Gardens Care Homestead

A relicensure survey with complaint #CO39720 was completed on 1/13/26. Deficiencies were cited. Based on observations and interviews, the residence failed to ensure all interior areas were free from accumulations of extraneous materials, affecting 32 current residents. (Cross-reference U1110, U2510)Findings Include:Observations.. Based on observations and interviews, the residence failed to ensure that qualified medication administration persons (QMAPs) apply nationally recognized protocols for basic infection control and prevention when preparing and adminis.. Based on observations and interviews, the residence failed to ensure the outdoor smoking area was monitored when residents were present, affecting 32 current residents. (Cross-reference U1110, U1382, U2702)Findings Include:Obser.. Based on observations and interviews, the residence failed to keep the grounds free of garbage and rubbish, affecting 32 current residents. (Cross-reference U1110, U2610)Findings Include:Observations on 1/13/26 starting at 7:3.. Based on observations, records review, and interviews, the residence failed to list all possible actions to be taken by the residence if any house rules are knowingly violated by a resident, affecting 32 current residents. (Cross-referenc.. Based on observations, records review, and interviews, the residence failed to prohibit smoking in areas where oxygen was used, affecting 32 current residents. (Cross-reference U1110, U1382, U2722)Specifically, the residence failed to .. Based on observations, records review, and interviews, the residence failed to provide a physically safe and sanitary environment and personal services either directly or indirectly, through a resident agreement, affecting 32 current r.. Based on records review and interviews, the residence failed to develop written policies and procedures to ensure the continuation of necessary care for all residents for at least 72 hours immediately following any emergency, affecting .. Based on records review and interviews, the residence failed to ensure the resident agreement was signed and dated by both parties, affecting one (#3) of seven sample residents. (Cross-reference U1034)Findings Include:Resident #3 w.. Based on records review and interviews, the residence failed to have emergency policies that addressed all minimum requirements, affecting 32 current residents. (Cross-reference U0914)Findings Include:On 1/13/26 at 7:30 a.m., the .. Based on records review and interviews, the residence failed to review its resident agreements annually and amend, affecting five of seven sample residents (#2, #3, #4, #5, #1). (Cross-reference U1030)Findings Include:Resident #4 wa.. Based on records review and interviews, the residence failed to update the comprehensive assessment for each resident annually, affecting two of four sample residents whose assessments were reviewed (#1, #3). (Cross-referenc..

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 7/31/23. 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

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 7/31/23. 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

A licensure complaint, prompted by #CO32988 and #CO33014, was completed on 7/31/23. Deficiences were cited. Based on observation, interview and record review, the residence failed to ensure that residents rights included the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence, affecting seven of nine sample residents (#5-#9, #12 and #14).Findings include:1. Residence PolicyThe residence' s undated Resident Rights Policy, read in part that residents had the right to choice and personal involvement regarding care and services, including the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence.2. Staff ScheduleThe residence' s staff schedule revealed that staff worked a.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was completed for each resident along with each of their signatures and, if used, their initials, affecting three of four sample residents whose medications were reviewed (#7, #13, #14).Findings include:1. Residence PolicyThe residence' s undated Medication Administration Policy, read as part of the medication administration record, the community maintained a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials ... each qualified medication administration person, nurse, or prac.. Based on record review and interview, the residence failed to ensure that all qualified medication administration persons (QMAPs) were trained in and adhered to medication procedures that included identification of the right resident for each medication administration or monitoring by asking for the resident' s name or comparing the resident to a photograph maintained specifically for medication administration identification, affecting one of four sample residents whose medications were reviewed (#14).Findings include:1. Residence PolicyThe residence' s undated Medication Administration Policy, read in part that all qualified medication administration persons are trained in and adhere to the following medication administration procedures ... identification of the right resident for each medica.. 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 7.10.1 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.14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.

A licensure revisit was completed on 7/31/23 for all previous deficiencies cited on 4/6/23. Deficiencies were cited. Based on observation, interview and record review, the residence failed to ensure that residents rights included the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence, affecting seven of nine sample residents (#5-#9, #12 and #14).This deficiency was cited previously during a state licensure survey 4/6/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s undated Resident Rights Policy, read in part that residents had the right to choice and personal involvement regarding care and services, including the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence.2. Staff ScheduleThe residence' s staff schedule revealed that staff worked a.. Based on record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 39 current residents.Findings include:The department completed a licensure complaint on 4/6/23. The event resulted in seven cited deficiencies. Tag Q722 C was cited at harm level for failure to ensure there was sufficient staffing. Tag Q1180 C was cited at harm level for failure to implement a fall management program. Tag Q1312 C was cited at harm level for failure to ensure residents received the right to be treated with dignity and respect and the right to be free from verbal/emotional abuse, humiliation and intimidation. The due date for the residence to request informal dispute resolution (IDR) was 6/15/23. The department imposed a $1,000 fine payable 7/5/23.The residence did not appeal the immediate condition.As of the morning of the 7/27/23 onsite visit, review of the department database revealed the residence had not yet paid the required fine of $1000 due by 7/5/23. On 7/27.. 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 7.10.1 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.14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.