Morningstar of Boulder

A relicensure survey was completed on 10/8/24. No deficiencies were cited.A change of ownership survey was completed on 9/5/23. 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.

A complaint revisit was completed on 10/8/24 for all previous deficiencies cited on 5/3/23. A deficiency was cited.The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. Based on interview and record review, the residence failed to update a comprehensive assessment whenever the resident' s condition changed from baseline status, affecting one sample resident (#32).This deficiency was cited previously during a state licensure survey on 5/3/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings Include:1. Residence PolicyThe residence' s Assessment policy, dated July 2021, read in part that the frequency of assessments included change in condition, not limited to a significant change in health requiring additional tasks added to the care plan. The residence' s Change of Condition and Short-Term Observation policy, dated July 2021, read in part: examples of changes in condition included wounds/skin tears. 2. Record reviewResident #32 was admitted to the residence on 3/6/24 with diagnosis including dementia.An incident report, dated 8/20/24, read Resident #32 had a small skin tear on his left knee.Progress notes read in part:On 9/30/29 while assisting Resident #32 to bed, a skin tear was discovered on his right shin, and it was actively bleeding. Resident #32 reported hitting his leg on his wheelchair. On 10/5/24 a skin tear was noted on the back of the residents right arm. The comprehensive assessment, dated 9/4/24, read in part that the resident had no skin concerns. The residence did not update the comprehensive assessment following any of the above changes in Resident #32' s condition.3. InterviewsOn 10/8/24 at approximately 4:00 p.m., the resident care coordinator said the skin tears for Resident #32 were addressed in the care plan. On 10/8/24 at approximately 4:30 p.m., the wellness director said the assessment should have been updated after the discovery of the Resident #32' s skin tears.

An appeal of an involuntary discharge survey prompted by #CO36166 was completed on 8/13/24. A 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 facts and evidence supporting each reason given by the residence and a recounting of events leading to the involuntary discharge, including interactions with the resident prior to the notice and actions that were taken to avoid discharge and failed to contain a practitioner assessment of the resident' s current needs in relation to the resident' s medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence' s staff or an external service provider, affecting one resident (#1).Findings include:The January 2024 Grievance Policy read in part that the residence administrator was in charge of the grievance process related to discharges and that the residence had no more than five business days after the submission of a grievance to respond to the grievance. The involuntary discharge notice, dated 5/1/24, revealed that the residence did not include in the 30-day involuntary discharge a detailed explanation of the reasons for the discharge, including facts and evidence supporting each reason given by the residence and a recounting of events leading to the involuntary discharge, including interactions with the resident prior to the notice and actions that were taken to avoid discharge, and failed to include a practitioner assessment of the resident' s current needs in relation to the resident' s medical condition when an involuntary discharge was initiated due to a medical condition that cannot be treated with services routinely provided by the residence' s staff or an external service provider a practitioner' s assessment of the resident' s current needs in relation to the resident' s medical condition that prompted the discharge.On 8/12/24 at 11:07 a.m., a representative of Resident #1 stated the residence did not include evidence that the resident' s health status had changed from the time the resident' s admissi..

A licensure revisit was completed on 5/3/23 for all previous deficiencies cited on 11/22/22. The residence is in compliance with all regulations surveyed. Deficiencies were cited. Based on observation, interview and record review the residence failed to ensure each resident care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting five of seven sample residents (#9, #16, #17, #22, #25) and two former residents (#28, #31). (Cross-reference Q1146)Findings include:1. Residence Agreement The residence' s resident agreement, dated 1/2020, read in part: Upon admission the residence performed a comprehensive preadmission assessment of the resident' s individual needs. The needs identified through the assessment were included in the individual care plan for the resident. The care plan was updated according to state regulations and as necessary according to the resident' s capabilities and changing needs. .. Based on record review and interview the residence failed to have a readily available roster that included emergency contact information and a residence diagram that showed room location, affecting 77 current residents. Findings include: On 5/2/23 at 8:45 a.m., the interim administrator provided two different copies of the residence' s resident roster. Review of the resident rosters revealed: The first copy of the resident roster was a single page that contained resident names and room numbers. The first copy of the resident roster did not include emergency contact information or a residence diagram that showed room location. The second copy of the resident roster was 12 pages and contained resident names, room numbers, date of birth, resident status, product type (secure environment or no.. Based on record review and interview, the residence failed to implement a fall management program that included detailing in each resident' s care plan the individualized approach necessary to address fall risk related to deficits in strength and balance, affecting two of four sample residents (#17, #22). Specifically, Resident #17 was admitted to the residence on 5/18/18. Resident #17 had documented falls on 3/3/23 and 3/20/23 resulting in no injury. The residence failed to update Resident #17' s care plan to include individual approaches necessary to address the resident' s fall risk. Subsequently, Resident #17 sustained a fall on 4/29/23 that resulted in a superficial abrasion approximately 11 centimeters (cm) in length down the posterior right ribcage believed to be from the wheelchair pedal. The reside.. 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