32
Inspections
41
Deficiencies
1
Actual Harm or Above
69
Occurrences
June 17, 2026
Last Inspection
S/S D/E/F Potential for harmS/S G Actual harm
The most recent inspection of PIONEER HEALTH CARE CENTER on record is dated June 17, 2026. Across 32 published inspections, state surveyors cited 41 deficiencies, 1 of which reached actual harm or immediate jeopardy.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
SNF/NF Dual Certification
Administrator
DiPasquale, Mary
Owner
12TH STREET OPERATIONS, LLC
Phone
(719) 254-3314
Payor Source
Medicare, Medicaid, Private Pay
City
ROCKY FORD
ZIP
81067
Inspections & Citations
32 inspections · 41 deficiencies6/17/2026Complaint Survey · ID 23633F-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2625346, #CO2660181, #CO2660476, #CO3025850, Incident #3034205, Incident #3034318 and Incident #3034399 was conducted on 6/16/26 to 6/17/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
6/17/2026Licensure Complaint Survey · ID 236341-H1No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A survey with #CO3025851 was completed on 6/16/26 to 6/17/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9/11/2025Complaint Survey · ID VP6Z11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2613734 and Incident #1942991 was completed on 9/10/25 to 9/11/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/15/2025Complaint Survey · ID OMG911No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO39845 and #CO40023 was conducted on 5/15/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/24/2025Revisit: Complaint Survey · ID X04K12No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit survey was completed on 4/24/25 for all previous deficiencies cited on 3/4/25. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
3/4/2025Complaint Survey · ID X04K111 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO39394, #CO39398, #CO39420, Incident #39335 and Incident #39408 was conducted on 3/3/25 to 3/4/25. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0600Free from Abuse and NeglectS/S D▼
Findings
Based on observations, record review and interviews, the facility failed to ensure two (#4 and #6) of four residents reviewed for abuse out of seven sample residents were kept free from abuse. Specifically, the facility failed to:-Protect Resident #4 from physical abuse by Resident #5; and, -Protect Resident #6 from physical abuse by Resident #2. Findings include:I. Facility policy and procedureThe Abuse and Neglect policy, undated, was provided by the director of nursing (DON) on 3/4/25 at 11:14 a.m. It read in pertinent part, "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish."The physician and staff will help identify risk factors for abuse within the facility. "The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect."II. Incident of physical abuse towards Resident #4 by Resident #5 on 2/8/25 A. Facility investigationThe investigation documented the following:On 2/8/25 it was alleged that Resident #5 hit Resident #4 in the head while walking past her in the hall. The incident was witnessed by Resident #7. Both residents were placed on 15-minute checks. The facility substantiated the abuse. A. Resident #5 (assailant)
1. Resident statusResident #5, age greater than 65, was admitted on 11/11/17 and readmitted on 12/12/22. According to the March 2025 computerized physician orders (CPO), diagnosis included schizophrenia, unspecified dementia with behavioral disturbances and wandering. The 1/16/25 minimum data set (MDS) assessment revealed, per staff assessment, the resident was rarely or never understood. He had short and long-term memory problems. His cognitive skills for daily living were moderately impaired. He had inattention and disorganized thinking which fluctuated. He required moderate assistance with bathing. He was independent with positioning, transfers and walking. He received an antipsychotic (medication to treat psychosis) and an antidepressant. 2. Record reviewResident #5's comprehensive behavioral care plan, initiated 10/3/22, documented the resident had behaviors related to schizophrenia and dementia. He had verbal aggression, physical aggression, obsessive pattern walking and had had resident-to-resident aggression. Pertinent interventions included administering medications as ordered, redirecting the resident to a calm environment, responding to the resident calmly, distracting and redirecting the resident, using consistent direction to calm changes gradually, having a quiet area to walk and checking on the residents location and ensuring safety every 15 minutes. A nursing progress note, dated 2/8/25 at 7:33 p.m., documented at approximately 4:00 p.m. the nurse was informed of the incident. Resident #4 reported Resident #5 made contact with her right eye. Both residents were separated and no injury was noted to Resident #5. A nursing progress note, dated 2/9/25 at 11:28 a.m., documented it was reported to the mental health physician that Resident #5's pacing was more than usual and was irritable with the staff. Frequent checks were initiated on the resident. C. Resident #4 (victim)
