MORNINGSTAR AT RIDGEGATE

A revisit survey was completed on 12/15/25 for all previous deficiencies cited on 8/14/25. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO40780 and #CO39706, was completed on 8/14/25. Deficiencies were cited.

Based on record review and interview the residence failed to comply with all occurrence reporting requirements by state law affecting one of one sample resident (#3) 1. Residence policy and referencesa. The Colorado Reportable Occurrence Procedures read, Reportable occurrences must be reported to HFEMSD by the next business day. Occurrences which may be reportable include physical, sexual or verbal abuse; brain injury; burns; deaths; drug diversion; life-threatening anesthesia complications or blood transfusions errors/reactions; malfunction/misuse of equipment; misappropriation of resident property; missing persons; neglect; and spinal cord injuries.b. According to the departments Occurrence Reporting Manual:, any occurrence involving neglect of a resident or resident as described in Section 26-3.1-101 (2.3), C.R.S." Section 25-1-124(e) C.R.S. One Element Needed: Failure to provide any care or services as provided above resulting in actual harm. C.R.S. Section 25-1-124(2)(e) states any occurrence involving caretaker neglect of a resident or resident, as described in section 26-3.1-101(2.3), C.R.S. is a reportable occurrence. C.R.S Section 26-3.1-101(2.3)(a) describes neglect as follows: ' Caretaker neglect ' means neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, or supervision is not secured for the at-risk adult is not secured for an at-risk adult 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 adult.c. The Occurrence Reporting Manual instructed to report an occurrence of neglect when a failure to provide any care or services as provided above resulted in actual harm. "Caretaker neglect" was defined as neglect that occurred when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, or supervision was not secured for an at-risk adult or was 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.d. The residence ' s Courtyard Access Reflections Protocol dated July 2021 read in part, team members will routinely monitor the courtyard to ensure resident safety. During extreme weather, doors will be locked for resident safety. 2. The residence failed to ensure occurrences were reported to the Department as required by state statute or regulation. Resident #31 was admitted to the residence 5/17/24 with a diagnosis of Alzheimer's Dementia. A care plan dated 7/24/25 read in part, Resident #3 had impaired cognition, impaired mobility and Risk of impaired consciousness (intoxication, dizziness, seizure disorder). A progress note date 7/28/25 read in part, Resident #3 was sitting out in the courtyard, Resident #3 was not answering to her name but somewhat coherent so we transferred her and gave some water but she kept spitting it out. Staff put wet cold washcloths to her neck and chest. Slowly she became responsive by the minute. The staff called the wellness nurse. An incident report dated 7/28/25 read in part,[Resident #3 ' s] family was concerned that Resident #3 was found in the courtyard when the family visited. She was warm and needed medical attention. Family feels Resident #3 was unattended for a long period of time. Family was concerned that Resident #3 was unattended in the courtyard and was not responding. Event; Resident #3 found in the memory care courtyard by family, passed out and convulsing. Once inside, with cool cloth and water, Resident #3 returned to baseline but was taken to the hospital. Conclusion: discharge paperwork from [hospital]- positive for COVID, Pneumonia and Encephalopathy. A progress note dated 7/31/25 read in part, wellness nurse received a call from [hospital] care manager [Resident #3] stating that doctors recommend that residents be discharged to a skilled nursing facility (SNF). A discharge summary dated 8/1/25 read in part, patient [Resident #3] admitted due to Ecephalopathy after being found lying in the sun outside the memory care unit. Diagnosis: disproportionately enlarged subarachnoid-space hydrocephalus, likely multifactorial due to pneumonia, COVID, dehydration. Discussed discharge options to skilled nursing facility (SNF) versus return to memory care. A care conference note dated 8/7/25 read, " when this nurse reviewed discharge paper from hospital it stated that [Resident #3] had COVID 19, PNA, and ECEPHALOPATHY (found outside memory care unit laying in sun). 3. Interview On 8/14/25 at approximately 8:40 am. Staff #1 stated she heard Resident #3 was left outside on the couch in the direct sun and had a heat stroke. Staff #1 also stated that since Resident #3's return from the hospital, she has been aggressive toward staff, refusing care needs, medications, pushing and scratching. Staff #1 further stated that Resident #3 wandered more and became "hard to care for" while requiring two to three person assistance. Staff #1 believed Resident #3 could benefit from a higher level of care. On 8/14/25 at 3:10 p.m., the Resident Care Coordinator (RCC) stated that Resident #3 ' s family felt she was left outside, after she was brought inside, she was somewhat coherent. Resident #3 was admitted to the hospital for about a week then discharged to rehab, she was then brought back to the residence. Since Resident #3 ' s return she had been increasingly combative and more agitated with cares. The RCC stated the residence did not deem the incident as a reportable offense. On 8/14/25 at 4:20 p.m., the Executive Director (ED) stated she did not deem the incident reportable at the time because Resident #3 was sent to the hospital and diagnosed positive for COVID. The ED further stated the state in which Resident #3 had been in, had happened previously. The ED stated she understood the requirement to report the incident and the failure to do so.

