Acoya Cherry Creek

A second initial licensure survey with complaint revisit was completed on 6/16/25 for the previous deficiencies cited on 12/18/24. 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 second initial licensure survey with complaint #CO38522 was completed on 12/18/24. Deficiencies were cited. Based on interview, and record review the residence failed to ensure medications were documented at the time of administration, and staff utilizing the medication administration record (MAR) used their initials and signatures affecting two of three sample residents (#1, #3) and former resident (#5). Findings include:1. Document at the TimeResident #3 was admitted to the residence on 12/8/23 with a diagnosis including anal cancer.a . A written pract.. Based on observation, interview, and record review the residence failed to only administer medication that had been ordered by an authorized practitioner affecting one of three sample residents (#3). Findings include:1. Residence PolicyThe Residence Changes to Medication Orders policy, undated, read "Community QMAP' s (Qualified Medication Administration Personnel) will follow a consistent workflow for processing orders for changes to medication orders th.. Based on observation, interview, and record review, the residence failed to ensure each staff member received orientation and training prior to providing any care services to a resident for one sample staff (#1), affecting 18 current residents. (Cross-reference S0648)Findings include: Chapter VII regulations governing assisted living residences, part 2.56, defines "Staff" as employees and contracted individuals intended to substitute for or suppleme.. Based on observation, interview, and record review, the residence failed to ensure each staff member received training prior to working independently with a resident for one sample staff (#1), affecting 18 current residents. (Cross-reference S0640)Chapter VII regulations governing assisted living residences, part 2.56, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal servi.. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#1, #3, #4) and one former resident (#5). Specifically, Resident #4 diagnosed with anxiety had a written practitioner' s order, dated 9/4/24, which directed the residence to administer lorazepam 1 mg twice daily. However, the November 2024 Medication Administ.. Based on the interview and record review the residence failed to ensure there was at least one staff member onsite at all times from a nationally recognized organization affecting 18 current residents. Findings include:First aid certifications and the staff schedule from 12/6/24 - 12/19/24 revealed the residence failed to have at least one staff member onsite at all times from a nationally recognized organization for six shifts as follows:12/9, 12/10, 12/11, 12/.. 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 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based crim..