1. Resident statusResident #4, age greater than 65, was admitted on 8/12/19 and readmitted on 6/29/23. According to the March 2025 CPO, diagnosis included bipolar disorder (mental illness), abnormalities of gait and mobility, weakness, unsteadiness on her feet, lack of coordination, difficulty in walking and delusional disorders. The 2/27/25 MDS assessment revealed, per staff assessment, her skills for daily decision making were moderately impaired. She had no behaviors and did not reject care. She used a wheelchair and required maximal assistance with toileting hygiene, bathing and lower body dressing. She required moderate assistance with personal hygiene, sit to stand and transfers. 2. Resident #4's interviewResident #4 was interviewed on 3/4/25 at 11:16 p.m. Resident #4 said Resident #5 was mean and had attacked other women in the facility as well. She said Resident #5 punched her for no reason causing pain, redness and swelling to her right eye. She said the staff applied ice to her right eye/forehead and the following days she was left with bruising to her forehead. 3. Record reviewResident #4's social behavioral care plan, initiated 11/30/22, documented the resident expressed inappropriate social behaviors verbally/physically towards staff and other residents. She had the potential to be physically aggressive related to anger, depression, poor impulse control, refusing psychotropic medications, throwing dishes and breaking them while in a manic phase. Pertinent interventions included administering medications as ordered, notifying the psychiatrist if the resident was refusing medications, if resident was in a safe location and away from others while being verbally or physically aggressive let her decompress before reengaging with her or trying to redirect her to a different location, notifying the resident's family and physician of increased behavioral concerns, observing the resident during smoke breaks for potential triggers from other residents when she was manic and observing the resident often for self safety and the safety of others. Resident #4's behavioral care plan, initiated 2/8/25, documented the resident had a behavioral problem related to bipolar disorder and delusional disorder. Resident #4 had severe episodes of manic and depressive phases. She could become verbally aggressive/argumentative and had been physically aggressive. She had made inappropriate comments about other residents putting her at risk for harm. Pertinent interventions included acknowledging the resident's delusional beliefs and not arguing with the resident, administering medications as ordered, notifying the physician of refusals, anticipating and meeting the resident's needs, attempting/encouraging aromatherapy to de-escalate when manic and crisis intervention and advocacy as needed, encouraging/assisting the resident away from other residents as allowed when in a manic phase and monitoring behavior episodes and attempting to determine the underlying cause. A nursing progress note, dated 2/8/25 at 7:46 p.m., documented at approximately 4:00 p.m. the nurse was informed of the incident. Resident #4 reported Resident #5 made contact with her right eye. Both residents were kept separated. Resident #4 was assessed and noted to have a discolored reddish area above her right eye. The resident accepted ice wrapped in a towel. A nursing progress note, dated 2/9/25 at 10:36 p.m., documented Resident #4's neurological checks were being monitored and the site above her right eyebrow remained discolored yellow and green. D. Additional resident interviewsResident #7 was interviewed on 3/4/25 at 11:18 a.m. Resident #7 said she was walking down the hallway and witnessed Resident #5 hit Resident #4 in the face. E. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 3/4/25 at 11:20 a.m. CNA #2 said Resident #5 wandered at times and paced. She said he liked his personal space and usually stayed to himself. She said she had heard he had aggressive behaviors with his peers, but had never witnessed those behaviors herself. Licensed practical nurse (LPN) #1 was interviewed on 3/4/25 at 11:25 a.m. LPN #1 said Resident #5 usually kept to himself. She said when he rejected care or said "no," the staff knew to reapproach at a later time to avoid aggressive behaviors. She said she assumed Resident #4 was sitting in her wheelchair in the hallway where Resident #5 was pacing at the time of the incident. She said Resident #4 was very friendly and probably said "hi" to him, and Resident #5 may not have understood. LPN #1 said Resident #4 yelled "my eye, my eye he got me in the eye." She said she placed ice wrapped in a towel on her right eye which was red. She said bruising developed the following days. The social services assistant (SSA) was interviewed on 3/4/25 at 2:25 p.m. The SSA said he had only been in his position for three weeks. He said he had not had any interactions with Resident #5 and was still in his training process. He said he had not heard of Resident #5 having any behaviors. He said he was still trying to learn who the residents were. He said he was in the process of familiarizing himself with the resident care plans and it was a work in progress. The DON was interviewed on 3/4/25 at 2:36 p.m. The DON said Resident #5 liked to