Modena Cherry Creek

A licensure complaint, prompted by #CO40618, was completed on 7/29/25. A deficiency was cited. Based on record review and interview, the residence failed to either directly or indirectly provide protective oversight, including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event affecting one former resident (#4). Specifically, a pre-admission assessment dated 7/21/23 read that Former Resident #4 had a history of suicidal tendencies. The residence put a safety plan in place dated 11/4/23, which read that if Former Resident #4 had any suicidal ideations, she would notify the assisted living director (ALD), the administrator, or a family member immediately. At a care conference on 7/4/25 with Former Resident #4' s family member, the administrator and the ALD, a family member of Former Resident #4 expressed their plan to commit suicide by jumping from a balcony. Former Resident #4 mentioned the same plan to another staff member on 7/5/25. However, the residence failed to provide protective oversight by taking appropriate measures when confronted with an unanticipated situation that required immediate individualized approach, and Former Resident #4 committed suicide on 7/6/25 at approximately 7:00 a.m. by jumping off a balcony of the residence.Findings include:1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences Part 2.38, defines "Protective oversight" as the guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (B) Monitoring the activities of the resident while on the premises to ensure the resident' s health, safety, and well-being.b. A review of the residence' s undated resident agreement revealed the agreement failed to include the mention of protective oversight, including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach.2. Former Resident..

A licensure complaint, prompted by #CO38140 and #CO38156, was completed on 11/5/24. Deficiencies were cited. Based on record review and interview, the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting two of four sample residents (#9, #11).Findings include:1. Resident #11 was admitted to the residence on 8/31/22.The October 2024 medication administration record (MAR) for Resident #11 revealed staff administered the following medications administered with no written practitioner orders:Cetirizine 10 mg administered on 10/7-10/9 and 10/11/24.Multivitamin administered on 10/8 and 10/9/24.N-Acetyl Cysteine (NAC) 600 mg administered on 10/7-10/9/24.Nicotine 4 mg patch administered on 10/8-10/13/24.Pravastatin sodium 20 mg administered on 10/7-10/9/24.Sulfasalazine 500 mg administered on 10/8 and 10/9/24.Vitamin B-12 administered on 10/8 and 10/9/24.Vitamin D2 1000 IU administered on 10/8 and 10/9/24.During the onsite investigation, the residence provided no written practitioner orders to administer the above medications to Resident #11.On 11/5/24 at approximately 2:00 p.m., the administrator stated she expected the residence to have signed practitioner' s orders for medications that staff administered.2. Similar deficient practice was identified for Resident #9. 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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident' s condition changes from baseline status.18.8 Resident records shall contain, but not be limited to, the following items:(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident' s changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.

A licensure complaint, prompted by #CO37081, was completed on 8/15/24. Deficiencies were cited. Based on interview and record review the residence failed to ensure the resident' s primary practitioner was notified when the resident experienced a change in condition affecting one former resident (#5). Cross-reference S1192Findings include:1. Former Resident #5 was admitted to the residence on 5/14/24 with diagnoses including: Unspecified dementia, unspecified severity; atherosclerotic heart disease of native coronary artery; polyneuropathy,.. Based on interview and record review, the residence failed to ensure the visitation policy aligned with regulations affecting 105 current residents. Findings include:1. ReferenceChapter VII regulations governing assisted living residence, requires in part 13.1 that the assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall obser.. Based on interview and record review, the residence failed to implement their policy on investigations of abuse affecting 26 current residents in the residence' s secure environment. Cross-reference S1322Specifically, on 8/8/24 an allegation of abuse was made regarding Former Resident # 4 and Staff #2 during evening care.The residence' s investigation revealed statements from the witness, the private caregiver (PCG), and Staff #2. However, the residenc.. Based on record review and interview the residence failed to ensure all residents were free from abuse and intimidation, affecting one Former Resident ( #4). Cross-reference S1410 Findings include:1. References and Residence Policya. The residence' s Abuse, Neglect, and Exploitation policy, dated 12/1/23, read in part:"Resident abuse, neglect, and exploitation are prohibited. Upon the notice of reported, observed, suspected, or at imminent risk of any form o.. Based on record review and interview the residence failed to ensure residents needing lift assistance were evaluated properly to determine whether lift assistance was appropriate by staff for two of two sample residents (#5 and #6). Cross-reference S1130Findings include1. Residence PolicyThe Falls policy, dated 12/1/23, read in part: The director of nursing or qualified medication administration person (QMAP) may allow the resident to be assisted up to a chair, if t.. Based on record review and interview, the residence failed to update a resident care plan that reflected the most current assessment information, promote resident mobility and safety, and detail specific service needs along with the staff tasks necessary to meet those needs affecting one sample resident (#1) who experienced falls. Finding include:1. Residence PolicyThe residence' s Fall policy, dated 12/1/23, read in pertinent part: "All Residents are evaluated for fa.. 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 VII.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 ..