BETHESDA GARDENS THORNTON

A licensure complaint, prompted by #CO42113, was completed on 6/15/26. No deficiencies were cited.

A complaint revisit was completed on 6/15/26 for the deficiencies cited on 2/12/26. The residence is in compliance with all regulations surveyed.

A complaint revisit was completed on 2/12/26 for the previous deficiency cited on 5/29/25. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25.

A licensure complaint, prompted by #CO41425 and #CO41603 was completed on 2/12/26. Deficiencies were cited.

Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of seven sample residents (#7-#10). (Cross-reference U1600)Findings include:1. Resident #7 was admitted on 8/8/19. A practitioner's order, dated 7/17/25, directed the residence to administer biotin 5,000 mcg once daily. However, the January and February 2026 medication administration records (MAR), read that Resident #17 did not receive their biotin 5,000 mcg from 1/30-2/11/26 for a total of 13 missed doses. On 2/12/26 at approximately 1:51 p.m., the administrator acknowledged that the residence was ultimately in charge of ensuring each resident under their care received their ordered medication to comply with the practitioner's order. 2. During the onsite visits on 2/11 and 2/12/26, similar deficient practice was found for Resident #8-#10.

Based on observation, record review, and interviews, the residence administered stock medication and failed to properly label over-the-counter medications with the residents' full names, affecting one of seven sample residents (#3). Findings include:1. Residence PolicyThe residence Medication System policy, dated 12/27/25, read in part: No stock or over-the-counter medication for resident use shall be kept in stock or bulk quantities. No medications are accepted for donation. 2. ObservationOn 2/11/26 at 8:30 a.m., an observation of the medication cart in the secure environment (SE) revealed a bottle of acetaminophen was not labeled with Resident #3's full name. Further observation of the medication storage room in the SE revealed two plastic bins labelled "overstock" contained medications, including but not limited to, vitamin B-12, zinc ointment, nystatin powder, acetaminophen, Pepto bismol, omega-3, D3, and multivitamin. An observation of the medication storage room of the assisted living revealed cabinets labeled "House Supply" contained medications, including but not limited to, glucosamine, vitamin B12, vitamin D3, acetaminophen, ibuprofen, Bayer low-dose aspirin, colace and multivitamins. 3. Record review A written practitioner's order for Resident #3's acetaminophen, dated 11/25/25, directed the residence to administer acetaminophen 500 mg tablets three times a day. 4. InterviewsOn 2/11/26 at 8:30 a.m., Staff #4 said if residents ran out of medications there was an overstock supply in the medication room. Staff #4 said if medications were not located in the medication cart or a resident's personal overstock supply, a second qualified medication administration personnel (QMAP) would double check, and if the medication was still not found, the memory care director (MCD) was informed and would pull from the overstock medication bin if available. Staff #4 said room numbers and not full names were used on over-the-counter medications to indicate which medications belonged to which resident. On 2/11/26 at 9:00 a.m., the MCD said if resident-specific medication was not found by a QMAP in the medication cart or the resident's specific supply, a second QMAP would look for the medication. If medications were not located, the QMAPS notified the MCD and the MCD would search the overstock bins and add the medication to the resident's supply if it was available. The MCD said some medication belonging to former residents were kept at the residence to administer to residents who needed them. On 2/11/26 at 9:00 a.m., the administrator acknowledged QMAP's and the MCD were utilizing stock medications for residents when the residents' medications were otherwise unavailable. On 2/12/26 at 1:56 p.m., the administrator said she was aware that all over-the-counter medications needed to be labeled with a resident's full name; however, she was not aware that this was not being done.

Based on records review and interviews, the residence failed to ensure staff accurately documented each medication administration event at the time the event was completed for two of seven sample residents (#7 and #10). (Cross-reference U1568)Findings Include:1. Resident #10 was admitted to the residence on 3/21/19. A practitioner's order dated 12/9/25 directed the residence to administer 110 mcg of fluticasone by inhaling two puffs a day. However, the February 2026 MAR read the medication was not available on 2/6-2/7/26 and from 2/9-2/11/26; however, read the medication was administered on 2/8/26. On 2/12/26 at approximately 10:40 a.m., the resident care coordinator (RCC) noted a staff error in recording the medication as administered on 2/8/26 and reported that she had confirmed this with the two staff members who documented it on the MAR, that it was not administered. On 2/12/26 at 1:59 p.m., the administrator acknowledged that she would expect staff to accurately document before the end of their shift. 2. There was a similar deficient practice for Resident #7.

A licensure complaint, prompted by #CO40128 was completed on 5/29/25. A deficiency was cited.

