MORNINGSTAR OF FORT COLLINS

An administrative relicensure survey was completed on 6/2/26. Deficiencies were cited. A change of ownership occurred on 1/6/26.

Based on record review and interview, the residence failed to ensure each resident's care plan promoted resident choice, mobility, independence, and safety, and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting one of four sample residents (#2). (Cross-reference U1410)Specifically, Resident #2 sustained a fall on 3/6/26 and experienced a change of condition on 3/14/26, where the resident experienced difficulty walking and required three staff members to assist him to his room. A progress note dated 3/15/26 read that it required three staff members to lift Resident #2 after a fall, and the resident sustained a rug burn on the left knee and expressed pain. Later, emergency medical responders informed the residence that Resident #2 stated the pain he experienced originated from his left hip. A progress note dated 4/24/26, read Resident #2 sustained a fall and was found on his back, yelling out in pain. Progress notes further revealed that Resident #2 experienced another change in condition on 4/27/26, and the resident was no longer able to get out of bed for dressing or toileting. However, the residence failed to update Resident #2's care plan with individualized interventions that reflected the resident's falls, changes in mobility, and increased assistance required for transfers, dressing, and toileting. Additionally, residence staff were unfamiliar with what fall interventions were in place for Resident #2 prior to his fall on 4/24/26. On 4/28 and 5/3/26, progress notes read that Resident #2 would scream in pain whenever the staff moved and changed him. Resident #2 passed away on 5/5/26.1. Record ReviewA document titled Fall Management Policy and procedure, dated September 2024, read that if a resident had onefall with or without injury an updated care plan with interventions would be completed as well as a change fromlow fall risk to moderate fall risk and follow up within 30 days to review the care plan again. Resident #2 was admitted to the residence on 1/7/26 with a diagnosis of behavioral disturbance, cognitivecommunication deficit, and vascular dementia. A progress note dated 3/6/26 read that Resident #2 was found on all 4's hands and knees crawling in the hallway. It stated that Resident #2 was able to stand up with staff assistance and the use of the hallway bars. A progress note dated 3/14/26 stated that Resident #2 was having a hard time walking. The progress note statedthat it took three staff members to assist Resident #2 to his room. "Resident (#2) was leaning forward and notstanding up all the way tall. Resident (#2) was holding the staff's hands and leaning forward, putting all his weight on the staff's hands. Resident (#2) was scared when this was happening and cussing at the staff. Staff assisted Resident (#2) into bed, where he calmed down." A progress note dated 3/15/26 read that Resident #2 was found lying on the floor next to his bed. His depends (incontinence briefs) and bedding were soaked with urine. Three staff members assisted him off the ground and into a chair, and then later into his bed. He would not stand up when staff assisted him off the ground, stating that he was in pain. He would not say where the pain was, and he had rug burn on his left knee. Emergency services were called and informed the residence staff that Resident #2's pain was in his left hip. Resident #2 did not go to the emergency room. A progress note dated 4/24/26 read that Resident #2 fell and seemed to be in a lot of pain to walk on his own. Resident #2 was found on the ground against the wall at the bottom of his bed by his recliner. He was lying flat onhis back and was yelling; three care staff had to assist in getting the resident off the ground and back into his bed. The resident was up all night lying in his bed yelling. The resident wet the bed, and it took three people to assist in safelytransferring the resident to a wheelchair for ambulation supportand change under garments and clothing. An emergency services report read that Resident #2 was taken to the hospital on 4/26/26 to be assessed. A progress note dated 4/27/26 stated that Resident #2 was no longer able to get up out of bed to change out ofsoiled clothes and staff had to change him in his bed. A progress note dated 4/28/26 stated that Resident #2 was groaning and screaming out in pain whenever staffmoved him to change him. The note read that Resident #2 would clench his hands and his whole body wouldshake with any type of movement. A progress note dated 5/3/26 stated that Resident #2 screamed out in pain when staff attempted to change hisunderwear. A progress note dated 5/5/26 read that Resident #2 had passed away. A care plan dated 1/7/26 read that Resident #2 would have activities of daily living (ADLS) nighttime/daytime safety checks, and if awake, staff would provide emotional support and address any needs as well as minimal evacuation assistance needed. The care plan further read that Resident #2 did not require assistance when transferring. A care plan dated 4/10/26 read that staff were to check Resident #2's gait. However, all additional interventionsremained the same as the care plan dated 1/7/26. On 5/27/26 at approximately 3:40 p.m., all updated care plans for Resident #2 were requested. The residence wasunable to provide any further care plans. 2. InterviewsOn 5/27/26 at approximately 2:00 p.m., the administrator stated the health and wellness director was responsible for updating care plans, and she expected all updated interventions to be included. On 5/27/26 at approximately 2:40 p.m., Staff #2 stated that she was not aware Resident #1 had fallen until she noted in the progress notes how much pain he was in when she attempted to change him in bed. She stated that before then, she was not made aware of any fall interventions. She stated that before his last two falls, he was walking just fine on his own. On 5/27/26 at approximately 5:00 p.m., Staff #1 stated that Resident #2's interventions were implemented after his "very bad fall" on 4/24/26, which included changing him in bed, transferring him, and escorting him because he was unable to walk due to the amount of pain he was in. Staff #1 stated that she was only aware of these interventions because the staff on the shift before hers gave her the information. She stated that after his fall in March 2026, he was no longer able to walk on his own, and he needed assistance transferring and more assistance with toileting.

