GARDENS AT COLUMBINE, THE

A relicensure survey was completed on 4/2/25. Deficiencies were cited.

Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 127 current residents. Findings include:On 4/1/25 at 8:07 a.m., the following records were requested from the administrator:All current staff cardiopulmonary resuscitation (CPR) and first aid certificatesFebruary, March, and April 2025 care staff and qualified medication administration person (QMAP) schedules, including call-off log and replacement staffElectronic health records (EHR) software accessResidence staff orientation and training curriculumInvoluntary discharge grievance policyStaff influenza vaccination tracking and infection mitigation planA list of 90 days of admissions and discharged residentsA list of 90 days of incident reportsA list of 90 days of internal grievances and complaint investigationsHowever, none of these we provided upon request. On 4/1/25 at 8:35 a.m., a printed slide show presentation was provided as an orientation curriculum; however, it did not meet the regulatory requirements. On 4/1/25 at 9:00 a.m., an assignment list of staff scheduled to work 4/1/25 was provided, as well as a schedule of dietary staff for one week. On 4/1/25 at 10:00 a.m., general access to the EHS software was granted. On 4/1/25 at 10:55 a.m., the following records were requested again from the administrator:All current staff CPR and first-aid certificationsPrinted schedule with staffed CPR/life saving certified employees from 3/1-4/7/25On 4/1/25 at approximately 12:00 p.m., full access to resident records in the EHS software was granted. On 4/1/25 at 12:45 p.m., a portion of the current staff's CPR and first aid certifications was provided, approximately four and a half hours after requested. On 4/1/25 at 1:00 p.m., the following records were requested for Staff #1-#3, and Former Staff #4:Hiring documentation and staff background checksOrientation and initial training On 4/1/25 at 2:00 p.m., the staff influenza vaccination tracking plan was provided approximately 6 hours after requested. On 4/1/25 at approximately 2:15 p.m., the following records were requested again from the administrator:Residence staff orientation and training curriculumOn 4/1/25 at 2:25 p.m., another portion of the current staff's CPR and first aid certifications was provided approximately six and a half hours after request. On 4/1/25 at 2:28 p.m., the administrator provided staff files for Staff #1-#3 and Former Staff #4 including a portion of their orientation and initial training. It did not include background check documentation for Staff #2. The following requested documents were never provided:A list of 90 days of admissions and discharged residentsA list of 90 days of incident reportsA list of 90 days of internal grievances and complaint investigationsOn 4/2/25 at 8:56 a.m. the background check for Staff #2 was requested again from the administrator. On 4/2/25 at 9:47 a.m., the administrator provided the required background check documentation for Staff #2 approximately twenty and a half hours after request. On 4/2/25 at 10:14 a.m., the administrator provided documentation for Staff #1-#3 of completed online Relias training modules. Additionally, he stated that there was no documented orientation or training for Former Staff #4 approximately 21 hours after request. On 4/2/25 at 10:55 a.m., the health and wellness director stated that not all staff CPR and first aid certifications were located in their file. She stated she would have to reach out to the staff to get copies from them. On 4/2/25 at 2:56 p.m., the administrator stated that he believed they provided documents as soon as possible.

Based on observation, interview, and record review, the residence failed to provide each staff member with initial orientation prior to providing any care or services to a resident for two sample staff (#1, #2) and one former staff (#4), affecting 127 current residents. (Cross-reference S0648 and S0664)Findings include: Chapter VII regulations governing assisted living residences, part 2.56, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein. The residence's Orientation and Training Policy dated 7/1/24 read in part the assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. A March 2025 medication administration record (MAR) for Resident #8 read Staff #1 worked on 3/29/25. Additionally, the March 2025 MAR for Resident #5 read Former Staff #4 worked on 3/2, 3/12, and 3/14-3/15/25 administering medication. On 4/1/25 at approximately 2:45 p.m., Staff #2 was observed working at the residence. Personnel files for Staff #1, #2 and Former Staff #4 read that their hire dates were:Staff #1, 3/18/25Staff #2, 3/16/25Former Staff #4, 2/13/25The personnel file for Staff #1 and #2 contained orientation ; however, they had not completed the required orientation to include topics such as emergency response policies and procedures, including: recognizing emergencies, relevant emergency contact numbers, basic first aid, automated external defibrillator (AED) use, if applicable, practitioner assessment. Where to immediately locate a resident ' s advance directive; and an overview of the assisted living residence ' s policies and procedures and how to access them for reference. The personnel files for Former Staff #4 contained no orientation. On 4/2/25 at approximately 2:46 p.m., Staff #2 stated that she had not completed the required orientation, as she was advised she had 30 days from her hire date on 3/6/25 to complete orientation. On 04/2/25 at approximately 10:55 a.m., the administrator and scheduling manager stated there were no additional orientation records to provide. On 4/2/25 at approximately 2:56 p.m., the administrator stated that he expected staff to be provided the required orientation but that it had not been completed.

