CHERRY CREEK RETIREMENT VILLAGE

A relicensure survey and complaint, prompted by #CO41927 and #CO41813, was completed on 5/20/26. No deficiencies were cited.

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 2. 2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities:(A) Individual client records.(B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department. 12.2.1 Infectious Disease Mitigation, Vaccine, and Treatment Plans(A) All facilities licensed under this chapter shall establish, maintain, and implement an infectious disease mitigation, vaccine, and treatment plan. The plan must demonstrate prevention of and responsiveness to communicable diseases that are or may become present in the individual facility setting. The plan may include testing, vaccination, and treatment. This plan shall address, at a minimum, the following:(1) Identification of designated staff who shall coordinate vaccine information, administration, and tracking and reporting of the vaccination status of staff and, if applicable, residents on an ongoing basis;(2) The name and location of the infectious disease vaccine and treatment provider(s) that will be used by the facility to facilitate administration of vaccines and treatment;(3) How the facility will assess and address the vaccination of new staff and, if applicable, residents.

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 7.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review.

A survey prompted by #CO42120 was completed on 4/23/2026. No deficiencies were cited.

A revisit survey was completed on 8/10/23 for all previous deficiencies cited on 1/29/23. 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 relicensure survey was completed on 1/19/23. Deficiencies were cited.