Based on record review and interview the residence failed to ensure the secure outdoor area is directly supervised by staff affecting one of five sample residents within the secured environment, Resident (#3). Findings Include:Resident #3 was admitted to the residence 5/17/24 with a diagnosis of Alzheimer's Dementia. A progress note date 7/28/25 read in part, Resident #3 was sitting out in the courtyard, Resident #3 was not answering to her name but somewhat coherent so we transferred her and gave some water but she kept spitting it out. Staff put wet cold washcloths to her neck and chest. Slowly she became responsive by the minute. The staff called the wellness nurse. An incident report dated 7/28/25 read in part,[Resident #3 ' s] family was concerned that Resident #3 was found in the courtyard when the family visited. She was warm and needed medical attention. Family feels Resident #3 was unattended for a long period of time. Family was concerned that Resident #3 was unattended in the courtyard and was not responding. Event; Resident #3 found in the memory care courtyard by family, passed out and convulsing. Once inside, with cool cloth and water, Resident #3 returned to baseline but was taken to the hospital. Conclusion: discharge paperwork from [hospital]- positive for COVID, Pneumonia and Encephalopathy. On August 14, 2025, at 8:18 a.m., Staff #2 stated that the courtyard was not monitored as closely before Resident #3's incident. On 8/14/25 at approximately 8:40 am. Staff #1 stated she heard Resident #3 was left outside on the couch in the direct sun and had a heat stroke. Staff #1 also stated that since Resident #3's return from the hospital, she has been aggressive toward staff, refusing care needs, medications, pushing and scratching. Staff #1 further stated that Resident #3 wandered more and became "hard to care for" while requiring two to three person assistance. Staff #1 believed Resident #3 could benefit from a higher level of care. On 8/14/25 at approximately 9:00 a.m., Staff #1 stated that after the incident with Resident #3 the staff was told by management to keep a closer eye on residents who entered into the secured courtyard. She stated new measures had been put in place that were not created prior to the incident with Resident #3. She stated once a resident opens the door to the secured courtyard a notification gets set to the staff's phone and a timer starts. She added that with the new measures, when staff are assisting residents that require 2 person assistance, sometimes the notification is missed. On 8/14/25 at 3:10 p.m., the Resident Care Coordinator (RCC) stated that Resident #3 ' s family felt she was left outside. After she was brought inside, she was somewhat coherent. Resident #3 was admitted to the hospital for a week then discharged to rehab, she was then brought back to the residence. Since Resident #3 ' s return she had been increasingly combative and more agitated with cares.

A relicensure and complaint revisit was completed on 8/14/25 for the previous deficiencies cited on 2/20/25. The residence 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 with complaint #CO39213 was completed on 2/20/25. Deficiencies were cited. A change of ownership occurred on 6/5/24.

