Morningstar of Arvada

An involuntary discharge appeal survey, prompted by #CO40298, was completed on 6/17/25. A deficiency was cited. Based on interviews and record review, the residence failed to reassess the resident to be discharged and revise his or her care plan to identify the resident' s current needs and what services the assisted living resident will provide to meet those needs, affecting one resident (#1). Findings Include:1. Record ReviewOn 5/9/25, Resident #1 received a Discharge Notice from the residence stating "Resident requires a level of care that the Facility does not provide. The resident continually refuses treatment, care, food and exhibits signs of behavioral health conditions. The resident is refusing medication and refusing to eat meals which has left the resident malnourished. As a result of the resident' s required level of care and concern for her safety, the Facility must terminate the Resident Agreement."On 6/10/25, at approximately 9:15 a.m., a request for documents from the administrator was made via email. The requested documents included care plans, progress notes showing efforts the facility took and measures to try and address the needs/circumstances related to the cause of the involuntary discharge, adult protection documentation, medication administration record (MAR), 30-Day Discharge Notice, Resident #1' s grievance, residence' s response to Resident #1' s appeal, residence policy on Involuntary Discharge, Resident #1' s signed Residential Agreement, medical documentation, resources that the residence provided assistance with housing search, Resident #1' s demographic/facesheet information, and any complaints submitted by Resident #1.On 6/10/25, the requested documentation was received the requested documentation from the administrator, including care plans dated 5/31/24, 6/4/24, 9/27/24, and a copy of the written notice of termination dated 5/9/25, terminating the resident agreement between the residence and Resident #1. The discharge notice did not include interactions with the resident prior to the notice and actions that were taken to avoid discharge, specifying the timing of the events and actions.O..

A complaint survey, prompted by #CO40107, was completed on 5/27/25. One deficiency was cited. Based on interviews and record review, the residence failed to include in the initial 30-day involuntary discharge a detailed explanation of the reasons for the discharge, including interactions with the resident prior to the notice and actions that were taken to avoid discharge specifying the timing of the events and actions, affecting one resident (#1). Findings include:On 5/27/25 at approximately 9:07 a.m., the residence provided a copy of the written notice of termination dated 5/9/25 terminating the resident agreement between the residence and Resident #1. The discharge notice did not include interactions with the resident prior to the notice and actions that were taken to avoid discharge, specifying the timing of the events and actions.On 5/27/25 at 3:34 p.m., the administrator affirmed the residence did not included in the discharge notice, information detailing interactions with the resident prior to the notice and actions that were taken to avoid discharge, specifying the timing of the events and actions.

A revisit survey was completed on 5/7/25 for all previous deficiencies cited on 2/4/25. 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 #CO36030, #CO36458, and #CO36527 was completed on 2/4/25. Deficiencies were cited. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#6) and one former resident (#8).Findings include:1. Resident #6 was admitted to the residence on 1/13/25 with diagnoses including depression.A written practitioner' s order dated 1/2/25 directed the residence to administer fluoxetine 10 mg once daily. However, the January 2025 medication administration record (MAR) for Resident #6 read the medication was not available and not administered on 1/17-1/22/25, for a total of six days.InterviewsOn 2/4/25 at 1:05 p.m., a family member of Resident #6 acknowledged the residence did not administer the medication to Resident #6 because she had brought in the wro.. Based on record review and interview, the residence failed to have a care plan that included a description of the resident' s known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident, affecting one sample resident (#6).Findings include:1. Resident #6 was admitted to the residence on 1/13/25 with diagnoses including Alzheimer' s disease, hemorrhagic stroke, and major depressive disorder.Progress notes for Resident #6 in January 2025 revealed the following:Resident #6 fell on 1/18, 1/23 and 1/29/25.On 1/30/25 at 1:53 p.m., Resident #6 fell after sliding off his bed earlier in the day and wandered around without his walker or wheelchair.On 1/31/25 at 1:18 a.m., Resident #6 slid off his walker and fell to the floor.A care plan for Resident #6 .. Based on the interview and record review, the residence failed to ensure there was at least one staff member onsite at all times certified in cardiopulmonary resuscitation (CPR), affecting 66 current residents. Findings include:On 2/3/25 at 1:03 p.m., CPR certification for all staff was requested from the administrator. On 2/4/25 at 2:41 p.m., certifications were provided. However, the CPR certifications revealed several staff members listed on the schedule did not have CPR certification.The staff schedule revealed the overnight shift from 10:00 p.m. to 6:00 a.m. did not have a person onsite at all times certified in CPR on the following days: 1/3, 1/17, 1/24, and 1/31/25.On 2/4/25 at 2:35 p.m., the administrator, assistant executive director (AED), Staff #6, and Staff #7 acknowledged that the reside.. 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 2 and 7.11.2.3. Facilities and agencies shall ensure that ninety percent (90%) of employees and direct contractors have received the influenza vaccine during a given influenza season. In order to demonstrate that the ninety percent (90%) rate has been meet, facilities and agencies shall: (A) By May 15th of every year, report to the Department, in the form and manner specified by the Department, the vaccination rate for employees and direct contracts for the most recent influenza season. (B) Have defined procedures to prevent the spr..