Sunrise at Flatirons

A revisit survey was completed on 1/23/25 for all previous deficiencies cited on 9/10/24. 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 licensure complaint, prompted by #CO33652, #CO34382, #CO35927, #CO36032, #CO36033, #CO36939, #CO37292, and #CO37343, was completed on 9/10/24. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to have written policies and procedures that provide for effective control and eradication of insects, and other pests, either directly or indirectly through a resident agreement, affecting 64 current residents. (Cross-reference S2230)Findings include1. ReferenceThe residence' s Pest Control Policy dated 10/12/15 read in part: [Residence] is committed to maintaining a pest free environment for residents, their families and team members."2. ObservationOn 9/10/24 at 8:28 a.m., during a walk through of the secure environment on the third floor of the residence, Resident #1 ' s room had clear trash bags with resident sheets inside. The trash bag had writing that read, "[Resident #1] treated".On 9/10/24 at 8:32 a.m., during a walk through of the secure environment on the third floor of the residence, former Resident #3 ' s room had a paper taped on the door. The paper was written by the resident' s family notifying staff that all furniture may be disposed o.. Based on record review, observation and interview, the residence failed to maintain resident records that included progress notes that contained pertinent information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affected a resident' s physical and functional condition, along with the action taken by staff to address the resident' s changed needs, affecting four of four sample residents. (Cross-reference S2710)1. References The residence policy, titled Injury of Unknown Origin, dated 4/4/23 read in part: the residence would investigate injuries of unknown origin including bruises, abrasions, and other injuries of unknown source. The residence would retain the documents related to the investigation, outcomes, and steps taken. The residence would make such documentation available for review at the Department' s request. The policy also read documentation of the investigation, outcomes, and steps taken may be maintained separately from the resident reco.. 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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.

A revisit survey was completed on 7/12/23 for all previous deficiencies cited on 5/10/23. No deficiencies 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 licensure complaint, prompted by #CO31074, was completed on 5/10/23. Deficiencies were cited. Based on observation, record review and interview, the residence failed to comply with practitioner orders for the administration of medications to two of seven residents (#3, #4) observed during the morning medication pass, and resident #1. Findings include:1. Resident #4: At approximately 7:58 a.m., staff #1 administered Omeprazole Oral Suspension to resident #4, instead of at 6:00 a.m. as practitioner ordered. The directions on the resident' s May 2023 medication administration record (MAR)read, "PLEASE GIVE AT SPECIFIED TIME LISTED." Staff #1 also administered the following five medications to the resident at the same time: acetaminophen oral liquid, citalopram, folic acid, vitam.. Based upon observation and record review, the residence failed to ensure each resident had the right to refuse medications, affecting one of seven sample residents, (#4), observed during the medication pass.Findings include: At approximately 8:10 a.m. staff #1 entered the room of resident #4, who was sleeping in bed. Staff #1 woke the resident and assisted her to sit at the edge of the bed. Staff #1 began administration of medications to resident #4, which included the following six medications: omeprazole oral suspension, acetaminophen oral liquid, citalopram, folic acid, vitamin D3, and memantine. During the administration, resident #4 repeatedly stated "No" and pushed the hand of St.. Based upon observation, record review and interview, the residence failed to ensure one of two qualified medication administration persons (QMAP #2) applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications. Findings include:At approximately 8:30 a.m. to 8:37 a.m., staff #2 removed medications from bubble packs for residents #5 and #6, by popping them into her gloved hand that had touched various items, including medications, cart handles and the computer mouse and placed them in plastic cups. Staff #2 then administered them to the residents. The residence' s medication adminstratio.. Based upon record review and interview, the Administrator and the QMAP Supervisor failed to audit the accuracy and completeness of medication adminstration records (MARs), affecting approximately 58 current residents, administered medications by the residence. Findings include: During the course of the investigation, non-compliance with practitioner orders was found. (Cross-reference Q1468) During interview at approximately 1:32 p.m., the administrator stated she was not aware there were issues with the 6:00 a.m. medication administration times. During interview at approximately 2:23 p.m., the administrator stated she was not conducting audits with the .. 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 VII. 10.1 The assisted living residence shall have readily available a roster of current residents, their roomassignments and emergency contact information, along with a facility diagram showing roomlocations.14.7 The assisted living residence shall ensure that each resident receives proper administrationand/or monitoring of medications.

A relicensure survey was completed on 2/10/23. A deficiency was cited. Based on observation, record review and interview, the residence failed to ensure a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective employee, affecting two of three sample staff (#1-#2).Findings include: A personnel file for Staff #1 contained a hire date of 1/15/20; however, the personnel file contained no name-based criminal background check conducted by CBI. A personnel file for Staff #2 contained a hire date of 6/10/22; however, the personnel file contained no name-based criminal background check conducted by CBI.The residence schedule, dated February 2023, read in part that Staff #1 worked at the residence on 2/1-2/2 and 2/5-2/7/23 and Staff #2 worked on 2/3-2/4, and 2/7-2/10/23.On 2/10/23 at approximately 2:30 p.m., the administrator stated the residence was expected to have completed a name-based criminal history report conducted by the CBI prior to staff member' s hire; however, the residence had no proof the residence conducted the name-based criminal history report in the personnel files of Staff #1 and #2.