Morningstar Assisted Living of Littleton

A relicensure survey with complaints #CO37338 and #CO37991 was completed on 10/23/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure residents were treated with dignity and respect, affecting two of two sample residents (#12, #13). (Cross-reference S1410)Specifically, Resident #12 said she did not want Staff #5 to work with her anymore because she had made Resident #12 "feel like such a burden," miserable, and disrespected. Resident #13 said Staff #5 was careless when she assisted her in putting on her shoes, said she caused h.. Based on interview and record review, the residence failed to provide steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury was not suspected abuse, neglect, or exploitation affecting two of six sample residents (#6, #9). Findings include:Resident #9 was admitted to the residence on 9/30/24 with diagnoses of frontal lobe and executive function deficit post cerebral.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration affecting three of six sample residents (#6, #10, #11). Findings include:1. Record ReviewResident #11 was admitted to the residence on 10/24/23 with diagnoses of hypertension, hyperlipidemia, glaucoma, and depression.Practitioner orders, dated 10/24/23, directed the residence to administer acetaminophen .. Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and identification of injuries of unknown origin, affecting one of six sample residents (#6).Findings include:1. Residence PolicyThe residence' s Abuse Prevention, Investigation and Reporting policy, dated July 2021, read in part, "Reports of abuse or suspected abuse will be promptly and thoroughly investigated. The inves.. Based on record review and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data System (CAPS) requirements prior to hiring staff who provided care to residents for one staff (#5), affecting 77 current residents. (Cross-reference S410)Findings include:The residence' s Abuse Prevention, Investigation and Reporting policy, dated July 2021, read in part, "Team members will maintain ethical and professio.. Based on record review and interview, the residence failed to report physical abuse to law enforcement within 24 hours of observation or discovery, affecting one of six sample residents (#6). (Cross-reference S1320 and B172)Findings include:1. Residence PolicyThe residence' s Abuse Reporting Protocol policy, dated September 2024 read, in part, "Mandatory reporter means any public or private official who is required by state abuse statutes to report alleged ab.. Based on record review and interview, the residence failed to report to the department an occurrence of physical abuse against a resident, affecting one of six sample residents (#6). (Cross-reference S410)Findings include:1. Reference and Residence Policya. The department' s occurrence reporting manual, revised May 2018, read in part, "Two elements were needed for physical abuse: intent, or knowingly or recklessly; and, bodily injury and/or serious .. 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 7.12.10 Each resident care plan shall: (B) Reflect the most current assessment information; (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs14.11..

A complaint revisit was completed on 10/23/24 for all previous deficiencies cited on 4/26/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration affecting three of six sample residents (#6, #10, #11). This deficiency was cited previously during a complaint survey 4/26/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewResident #11 was admitted to the residence on 10/24/23 with diagnoses of hypertension, hyperlipidemia, glaucoma, and depression.Practitioner orders, dated 10/24/23, directed the residence to administer acetaminophen 1000 mg twice daily. Practitioner orders, dated 4/10/24, directed the residence to discontinue administering docusate sodium.The October 2024 medication administration record (MAR) revealed that the residence administered acetaminophen 500 mg twice daily from 10/1 to 10/22/24. The October 2024 MAR read that the residence administered docusate sodium daily from 10/1 to 10/22/24. 2. InterviewsOn 10/23/24 at 8:45 a.m., the administrator stated that the wellness nurse (WN) was responsible for updating MARs to match practitioner orders.On 10/23/24 at 9:44 a.m., the WN stated that staff sometimes added duplicate practitioner orders to the MAR and overlooked it, and this was possibly what caused staff to administer the incorrect dose of acetaminophen. On 10/23/24 at 10:18 a.m., the administrator stated that this citation was being recited because staff did not ensure that the medications were in stock.Similar deficient practice was found for Residents #6 and #10.

A licensure complaint prompted by #CO31644, was completed on 4/26/23. Deficiences were cited. Based on observation, record review and interview, the residence failed to admit a resident whose needs could be fully met by the existing staff and services already being provided, affecting one of two sample residents (#1) and one former resident (#5).Findings include: 1. Residence PolicyThe residence' s admission policy, dated July 2021, read in part: Residents must be able to minimally transfer with one care staff, residents could not be admitted if they required medical or nursing services 24 hours a day seven days a week, or had stage three or four pressure sores would only be admitted on a case-by-case basis.2. Resident #1 was admitted to the residence on 3/4/23 with diagnoses including parkinson' s disease, venous insufficiency, cardiomegaly, osteoarthritis, blindness left eye, anemia and chro.. Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four sample residents (#1-#4) and one former resident (#5) whose medications were reviewed.Specifically, Resident #1 was admitted to the residence on 3/4/23 with a diagnosis of Parkinson' s disease. The record for the resident contained a written practitioner' s order, dated 2/8/23, which directed the residence to administer carbidopa-levodopa 25-250 mg three times daily. A second written practitioner' s order, dated 4/14/23, directed the practitioner to administer carbidopa-levodopa 25-100 mg four times daily to be taken with 25-250 mg. However, the April 2023 electronic medication administration record (eMAR) read .. Based on record review and interview, the residence failed to accurately document each medication administration or monitoring event at the time the event was completed for each resident, affecting one former resident (#5).Findings include:1. The residence' s medication administration policy, dated July 2021, read in part: "Medication assistant or qualified medication administration personnel (QMAPS) shall document when a medication is unavailable in the electronic medication administration record (eMAR)."2. Former Resident #5 was admitted to the residence on 3/13/23, with a diagnosis of striatonigral degeneration. a. PregabalinA written practitioner' s order, dated 2/27/23, directed the residence to administer 100 mg of pregabalin twice daily. However, the March 2023 eMAR revealed no evidence of do.. 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 7.11.16 The assisted living residence shall provide written notice of any discharge to the resident or legal representative 30 calendar days in advance of discharge except in cases of imminent physical harm to or by the resident or medical emergency, whereupon the assisted living residence shall notify the legal representative as soon as possible.14.39 Controlled substances shall be kept in double lock storage.(A) Two individuals who are either qualified medication administration persons, nurses, or practitioners shall jointly count all controlled substances at t..