SUNRISE AT ORCHARD

An administrative relicensure survey was completed on 4/27/26. No deficiencies were cited.

A licensure complaint, prompted by CO#41014 and CO#41583 was completed on 4/22/26. No deficiencies were cited.

A licensure complaint, prompted by ##CO38752 and #CO39319, was completed on 8/6/25. No deficiencies were cited.

A revisit survey was completed on 2/8/24 for all previous deficiencies cited on 12/7/23. No deficiencies 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 12/7/23 for the previous deficiency cited on 8/30/23. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaints #CO34190, #CO34377 was completed on 12/7/23. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to ensure a name-based criminal history report was requested prior to hire and conducted by the Colorado Bureau of Investigation (CBI) for four of four sample staff (#1-#4), affecting 61 current residents. Findings include:1. Residence PolicyThe residence's Background Check policy, dated 5/31/19, read that the residence conducted multi-county and federal criminal history; however, the policy contained no reference to state-level name-based checks conducted by the CBI.2. ObservationOn 12/7/23 from approximately 7:20 a.m. to 7:35 a.m., Staff #1 worked as a qualified medication administration person (QMAP) at the residence. 3. Record ReviewThe personnel record for Staff #1 read the staff was hired on 6/26/23. The residence's name-based background check for Staff #1, dated 6/12/23, the record contained a criminal history report; however, the CBI did not conduct the criminal history report. The residence's November and December 2023 schedule read in part that Staff #1 worked at the residence 22 times on the following dates:11/1 and 11/211/5-11/911/12-11/1611/26-11/3012/3-12/7The personnel record for Staff #2 read the staff was hired on 8/14/23. The residence's name-based background check for Staff #2, dated 8/7/23, contained a criminal history report; however, the CBI did not conduct the criminal history report. The residence's November and December 2023 schedule read in part that Staff #2 worked at the residence 19 times on the following dates:11/3-11/611/9-11/1411/1611/2411/2611/2711/3012/1-12/4The personnel record for Staff #4 read the staff was hired on 8/21/23. The residence's name-based background check for Staff #4, dated 8/15/23, contained a criminal history report; however, the CBI did not conduct the criminal history report. The residence's November and December 2023 schedule read in part that Staff #4 worked at the residence 11 times on the following dates:11/811/1011/1111/1311/1411/2611/2811/2912/3-12/5The personnel record for Staff #3 read the staff was hired on 10/16/23. The residence's name-based background check for Staff #3, dated 10/5/23, contained a criminal history report; however, the CBI did not conduct the criminal history report. The residence's November and December 2023 schedule read in part that Staff #3 worked at the residence eight times on the following dates: 11/2411/2711/2812/1-12/54. InterviewsOn 12/7/23 at 12:21 p.m., the business office coordinator stated that the residence name-based criminal history report check included multi-county, federal, sex offender registry, and abuse registry; however, the check had not included a check conducted by the CBI. On 12/7/23 at 3:45 p.m., the administrator stated that name-based criminal background checks were required for all staff prior to working with residents. She added that she was unaware that the residence had not conducted the checks with the CBI and had assumed that the checks conducted by the residence's home office had included checks conducted using the CBI.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization such as the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute, affecting 61 current residents. Findings include:1. ReferenceAccording to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA (Occupational Safety and Health Administration), the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation), and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/According to the American Red Cross: "Obstructed Airway Care for Adults ... If the patient is able to speak to you or is coughing forcefully: Encourage the patient to keep coughing but be prepared to clear the airway if the patient's condition changes ... Obtain consent ... Perform abdominal thrusts ... Perform alternate techniques-back blows, chest thrusts, or airway management ... Continue to clear the airway ... If the patient becomes unresponsive, carefully lower them to a firm, flat surface, while protecting their head. Immediately begin CPR, starting with chest compressions. After each set of compressions and before ventilation, open the patient's mouth and look for the object-if seen, remove it using a finger sweep." American Red Cross (2019) Skill Sheet: Obstructed Airway Care for Adults and Children, retrieved from: https://www.redcrosslearning.com/course-bin/bls-healthcare-resuscitation/app/content/a/en-US/resources/SS-Obstructed-Airway-Care-for-Adults-and-Children.pdf 2. Record ReviewThe personnel file for Staff #5 read that the staff was hired on 4/6/21. The file contained a CPR certification for Staff #5; however, the certification was not from a nationally recognized organization and contained no hands-on skill demonstration. The residence's November and December 2023 schedule read in part that Staff #5 worked without another CPR certified staff three times from 9:45 p.m. to 6:15 a.m. on the following dates:11/27 12/0512/113. InterviewOn 12/7/23 at 3:45 p.m., the administrator stated all staff should have CPR training, including the hands-on skills demonstration, within 30 days of their start date. She acknowledged that Staff #5 had not completed the CPR certification hands-on skills demonstration portion.