Based on observation and interview, the residence failed to directly or indirectly provide personal services, including but not limited to a system for identifying and reporting resident concerns that require either an immediate approach or an individualized approach or ongoing monitoring and possible re-assessment affecting one of eight residents (#9). (Cross-reference S1130, S1194, and S2230) Findings include:Resident #9 was admitted to the residence on 1/5/20 with diagnoses including Alzheimer's and moderate cognitive impairment. A progress note, dated 12/28/24, read in part that the resident returned from the hospital, and the family asked if vitals could be checked. An external provider note, dated 12/28/24, had the discharge instructions for the caregivers that read in part, "Wash the left elbow at least once daily and apply either bacitracin or vaseline to the area ... change (wound) bandage at least once daily. Please perform vital checks daily, including temperature, to ensure no fever." There was no documentation of wound care done on Resident #9's elbow for 12/31/24-1/6/25. There was also no documentation of vitals being checked for 12/31/24-1/2/25 and 1/4-1/6/25. A progress note dated 12/31/24, read in part that the family asked why wound care had not been done for Resident #9. The note continued to read that the residence would refer Resident #9 to external home health services to get his wound care needs met, however due to the holiday there was a delay with getting an order. A progress note dated 1/2/25, read that the residence followed up about the order for wound care. A progress note date 1/3/25 read the wound care referral had been sent. An internal investigation document for the discharge instructions not being followed revealed the residence concluded that orders for daily dressing changes were not followed on 12/29, on 12/31 the wound was observed and not changed, and was not changed from 1/1-1/3/25. On 2/19/25 at 5:08 p.m., the associate executive director (AED) stated she worked on 1/4/25 when Resident #9 returned home from the hospital. The AED stated she did not ask Resident #9's family for the discharge paperwork, therefore the residence failed to follow the wound care instructions. On 2/20/25 at 10:10 a.m., the administrator stated that the staff member who received the hospital discharge paperwork failed to follow the residence procedure for external provider notes on 12/28/24. She stated the caregiver filed the hospital discharge paperwork directly into Resident #9's paper record, failing to ensure that all other caregivers or nurses could retrieve pertinent information from the discharge documents to perform the requested care for the resident. She continued to say that she expected the AED to request the discharge paperwork from Resident #9's family upon his return to the facility from the hospital on 1/4/25 to ensure the resident received all personal services required.

Based on record review and interviews, the residence failed to contact the resident's primary practitioner when the resident experienced a significant change in their baseline status, affecting two of two residents (#2, #9). Specifically, on 1/17/25-1/29/25, Resident #2 experienced increased pain while urinating, which led to heightened behaviors and a fall. According to staff members, this was a significant change in her baseline status. The residence failed to contact the resident's practitioner. Subsequently, Resident #2 was sent to the emergency department on 2/5/25 after experiencing an unwitnessed fall that left her unresponsive to staff. After returning to the residence from the emergency department, Resident #2 was diagnosed with a urinary tract infection (UTI). Findings include:1. Resident #3 was admitted into the secure environment at the residence on 1/29/25 with diagnoses including vascular dementia, mood disturbance and anxiety. A progress note, dated 1/17/25, read in part that Resident #2 stated that she was in pain when she urinated. A progress note, dated 1/18/25, read in part that Resident #2 complained about a burning sensation when she urinated. A progress note, dated 1/19/25, read in part that Resident #2 was still experiencing burning while urinating. A progress note, dated 1/20/25, read in part that staff found Resident #2 lying in her bed. Resident #2 had put her incontinence brief over the heater and was wearing different colored socks. She told staff that she was not feeling well. A progress note, dated 1/27/25, read in part that Resident #2 was crying while urinating and complaining about it burning. A progress note, dated 1/29/25, read in part that Resident #2 did not want to get out of bed. She told Staff #1 that she was screaming because it burned when she urinated. A progress note, dated 2/5/25, read in part that Resident #2 had an unwitnessed fall and was not responding to staff. Resident #2 was sent to the emergency department. A progress note, dated 2/6/25, read in part that Resident #2 was diagnosed with a urinary tract infection. On 2/19/25 at 9:04 a.m., the wellness director (WD) stated that she was unaware Resident #2 was experiencing pain while urinating. She also mentioned that she could not find any documentation showing that staff or nurses contacted the resident's practitioner. The WD acknowledged that the residence failed to follow protocol and never contacted the practitioner. On 2/19/25 at 11:39 a.m., Resident #2's external provider stated that they were not informed of any changes in her baseline status regarding a possible UTI from 1/17-2/5/25 . They also mentioned that they expected the residence to contact them regarding the signs and symptoms Resident #2 was experiencing. On 2/20/25 at approximately 10:55 a.m., the administrator stated that the residence should have contacted the practitioner at the first sign of Resident #2's pain. She further stated that this was not the expectation and that she needed to investigate why the residences' protocol call was not followed. 3. Similar deficient practice was found for Resident #9.

