Sunshine Gardens West Assisted Living

A revisit survey was completed on 1/14/25 for previous deficiencies cited on 10/23/24. The agency 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

A revisit survey was completed on 1/14/25 for previous deficiencies cited on 10/23/24. The agency 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

A licensure revisit was completed on 10/23/24 for all previous deficiencies cited on 6/28/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on record review and interview, the residence failed to keep annually updated comprehensive assessments for each resident or update comprehensive assessments after a resident' s condition changed from baseline status, affecting three of 17 sample residents (#32, #33, and #38).This deficiency was cited previously during a state licensure survey completed on 6/28/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewResident #32 was admitted to the residence on 1/3/20 with diagnoses of dementia, major depressive disorder, and hypertension.A comprehensive assessment for Resident #32, dated 6/6/24, read in part that Resident #32 displayed unsafe behaviors such as stealing and hoarding colorful items which did not belong to the resident. Resident #32 could become verbally abusive when upset. Resident #32 also wandered but did not elope.A progress note, dated 9/20/24 at 1:00 p.m., read in part that Resident #32 was "rude" to an external service provider (ESP). Resident #32 made "mean" statements to the ESP and stated she did not like them.A progress note, dated 10/16/24 at 1:00 a.m., read in part that Resident #32 hit another resident in the back with a closed fist in the dining room at 8:02 a.m. This was verified on a video recording. The other resident told her not to do that. Resident #32 then went back to the table she was sitting at with her family, and the other resident went back to the table to tell them that kind of behavior was not acceptable.A progress note, dated 10/16/24 at 10:30 a.m., read in part that Resident #32 was observed kicking another resident in the back in the dining room. The other resident was using a walker, and walking to a table. This was on a video recording as well.2. InterviewOn 10/23/24 at 11:00 a.m., the administrator acknowledged that the residence should have updated the comprehensive assessment after Resident #32' s behavior issues started escalating...

A recertification survey with complaints #CO34712, #CO34608, #CO34233, #CO34230, and #CO34173 was completed on 10/23/24. Deficiencies were cited. Based on observation and interview, the facility failed to ensure common areas of the residential setting were free from cameras affecting 48 current residents.Findings include:On 10/22/24 at 8:00 a.m., observations revealed cameras were installed in each of the hallways with member living spaces.On 10/22/24 at 2:00 p.m., the administrator acknowledged that the facility was not free from cameras in the common areas and stated the cameras were used to resolve complaints, prevent theft, and report fall events. Based on record review, observation, and interview, the facility (residence) failed to provide the opportunity for members (residents) to have meaningful input in menu planning, affecting 48 current residents.Findings include:Resident council meeting notes for August through October 2024 read that residence provided residents with an opportunity to plan one single monthly meal.During the onsite visit on 10/22/24, Residents #39 and #40 expressed in their interviews that they would like to have more input in the meal planning process and stated that the residence did not ask them what their preferences were for daily or weekly meals. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10, Section 8.7000.8.7505.F Alternate Care Facility Provider Agency5. Environmental Standards a. The Alternative Care Facility shall be an environment that supports individual comfort, independence, and preference, maintains a home-like quality and feel for Members at all times, and provides Members with unrestricted access to the Alternative Care Facility in accordance with the residency agreement or modifications as agreed to and documented in the Member' s Person-Centered Support Plan. b. Alternative Care Facilities shall provide an outdoor area accessible to Members without staff assistance that is well maintained, facilitates community gatherings, and is appropriately equipped for the population served. c. Alternative Care Facilities shall maintain a co..