Morningstar at Ridgegate

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 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 c.. 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 state..

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)... 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 approximat.. 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, S11.. 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 fil.. 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 informati.. 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 i.. 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 tim.. 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.. 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 cla..

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 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 ..... 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 c..