Based on record review and interview, the residence failed to ensure a resident had the right to be free from neglect, affecting one former resident (#1) who resided in the secure environment. Specifically, the residence failed to provide, in a timely manner, physical care and medical care for Resident #1. On 9/29/24, Resident #1 fell and sustained a closed fracture of multiple ribs of the left side. On 10/2/24 at 4:30 a.m., staff found Resident #1 on the floor on top of her walker, redness and bruising on the right side of her jaw, bruising on her right elbow, and a skin tear on her left hand. Resident #1 reported no current pain, but pain from a previous fall. The residence failed to provide adequate physical care and medical care for Resident #1 after her fall on 10/2/24 and was found by a family member about six hours after the fall with a bruise on her face, dried red residue on her face and clothing, along with a band-aid partially covering a wound on their left thumb. Resident #1 required wound care to be provided by an external service provider to properly care for the skin tear on her left hand twice a week. Specifically, the residence failed to provide, in a timely manner, physical care and medical care for Resident #1. Resident #1 attempted to elope from the residence on 4/30/25 around 4:03 a.m., became aggressive, and started swinging her luggage at staff. The staff attempted to grab the luggage from Resident #1, and she sustained a skin tear due to the luggage catching the watch on Resident #1's wrist. The residence failed to provide adequate physical care and medical care for Resident #1 after sustaining an injury when attempting to elope, and was found by family about six hours later with a wound that was not adequately cared for. Resident #1 required wound care to be provided by an external service provider to properly care for the left arm wound. Findings include:1. Reference and residence policiesa. Chapter VII regulations governing assisted living residences, part 2.12, defines"Caretaker neglect" means neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person. b. The residence's fall recovery policy dated July 2024 read in part, if the resident was confused, shaky, or shows signs of weakness, pain, or dizziness, call 911. If the resident hit their head, complete a head injury check form. Check the resident's alertness and vital signs every shift for 72 hours post-fall and document in the resident's medical record.c. The residence's at-risk behaviors policy dated 9/11/24 read in part, a resident that had any verbal or physical behaviors (including serious verbal threats) which indicated that he/she was an immediate threat to the health or safety of themselves or others, or a resident had a sudden, intense, or out of control behavior that presented an immediate threat to themselves or others. Such behaviors include, but are not limited to, hitting, kicking, and biting. Actions staff shall take included: if another resident was not in danger, attempt to walk away from the resident and follow the other requirements below. Contact emergency services by calling 911. If possible, do not attempt to restrain the resident. Send the resident by emergency medical services to the emergency department for evaluation. 2. Resident #1 was admitted to the residence on 7/5/24 with a diagnosis of Alzheimer's disease.a. Neglect after Resident #1 fellEmergency department discharge summary dated 9/29/24 read in part, Resident #1 was admitted to the emergency department due to a fall and sustained a closed fracture of multiple ribs of the left side. Instructions included to return to the emergency department for worsening breathing or pain. An incident report dated 10/2/24 at 5:08 a.m. read in part, staff found Resident #1 on the floor when doing rounds. Resident #1 was found by her bed and the entrance of her bathroom on top of her walker. Staff reported observations of redness and bruising on Resident# 1's right side of her jaw, bruising on her right elbow, and a skin tear on her left hand. Resident #1 reported she did not have pain at the moment, other than the pain she had from a previous fall. Resident #1 was found at 4:30 a.m. The incident report marked "no" on both whether the resident was injured and taken to the hospital. On 10/2/24 at 5:08 a.m., a voicemail message from Staff #1 to Resident #1's family member read in part, staff had found Resident #1 on the floor, she had several bruises and had bruised her right chin, cheek, jaw area, right elbow, and a skin tear on her left hand by her thumb. It's a big skin tear. Staff figured she was going to the bathroom and had black slippery socks on. Staff reported Resident #1 was good and they took her vitals, which were in the normal range. A picture dated 10/2/24 at 10:42 a.m. showed Resident #1 sitting in a chair wearing a flower-printed article of clothing that appeared to have two red stains on it near the torso. Resident #1's left hand near her thumb appeared to be bruised and had a bloody band-aid partially covering a skin tear. A picture dated 10/2/24 at 11:08 a.m. showed Resident #1's lower cheek and jaw with red marks and dried red residue. A picture dated 10/2/24 at 11:08 a.m. showed red residue on a door frame. A picture dated 10/2/24 at 11:19 a.m. showed two dark red stains on a flower-printed article of clothing. No progress notes were documented on 10/2/24. The care plan last updated on 12/23/24, failed to document that Resident #1 had refusals regarding care. An email dated 10/3/24 at 7:43 a.m., written to the administrator, read in part, Resident #1 had a bad fall and was assisted up by staff. Staff called the writer of the email and left a detailed message about the incident. The writer of the email explained they had arrived at the residence at 10:30 a.m., five plus hours after Resident #1 had fallen. Resident #1 was observed to be sitting in a gown that had blood over the front and back, her left hand had a bandage that overflowed with blood, her hand was completely covered in dried blood, and the right side of her cheek was covered in dried blood while sitting in the dark. The writer of the email pushed Resident #1's emergency call button and asked staff to contact the residence's licensed practical nurse (LPN). The writer explained they were the only one who changed Resident #1 out of her bloody gown, cleaned her left hand, and blood off her face. The writer claimed that the staff only put a bigger band-aid on. The writer stated it was unacceptable that Resident #1 was left in that condition for hours, and the LPN agreed it was unacceptable. An email dated 10/3/24 at 11:18 a.m., written by the administrator, read in part, Resident #1 had been consistently walking without her walker, which had led to two falls in the last week or so. Resident #1 had a skin tear to her left hand and right wrist. Staff at the time bandaged her wounds with a band-aid, but the wounds probably needed further bandaging. She stated she spoke with the memory care director and LPN to let them know any further falls with minor or major injuries will require Resident #1 to be sent out for further evaluation. The administrator explained she spoke with staff who reported that after the fall, Resident #1 refused to have her gown changed and isolated herself in her room, and refused assistance. An email dated 10/3/24 at 11:41 a.m., written to the administrator, read in part, the writer explained it would have been simple for the staff to put a wet wash cloth and hand towel at Resident #1's table along with a clean gown. A practitioner's order dated 10/3/24 read, evaluate and treat for physical and occupational therapy and skilled nursing wound care. An external service provider's note dated 10/5/24 read, evaluation wound assessment. Plan to see twice a week for skin tear to left