Morningstar at Bear Creek

A revisit survey was completed on 9/4/24 for all previous deficiencies cited on 5/21/24. 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 relicensure survey with complaint #CO29820, #CO30054, and #CO30096 was completed on 5/21/24. Deficiencies were cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one current sample resident (#4) and one former resident (#5).Findings include:The undated residence Medication Administration policy read in part that the residence administered all medication ordered by the resident' s practitioner. Resident #4 was admitted to the residence on 7/17/20 with diagnoses including dementia and anxiety.A written practitioner' s order, dated 4/5/24, directed the residence to administer lorazepam 2 mg/2 ml three times daily. However, the May 2024 medication administration record (MAR) read that the residence failed to administer the medication from 5/5 to 5/8/24 because the medication was unavailable, for a total of eight missed doses.On 5/21/24 at 12:40 p.m., a family member of Resident #4 stated that the residence was out of Resident #4' s lorazepam in early May 2024 for approximately four da.. Based on record review and interview, the residence failed to ensure health information records for residents were kept on site for at least three years following the termination of the resident' s stay, affecting one former resident (#6).Findings include:The residence' s July 2021 Resident Records: Access Confidentiality policy read in part that the residence ensured the storage and maintenance of the resident records for at least seven years.Former Resident #6 was admitted to the residence on 7/3/22 and passed away on 9/17/22.A care plan, dated 7/3/22, read that the residence was required to administer all practitioner-ordered medications to the resident.An external service provider (ESP) document, dated 9/16/24, read the resident received external hospice services. The entire record for Former Resident #6 was requested on 5/21/24 at 9:40 a.m.; however, the residence was unable to provide written practitioner orders, ESP notes, or any after-visit summaries from the resident' s practitioner. On 5/21/24 at 2:07 p.m... 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 7.25.26 A secure environment shall meet the following criteria: (F) There shall be a secure outdoor area that is available for resident use year-round that:(1) Is directly supervised by staff,(2) Is independently accessible to residents without staff assistance for entrance or exit,(3) Has comfortable seating areas,(4) Has one or more areas that provide protection from weather elements, and(5) Has a fence or enclosure around the perimeter of the outdoor area that is no less than six (6) feet in height and constructed to reduce the risk of resident wandering or elopement from the area.(a) If the fence or enclosure has gated access which is locked, all staff assigned to the secure environment shall have a readily available means of unlocking the gate in case of emergency.