Based on observation and interview, the residence failed to prohibit the use of portable heaters in the residents ' rooms, affecting four of six sample residents (#8, #9, #10, #11) who experienced heating concerns in their rooms. Findings Include:1. ObservationsOn 12/8/23 at 12:31 p.m., two portable heaters were present in the room of Resident #11, one heater was turned on. On 12/8/23 at 12:59 p.m., a portable heater was in the room of Resident #9. On 12/8/23 at 1:19 p.m., a portable heater was in the room of Resident #10 and was turned on. The thermostat in the room measured 74 degrees fahrenheit. On 12/8/23 at 1:25 p.m., a portable heater was in the room of Resident #8 and was turned on. 2. InterviewsOn 12/8/23 at 12:15 p.m., the maintenance coordinator stated the individual room control board broke in six rooms on 11/25/23, and he placed portable heaters in the rooms to keep residents warm until the new part to repair the control board arrived. On 12/8/23 at 1:05 p.m., Resident #8 stated the heat in his room had not been working, and the residence provided him with a portable heater. He said "If I have my blankets on I can stay warm with the portable heater"On 12/8/23 at 1:19 p.m., Resident #10 stated the heat in her room had not been working, and the residence provided her with a portable heater. She said the temperature has gone up one degree since she checked in the morning. On 12/8/23 at 1:25 p.m., Resident #11 stated the heat in his room had not been working, and the residence provided him with a portable heater. On 12/8/23 at 3:49 p.m., the administrator said, "I don't think I have ever read that using portable heaters is unsafe for non-continuous time. If it is really cold because the main heater is not working, you want to make sure the resident is warm."

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 7.13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: (D) The right to choice and personal involvement regarding care and services, including: (4) The right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence.

A licensure revisit was completed on 8/30/23 for all previous deficiencies cited on 5/26/22. A deficiency was cited.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#3, #7, #8). This deficiency was cited previously during a state licensure survey 5/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Medication policy, dated 7/1/19, read in part, "Resident medication administration or assistance is performed in accordance with all state regulations and (residence) standards." 2. Resident #3 was admitted to the residence on 4/10/22 with diagnoses including myocardial infarction, presence of a pacemaker, and overactive bladder. a. Dutasteride A written practitioner's order, dated 6/9/23, directed the residence to administer dutasteride 0.5 mg at bedtime (HS). However, the August 2023 medication administration record (MAR) read on 8/27 and 8/28/23, the medication was unavailable, for a total of two missed doses. b. Venlafaxine A written practitioner's order, dated 6/9/23, directed the residence to administer venlafaxine 75 mg three tablets once daily. However, the August 2023 MAR read on 8/20 and 8/21/23, the medication was unavailable, for a total of two missed doses. c. CarvedilolA written practitioner's order, dated 6/9/23, directed the residence to administer carvedilol 6.25 mg one tablet two times daily. However, the August 2023 MAR read the medication was unavailable on 8/25/23 for the morning dose, for a total of one missed dose. 3. Resident #7 was admitted to the residence on 11/17/20 with a diagnosis of anxiety disorder. A written practitioner's order, dated 8/8/23, directed the residence to administer busprione 10 mg one tablet twice daily. However, the August 2023 MAR read from 8/8-8/10/23 the medication was unavailable, for a total of six missed doses. 4. Resident #8 was admitted to the residence on 4/23/22 with a diagnosis of anxiety disorder. A written practitioner's order, dated 8/22/23, directed the residence to administer sertraline 50 mg one tablet daily. However, the August MAR read the medication was discontinued on 8/22/23; therefore, the medication had not been administered, for a total of six missed doses. On 8/30/23 at 2:30 p.m., the discontinued order for the sertraline 50 mg was requested; however, the licensed practical nurse (LPN) was unable to provide the documentation. On 8/20/23 at 2:45 p.m., the LPN stated she contacted Resident #8's provider and was informed that there was no discontinue order for the sertraline and that the residence should have administered the medication to the resident. She stated the nurse on shift was responsible for transcribing medication orders and discontinue orders onto the MARs. The LPN stated she was not on shift the day Resident #8's sertraline had been discontinued. She stated she was unsure why the other nurse had discontinued Resident #8's sertraline without an order from the provider. 4. InterviewsOn 8/30/23 at 2:45 p.m., the LPN stated the qualified medication administration persons (QMAPs) were responsible for ordering medication when there were seven days left of the medications. She stated the residence had switched pharmacies a month prior to the onsite visit and had significant issues with the new pharmacy. The LPN stated the biggest issue was the residence did not receive medications they had orders for in a timely manner. She confirmed Resident #3 and #7 were not administered medications as ordered. On 8/30/23 at 3:15 p.m., the administrator stated the QMAPs were responsible for ordering medications when there were at least seven days left. She stated the residence had recently switched pharmacies and occasionally had some issues with receiving medications on time. The administrator believed the issues withthe pharmacy were the reason the previous citation had not been corrected. She confirmed if a medication was documented as unavailable that the residents were not administered the medications as ordered.

A licensure complaint, prompted by #CO33472, was completed on 8/30/23. No deficiencies were cited.