hand will get orders, first aid done today. On 5/28/25 at 2:51 p.m., the memory care director acknowledged what was written in the incident report on 10/2/24 and stated the residence followed their fall recovery policy. He stated Resident #1's injuries from their fall on 10/2/24 were not bad enough to have sent her to the emergency department, and that Resident #1 required staff to apply basic first aid to care for the skin tear, which was provided. He stated Resident #1 had a fall with injury on 9/29/24, however, she did not report new pain after falling on 10/2/24. The memory care director stated the residence followed up with the external service provider on 10/3/24 to assist with wound care. He acknowledged that staff should have wiped the blood off Resident #1's face, changed her clothes, cleaned up the blood in her room, and documented better. On 5/29/25 at 7:15 a.m., the administrator acknowledged what was written in the incident report on 10/2/24 and stated the residence did not necessarily follow their fall recovery policy, however, they were able to manage the injury at the residence with their nurse and external service providers to assist with wound care. She stated external service providers were ordered the next day to provide wound care. When the administrator was asked if the proper bandaid was applied per the picture and time taken, she stated she believed the residence provided appropriate care to Resident #1 and that they were not sitting for a long period of time unattended.b. Neglect after a skin tearAn incident report dated 4/30/25 at 4:03 a.m., read in part, staff observed Resident #1 walking with their luggage, pushed open the front door of the secure environment, and walked into the lobby of the residence. Staff attempted to redirect Resident #1, which resulted in Resident #1 swinging her luggage at staff and trying to hit them. Staff attempted to grab Resident #1's luggage, which caught onto the watch on Resident #1's wrist, causing a skin tear. Resident #1 started bleeding, and the staff got a tissue. Resident #1 refused to let the staff clean it due to being so mad. Another staff member attempted to clean the skin tear, but Resident #1 was so mad she grabbed their shirt. Staff just let Resident #1 settle in her room. The incident report marked "no" on both whether the resident was injured and taken to the hospital. A progress note dated 4/30/25 at 9:37 a.m., read, the morning care staff and qualified medication administration personnel (QMAP) recognized the severity of Resident #1's skin tear that happened overnight. The health and services director was contacted to evaluate the wound. The health services director suggested that Resident #1 be taken to the emergency department. The family member was informed and was coming to take Resident #1 to the emergency department. A picture dated 4/30/25 at 10:46 a.m. showed Resident #1's lower part of the arm with dark red bruising, and a wound that appeared to be bloody, swollen, raw, and several inches long and an inch or two in width. A progress note dated 4/30/25 at 2:40 p.m., read in part, Resident #1 returned from the emergency department with their family member. Resident #1's wound on their arm was wrapped and not visible. The wound was unable to be stitched, so steri-strips were applied, which needed to remain on the wound for one week. External service providers were ordered to assist with wound care. A practitioner's order dated 4/30/25 read, evaluate and treat for skilled nursing wound care. An external service provider's note dated 5/7/25 documented, Resident #1 had an injury to her left arm that required steri-strips to keep the wound closed per the practitioner's communication. The external service provider could not measure the wound due to the steri-strips. Wound care would continue. The care plan last updated on 4/16/25, failed to document that Resident #1 had refusals regarding care. On 5/28/25 at 12:50 p.m., Staff #1 stated Resident #1 attempted to elope on 4/30/25 with a suitcase, and became very agitated and started to hit staff with the suitcase. She reported giving Resident #1 space due to her being very aggressive, not letting staff touch her, and having difficulty getting her back into the secure environment door. Staff #1 reported that when Resident #1 swung the suitcase and hit her, a cut was noticed on Resident #1's wrist due to catching on Resident #1's watch. She described the skin tear as medium-sized and was unsure how deep. She reported Resident #1 refusing care for the skin tear and having to make several attempts to attend to it due to Resident #1 being so mad. Staff #1 reported putting a tissue on the skin tear, no band-aid. Staff #1 reported she contacted the health services director and informed her about the tear, as well as the morning staff. Staff #1 reported being unsure why she did not call emergency medical services (EMS) and being unsure if she should have. She acknowledged looking back, she should have contacted EMS due to the resident refusing care from staff and the severity of the wound. On 5/28/25 at 2:37 p.m., the memory care director reported Resident #1 should have been sent out to the emergency department due to staff being unable to determine the severity of the skin tear and needing the residence's nurse to properly assess it. On 5/29/25 at 7:15 a.m., the administrator acknowledged the at-risk behaviors policy and stated the residence followed their policy and handled the incident appropriately. She stated that if the aggressive behavior continued, they would have called EMS, but the behaviors were not that extreme. She stated Resident #1 was refusing care and felt staff handled the situation appropriately. The administrator stated the behaviors were monitored and stopped when the family arrived. On 5/29/25 at 8:40 a.m., Staff #2 reported that staff informed the health services director around 7:00 a.m. of Resident #1's skin tear, and the health services director came to bandage it up. Staff #2 reported being unsure if Resident #1 should have been transported to the emergency department. She stated she lets management know and they decide. On 5/29/25 at 8:51 a.m., Staff #3 stated Resident #1's wound was about 1.5 to 2 inches in length, was raw and exposed when she arrived in the morning, and that it should have been bandaged. She reported she would have sent Resident #1 to the emergency department due to the skin tear needing steri-strips. Staff #3 stated that Resident #1 should have been sent out sooner. On 5/29/25 at 10:41 a.m., the health services director acknowledged the at-risk behaviors policy and stated the overnight staff did not follow it. She stated the skin tear was located on the left anterior part of the forearm, superficial layer of the skin, not deep, and was 3 inches in length by 2 inches in width. She stated that due to the scope of practice of the residence, this skin tear required EMS to provide wound care due to the size of the skin tear, and it needed steri-strips. She stated she expected staff to contact EMS for Resident #1 to be transported to the emergency department. The health services director reported that when she saw Resident #1 in the morning, the staff had applied gauze, but she removed it, cleaned the skin tear, and rebandaged it. She reported that Resident #1 was not combative at that time. The health services director stated that Resident #1 did not receive adequate care at the time the incident happened. The health services director stated the residence had done staff training on mandatory reporting and expectations when contacting and reporting incidents to management.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.18.8 Resident records shall contain, but not be limited to, the following items: (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.

