Morningstar of Wheat Ridge

A relicensure revisit was completed on 7/9/25 for the previous deficiencies cited on 3/5/25. The residence/facility is in compliance with all regulations surveyed.The deficiencies cited for Event FHXL12 were cited prior to the regulation revision that was implemented on 7/1/25. 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 was completed on 3/5/25. Deficiencies were cited. Based on interview and record review the residence failed to ensure there was at least one staff member on-site at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization, affecting 49 current residents. Findings include:A review of the staff CPR certifications and staff schedule from 2/16/25 to 3/1/25 revealed the following four shifts were without a staff member certified in CPR:Overnight shifts: .. Based on observation, interview, and record review, the residence failed to be responsible for the coordination of resident care services with known external service providers (ESPs), affecting one of the sample residents who required a special diet to prevent choking and aspiration (#3). Specifically, Resident #3 was admitted to the residence on 1/11/24 with diagnoses of a transient ischemic attack and vascular dementia. According to the speech language p.. Based on observation, record review, and interview, the residence failed to implement policies and procedures regarding the continued service of any staff member whose criminal history did not reveal good, moral, and responsible character that could pose a risk to the health, safety, and welfare of the residents, affecting 49 current residents. (Cross-reference S0610)Findings include:1. ObservationOn 3/4/25 from 7:30 a.m. to 2:00 p.m., Staff #4 wo.. Based on observation, record review, and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for each prospective staff member for one staff (#4), affecting 49 current residents. (Cross-reference S0622)Findings include:1. ObservationOn 3/4/25 from 7:30 a.m. to 2:00 p.m., Staff #4 worked at the residence directly with residents. On 3/4/25 staff record.. Based on record review and interview the administrator of record had not completed the 40 hours of training, affecting 49 current residents. On 3/4/25 at approximately 7:30 a.m., a request for 40 hour administrator training certification was made, however, the residence was unable to provide such proof. On 3/5/25 at 3:50 p.m., the administrator of record said she had 30 hours of training and lacked the additional 10 hours required as of 7/1/24. Th.. Based on record review and interview the residence failed to notify the department of an interim administrator, affecting 49 current residents.On 3/4/25 the department' s database read the administrator on record was not the acting administrator.On 3/4/25 at 7:30 a.m., upon entering the residence an individual not listed as the administrator of record introduced themselves as the interim administrator and continued to inform it was their last day and some.. 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 7.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error rep..

A licensure complaint, prompted by #CO34800, was completed on 06/4/24. One deficiency was cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting two of four (#2 and #5) sample residents.Findings include:1. The undated residence medication administration policy read in part that the residence administered all medication ordered by the resident' s practitioner. 2. Resident #5 was admitted to the residence on 4/17/23 with diagnoses including chronic obstructive pulmonary disease (COPD).A written practitioner' s order, dated 4/24/24, directed the residence to administer Bactrim one tablet twice a day for 10 days. However, the April 2024 and May 2024 medication administration records (MARs) read that the residence failed to administer the medication on 4/26/24, 4/28/24, 4/30/24, and 5/1/24 because the medication was unavailable and 4/25/24 was left blank for a total of five missed doses. Furthermore, the written practitioner' s order directed the residence to administer 20 total doses; however, the MARs revealed that the residence only scheduled 19 doses. On 6/5/24 at 7:30 a.m., Staff #2 said the pharmacy did not always deliver antibiotics in a timely manner. Staff #2 said when the residence did not have medication in stock, he called the pharmacy and documented it on the MAR. Staff #2 said he followed the MAR when administering medications.On 6/5/24 at 12:44 p.m., the administrator said qualified medication administration persons (QMAPs) were required to follow the instructions on the MAR. The administrator said when the residence was out of medication; the staff reordered the medication or notified the pharmacy. The administrator said the residence ensured the medicines were available and the MAR matched the written practitioner' s orders. The administrator said the pharmacy delivers the ordered doses of antibiotics. Staff document medications that are not available as missing medications. If an antibiotic is missed, the staff will continue administering it until the recommended dose is comple..