Based on record review and interview, the residence failed to investigate injuries of unknown origin affecting two of four sample residents (#1 and #2). (Cross-reference U1150)Findings Include:1. Record ReviewResident #2 was admitted to the residence on 1/7/26 with a diagnosis of behavioral disturbance, cognitive communication deficit, and vascular dementia. On 5/18/26 at approximately 2:30 p.m., all injuries of unknown origin documented within 90 days were requested. The residence denied that any injuries of unknown origin occurred within that time frame. A progress note dated 3/13/26 read that Resident #2 had a bruise on his left foot. However, there was no documentation in progress notes about how Resident #2 sustained the bruise. 2. InterviewOn 5/28/26 at approximately 2:00 p.m., the administrator stated that there was no investigation of injury of unknown origin that she was aware of. The administrator confirmed that she expected there to be one. 3. Similar deficient practice was found for Resident #1.

A revisit survey was completed on 12/1/25 for all previous deficiencies cited on 7/15/25. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO40830, was completed on 9/9/25. No deficiencies were cited.

A licensure complaint, prompted by #CO39576 and #CO40532, was completed on 7/15/25. A deficiency was cited.

Based on records review and interviews, the residence failed to comply with authorized practitioner orders affecting one (#1) of four sample residents. Findings include:Resident #1 was admitted to the residence on 12/31/20 with a diagnosis including hypertension and congestive heart failure. 1. FurosemideA written practitioner order, dated 2/24/25, directed the residence to administer furosemide 20 mg orally once daily. The June 2025 medication administration record (MAR) indicated the medication was not administered 6/4-6/7 and 6/20-6/21/25.2. NabumetoneA written practitioner order, dated 2/24/25, directed the residence to administer nabumetone 500 mg once daily. The June 2025 MAR indicated the medication was not administered on 6/12/25.3. Fluticasone-salmeterolA written practitioner order, dated 3/10/25, directed the residence to administer Fluticasone-salmeterol 250-50 inhaler one puff twice daily. The June 2025 MAR indicated the medication was not administered on 6/1/25 for one dose. On 7/15/25 at 11:30 a.m., the licensed practical nurse (LPN) said staff did not properly inform her when medication was unavailable. She acknowledged that the MAR for Resident #1 showed five instances of documentation indicating that the medication was either unavailable or not in the cart. She said the expectation was that all prescribed medications should be available. She acknowledged failure to ensure the medication had been available. On 7/15/2025, at 11:40 a.m., the administrator stated that her expectation was that all medications by practitioners were available for administration. She acknowledged that the MAR showed medication was unavailable. Additionally, she acknowledged failure to ensure the medication had been available.

A revisit survey was completed on 4/16/25 for all previous deficiencies cited on 10/30/24. 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 revisit survey was completed on 4/16/25 for all previous deficiencies cited on 10/30/24. 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 10/30/24 for all previous deficiencies cited on 9/8/22. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

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

Based on record review and interview the residence failed to detail in each resident's care plan the individualized approaches necessary to address fall risk, affecting one of three sample residents (#20). This deficiency was cited previously during a state licensure survey 9/8/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #20 was admitted to the residence on 2/16/23 with diagnoses of Alzheimer's disease. A progress note, dated 6/23/24 read in part, the resident was found on the floor of his bedroom by staff on 6/23/24 at approximately 5:15 a.m,. He was soiled and combative toward staff when assisting him off the floor. Staff then performed a shower where it revealed a bump to the resident's head. The resident was sent to the emergency department per power of attorney. The resident returned that evening with no further orders or concerns. A care plan, dated 2/19/24, read in part that the resident used a walker and had difficulty maintaining balance without his walker. However, the care plan had not been updated since before the fall to assist in mitigating any further fall risks as required. On 10/30/24 at approximately 12:00 p.m., the administrator stated the residence was not aware they had not updated the care plan with any interventions to help mitigate falls after the residents fell. The administrator stated the previous deficient practice was not corrected because of a high staff turnover and it must have been missed during the transition.