pace back and forth and could have verbal outbursts and physical aggression but never actually hit a resident. She said the last incident involved physical contact with Resident #4. She said the staff would redirect him when he escalated. She said they had even tried a sensory program with therapy to identify a root cause for his behaviors. III. Incident of physical abuse between Resident #6 and Resident #2 on 2/16/25 A. Facility investigationThe investigation documented the following:On 2/16/25 it was alleged that Resident #6 pushed Resident #2. However, after review of the facility cameras, it was determined that Resident #2 pushed Resident #6. Resident #6 said Resident #2 hit and pushed her. Resident #2 was placed on line of sight monitoring. The facility unsubstantiated the abuse allegation. -However, abuse occurred when Resident #2 pushed Resident #6. A. Resident #2 (assailant)
1. Resident status Resident #2, age greater than 65, was admitted on 3/31/23 and readmitted on 11/1/24. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances, Alzheimer's disease, bipolar disorder, insomnia due to mental disorder, vascular dementia, restlessness and agitation. The 12/12/24 MDS assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. She required moderate assistance with bathing. She required set-up assistance with oral hygiene, upper/lower body dressing, personal hygiene, putting on/off footwear, sitting to stand, toilet transfers and walking. She received an antipsychotic medication and an antidepressant medication. 2. Record reviewResident #2's mood/behavior care plan, initiated on 4/17/23, documented she had mood/behavior problems related to bipolar disorder, vascular dementia, Alzheimer's disease, insomnia, restlessness, agitation and making false accusations about other residents. She had resident-to-resident altercations which she initiated and was the aggressor. Pertinent interventions included administering medications as ordered, anticipating and meeting the residents needs, providing behavioral health consults, ensuring the resident was in line of sight when out of her room, providing frequent checks for the resident's safety, redirecting the resident and providing one-to-one care when needed. A nursing progress note, dated 2/16/25 at 9:28 p.m,. documented the staff reported a resident-to-resident altercation between Resident #2 and Resident #6 took place in the hallway. The residents were separated, interviewed and assessed for injury. No injuries were observed on either resident. Labs were ordered for Resident #6. A risk review note, dated 2/18/25 at 10:01 a.m., documented Resident #2 reported to staff that Resident #6 made contact with her on the previous shift. The incident was not observed by staff at the time of the report. Upon further investigation it was noted that in fact the initial alleged victim (Resident #2) was the aggressor. C. Resident #6 (victim)
1. Resident statusResident #6, age greater than 65, was admitted on 2/17/23. According to the March 2025 CPO, diagnoses included major depressive disorder, unspecified dementia, anxiety disorder, muscle weakness, vascular dementia and collapsed vertebra (back). The 2/6/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. Shehad hallucinations and delusions. She required maximal assistance with toileting hygiene and bathing. She was independent with positioning, transfers and walking. She received an antipsychotic medication. 2. Resident interviewResident #6 was interviewed on 3/4/25 at 11:03 a.m. Resident #6 said Resident #2 pushed her and she fell. She said she did not know why. She said it hurt, but she did not get injured. 3. Record reviewResident #6's behavior care plan, initiated 4/17/23, documented she had mood/behavior problems related to vascular dementia, anxiety, major depressive disorder and could become aggressive with other residents. Resident #6 had become physically agitated with other residents. Pertinent interventions included administering medications as ordered, anticipating and meeting the residents needs, providing a psychiatric consult, assisting the resident to develop more appropriate methods of coping and interacting, providing frequent checks for the safety of others and keeping the resident in line of sight when she was out of her room. A nursing progress note dated 2/16/25 at 10:22 p.m. documented the alleged victim (Resident #2) claimed Resident #6 made contact with her. The altercation was not witnessed and the residents were separated and taken to separate rooms for assessments. There were no injuries observed. A risk review note, dated 2/18/25 at 10:02 a.m., documented Resident #2 reported to staff that Resident #6 made contact with her on the previous shift. The incident was not observed by staff at the time of the report. Upon further investigation it was noted that in fact the inital alleged victim (Resident #2) was the aggressor. 