Based on observation, interview, and record review, the residence failed to provide each staff member with training relevant to their specific duties and responsibilities for one sample staff (#2), affecting 127 current residents. (Cross-reference S0640 and S0664)Findings include: Chapter VII regulations governing assisted living residences, part 2.56, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein. The residence's 6.02 Training of Staff Policy dated 7/1/24 read in part the assisted living residence will provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. On 4/1/25 at approximately 2:45 p.m., Staff #2 was observed working independently at the residence. Personnel files for Staff #2, revealed a hire date of 3/16/25. The personnel file for Staff #1 contained training; however, she had not completed the required training such as recognizing behavioral expression and management techniques, as appropriate for the population being served; how to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served; food safety; and understanding the staff or volunteer ' s role in end of life care including hospice and palliative care. On 4/2/25 at approximately 10:55 a.m., the administrator and scheduling manager stated there were no additional training records to provide. On 4/2/25 at approximately 2:46 p.m., Staff #2 stated that she had not completed the required training, as she was advised she had 30 days from her hire date. On 4/2/25 at approximately 2:56 p.m., the administrator stated that he expected staff to be provided the required training but that it had not been completed.

Based on observation, record review, and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 127 current residents. Findings include: 1. Residence PolicyThe residences Required Certifications policy dated 7/1/24, read in part, there shall be at least one staff member present in the assisted living residence who has current certification in first aid from a nationally recognized organization. 2. Staff Schedule and First Aid CertificationsThe staff schedule from 3/30 to 4/2/25 and first aid certifications revealed 5 shifts from 6:00 a.m., to 8:00 a.m., had no one onsite with current first aid certification. 3. Interview On 4/2/25 at 2:56 p.m., the administrator stated he expected one staff member with a nationally recognized certification in first aid to be in the building at all times and acknowledged the shifts and times lacking someone with a first aid certification.

Based on observation, interview, and record review, the residence failed to ensure that at all times, at least one staff member who had current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization was onsite, which affected 127 current residents. Findings include 1. Residence policy The residence's minimum staffing policy dated 7/1/24, read in part, there shall be at least one staff member present in the assisted living residence who has current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization. 2. Staff Schedule and certifications in CPRThe staff schedule from 3/30 to 4/2/25 and CPR revealed 5 shifts from 6:00 a.m., to 8:00 a.m., had no one onsite with current CPR certification. 3. Interview On 4/2/25 at 2:56 p.m., the administrator stated he expected one staff member with a nationally recognized certification in CPR to be in the building at all times and acknowledged the shifts and times lacking someone with a CPR certification.

Based on observation and interview the residence failed to place in a visible location a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR), affecting 127 current residents. Findings include: On 4/1/25 at approximately 7:30 a.m., a posted list of staff with current first aid and CPR certification was requested. The provided document was not current or updated with staff that had current first aid and CPR certifications. On 4/1/25 at approximately 2:56 p.m., the administrator confirmed that a list of CPR and first aid certified staff was not updated or posted and stated he was aware it was a requirement. On 4/2/25 at 2:20 p.m., Staff #5 stated that she was unaware of a posted list of CPR and first aid certified staff anywhere in the residence. Staff #5 stated that one might be in the wellness office but she was not sure that to be true.

Based on record review and interview, the residence failed to evaluate the resident who had fallen and safely provide lift assistance when the resident had no pain, affecting one resident (#4) of 10 sample residents. Specifically, Resident #4 was admitted to the residence on 7/24/21 with diagnoses of Alzheimer's disease, eye disorder, macular degeneration, neuropathy, and osteoarthritis. He fell on 3/10/25 and hit his head. He fell again on 3/14/25 and reported lower back pain. He fell again on 3/16/25 and reported back pain and shortness of breath, as well as an abrasion on his chin; however, Resident #4 was lifted by staff without contacting emergency medical services (EMS) to evaluate the resident after reporting pain and shortness of breath. The residence's lift assistance policy, dated 7/1/24, read in part: If the resident experienced an increase in pain when lifting was attempted, then the staff would call 911. An incident report for Resident #4, dated 3/10/25, read in part: The resident pressed his pendant. When staff responded, she observed the resident on the floor. The resident had hit his head when falling, "resident did not want to go to the hospital [and] stated he was okay". An incident report for Resident #4, dated 3/14/25, read in part: Staff walked into the resident's apartment and observed the resident on the floor face down. The staff called for assistance and, with the help of three staff members, lifted the resident. The resident reported that he had lower back pain at a level of two out of ten. An incident report for Resident #4, dated 3/16/25, read in part: Staff entered the resident's apartment in response to the call pendant. Staff observed the resident on the floor face down. Staff assisted the resident up. Staff observed a rug burn on the resident's chin. The resident complained of back pain and shortness of breath. On 4/2/25 at 2:56 p.m., the administrator stated that he wanted staff to contact the nurse or EMS if a resident complained of pain, had a head injury, or was significantly injured in some other way before providing lift assistance. He stated that he agreed the residence had the responsibility of protective oversight and staff should always contact EMS or the nurse should Resident #4 report pain. He agreed that staff should not have provided lift assistance to Resident #4 if he was complaining of pain, shortness of breath, and had hit his head.

