Gardens on Quail

A licensure complaint, prompted by #CO37570, was completed on 10/1/24. Deficiencies were cited. Based on interview and record review, the residence failed to investigate an allegation of abuse in accordance with the residence' s written policy, affecting one sample resident (#2). The residence' s abuse and neglect policy, dated 7/1/24, read that the residence completed the following steps when investigating an allegation of physical abuse: the residence described the investigative steps taken and attempted to have a conversation with the residents involved and made notes of the conversation. The residence included in the notes the residents' reactions and responses to the incident. The residence assessed the residents for injuries. The residence documented the conclusion of the investigation. The residence documented how the residence kept the residents safe while the investigation was conducted. The residence documented the actions the residence took with the alleged assailant. Documented interventions that were put in place to ensure there was not a repeated incident.Documentation of an investigation of physical abuse, dated 7/24/24, read in part: "(Resident #3) was agitated and began stating that she owned the building and began trying to force other residents out of their rooms. (Resident #3) would hit (caregiver) and QMAP [qualified medication administration person] when trying to redirect the resident away. The resident then entered th.. Based on observation, record review and interviews the residence failed to ensure resident care plans include how residents will have continuous independent access to their room, along with the residence plan to protect residents from unwanted visitation by other residents, affecting five sample residents (#1-#5) who resided in a secure environment (SE). (Cross-reference S1410).Findings include:1. Residence PolicyThe residence' s Enhanced Resident Care Plan policy, dated 1/1/24, read in part, each resident of the secure environment will have an enhanced resident care plan. The enhanced care plan for each resident in a secure environment shall include a description of how the resident will have continuous independent access to his or her individual room and include the plan to protect the resident from unwanted visitation by other residents.2. Resident #1 was admitted to the residence on 5/30/24 with a diagnosis including dementia. On 10/1/24 at 2:00 p.m., Resident #7 opened the door to another resident' s room, looked inside, closed the door, and opened and closed the door again and walked away. An incident report, dated 6/4/24, read in part, Resident #1 stated she was hit by another resident. Resident #1 stated another resident was lying in her bed and she was hit by the other resident when she attempted to get the resident out of her bed.The care plan, dated 7/11/..

A licensure complaint prompted by #CO36049 and #CO36112 was completed on 6/12/24. Deficiences were cited. Based on interview and record review, the residence failed to ensure the electronic medication administration records (eMARs) contained accurate information, affecting two of four sample residents whose medications were reviewed (#1 and #2). Findings include:1. Residence PolicyThe residence' s undated Medication Administration policy read in part: "each qualified medication administration person (QMAP), nurse or practitioner must accurately document each medication administration or monitoring event at the time the event is completed for each resident."2. Resident #1 was admitted to the residence on 10/21/22 with a diagnosis of dementia.a. EscitalopramA written practitioner' s order, dated 8/17/23, directed the residence to administer escitalopram 10 mg twice daily. However, the August through D.. Based on observation, interview, and record review, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting three of five residents (#1-#3).Findings include: 1. Residence Policy The residence' s undated Medication Administration policy read in part, "Prescription and non-prescription medications must be administered by a qualified medication administration person (QMAP) only upon written order of an authorized practitioner." 2. Resident #2 was admitted to the residence on 3/10/23 with diagnoses including eye disease (dry eye) and insomnia.a. LatanoprostA written practitioner' s order, dated 3/27/24, directed the residence to administer latanoprost 0.005% eye drops one drop in each eye at bedtime. However, the March through .. Based on observation, record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting 26 current residents that resided in the secure environment.Findings include:1. Residence PolicyThe residence' s Unanticipated Illness and Serious Injury policy, dated September 2019, read in part: "In the event that an individual resident experiences an unanticipated illness or injury, emergency care will be provided ... the community notifies a resident' s emergency contact person, the primary care provider, and the appropriate case managers when an unanticipated illness (or) serious injury ... occurs." However, the policy failed to include how the residence w.. Based on observation, record review, and interview, the residence failed to ensure the resident agreement did not relieve the residence of compliance with any requirement under state regulation, affecting 26 residents that resided in the secure environment (SE).Findings include:1. Reference and Residence Policya. The residence' s undated resident agreement read in part, "The resident is responsible for any personal hygiene products and any paper goods ..."However, the resident agreement was written to relieve the residence from compliance with Chapter VII regulation, part 22.23.b. Chapter VII regulations governing assisted living residences, part 22.23, requires that each assisted living residence shall provide toilet paper in each resident bathroom, except where a resident has a specific ..

A licensure complaint prompted by #CO30634 and #CO31397, was completed on 3/27/23. Deficiencies were cited. Based on interviews and record reviews, the residence failed to ensure the qualified medication administration personnel (QMAP) did not perform decision making regarding PRN or "as needed" medication administration or administer medications for the purpose of restraint, affecting one sample resident (#3) in the secured environment who was administered PRN medication when unable to request it. (Cross-reference Q1180, Q1312, Q1146 and Q2960)Findings include:1. References and Residence Policya. The residence' s undated medication policy, read in part: "medication may not be administered by a qualified medication administration person on a PRN or as needed basis ex.. Based on observation, interview and record review, the residence failed to ensure the residents had the right to be free from restraint affecting one current resident (#3). (Cross-reference Q1180, Q1146, Q1428 and Q2960)Specifically, on 3/19/23, Resident #3 was found by her hospice nurse in the dining room of the secured environment in distress attempting to get out of her wheelchair. However, Resident #3 was unable to get out of her wheelchair as staff buckled the resident in the chair with a seatbelt. External hospice informed staff that they were restraining the resident and directed them to unbuckle the seatbelt. Resident #3 once the restraint was released became relieved a.. Based on observation, record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' conditions changed from baseline status, affecting one of five sample residents (#3). (Cross-reference Q1180).Findings include:1. Reference a. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items: (J) History and circumstances of recent falls and any known approaches to prevent future falls. 2. Resident #3 was admitted to the residence on 3/25/22, with diagnoses including dementia and arthritis. Resident #3 was admitted to .. Based on observation, record review and interviews, the residence failed to implement a fall management program, affecting two of two sample residents (#3, #8). (Cross-reference Q1146 and 1428).Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.9, defines a "care plan" as a written description in lay terminology of the functional capabilities of an individual, the individual' s need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual' s needs. In order to deliver person-centered care, the care plan shall take into account the resident' s p.. Based on record review and interview, the residence failed to ensure resident care plans contained a description of the resident' s known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident, affecting one of one sample residents (#3) who resided in the secure environment. (Cross-reference Q1146, Q1312 and Q1428).Findings include:1. Residence PolicyThe residence' s undated Enhanced Resident Care Plan policy, read in part: "The care plan for each resident residing in the secure memory care will include a description of the resident' s wandering patterns and known behavioral expressions, along with the individua..