4. Staff interviewsCNA #1 was interviewed on 3/4/25 at 11:08 a.m. CNA #1 said Resident #2 could get grumpy at times. He said he was not working the day of the altercation and had never seen Resident #2 become aggressive. LPN #1 was interviewed on 3/4/25 at 11:11 a.m. LPN #1 said Resident #2 liked to straighten and organize things. She said Resident #2 preferred to stay in her room. She said she was not working the day of the altercation. She said Resident #2 was not usually aggressive but could get frustrated. The SSA was interviewed on 3/4/25 at 2:25 p.m. The SSA said he was not aware of any aggressive behaviors from Resident #2. He said she usually just walked from her room to the dining room. He said he was not aware of the altercation. The DON was interviewed on 3/4/25 at 2:36 p.m. The DON said the previous nursing home administrator (NHA) conducted the investigation. The DON said Resident #2 would report false allegations and liked to fidget with things throughout the day even if the items were not hers. She said Resident #2 reported she fell, but when the NHA reviewed the cameras, Resident #2 pushed Resident #6, but she did not fall. She said she was not working the day of the altercation.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL F600 Free from Abuse, Neglect and Exploitation. Correction: Resident #4 has been free from any further physical abuse from resident #5. Resident #5 had a medication review by in-house psychiatrist which resulted in an increase in his Trazodone dosage to 50 mg three times daily. A decision was made to discontinue Zoloft 50 mg daily which was being prescribed for OCD symptoms. A p.r.n. Trazodone was also ordered when his dosage increase occurred. The increased dosage of Trazodone appeared to result in significant behavioral improvements. #6 has been free from any further physical abuse from resident #2. Residents have been kept apart and engaged with activities of choice while out in commons and line site provided. No noted behaviors from either resident since interventions were put in place. Identification: Residents currently residing in the facility have the potential to be affected by this deficient practice. Residents that are currently being followed for behaviors we identified and audited and behaviors trackers reviewed for appropriate updates. Systemic: The measures the facility will take or systems the facility will alter to ensure thatthe alleged deficient problem will be corrected and attempt prevention to recur:-All staff were in serviced on the facility Abuse Prevention Policy and Procedureand the resident right to be free from verbal, sexual, physical, and mentalabuse, corporal punishment, and involuntary seclusion.-All Facility staff are being in-serviced on the facility Trigger and Approaches Sheets, where they could find them.-All staff were also instructed to notify the SSD (social services director) if they note any new triggers or approaches that work on the Resident that are not on the sheets so that they may be added. This was done on 3/21/25, by the NHA (nursing home administrator)/Social Services Director. -The Social Services Director, with input from the IDT (interdisciplinary team) and facility staff, have been reviewing the Behavior Trigger and Approaches Sheets on each resident. This is to ensure that both the triggers identified currently are accurate and that the approaches are appropriate and still are the best for each resident identified. Then these Trigger and Approaches Sheets will be updated, along with the Residents care plans by the IDT. Staff will be made aware of these updates to the sheets by 3/28/25. -The facility has rolled out an updated Abuse Investigation form which was implemented in part of the training received from the CHCA and Telligen meetings on Abuse prevention. It better assists the facility to develop a thorough investigation to determine the root cause analysis of the circumstances of the situation or behavior which resulted in the allegation of abuse. This also guides the development of the right interventions to address the triggers to address that caused the abuse and to assist the facility to have a greater chance to prevent re-occurrence. -IDT is reviewing the 24-hour report Monday through Friday for residents who are demonstrating behaviors that may show signs of increased agitation, impulsiveness, or aggression. Nurse managers will assess them and discuss this with the Physician regarding next steps. IDT will identify changes needed to the specific Residents plan to address the acute change in Residents condition,and what immediate interventions need to be implemented to prevent a unwanted episode from occurring. These acute changes to a Residents plan will be communicated to the staff via Trigger and Approaches Sheets. Then at such a time it will be reviewed by IDT At Risk Meeting whether this acute change is to become a permanent change to the resident’s plan of care or if the acute situation has resolved and so has the behavior. The Residents care plan will be updated as needed. Monitor NHA (nursing home administrator)/designee will track all occurrences and determined root cause analysis findings of these, any trending issues will be reported to the QAPI Committee Monthly to determine if PIPs should be developed due to identified trends. This will be reviewed monthly x3 or until the QAPI Committee feels that compliance is being maintained. This will be documented on an audit sheet in binder for POC.
