 a.m. to 6:00 p.m., one assisted living (AL) staff member (Staff #5) was scheduled.On 7/27/25, from 7:00 a.m. to 3:00 p.m., Staff #6 was scheduled to float between the residence and the SR.On 7/27/25, the residence scheduled only one staff member from 6:00 a.m. to 7:00 a.m., and from 3:00 p.m. to 6:00 p.m., and intermittently had only one staff member on-site from 7:00 a.m. to 3:00 p.m.On 7/28/25, from 6:00 a.m. to 6:00 p.m., Staff #1 was scheduled.On 7/28/25, from 6:00 a.m. to 9:00 a.m., Staff #3 was scheduled to float between the residence and the SR.On 7/28/25, from 8:00 a.m. to 4:00 p.m., the AD was scheduled to manage both the residence and the SR.On 7/28/25, the reside..

A relicensure survey with complaint #CO39530 was completed on 7/29/25. A deficiency was cited. Based on observations, record review, and interview, the residence failed to maintain sufficient staffing to help residents needing or potentially needing assistance, affecting 12 current residents.Findings include:1. ObservationsOn 7/29/25 from 7:00 a.m. to 3:00 p.m., two staff members were present from 7:00 a.m. until approximately 10:00 a.m., when the support staff ' s shift ended. The administrator designee (AD) arrived at approximately 8:00 a.m. and floated between the assisted living residence and a sister residence (SR). The AD floated between the residence and the SR approximately every hour, alerting Staff #1 each time she was leaving the residence.2. Record Reviewa. Resident Agreement and CensusThe residence template resident agreement, undated, read in part: The residence employed sufficient staff to ensure the provision of services necessary to meet the needs of the residents. This included trained staff members for both the assisted living and memory care secured environments. Staffing considerations included: services to meet the residents' needs, services to be provided under the care plan, and services to be provided under the resident agreement.A resident roster, dated 7/16/25, revealed that 12 residents resided in the residence.b. Staff ScheduleA staff schedule for 7/27/25 through 8/2/25 revealed the following staffing pattern:On 7/27/25, from 6:00 .. 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 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.(A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI).(B) If the applicant has lived in Colorado for three years or less at the time of application, the assisted living residence shall obtain a name-based criminal history report for each state in which the applicant has lived for the past three years, conducted by the respective states ' bureaus of investigation or equivalent state-level law enforcement agency or other name-based report as determined by the Department.(C) The cost of obtaining such information shall be borne by the assisted living residence, the contract staffing agency or the individual who is the subject of such check..

A recertification revisit was completed on 10/11/24 for the previous deficiency cited on 3/15/24. The facility is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. The deficiency cited for Event QD1U14 was cited prior to the regulation revision that was implemented on 1/14/24. 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 revisit was completed on 10/11/24 for the previous deficiency) cited on 3/15/24. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 1/14/24.The deficiency cited for Event 7G2Z413 was cited prior to the regulation revisions that were implemented on 6/14/23 and 7/1/24, respectively. 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 revisit was completed on 10/11/24 for the previous deficiency cited on 3/15/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. 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