Based on record review and interview, the residence failed to ensure resident records contained progress notes that included out-of-ordinary events along with the action taken by staff to address the resident's changing needs, affecting one of three sample residents (#7) in the secure environment. (Cross-reference S3060). Findings include: This deficiency was cited previously during a state licensure survey 9/8/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Resident #7 was admitted to the residence on 7/28/21 with a diagnosis of dementia, a fractured neck, and femur. The residence's progress notes for Resident #7, dated 7/29/24, read that a staff member noticed pink spots on her back that may have been in the beginning stages of "pressure sores." No other progress note documentation was provided despite Resident #7's recurring history of pressure sores. A practitioner's order dated 9/20/24, read that Resident #7 was diagnosed with a stage two pressure injury. The residence's progress notes for Resident #7 did not address any other progress of the pressure injury, nor did they indicate whether Resident #7 complained of pain or any other notes regarding the healing stages or staff actions necessary to address the pressure sore. On 10/30/24 at 8:31 a.m., Staff #17 acknowledged that the progress note written on 7/29/24 failed to show the follow-up on the pressure sore. She acknowledged that there were no other progress notes written for Resident #7 after 7/29/24, even after she was diagnosed with a pressure sore on 9/20/24. Staff #17 said that the progress note system was new and the residence had failed to develop a process that captured the follow-up of the pressure sore. On 10/30/24 at 11:15 a.m., the director of resident services (DRS) stated that Resident #7 had a history of pressure sores. On 10/30/24 at 12:10 p.m., the administrator stated she expected staff to include all details of an incident within a progress note. Further, the administrator stated she believed the residence failed to maintain progress notes after staff turnover.

Based on record review, and interview, the residence failed to ensure the enhanced care plan for each residence in the secure environment included a resident's known behavioral expressions along with individualized approaches to be implemented, affecting one of one sample residents (#7) with an enhanced care plan. (Cross-reference S2230)This deficiency was cited previously during a state licensure survey 9/8/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #7 was admitted to the residence on 7/28/21 with a diagnosis of dementia, a fractured neck, and femur. The residence's progress notes for Resident #7, dated 7/29/24, read that a staff member noticed pink spots on her back and may have been in the beginning of "pressure sores." The residence's care plan for Resident #7, dated 10/25/24, read that Resident #7 did not show any behavior expressions or a history of pressure sores. A practitioner's order dated 9/20/24, read that Resident #7 was diagnosed with a stage two pressure injury. On 10/30/24 at 8:31 a.m., Staff #17 stated that Resident #7 had a history of pressure sores and was typically surface-level with no tunneling. She acknowledged that the care plan did not include her history of pressure sores, what they looked like, how to prevent them, etc. Staff #17 also stated that Resident #7 liked to lie in specific spots on her bed, and when staff would go in to place her in a different position, she would yell. Staff #17 acknowledged that the enhanced care plan did not include the everyday behavioral expressions she had. On 10/30/24 at 11:15 a.m., the director of resident services (DRS) stated that the care plan provided was the most up-to-date version and it failed to state that she had a history of pressure sores, how to mitigate them and also did not include behavioral expressions for when staff moved Resident #7 to different positions without the hoyer lift. On 10/30/24 at 12:11 p.m., the administrator stated she expected staff to include all details in an enhanced care plan. Further, the administrator stated that the residence failed to maintain updated and accurate enhanced care plans after staff turnover.

A relicensure survey with complaint #CO38045 was completed on 10/30/24. Deficiencies were cited.

Based on interviews and record review, the residence failed to ensure that personnel files included written documentation of orientation and training, first aid and CPR certifications, and follow-up for three sample staff (#13-#15) and one former staff member (#16), affecting 79 current residents. Findings include:1. Record ReviewThe personnel files for Staff #13-#15 and former Staff #16 were reviewed. They revealed they were hired on 10/26/23, 2/13/24, 5/20/24, and 9/27/20, respectively. However, there was no evidence of orientation or CPR and first aid. 2. Interview On 10/30/24 at 8:15 a.m., Staff #13- #15 stated they had completed or attended an orientation. On 10/29/24 at 9:24 p.m., the business office manager said she did not have the documented training or documented orientation for sample staff #13-#15 or former staff member #16. She acknowledged her failure to ensure all staff had documented training in their personnel files. Additionally, she acknowledged failure to have CPR certifications in staff #14 in personnel records. On 10/30/24 at 12:00 p.m., the administrator acknowledged the residence's failure to document orientation in staff files.

Based on observation, record review, and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of six sample residents (#7, #17, #18, #19, #20, and #23). Findings include:1. Resident #23 was admitted to the residence on 6/10/22 with diagnoses including high blood pressure. Benazepril A written practitioner's order, dated 3/1/24, directed the residence to administer benazepril HCL 40 mg one tablet daily. However, the October 2024 medication administration record (MAR) read the medication was not administered on 10/15-10/18/24 due to the medication not available, for a total of four missed doses. 2. InterviewsOn 10/29/24 at 12:52 p.m., the assisted living coordinator stated that if the MAR read medication was not available, the medication was not administered to the resident. She acknowledged it was the failure of the residence to have the medications ordered by the practitioner. On 10/30/24 at 1:00 p.m., the administrator stated it was her expectation that medication was to be administered as ordered by the practitioner. She acknowledged the failure of the residence to have the medications. 3. Evidence revealed the residence failed to follow the practitioner's orders for Residents #7, #17, #18, #19, and #20, .

