GARDEN SQUARE AT WESTLAKE

A revisit survey was completed on 9/22/25 for all previous deficiencies cited on 4/30/25. The facility is in compliance with all deficiencies that were cited.

A relicensure survey with complaint #CO37344 was completed on 4/30/25. Deficiencies were cited. A change of ownership occurred on 1/3/25.

Based on interview and record review the residence failed to provide, upon request, access to relevant information from requested documents, affecting seven of seven (#1 - #7) sample residents (Cross-reference S2230). On 4/29/25 at 9:46 a.m., the executive director was emailed with a request for 90 days of incident reports, occurrences, investigations of unknown injury, grievances, complaints and investigations. On 4/29/25 at 2:30 p.m., the executive director said the items requested were considered internal documents by the residence's legal department and they would not be provided to the survey team. The executive director said she informed the legal department only documents for a sample of residents #1 - #7 were being requested, however, she was not permitted to provide the requested documents but she was still working on it. On 4/30/25 at 1:10 p.m., the onsite survey was concluded and the residence had not provided relevant information from documents requested by the department.

Based on observation, interview and record review the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#3). Findings include:ObservationOn 4/29/25 at 7:30 a.m., Staff #1 dispensed and crushed all scheduled medications listed on the medication administration record (MAR) except Duloxetine HCL capsule and a multivitamin adult gummies chew for Resident #3. 2. Record reviewResident #3 was admitted on 8/27/2 gastro-esophageal reflux disease (GERD). The record for Resident #3 failed to include a physician's order to crush medications. On 4/30/25 at 10:01 a.m., during the onsite visit, the executive director retrieved an order from the physician that read in part: Continue to crush medications due to risk of aspiration. 3. InterviewOn 4/30/25 at 7:35 a.m., Staff #1 said her MAR charting screen had displayed instructions to crush meds in the past but was unable to locate those instructions currently. On 4/30/25 at 8:30 a.m., the resident care coordinator (RCC) said she was unable to locate a physician's order to crush medications for Resident #3. The RCC said Duloxetine HCL capsule and a multivitamin adult gummies chew should not be crushed. The RCC said staff should not crush resident medications without a physician's order. On 4/30/25 at 9:00 a.m., the ED acknowledged the need for a physician's order prior to crushing and administering medication.

Based on record review and interview the residence failed to individualize resident care plans, require staff members to document any out of the ordinary events or issues, before the end of shift, regarding a resident they personally observed or was reported to them along with actions taken to address the residents changing needs and documentation of on-going services provided by external service providers, affecting two of seven sample residents (#1 and #4). Findings include:Record reviewResident #1 was admitted to the residence initially on 12/21/24 with a diagnosis of bipolar disorder. Resident #1 had a psychiatric hospitalization from 4/9/25 to 4/28/25 for mania. A progress note, created on 4/6/25 with an effective date of 4/1/25, read in part: Resident #1 had not slept for two consecutive nights and reported 'they' told him he could not sleep. Resident #1 was found lingering in front of another resident's room and when asked to return to his room he mumbled profanity while complying with the request. Resident #1 was found waking the same resident up at 3:00 a.m. Resident #1 was frequently up during the night and the physician was notified. Resident #1 was spoken to by the residence's executive director (ED) about entering another resident's room and being up all night. Resident #1 became angry and yelled that he was told to stay up by 'them', threw his hat and began shouting. The residence notified Resident #1's physician and requested the resident be seen by emergency medical services (EMS) for a behavior health evaluation. Resident #1 was seen by EMS and police. Resident #1 was initially yelling at EMS and the police but ultimately went with EMS for an evaluation. However, there was no other documentation for these out of the ordinary events. InterviewsOn 4/29/25 at 8:00 a.m., Staff #1 said Resident #1 had reported only sleeping three out of eleven consecutive nights to an overnight caregiver and had refused medications. Staff #1 said Resident #1 was normally compliant with medication administration and went to bed late but usually slept. Staff #1 said Resident #1 had returned to the residence on 4/28/25 from in patient care at a geriatric psychiatric unit. Staff #1 said pertinent information and out of ordinary events were passed through verbal communication and not documented anywhere so was unable to provide specific dates or accurate accounts or events leading to in-patient psych hospitalization. Staff #1 said they were made aware of Resident #1's sleepless and medication refusal when the executive director asked if she [Staff #1] observed out of the ordinary events for Resident #1. Staff #1 said resident care tasks for bathing, toileting and dressing were documented by staff on a tablet, however, approaches were not individualized. On 4/29/25 at 2:45 p.m., the ED said Resident #1 began displaying behavioral concerns with not sleeping or eating routinely on 4/3/25. The ED said the behavioral concern for Resident #1 was verbally reported to her by an overnight staff member. The ED said the information should have been documented in a progress note but was not. The ED said she unaware staff were required to document, before the end of shift, any out of ordinary events or issues personally observed or reported to them. The ED said when any out of ordinary events occurred they were documented in the electronic medical record (EMR) under risk assessments or an incident report was completed, however, these were considered internal documents. The ED said she had a meeting with Resident #1, his case manager from an outside agency and herself to discuss behaviors, however, the meeting notes had not been entered into the resident's record. The ED said a behavioral health crisis team was called on 4/7/25 after Resident #1 had continued sleeplessness, defecated on himself and believed people were stealing from. The ED said she would attempt to mental health notes from the outside agencies involved with Resident #1 because they had not been previously obtained or added to the resident's chart. On 4/30/25 at 7:30 a.m., Staff #2 said Resident #1 had not been sleeping, was incontinent of bowel for an entire day and would not change or allow staff assistance with cleaning, had refused medication administration for the overnight or evening staff, was pacing halls, cussing, knocking on various resident rooms and ran out of the building after a resident saying he was that residents POA. Staff #2 said she was unaware of the exact dates of events or when he went to the hospital and knew of behaviours through verbal communication. Staff #2 said, in her experience, Resident #1 was compliant with medication administration and pleasant in interactions. Staff #2 said shift reports and out of the ordinary events were verbally communicated from shift to shift and not written down. Staff #2 said resident care was documented using a tablet to record tasks of bathing, toileting, dressing and meals attended. On 4/30/25 at 12:09 p.m., the ED acknowledged care plans were not currently updated with individual approaches, adding, the electronic medical record (EMR) being used was new to her and she had recently learned how to add information. 3. Similar deficient practice was found for Resident #4.