A revisit survey was completed on 5/1/25 for all previous deficiencies cited on 2/5/25. The facility is in compliance with all deficiencies that were cited.

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 complaint revisit was completed on 2/5/25 for the previous deficiencies cited on 4/29/24. The residence/facility 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 complaint revisit was completed on 2/5/25 for the previous deficiencies cited on 4/29/24. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaint #CO37626 and #CO39129 was completed on 2/5/25. A deficiency was cited.

Based on observation, record review and interview, the residence failed to reassess residents for their continued need for a secure environment every six months or when the resident's condition changed from baseline status affecting two of two sample residents (#6, #7). Findings include:1. Resident #6 was admitted to the residence on 2/18/18 with a diagnosis of Alzheimer's disease. The record for Resident #6 contained evaluations for a secure environment, dated 5/22/24. The record contained no further evidence that the residence re-assessed the resident every six months for the need of a secure environment. 2. Resident #7 was admitted to the residence on 5/20/24 with a diagnosis of dementia. The record for Resident #7 contained no evidence of an assessment every six months to ensure the continued need for a secure environment. On 2/5/25 at approximately 11:00 a.m., the administrator stated they were not aware residents needed to be reassessed every six months for the continued need of a secure environment.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.18.8 Resident records shall contain, but not be limited to, the following items:(F) Documentation of on-going services provided by external service providers including, but not limited to, caregivers, essential caregivers, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and care providers;

A complaint revisit was completed on 2/5/25 for the previous deficiencies cited on 4/29/24. The residence/facility is in compliance with all regulations surveyed.