Based on record review and interview, the residence failed to for comply with authorized practitioner orders associated with medication administration, affecting four of six sample residents (#2, #4-#6). Findings include: 1. Residence PolicyA resident agreement dated December 2016, read in part: "staff may administer medications in an assisted living community to ensure prescribed. Medications are delivered to the appropriate resident at the appropriate time as prescribed by the physician."2. Resident #2 was admitted to the residence on 12/28/22, with diagnoses including systemic inflammatory response syndrome, hypotension, gastro-esophageal reflux disease, hypovolemia, and vitamin deficiency.a. SennaA written practitioner order, dated 12/15/22, directed the residence to administer an 8.6 mg tablet of senna, twice daily. However, the January 2023 read senna was not administered on 1/1-1/3/23, 1/4/23 in the evening, 1/5/23, and 1/6/23 in the evening, due to the medication being unavailable, for a total of ten missed doses.b. MetoprololA written practitioner order, dated 12/3/22, directed the residence to administer 12.5 mg of metoprolol twice daily. However, the January 2023 eMAR read that metoprolol was not administered 1/1-1/3/23, and 1/4/23 in the evening, and 1/5/23, due to the medication being unavailable, for a total of nine missed doses.c. CarboxymethylcelluloseA written practitioner order, dated 12/15/22, directed the residence to instill one drop of 0.5 carboxymethylcellulose in each eye two times daily. However, the January 2023 eMAR read that carboxymethylcellulose was not administered on 1/1-1/2/23 in the evening, 1/4/23 in the evening, 1/5/23, 1/6/23 in the evening, and 1/7/23, due to the medication being unavailable, for a total of eight missed doses.d. MultivitaminA written practitioner order, dated 12/3/22, directed the residence to administer 400 mcg of multivitamin, once daily. However, December 2022 and January 2023 eMAR read that multivitamin was not administered on 12/31/22, and 1/1-1/5/23 due to the medication being unavailable, for a total of six missed doses. e. CholecalciferolA written practitioner order, dated 12/3/22, directed the residence to administer 50 mcg of cholecalciferol daily. However, the January 2023 eMAR read that cholecalciferol was not administered on 1/1-1/5/23 due to the medication being unavailable, for a total of five missed doses. f. OmeprazoleA written practitioner order, dated 12/3/22, directed the residence to administer 20 mg of omeprazole daily. However, the January 2023 eMAR read omeprazole was not administered on 1/1-1/5/23, due to the medication being unavailable, for a total of five missed doses. On 1/19/23 at 4:52 p.m., the executive director (ED) stated that they had problems getting Resident #2 his medications from the pharmacy after he came back from advanced care at the end of December 2022. 3. Resident #4 was admitted to the residence on 5/31/18, with diagnoses including essential (primary) hypertension, hypothyroidism, asthma, gastro-esophageal reflux disease without esophagitis, constipation, age-related osteoporosis, tachycardia, and low back pain.a. Fluticasone SalmeterolA written practitioner order, dated 12/1/22, directed the residence to administer 113-114 MCG/ACT fluticasone salmeterol inhalation aerosol powder two times daily. However, the December 2022 eMAR read that fluticasone salmeterol was not administered on 12/1-12/4/22 in the morning, 12/2/22 in the evening, 12/6-12/11/22 in the morning, 12/7-12/8/22 in the evening, 12/13/22 and 12/16/22, 12/14/22 in the evening, 12/15-12/16/22 in the morning, due to the medication being unavailable, for a total of nineteen missed doses.b. AirDuo RespiclickA written practitioner order, dated 12/21/22, directed the residence to administer 113-114 MCG/ACT airduo respiclick aerosol powder once daily. However, the January 2023 eMAR read that airduo respiclick was not administered on 1/11-1/16/23 and 1/18-1/19/23, due tothe medication being unavailable, for a total of eight missed doses. A medication cart audit conducted on 1/19/23 at 3:29 p.m., revealed there was no airduo respiclick in the medication cart.c. Losartan PotassiumA written practitioner order, dated 5/26/22, directed the residence to administer 25 mg losartan potassium two times daily. However, the January 2023 eMAR read that losartan was not administered on 1/14/23 in the evening, due to the medication being unavailable, for a total of one missed dose. On 1/19/23 at 4:04 p.m., the RCD stated that they have had issues with Resident #4's pharmacy and had issues waiting on prior authorizations, which was why there were missed doses of fluticasone salmeterol in December 2022. On 1/19/23 at 4:52 p.m., the ED stated when Resident #4 returned from a rehabilitation facility in early January 2023, and had been waiting on Resident #4's pharmacy to deliver AirDuo Respiclick, and it still had not arrived. 4. Resident #5 was admitted to the residence on 9/9/21, with diagnoses including hypothyroidism, hyperlipidemia, and hypo-osmolality.a. CarveidololA written practitioner order, dated 7/10/21, directed the residence to administer a 3.125 mg tablet of carvedilol twice daily. However, the December 2022 eMAR read that carvedilol was not administered on 12/8/22 in the evening, and 12/9/22, due to the medication being unavailable, for a total of three missed doses.b. LevothyroxineA written practitioner order, dated 7/10/21, directed the residence to administer 50 mcg levothyroxine once daily. However, the December 2022 eMAR read that levothyroxine was not administered on 12/31/22, due to the medication being unavailable, for a total of one missed dose. 5. Resident #6 was admitted to the residence on 6/7/21, with diagnoses including age-related cataract, parkinson's disease, and chronic obstructive pulmonary disease.a. Propylene glycolA written practitioner order, dated 3/22/22, directed the residence to instill propylene glycol in both eyes two times daily. However, the January 2023 eMAR read that propylene glycol was not administered on 1/15/23 in the evening, 1/16/23 in the morning, and 1/18-1/19/23 in the morning, due to the medication being unavailable, for a total of four missed doses. A medication cart audit conducted on 1/19/23 at 3:29 p.m., revealed there was no propylene glycol in the medication cart.b. Stiloto Respimat A written practitioner order, dated 1/15/22, directed the residence to administer two puffs of 2.5 MCG/ACT stiloto respimat aerosol solution every morning. However, the December 2022 eMAR read that stiloto respimat was not administered on 12/21/22, due to the medication being unavailable, for a total of one missed dose. On 1/19/23 at 4:04 p.m., the RCD stated that the residence had struggled with Resident #6's pharmacy because they did not communicate with the residence about the status of the medication refill. On 1/19/23 at 4:52 p.m., the RCD stated because they were having a hard time ensuring that the pharmacy filled Resident #6's medications, they had to get self-administration orders for some of his medications. The RCD stated the missed medications that were managed by staff have been communicated with Resident #6's family and practitioner. 6. InterviewsOn 1/19/23 at 3:54 p.m., the RCD stated that when medication was marked off as not administered for just one dose, it was because staff did not look hard enough in the medication cart for it. The RCD stated that all of the other medications for Residents #2 and #4-#6 that were not just one dose missed, were out of stock. On 1/19/23 at 4:04 p.m., the RCD stated that QMAPs were responsible for ordering medication when low, and re-training needed to be done to ensure that staff were making sure to order medications and follow up with the pharmacies. On 1/19/23 at 4:52 p.m., the ED stated that he expected staff to comply with orders. The ED stated he expected medication to be given, or to get a hold order if the pharmacy wouldnot send in medications.