1/29/2025Complaint Survey · ID F4U311No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO38855, #CO38857, #CO38860, #CO38864, #CO38866 and Incident #39066 was conducted on 1/28/25 and 1/29/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
10/8/2024Revisit: Complaint Survey · ID JQN212No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit survey was completed on 10/8/24 for all previous deficiencies cited on 8/29/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
8/29/2024Complaint Survey · ID JQN2113 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO37238, #CO37269, and #CO37270 was conducted on 8/27/24 to 8/29/24. Three deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0584Safe/Clean/Comfortable/Homelike EnvironmentS/S E▼
Findings
Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 28 of 55 resident rooms. Specifically, the facility failed to ensure:-The walls, ceilings, baseboards and floors were properly maintained;-The resident's rooms were cleaned and free of mice feces, flies; and, -The wooden handrails in the hallways were cleaned and free of wood splinters. Findings include: I. ObservationsObservations of the resident's living environment were conducted on 8/27/24 at 9:44 a.m. and revealed the following:Room #100: The ceiling had three missing 12 inch by 12 inch tiles. The walls had several sections approximately four inches in circumference on the wall next to the bathroom. The resident had a five drawer dresser in the corner of his room with each drawer containing dried mice droppings. The floor was sticky. There were tissues and other trash under the resident's bed. Room #113: The wall next to the bathroom had chipped and peeling plaster approximately 14 inches high by four inches wide. The floors were sticky and there was a strong odor of urine. The window blinds had four broken slats with seven missing slats close to the bottom of the blinds. The ceiling tiles outside of room #113 had a large water stain approximately 48 inches long by 50 inches wide. Room #101: The bottom of the baseboard next to the bathroom was missing. The resident had a five drawer dresser, which had mice droppings in all of the drawers. There were three unpainted areas next to the bathroom approximately three inches in circumference. The floors were sticky and had not been cleaned, with remnants of spilled liquids. Room #102: There was a puddle of urine underneath the resident's bed. The walls in the room had five areas of unfinished repair work. The five drawer dresser had mice feces in all drawers. Room #112: The wall north of the sink had five areas of chipped and peeling paint. There were two other large chips above the sink approximately three inches in circumference. The ceiling had approximately six 12 inch by 12 inch tiles missing. The baseboard cover, which covered the joint between the wall and the floor next to the bed, was missing a section approximately 24 inches long by four inches wide. The floor was dusty, had dried urine stains, was cluttered and had debris underneath the beds. Room #101: The resident room had several areas of white repair work on the green wall which had not been completed. The floors were sticky and stained with urine. Room #111: The wall next to the bed was missing a section of the baseboard that was approximately 12 feet long by four inches wide. The wall had deep scratches. The corner edging, which protected the corners from damage, was missing a section which was approximately five feet high by four inches wide. The lights above the residents' beds had chipped and peeling paint approximately four feet long by six inches wide. The hand sanitizer next to the door had an area surrounding it that was approximately 12 inches long by six inches wide of chipped paint. The floor in the whole room was cluttered with trash, food packages, tissue and an empty plastic cup. Room #103: The wall underneath the sink had an area approximately 30 inches by 29 inches of bubbling paint from water damage. There were 10 areas of unfinished hole spackled repair work next to both beds. The corner wall next to the bathroom had chipped and cracked paint approximately 12 inches high by eight inches wide. The floors were sticky with urine stains. The floor in the whole room had dirt accumulation and was cluttered with debris underneath the beds. Room #108: The wall which the light fixture was mounted to had chipped and peeling paint approximately four feet long by six inches wide. The walls above both of the beds had chipped and peeling paint approximately five inches in circumference. The corner strip on the wall was missing a section which was approximately five feet high by four inches wide. The five drawer dresser had mice feces in all of the drawers. The floors were sticky with remnants of spilled liquid. Room #104: The wall behind the resident's bed was damaged from the bed being lifted and lowered. The wall which the light was mounted to had chipped and peeling paint approximately four feet long by six inches wide. The baseboard cover, which covered the joint between the wall and the floor, was missing next to the bathroom. There was a large chipped area approximately 10 