The administrator of a Boulder assisted living facility allegedly tried to cover up evidence of safety lapses and missed warning signs that preceded a resident’s suicide in February.
Inspectors from the Colorado Department of Public Health and Environment cited MorningStar Assisted Living and Memory Care of Boulder for failing to conduct quarterly checks that could have revealed the resident possessed a weapon and for not taking action when the resident voiced thoughts of suicide.
State inspectors also said the administrator attempted to hide or falsify information, to make it appear staff had checked the resident’s room and hadn’t reported the suicidal statements.
It isn’t clear whether the administrator who was in charge when the inspectors’ report was filed in March still works at the facility. The report didn’t identify the administrator or any other staffers or residents, including the man who died by suicide.
The Boulder site’s current executive director and MorningStar’s corporate office didn’t respond to calls from The Denver Post seeking comment.
The resident of MorningStar’s facility at 575 Tantra Drive died Feb. 20, one day after staff said he had asked them to kill him, according to the report. The resident had a history of depression and staff members who the state inspectors interviewed anonymously said he previously had mentioned dying by a specific method repeatedly in the months before.
The resident died less than three weeks after another incident involving prohibited weapons at an assisted living facility in Boulder County. On Feb. 3, a resident of Legacy Assisted Living in Lafayette fatally shot a staff member, who he said had been stealing from him. In that case, staff had taken guns from him before, but he managed to obtain another weapon.
A MorningStar staff member told state inspectors she had filed an incident report that included the resident’s statements the day before he died. After the resident’s death, however, the reference to his statement about dying was scrubbed from the report, she told inspectors.
Other staff members said they had reported the resident’s previous statements about suicide in October and December 2020, and again in January 2021. One staff member said that the resident had told her, earlier in February, that he intended to die and would leave her some money.
Giving away or making plans to distribute possessions can be a sign that a person who has thought about suicide has a concrete plan. Other warning signs can include talking about feeling hopeless, wanting to die or being a burden to others; increasing alcohol or drug use; withdrawing from others; or showing rage or talking about revenge.
The MorningStar at Boulder administrator told inspectors she had never seen any specific reports that the resident was suicidal, and had told staff that they should listen respectfully to the resident’s feelings.
The National Suicide Prevention Lifeline does recommend listening without judging the person, but also seeking professional help, asking the person if they have a plan and trying to reduce their ability to carry out that plan.
In the case of the MorningStar resident, staff could have removed the lethal means, because all residents agree not to have certain items, including weapons. MorningStar policy requires staff to check residents’ rooms at least quarterly for hazards that could cause accidental injury, like a rug that a resident could trip on, and staff members are allowed to look for prohibited items, including weapons.
The inspectors believed the administrator attempted to fake documentation to make it looked like staff had checked the resident’s room recently, according to their report.
Five staff members said they hadn’t seen any room checks in February, and some said they hadn’t been done for far longer. The administrator and another staff member said they had checked rooms, but inconsistencies in the documentation they provided suggested that wasn’t true, inspectors found.
MorningStar of Boulder pledged to retrain staff and develop a policy to prevent suicides, according to a correction plan filed with the state. It also said staff would check apartments quarterly, and the executive director wouldn’t be able to alter reports going forward.
Generally, long-term care facilities aren’t penalized financially if they follow through on their correction plans.
If you believe someone you know is considering suicide:
- Call 911, if you think the person is in immediate danger
- Ask the person if they are considering suicide, and listen nonjudgmentally
- Stay with the person until help arrives
- Remove anything the person could use to harm themselves
For assistance, call the National Suicide Prevention Lifeline, 800-273-8255.