Based on record review and interview the residence failed to ensure qualified medication administration persons (QMAPs) did not assess residents or make decisions regarding administering medications pro re nata (PRN), affecting three of three sample resident (#1-#3) residing in the secure environment. Findings include:Resident #2 was admitted to the residence on 7/21/23 with a diagnoses including dementia, osteoarthritis and spinal stenosis. A written practitioner ' s order, dated 1/12/25, directed the residence to administer lorazepam 0.5 mg every four hours as needed. The March 2025 medication administration record (MAR) revealed that the memory care coordinator (MCC) administered lorazepam four times between 3/28-3/31/25. A written practitioner ' s order, dated 1/12/25, directed the residence to administer oxycodone 5 mg as needed three times a day. The March 2025 MAR revealed that the MCC administered oxycodone 5 mg on 3/17/25. On 4/2/25 at approximately 12:30 p.m., the resident care coordinator (RCC) stated that Resident #2 would not be able to request his lorazepam or his oxycodone due to cognitive decline. On 4/2/25 at approximately 1:30 p.m., the memory care coordinator (MCC) stated that if Resident #2 experienced pain, anxiety, or began to exhibit signs of behavioral expressions, she contacted hospice or the nurse and conducted an assessment of Resident #2's behavioral and facial expressions over the phone. She further stated that the nurse provided verbal confirmation that the pro re nata (PRN) could be administered by the QMAP.On 4/2/25 at approximately 3:24 p.m., the administrator acknowledged that QMAPs made assessments of the memory care residents and provided that information over the phone to hospice or a nurse. On 4/2/25 at approximately 3:45 p.m., the health and wellness director stated that she was unaware that QMAPs could not make an assessment for a PRN medication. She further stated that she was unaware of the regulation and it would be corrected immediately. Similar deficienct practice was found for Resident #1 and #3

Based on interview and record review, the administrator failed to routinely complete audits of the accuracy and completeness of medication administration records (MARs), medication error reports, and medication disposal records affecting all residents whose medications were managed by the residence. Findings include:The residence's MARs audit tool failed to indicate that the administrator had completed the audits quarterly. On 4/2/25 at 1:22 p.m., the resident care coordinator stated that she had completed the quarterly MAR audits and the administrator was not involved in reviewing the accuracy and completeness of the MARs. On 4/2/25 at 2:56 p.m., the administrator stated that the health and wellness director (HWD) and the previous administrator had originally completed the quarterly medication audits. He stated that the HWD and the resident care coordinator had been partnered on completing the audits since. He then stated that the new plan going forward was for the HWD and the administrator to complete them together. He finally explained that he and the HWD have not had time to complete the previous quarterly audit together.

Based on record review and interview, the residence failed to have a policy and procedure regarding the training of staff providing services in secure environment, which includes information on the appropriate staff response and procedure for the distribution of staff when a resident is deemed missing, ensuring continued supervision for all other residents, affecting 19 current residents in the secure environment. Findings include 1. Residence PolicyThe residence's Secure Environment Staff Training Policy dated 1/1/24 read, staff will be trained in the appropriate response when there is a missing resident and the distribution of the staff ensures there is sufficient staff to continue to supervise the other residents, see missing resident policy. The residence's Missing Resident Policy dated 7/1/24 read in part, the staff member that first notices the resident is missing will notify the Executive Director (ED), all coworkers within the building and the legal representative of the resident. Immediately search inside the building and the surrounding areas, notify the police department and create an incident report. The missing resident policy does not include a procedure for distribution of staff to supervise all other residents. 2. InterviewOn 4/2/25 at 2:56 p.m., the administrator stated he expected staff to notify all other staff in the building when a resident went missing. Staff were expected to reallocate all other residents to the common area and provide a distraction to the residents. The administrator acknowledged the residence's policy provided unclear procedure for staff distribution in compliance with the regulation.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident ' s condition changes from baseline status. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (A) A description of the resident ' s wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact; (B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR ' s plan to protect the resident from unwanted visitation by other residents; (C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and (D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.