Based on record review and interview, the residence failed to document and implement effective actions that were to be taken by staff to prevent reoccurrence of falls for one of eight sample residents (#9) with repeated falls. (Cross-reference S1110, S1130, and S2230) Specifically, on 12/28/24, 1/3/25, and 1/4/25, Resident #9 experienced increased falls. On 12/28/24, the resident fell with multiple injuries, including an abrasion on the knee, elbow, face, and ear. No interventions were put in place for prevention of falls. On 1/3/25, Resident #9's fall did not result in an injury. No interventions were documented to help prevent falls. On 1/4/25, Resident #9 fell, hit his head, and denied going to the hospital for a full check-up. Later, on 1/4/25, Resident #9 complained of pain in his rib area, and his family took him to the hospital. Upon his return, the residence failed to request a copy of the discharge paperwork. The discharge paperwork revealed a diagnosis of rib fractures on the right lateral fifth, sixth, seventh, eighth, and possibly ninth ribs. Findings include:The residence's fall/injury response policy, dated 7/1/20, read in part that there is a five-step process overview, which included documentation. Documentation included an incident report, updated care communication tools, and investigated the fall. Resident #9 was admitted to the residence on 1/5/20 with diagnoses including Alzheimer's and moderate cognitive impairment. A review of Resident #9's record revealed the resident had three falls on 12/28/24, 1/3/25, and 1/4/25. The care plan was last updated on 12/3/24 and did not have fall interventions. Additionally, the service plan was last updated on 12/3/24 and read Resident #9's fall risk interventions were, "... check immediate environment and lighting to meet needs." However, there was no care plan created/updated after the three falls. An incident report dated 12/28/24 at 8:25 a.m., read in part, Resident #9 had an unwitnessed fall with injuries which included an abrasion to the left knee, ear, elbow, and head. The care plan was not updated, and the interventions section of the incident report was left blank. An incident report dated 1/3/25 at 8:00 a.m, read in part, Resident #9 had an unwitnessed fall with no injuries. The care plan was not updated, and the interventions section of the incident report was left blank. An incident report dated 1/4/25 at 12:16 p.m., read in part, Resident #9 had an unwitnessed fall where he hit his head with no complaint of other injuries. The care plan was not updated, and the interventions section of the incident report was left blank. A progress note dated 1/4/25 read that Resident #9's family took him to the hospital because he complained of pain in the rib area, was lethargic, and had some incontinence. On 2/19/25, an initial request was made for hospital discharge paperwork for Resident #9. However, there was no evidence in the record. Later, the discharge paperwork from the hospital from 1/4/25 read that the resident was diagnosed with a fracture of the right lateral fifth, sixth, seventh, eighth, and possibly ninth ribs. It also had a disclaimer which read in pertinent part, "If at any time you have chest pain ... pain that radiates from your chest to your neck, back, jaw or arm then seek emergency medical attention by either calling 911 or going to the nearest [emergency room] ER."A progress note dated 1/6/25 at 5:43 a.m. read Resident #9 complained he was hurt on the right side of his body. A progress note dated 1/6/25 at 8:08 a.m. read that Resident #9 was still in bed and in a lot of pain. A progress note dated 1/6/25 at 1:18 p.m., a caregiver noted she notified the family at 11:30 a.m. about Resident #9's pain. A progress note dated 1/8/25 at 2:27 p.m., the wellness director (WD) wrote that the family returned Resident #9 to the residence with a pro re nata (PRN) or "as needed" pain medication. The associate executive director (AED), and WD relayed a message to the family informing them to request an order for scheduled pain medication for Resident #9. The hospital changed the order to a scheduled medication, two Tylenol tablets every six hours, 500 mg. She continued to write, "Even thought (sic) this nurse was off on Saturday, this nurse put in order in (sic) system." 2. InterviewsOn 2/19/25 at 3:35 p.m., the WD stated she was on vacation when Resident #9 returned from the hospital. She continued to say that she was made aware of the new medication order he was prescribed for the pain he experienced due to falls. On 2/19/25 at 5:08 p.m., the AED stated that she did not ask Resident #9's family for discharge paperwork on 1/4/25 and that no one encouraged her to do so upon his return, therefore, staff remained unaware of the resident's fall injuries. On 2/20/25 at 10:10 a.m., the administrator stated she expected the AED to request the discharge paperwork from Resident #9's family upon his return to the facility from the hospital. The administrator admitted she was not aware of any fall interventions put in place for Resident #9 after his falls.