Based on record review and interview, the residence failed to ensure resident records contained progress notes that included out-of-ordinary events along with the action taken by staff to address the resident's changing needs, affecting one of three sample residents (#7) in the secure environment. (Cross-reference S3060)Findings include: Resident #7 was admitted to the residence on 7/28/21 with a diagnosis of dementia, a fractured neck, and femur. The residence's progress notes for Resident #7, dated 7/29/24, read that a staff member noticed pink spots on her back that may have been in the beginning stages of "pressure sores." No other progress note documentation was provided despite Resident #7's recurring history of pressure sores. A practitioner's order dated 9/20/24, read that Resident #7 was diagnosed with a stage two pressure injury. The residence's progress notes for Resident #7 did not address any other progress of the pressure injury, nor did they indicate whether Resident #7 complained of pain or any other notes regarding the healing stages or staff actions necessary to address the pressure sore. On 10/30/24 at 8:31 a.m., Staff #17 acknowledged that the progress note written on 7/29/24 failed to show the follow-up on the pressure sore. She acknowledged that there were no other progress notes written for Resident #7 after 7/29/24, even after she was diagnosed with a pressure sore on 9/20/24. Staff #17 said that the progress note system was new and the residence had failed to develop a process that captured the follow-up of the pressure sore. On 10/30/24 at 11:15 a.m., the director of resident services (DRS) stated that Resident #7 had a history of pressure sores. On 10/30/24 at 12:10 p.m., the administrator stated she expected staff to include all details of an incident within a progress note. Further, the administrator stated she believed the residence failed to maintain progress notes after staff turnover.

Based on record review, and interview, the residence failed to ensure the enhanced care plan for each residence in the secure environment included a resident's known behavioral expressions along with individualized approaches to be implemented, affecting one of one sample residents (#7) with an enhanced care plan. (Cross-reference S2230 ) Findings include:Resident #7 was admitted to the residence on 7/28/21 with a diagnosis of dementia, a fractured neck, and femur. The residence's progress notes for Resident #7, dated 7/29/24, read that a staff member noticed pink spots on her back and may have been in the beginning of "pressure sores." The residence's care plan for Resident #7, dated 10/25/24, read that Resident #7 did not show any behavior expressions or a history of pressure sores. A practitioner's order dated 9/20/24, read that Resident #7 was diagnosed with a stage two pressure injury. On 10/30/24 at 8:31 a.m., Staff #17 stated that Resident #7 had a history of pressure sores and was typically surface-level with no tunneling. She acknowledged that the care plan did not include her history of pressure sores, what they looked like, how to prevent them, etc. Staff #17 also stated that Resident #7 liked to lie in specific spots on her bed, and when staff would go in to place her in a different position, she would yell. Staff #17 acknowledged that the enhanced care plan did not include the everyday behavioral expressions she had. On 10/30/24 at 11:15 a.m., the director of resident services (DRS) stated that the care plan provided was the most up-to-date version and it failed to state that she had a history of pressure sores, how to mitigate them and also did not include behavioral expressions for when staff moved Resident #7 to different positions without the hoyer lift. On 10/30/24 at 12:11 p.m., the administrator stated she expected staff to include all details in an enhanced care plan. Further, the administrator stated that the residence failed to maintain updated and accurate enhanced care plans after staff turnover.

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 7.10.6 Each assisted living residence ' s emergency policies shall address, at a minimum, all of the following items:(B) A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes;(G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; (H) Protection and transfer of health information as needed to meet the care needs of residents; (I) and In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. "14.30 The assisted living residence shall maintain a record on a separate sheet for each resident receiving a controlled substance which contains the name of the controlled substance, strength and dosage, date and time administered, resident name, name of authorized practitioner, and the quantity of the controlled substance remaining. 25.5 Before an individual moves in, the assisted living residence shall complete a pre-admission assessment to determine the appropriateness and need for secure environment residency. The pre-admission assessment shall include all the items required for the comprehensive assessment in Part 12.7(A) through (M), plus the following: (A) An evaluation by a licensed practitioner which has occurred within the previous ninety (90) calendar days and which describes the resident ' s medical condition and any cognitive deficits that contribute to wandering, compromised safety awareness, and other types of conduct.

An involuntary discharge appeal survey, prompted by #CO36064, was completed on 5/29/24. No deficiencies were cited.