A complaint revisit was completed on 04/02/25 for all previous deficiencies cited on 5/8/23. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO31981 was completed on 5/8/23. Deficiencies were cited.

Based on interview and record review, the residence failed to have a roster of current residents that included their emergency contact information, along with a residence diagram showing room locations, affecting 118 current residents. Findings include:On 5/8/23 at approximately 7:00 a.m. the resident roster was requested and provided. However, the resident roster did not include the residents' emergency contact information, along with a residence diagram showing room locations. On 5/8/23 at approximately 7:15 a.m., the receptionist stated the provided resident roster, in addition to individual face sheets, was what emergency services would have been provided. On 5/8/23 at approximately 12:37 p.m., the administrator stated he was not aware that residents' emergency contact information or a residence diagram showing room locations was required to be included with the resident roster. He stated that when emergency services entered the residence, they were provided with individual face sheets for each resident.

Based on observation, interview and record review, the residence failed to provide residents with protective oversight, affecting one of three sample residents (#1). Specifically, Resident #1 was admitted to the residence on 12/18/22 with diagnoses including arthritis. A care plan, dated 4/14/23, directed the staff to provide the resident with two person transfer assistance. However, on 4/26/23, Staff #1 improperly transferred the resident alone, which resulted in a skin laceration to the resident's left shin that required 11 stitches. Findings include:The undated sample resident agreement, read in part; the residence would provide protective oversight to all residents. Chapter VII regulations governing assisted living residences, part 2.38, defined "Protective oversight" as guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (A) Being aware of a resident's general whereabouts, although the resident may travel independently in the community; and (B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being. Resident #1 was admitted to the residence on 12/18/22 with diagnosis including arthritis. A care plan, dated 4/14/23, read in part; the resident required two person transfer assistance with a gait belt. An incident report, dated 4/26/23, read in part; a single staff member (Staff #1) transferred the resident alone, which resulted in a skin laceration the the left shin. A progress note, dated 4/26/23, read in part; Staff #1 transferred the resident from her bed to her wheelchair and her left leg got stuck on her wheelchair which caused a laceration. The resident reported pain. On 5/8/23 at 7:58 a.m., Staff #2 stated she worked on 4/26/23 when the skin laceration occurred. She stated she told Staff #1 to telephone for assistance when it was time to transfer the resident from her bed to her wheelchair. She also stated that all staff were aware that the resident required two person transfer assistance, however, Staff #1 never telephoned her for assistance. Additionally, Staff #2 stated she saw the resident's injury to her left shin, which resulted in 11 stitches. On 5/8/23 at 8:12 a.m., the administrator stated Staff #1 transferred Resident #1 alone on 4/26/23 which resulted in a large skin laceration to the resident's left shin. He confirmed the resident required two person transfer assistance and should not have been transferred with only one staff member. On 5/8/23 at 8:26 a.m., the wellness director stated Resident #1 required two person transfer assistance and that Staff #1 was aware of the requirement. However, she stated the staff member tried to transfer the resident alone, which resulted in a skin tear on the resident's left shin. She also stated the resident required stitches due to the skin laceration caused by the resident's wheelchair. On 5/8/23 at 11:05 a.m., Staff #1 confirmed she transferred the resident unsafely and without the help of another staff member on 4/26/23. She also confirmed she was aware the resident required two person transfer assistance, however; she thought she could do it on her own. Staff #1 stated the improper transfer caused a skin laceration to the resident's left lower leg. On 5/8/3 at 12:02 p.m., the external hospice nurse confirmed the resident required two person transfer assistance. However, she stated that Staff #1 transferred the resident alone which resulted in a large skin laceration to the resident's left shin. She stated the laceration required 11 stitches. On 5/8/23 at approximately 12:02, Resident #1 stated she could not remember how she sustained the injury. On 5/8/23 at approximately 12:02 p.m., the resident had a large black and blue area on her left shin. During a second interview on 5/8/23 at 12:37 p.m., the administrator confirmed that due to the improper transfer that resulted in a skin laceration of the resident's shin, the staff member failed to provide the resident with protective oversight as required.

A licensure complaint, prompted by #CO30469, was completed on 3/13/23. No deficiencies were cited.