Based on interviews and record review, the residence failed to document accurate information in the electronic medication administration record (eMAR), affecting three of six sample residents (#2, #4, and #6). (Cross-reference Q1468)Findings include:1. Resident #2 was admitted to the residence on 12/28/22, with diagnoses including systemic inflammatory response syndrome, hypotension, gastro-esophageal reflux disease, hypovolemia, and vitamin deficiency.a. Carboxymethylcellulose Written practitioner's orders, dated 12/15/22, directed the residence to instill one drop of 0.5% carboxymethylcellulose in each eye two times daily. However, the January 2023 eMAR contained check marks that an out-of-stock medication was given on 1/2-1/4/23 in the morning, 1/6/23 in the morning, and 1/3/23 in the evening.b. MetoprololWritten practitioner's orders, dated 12/3/22, directed the residence to administer 12.5 mg of metoprolol twice daily. However, the January 2023 eMAR contained check marks that an out-of-stock medication was given on 1/4/23 in the morning.c. Senna Written practitioner's orders, dated 12/15/22, directed the residence to administer an 8.6 mg tablet of senna, twice daily. However, the January 2023 eMAR contained check marks that an out-of-stock medication was given on 1/4/23 in the morning. 2. Resident #4 was admitted to the residence on 5/31/18, with diagnoses including essential hypertension, hypothyroidism, asthma, gastro-esophageal reflux disease without esophagitis, constipation, age-related osteoporosis, tachycardia, and low back pain.a. Fluticasone salmeterolWritten practitioner's orders, dated 12/1/22, directed the residence to administer 113-114 MCG/ACT fluticasone salmeterol inhalation aerosol powder two times daily. However, the December 2022 eMAR contained check marks that an out-of-stock medication was given on 12/1/22 in the evening, 12/3-12/4/22 in the evening, 12/5/22, 12/6/22 in the evening, 12/9-12/11/22 in the evening, 12/12/22, 12/14/22 in the morning, and 12/15/22 in the evening. b. AirDuo RespiclickWritten practitioner's orders, dated 12/21/22, directed the residence to administer 113-114 MCG/ACT airduo respiclick aerosol powder once daily. However, the January 2023 eMAR contained check marks that an out-of-stock medication was given on 1/17/23.3. Resident #6 was admitted to the residence on 6/7/21, with diagnoses including age-related cataract, parkinson's disease, and chronic obstructive pulmonary disease.a. Propylene glycolWritten practitioner's orders, dated 3/22/22, directed the residence to instill propylene glycol in both eyes two times daily. However, the January 2023 eMAR contained check marks that an out-of-stock medication was given 1/16-1/18/23 in the evening, and 1/17/23 in the morning. 4. InterviewsOn 1/19/23 at 3:54 p.m., The RCD stated that the check marks on Resident #2, #4, and #6's eMARs for the medications listed as administered on the dates above, could not have been given when a medication was out-of-stock, and would be considered a medication error. The RCD stated that she had terminated a staff member in the past, or taken them off the medication cart for inaccurately marking off out-of-stock medication as given. The RCD stated that there needed to be some re-training of staff, and incident reports needed to be made for all the out-of-stock medications marked as given when they were not. On 1/19/23 at 4:48 p.m., the ED stated that they hired brand new QMAPs who were put on the medication carts at the beginning of January 2023 due to issues that had occurred in early January 2023 and prior, with inaccurate documentation. The ED stated that he needed to investigate why inaccurate documentation was still occurring and re-train staff or take them off the medication carts and put them in caregiver roles. The ED stated they have been working on correcting this issue, and he stated it was originally brought to his attention when the RCD conducted eMAR audits.

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, Chapter2 and Chapter 7.7.13 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee's or volunteer's personnel file: (A) Documentation that the individual's name appears on the Department's list of individuals who have successfully completed the medication administration competency evaluation; and (B) A signed disclosure that the individual has not had a professional medical, nursing, or pharmacy license revoked in this or any other state for reasons directly related to the administration of medications. 11.2.3 Facilities and agencies shall ensure that ninety percent (90%) of employees and direct contractors have received the influenza vaccine during a given influenza season. In order to demonstrate that the ninety percent (90%) rate has been meet, facilities and agencies shall: (B) Have defined procedures to prevent the spread of influenza from unvaccinated healthcare workers. 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents:(A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population. 13.8 Before the next regularly scheduled meeting, assisted living residence staff shall respond in writing to any suggestions or issues raised at the prior meeting. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.