Based on observation and interview, the residence failed to place the process of addressing grievances and complaints in a visible on-site location that included information for the state long-term care ombudsman and local ombudsman, affecting 79 current residents residing in the non-secure environment. Findings include:On 2/18/25, from approximately 7:00 a.m. to 9:00 a.m., there was no posting of the state long-term care ombudsman or local ombudsman. On 2/18/25 at approximately 9:00 a.m., the concierge stated she was unaware of where the posting was. On 2/20/25, at approximately 10:00 a.m., the administrator said the ombudsman information was typically posted, and she expected it to be posted for her residents.

Based on observations and interviews, the residence failed to ensure that each resident received proper monitoring of medications, affecting two out of two residents (#1, #5) 1. ObservationOn 2/19/25 from 12:24 p.m. to 12:57 p.m., Staff #1 was observed crushing medications for Resident #1. Staff #1 placed the crushed medications in a glass cup filled with chocolate liquid. Staff #1 placed the glass cup with crushed medications in front of Resident #1 who was seated at the dining room table. Resident #1 was seated directly across from an unidentified resident. Resident #4 was observed walking near Resident #1 in close proximity to the glass cup with crushed medications. Staff #1 did not stay and monitor Resident #1 to ensure her medications were properly administered. Staff #1 continued to walk in and out of the dining room to administer medications to other residents and was not in plain sight of Resident #1 at all. 2. InterviewsOn 2/19/25 at 1:01 p.m, Staff #1 acknowledged there were crushed medications in Resident #1's chocolate drink and said he always crushed Resident #1's medications and placed them in chocolate liquid because she refused to ingest her medication crushed in other food. He added he checked on Resident #1 frequently to ensure she drank the cup of crushed medication. (Contrary to the observations on 2/19/25 from 12:24 p.m. to 12:57 p.m.)On 2/20/25 at 9:59 a.m., the reflections coordinator (RC) stated on 8/6/24, she had a verbal conversation with Staff #1 regarding putting residents' medications into liquids, walking away, and not monitoring whether they received all their medications. She further stated that staff members had more recently notified her that Staff #1 was still putting medications in liquids and walking away. On 2/20/25 at approximately 11:00 a.m., the administrator stated that she did not expect a qualified medication administration personnel (QMAP) to pass medication to a resident and walk away without ensuring the resident ingested all of their medication. She further stated that this was not how the residence trained their staff. Similar deficient practice also affected Resident #5.

Based on observation, record review, and interview, the residence failed to ensure that resident records contained documentation of on-going services provided by external service providers including but not limited to other practitioners, assistants, and care providers affecting one of eight sample residents (#9). (Cross-reference S1110, S1130, and S1194) Findings Include:1. Record ReviewResident #9 was admitted to the residence on 1/5/20, with diagnoses including Alzheimer's and moderate cognitive impairment. A review of Resident #9's record revealed the resident had three falls on 12/28/24, 1/3/25 and 1/4/25. An incident report dated 12/28/24 at 8:25 a.m., read in part, Resident #9 had an unwitnessed fall with injuries which included an abrasion to the left knee, ear, elbow, and head. An incident report dated 1/3/25 at 8:00 a.m, read in part, Resident #9 had an unwitnessed fall with no injuries. An incident report dated 1/4/25 at 12:16 p.m., read in part, Resident #9 had an unwitnessed fall where he hit his head with no complaint of other injuries. A progress note dated 1/4/25 read that Resident #9's family took him to the hospital because he was complaining of pain in the rib area, was lethargic and had some incontinence. On 2/19/25, an initial request was made for hospital discharge paperwork for Resident #9. However, there was no evidence of paperwork in his record. The residence later provided the discharge paperwork for 1/4/25 that read that the resident was diagnosed with a fracture of the right lateral fifth, sixth, seventh, eighth, and possibly ninth ribs. A progress note dated 1/6/25 at 5:43 a.m. read Resident #9 fought and complained he was hurt on the right side. A progress note dated 1/6/25 at 8:08 a.m. read that Resident #9 was still in bed and in a lot of pain. A progress note dated 1/6/25 at 1:18 p.m., a caregiver noted she notified the family at 11:30 p.m. about Resident #9's pain. 2. InterviewOn 2/19/25 at 5:08 p.m., the associate executive director (AED) stated she worked on 1/4/25 when Resident #9 returned home from the hospital. The AED stated she did not ask Resident #9's family for discharge paperwork, and no one encouraged her to ask for it upon his return therefore the external service documentation was not included in the resident record. On 2/20/25 at 10:10 a.m., the administrator stated she expected the AED to request the discharge paperwork from Resident #9's family upon his return to the residence from the hospital and place it into the resident's record. She also stated that upon investigation she conducted on 1/7/25, she learned that the caregiver who documented Resident #9's pain at 8:08 a.m. and 1:13 p.m. failed to notify the nurse on-site until the resident had left the building. She acknowledged the failure that was made due to the lack of documentation.

Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment that included an evaluation by a licensed practitioner that described the resident's cognitive deficits that contributed to wandering, compromised safety awareness and detailed information from the resident's family that revealed a history and pattern of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, affecting four of six residents (#1, #2, #5, #6) who resided in the residence's secure environment. Findings include: 1. Resident #5 was admitted to the residence on 11/29/24. The Evaluation for a Secure Environment form, dated 11/18/24, included five areas where the practitioner was required to check off, if appropriate for Resident #5. The areas did not include any resident specific information that identified Resident #5's specific cognitive deficits that contributed to wandering, compromised safety awareness nor did it include detailed information from the resident's family that revealed a history and pattern of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering. 2. During the onsite visits on 2/18- 2/20/25, similar deficient practice was found in the records of Resident #1, #2, and #6.3. On 2/20/25 at approximately 10:00 a.m., the administrator said what was missing from the residence's Evaluation for Secure Environment forms were prior interventions tried before being moved to a secure environment. She added she expected more details to be included on the forms for residents in the secure environment. The administrator said she was not aware detailed information from the residents family was a requirement.

Based on record review and interview, the residence failed to update the care plan to reflect changes in the staff approach required to meet resident needs and when any medical assessment, appraisal, or observations indicated the resident's care needs had changed, affecting one of eight sample residents (#5). Specifically, Resident #5 fell five times from November 2024 through February 2025. After a fall on 1/26 and 1/28/25, Resident #5 complained of pain. There were no care plan updates to reflect changes in staff approach to meet Resident #5's needs when progress notes and incident reports indicated Resident #5's care needs had changed after she fell on 11/30, 12/12/24, 1/26, 1/28 or 2/17/25. Staff interviewed on 2/19/25 revealed they were not made aware of any changes specific to Resident #5 to address their approaches after she fell five times. Findings include:1. Resident #5 was admitted to the residence on 11/29/24 with diagnoses including muscle weakness and cognitive communication. Progress notes and incident reports in Resident #5's record for November through December 2024 and January through February 2025 revealed the following:On 11/30/24 Resident #5 was found on the floor. On 12/12/24 Resident #5 tried to transfer herself and fell. On 12/13/24 Resident #5 was crawling on the floor. On 1/26/25 Resident #5 fell in the common area. On 1/28/25 Resident #5 complained of back pain. On 1/28/25 Resident #5's family member said she fell a couple of days ago in his apartment. Resident #5 complained of rib and back pain. On 2/17/25 Resident #5 fell. Care plans updated in Resident #5's record revealed the following:On 11/20/24 read Resident #5 required four checks during the overnight shift, has a history of falls prior to move in, and required as needed environmental checks. On 1/7/25 read no change from 11/20/24 care plan approaches/interventions. On 1/21/25 read nighttime wellness checks reduced to two times during the overnight shift. No other approaches or interventions were added. There were no other care plan updates to reflect changes in staff approach to meet Resident #5's needs when progress notes and incident reports indicated Resident #5's care needs had changed after she fell on 11/30, 12/12/24, 1/26, 1/28 or 2/17/25. 2. InterviewsOn 2/19/25 at 9:17 a.m., Staff #1 said no additional education was provided by the residence after Resident #5 fell five times from when she moved in to her last fall on 2/17/25. On 2/19/25 at 9:27 a.m., Staff #5 said she was not provided any education or additional trainings after Resident #5 fell five times from move-in until 2/17/25. On 2/19/25 at 9:29 a.m., Staff #6 said she was told to keep Resident #5 was unsteady on her feet and to keep her in the common areas. She added, no other resident specific training was provided after she fell. On 2/19/25 at 9:42 a.m., the wellness director said the care coordinators and nurses were responsible for updating resident care plans after a resident falls. She added she expected staff to be educated on the changes. On 2/20/25 at approximately 10:00 a.m., the administrator said she expected the care plans for residents in the secure environment to reflect the changes in staff approach to meet the residents needs when any medical assessment or observation indicated the residents care needs have changed. She added she was not aware that Resident #5's care plan was not updated to include changes in approaches to meet care needs after multiple falls. The administrator said the approaches should be discussed in crossover meetings with shift change.

