Garden Creek

At 9:30am, on 10/7/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to deliver final findings to the allegation of this complaint. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit. On the allegation, staff are not dispensing medication as prescribed. It was alleged that facility staff failed to bring a resident their medication timely, and when the medication was later brought, the staff also left a cup of another resident’s medications in the room, which was returned to staff. LPA record review and interviews revealed that 49 of 60 residents at the facility receive assistance with medication management from the facility staff and multiple residents who receive this assistance take the medication carbidopa-levodopa for Parkinson’s disease, including Resident #1 (R1). (Continued on LIC9099-C) SubstantiatedRead the full finding— CDSS inspection report, October 7, 2025 · control 29-AS-20250911081035

On 6/10/2025 at 08:50am Licensing Program Analyst (LPA) Haner-Tomasko conducted a 10-day complaint visit to the facility above. LPA met with Administrator Liza Hix and explained the purpose of the visit. LPA requested the following records: Resident Roster, Staff Roster, and Resident 1's (R1's) preadmission appraisal, current physician report and care plan. From 09:34am to 11:54am LPA conducted interviews with staff and R1. On allegation: Facility staff are not meeting resident’s care needs. It was alleged R1 requires more care than staff thought and staff are unable to provide R1 water or check on R1 overnight and therefore R1 frequently wakes up dehydrated, and was recently sent to the hospital, but later released because of dehydration. (Continued on LIC9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, June 10, 2025 · control 29-AS-20250609084320

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Liza Hix, Administrator and explained the purpose of the visit. LPA requested the following records: Resident Roster, Staff Roster, All incident reports on R1, Death report for R1, Procedure or policy for Reports, falls, discharge and extra care after discharge of residents at the facility, admission agreement for R1, refund of rent paid and refunded for R1, disciplinary report for staff, hospital discharge paperwork, and notes or charting for R1. The facility was able to provide resident roster, staff roster, staff schedules for December 2023, R1's admission agreement, Refund of rent paid and refund issued, staff email to supervisor/managers reporting R1 going to Hospital. Facility was not able to provide any other records requested. LPA De Leon conducted interviews with staff at 10:15am, 10:45am, 11:04am, 12:40pm, 12:50pm, 1:28pm, 2:06pm, 2:14pm, and 2:45pm, SubstantiatedRead the full finding— CDSS inspection report, November 14, 2024 · control 29-AS-20241107133319

At 1:00pm on 08/08/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to issue final findings on the allegation above to this complaint. LPA met with Business Manager, Lisa Hulse, announced who he was and the reason for the visit. As to the allegation of, “Resident was unconscious in the facility bathroom for a long period of time.” It was discovered through interviews and documentation that, on 05/02/2023 Resident 1 (R1) was found unconscious at approximately, 7:45am sitting in their privet restroom. Facility call button record for the date of 05/02/2023 show that R1’s privet bathroom call button was pressed at 4:52am and cleared at 4:54am on 05/02/2023. LPA interviewed Staff 1 (S1) on 08/02/2023, S1 stated that at 4:54am S1 helped R1 back to bed and did not recall anything abnormal care about R1’s visit to their privet restroom at the 4:52 am - 4:54 am resident call for assistance going to and from their privet bathroom. LPA reviewed R1 LIC602 (PhysiciRead the full finding— CDSS inspection report, August 8, 2023 · control 29-AS-20230518172833