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 revisit survey was completed on 3/27/23 for all previous deficiences cited on 9/20/22. 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