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 7.14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 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.

A revisit survey was completed on 4/17/24 for all previous deficiencies cited on 7/19/23. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO29598, was completed on 7/19/23. Deficiencies were cited.

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 first aid from a nationally recognized organization such as the American Red Cross, the American Heart Association, National Safety Council, or American Safety and Health Institute, affecting 91 current residents. Findings include:1. Reference and Residence Policya. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training." VeryWell Health (6/23/23) First Aid Instructions for 10 Medical Emergencies, retrieved from: https://www.verywellhealth.com/basic-first-aid-procedures-1298578 b. The residence's undated staffing policy read in part that, in compliance with state law, the residence had at least one staff member who was certified in first aid onsite at all times.c. The residence's resident agreement, dated January 2020, read in part that the residence had, at minimum, one staff on each shift who was certified in first aid. 2. Record ReviewOn 7/19/23, a review of staff first aid certifications revealed that Staff #1-#8 had no current certification in first aid at all. Additionally, Staff #9 was certified through an organization that was not nationally recognized. The July 2023 staff schedule revealed there was one staff on duty with first aid certification from an organization that was not nationally recognized on 7/3/23 from 10:00 p.m. to 6:00 a.m., when Staff #9 worked. Additionally, the July 2023 schedule revealed that the residence failed to ensure that staff with certification in first aid were on site from 10:00 p.m. to 6:00 a.m. on 7/2/23, 7/9/23, and 7/16/23.3. InterviewOn 7/19/23 at approximately 1:58 p.m., the administrator stated she was aware of the requirement to ensure there was at least one staff certified in first aid from a nationally recognized organization on site at all times. She acknowledged that Staff #1-#8 did not have current first aid certifications and that Staff #9 did not have certification through a nationally recognized organization. The administrator stated the residence needed to implement a better system to track expiration dates for certifications as well as first aid certifications for new staff.

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 91 current residents. Findings include:1. Reference and Residence Policya. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (2/12/22) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 b. 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 c. The residence's CPR policy, dated June 2021, read in part that when a resident was in need of CPR, qualified staff initiated CPR unless the resident had documentation to not resuscitate. Staff completed CPR training by a nationally recognized program such as the American Heart Association, the National Safety Council or the American Safety and Health Institute, and will include staff demonstration of CPR techniques.d. The residence's resident agreement, dated January 2020, read in part that in the event of an emergency, CPR was not performed by staff except as required by applicable state law. At minimum, the residence had one staff member who was CPR certified on duty for each shift. 2. Record ReviewOn 7/19/23, a review of staff CPR certifications revealed that Staff #1-#4, #8 and #9 had no current certification in CPR at all. The July 2023 schedule revealed that the residence had no CPR certified staff on duty 10:00 p.m. to 6:00 a.m. on 7/9/23 and 7/16/23.3. InterviewOn 7/19/23 at approximately 1:58 p.m., the administrator stated she was aware of the requirement to ensure there was at least one staff certified in CPR from a nationally recognized organization on site at all times. She acknowledged that Staff #1-#4, #8, and #9 did not have current first aid certifications and worked alone on 7/9/23 and 7/16/23. The administrator stated the residence needed to implement a better system to track expiration dates for certifications as well as CPR certifications for new staff.