Gardens Care Saddle Rock

An initial certification survey was completed on 12/24/25. A deficiency was cited. Based on observation and interviews, the facility (residence) failed to be in compliance with all applicable regulations.Findings include: 1. Record Review On 12/18/25, during the initial certification survey, the CDPHE database revealed the residence was a secure environment and had 64 licensed beds, which exceeded the maximum number of beds allowed under 8.7506.G. On 12/23/25 at 11:02 a.m., the administrator stated she was under the impression that the residence was allowed 30 beds under the alternative care facility standards for a secured environment, in addition to the beds that were private pay. Additionally, she was unaware that there was a maximum of 30 licensed beds in a secured environment and had not filed a waiver requesting additional licensed beds.

A revisit survey was completed on 11/4/25 for all previous deficiencies cited on 5/27/25. 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 relicensure survey was completed on 5/27/25. Deficiencies were cited. Based on observation and interview, the residence failed to ensure that controlled substances were stored in double-lock storage, affecting 26 current residents.Findings include:On 5/27/25 at 7:32 a.m., a medication refrigerator containing lorazepam concentrate 2 mg/mL was observed unlocked in a medication storage room, which .. Based on observation and interview, the residence failed to ensure that garbage and rubbish were contained in a tight-fitting container, affecting 26 current residents. Findings include:On 5/27/25 at 9:48 a.m., an environmental tour of the exterior of the residence revealed an area designated for garbage and rubbish. A brown rubbish bin lid wa.. Based on observation and interview, the residence failed to ensure that medications were stored in a locked cabinet, cart, or storage area when unattended by a qualified medication administration person (QMAP) or licensed staff, affecting 26 current residents.Findings include:On 5/27/25 at 7:32 a.m., a medication overflow cart containing medi.. Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) applied nationally recognized protocols for basic infection control and prevention during medication preparation and administration, affecting 26 current residents.Findings include:On 5/27/25 at 7:50 a.m., Staff #1 wa.. Based on observation and interview, the residence failed to ensure that screens on exterior opening windows fit with sufficient tightness to exclude pests, affecting 26 current residents.Findings include:On 5/27/25 at 7:18 a.m., observation of exterior windows revealed several with missing and ill-fitting screens.On 5/27/25 at 9:48 a.m., an env.. Based on observation and interview, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting 26 current residents. Findings include:On 5/27/25, during an environmental tour of the common use courtyard at approximately 7:00 to 7:30 a.m., slopes and tripping hazards were identified as follows: On.. Based on record review and interview, the residence failed to request, prior to hire, a correct named-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for one sample staff (#5), affecting 26 residents in a secure environment. Findings include:On 5/27/25, Staff #1 was observed providing care and services to.. Based on record review, observation, and interviews, the residence failed to ensure that chemicals that could pose a risk or danger were inaccessible in a designated storage area to residents, affecting 26 residents in a secure environment. Findings include: The current care plan for Resident #2, admitted to the residence on 12/7/23, read 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 7.8.8 Each assisted living residence shall place in a visible location a list of all staff who have ..

A licensure complaint, prompted by #CO34984 and #CO34995, was completed on 1/15/25. Deficiencies were cited. Based on observation, interview and record review, the residence failed to make available, either directly or indirectly through a resident agreement, protective oversight, affecting two of five sample residents (#1, #2). Findings include: 1. Residence PoliciesThe resident rights policy, undated, read in pertinent part: "The right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence."The medication administration policy, dated 10/26/24 read in pertinent part: "The community is responsible for complying with physician orders associated with the administration of medication or treatment ...this community coordinates care with external providers or accepts responsibility for performing all necessary care using community staff. This community trains staff regarding the parameters of the ordered care as appropriate."2. Resident #1 was admitted to the residence on 10/24/20 with a diagnosis including dysphagia.On 5/16/24, the authorized practitioner instructed the residence to modify the diet to a mechanical soft.Resident #1' s care plan dated 6/11/24, read in pertinent part: Resident #1' s diet was mechanical soft, nectar thick liquids at all times including medication administration, snacks, and hydration. Resident #1 required consistent assistance with all dietary needs.Resident #1' s six-month assessment dated 6/11/24, read in pertinent part: "Requires staff monitoring, verbal prompts and cues while eating for adequate and safe intake. Staff will be present during all meals and snacks and will provide physical assistance with eating as needed. Allow adequate eating time. Resident is on a Mechanical soft diet and nectar thick fluids. Encourage socialization and interaction with others during meals. Assist as needed with opening packets, pouring liquids, cutting foods, etc. Ensure that all snacks and beverages offered comply with any diet and fluid restrictions. Observe for and report any decrease in food or fluid intake, dehy..

A licensure complaint, prompted by #CO34678 and #CO34714, was completed on 1/24/24. Deficiencies were cited.A change of ownership occurred on 12/6/23. Based on interview and record review, the residence failed to maintain resident records for at least three years following the termination of the residents stay in the assisted living residence, affecting three of three sample residents (#1-#3) and three of three former residents (#3-#6). Findings include: On 1/23/24 at approximately 1:00 p.m., the resident records were requested for Residents #1-#3 and Former Residents #4-#6; however, the progress notes were not provided. On 1/23/24 at 2:25 p.m, the administrator designee stated that she had been having a difficult time in locating the progress notes for Residents #1-#3 and for Former Residents #4-#6 within the previous administration' s electronic record system. She added that the previous staff that had known how to access the records were no longer employed and therefore, she did not have access to the records as required. On 1/24/24 at 1:07 p.m., the administrator designee stated she was aware of the requirement that resident records are to be maintained for at least three years following the termination of a residents stay. She stated that her expectation was that she was taught how to access the records and that was not provided by the previous administration. She added that the system is not ' user friendly' and acknowledged that the records were not provided due to her not being able to access them. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioners orders associated with medication administration, affecting one of three sample residents (#1).Findings include:1. Residence Policy The residence' s Medication Administration Policy, dated 7/2019, read in part: "the community is responsible for complying with physician orders, associated with the administration of medication ..." 2. Resident #1 was admitted to the residence on 12/7/23 with diagnosis including parkinson' s disease and parkinson' s dementia. a. RytaryA written practitioner' s order, dated 11/29/23, directed the residence to administer Rytary 61.25- 245 mg three capsules daily at 6:00 a.m. no hour before or after window must be given at specific times each day.A medication error report, dated 1/16/24, for Resident #1 read that his Rytary medication was given at approximately 7:13 a.m. on 1/16/24. 3. Interviews On 1/24/24 at approximately 9:25 a.m., a family member of Resident #1 stated she had notified the residence that he had not received his 6:00 a.m. medication when she noticed via the two way camera in Resident' s #1 room that the qualified administration person (QMAP) had not come to administer the medication. She confirmed that the medication was given an hour past the specific ordered time and ..