Sunrise of Westminster

A licensure complaint, prompted by #CO40720 was completed on 3/26/26. A deficiency was cited. Based on observations, interviews, and record review, the residence failed to ensure medications were stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons (QMAP) or other licensed staff, affecting 3 out of 7 sample residents (#5-#7).Findings include:Residence Policy:The Medication Oversight Program policy, dated 4/20/23, read in part, "Prescription and over the counter medications are stored as follows: All medications are secured in a locked medication cart or other container/area that is locked." ObservationsObservation on 3/26/26 revealed unsecured over-the-counter medications in resident rooms unattended by QMAPs.In Resident #6' s room there were capsules of Tylenol Extra Strength 500 mg observed on the bedside table.In Resident# 5' s room there were capsules of Benadryl Liquid 25 mg, which were observed unsecured in the bathroom cabinet.Resident #7 had a bottle of Pepto Bismol 262 mg located in an open basket in her bathroom. Record reviewA care plan dated 12/9/25 for Resident #5 read in part, staff was required to administer Resident #5 medications.A written practitioner' s order for Resident #6, dated 6/4/25, directed the residence to administer acetaminophen (Tylenol) 500 mg as needed every 8 hours. However, the order did not explicitly read the resident was able to self administer the medication.The Resident Agreement/Service Level Documents, dated June 2025, for Resident #7 read the residence staff was responsible for medication administration and oversight. InterviewsOn 3/26/26 at 9:15 a.m., the administrator stated over the counter medication was managed by staff unless there was a practitioner order stating otherwise. The administrator reviewed the medications that were found in Resident #5-#7' s rooms and confirmed the residents did not have orders that allowed self administration of medications and they should not have been in their rooms. On 3/26/26 at 1:10 p.m. the administrator stated that if the residence was providing medicatio..

A licensure complaint, prompted by #CO35044, was completed on 3/5/24. A deficiency was cited. Based on record review and interview, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting two of six controlled substance log books.Findings include:1. Residence PolicyThe residence' s Medication Oversight Program, dated April 2023, read in part, " All controlled substances are counted at the beginning and ending of each shift ... Both team members sign the controlled substance count log in the appropriate box after verifying accuracy of drugs."2. ObservationThe residence had two separate buildings: Sunrise Villa and Mountain Villa. The residence had a total of six medication carts, each with one controlled substance log book.3. Record ReviewStaff #3 was the qualified medication administration person (QMAP) who was assigned to count the controlled substance lists in the Mountain Villa building. The two controlled substance log books did not include Staff #3' s incoming signatures and only included Staff #4' s outgoing signatures.4. InterviewsOn 3/5/24 at 8:39 a.m., Staff #3 said she forgot to sign the controlled substance log books at the time she counted controlled substances with Staff #4 the morning of the onsite investigation.On 3/5/24 at 8:40 a.m., the resident care director said she expected both QMAPs to sign the controlled substance log books. On 3/5/24 at approximately 3:00 p.m., the administrator said he expected the QMAPs to sign the controlled substance log books immediately after the medications were counted.