inches long by five inches wide next to the door. The floor had an accumulation of dirt and was sticky from liquid being spilled. Room #105: The floors were stained with urine and sticky and the bathroom had a strong odor of urine. Room #106: The wall next to the closet had chipped and missing plaster approximately 12 inches high by six inches wide. The floors were sticky and had dirt build up under the bed. Room #118: The wall next to the door had an area approximately eight inches high by four inches wide of chipped and peeling plaster. There were several areas of chipped and peeling paint next to the sink. The window next to the resident's bed had a large piece of plywood covering the window. The floor was sticky and had remnants of spilled liquid. Room #117: The wall next to the bathroom had chipped and peeling plaster approximately six inches high by four inches wide. The wall behind the dresser had an area approximately 24 inches by 24 inches wide which had chipped and peeling paint. The room had a strong odor of urine. The floors were sticky and stained with urine. The resident had a five drawer dresser. There was mice feces in all of the drawers. Room #113: The room had a strong odor of urine. The floors were sticky and stained with urine. There was urine around the base of the toilet. The resident had a five drawer dresser. All of the drawers had mice feces. The floor was cluttered with used tissues, empty plastic cups and plastic silverware was underneath the beds. Room #114: The lights above the residents' beds had chipped and peeling paint approximately four feet long by six inches wide. The floors were dirty and sticky. The wall next to the dining room was missing a section of wood railing approximately eight feet long. Room #9: The air conditioner was not working and had a large amount of dust on the outside of the unit. The wall next to the resident's bed had four dime sized holes with an outline of the electrical system approximately 32 inches high by two inches wide when it was removed. The room was cluttered and the floors were sticky. Room #2: The wall next to the bathroom had chipped and peeling paint approximately 24 inches high by three inches wide. The floors were sticky and there was a strong odor of urine in the room. Room #8: The wall next to the resident's bed had three areas approximately three inches in circumference which had not been repaired. The floors were sticky and had remnants of spilled juice. Room #3: The room had approximately 14 areas of spackled hole repair work next to the resident's bed. Room #4: The room had several exposed glue traps on the floor with several large bugs on them. Room #17: The wall next to the bathroom had three dime sized holes and peeling paint. The wall next to the door had an area approximately six by three which was unpainted. Room #35: The floors had an accumulation of dirt built up with dust mites underneath the bed. Room #23: The window blinds were broken with six broken slats and approximately six slats missing and the floors were sticky with urine stains. Room #27: The floors were sticky and water stained. Room #26: The floors were sticky and had an accumulation of dirt and urine stains. There was a strong odor of urine in the bathroom. Room #24: The floors were sticky. There was a strong odor of urine and there were urine stains on the bathroom floor. The floor had chipped tiles approximately 12 inches by 12 inches. Room #21: The floors were sticky with remnants of spilled liquid. The hallway next to room #20 had damaged floor tile approximately 12 feet long by 12 inches wide. The shower room on the south hall had approximately 18 12 inch by 12 inch ceiling tiles missing. The sheetrock on the walls had water damage and repair had not been completed. The hand rail from room #100 to room #113 was dirty and sticky and had chipped and splintering wood. The plastic rail bracket was broken with sharp edges between room #103 and Room #104. The shower room on the south hall had approximately 18 12 inch by 12 inch ceiling tiles missing. The sheetrock on the walls had water damage and repair had not been completed. The maintenance closet had a glue trap with several large bugs in it. The wall next to the dining room was missing a section of wood railing approximately eight feet long. II. Environmental tour and staff interviewThe environmental tour was conducted with the maintenance supervisor (MS) on 8/28/24 at 11:06 a.m. The above detailed observations were reviewed. The MS said the facility utilized work orders as well as a computer system to identify environmental issues. The MS said he did not have work orders for the damage identified during the environmental tour. The MS said repairs should have been repaired and addressed in a timely manner. The MS said the mice were an ongoing problem. He said with the bad weather, the mice were coming into the facility. He said the building was old and the heat vents gave mice easy access to the facility. The MS said housekeeping had initiated a new program called safety culture. He said the program had been going on for about two months and he was hoping it would result in a better cleaning system. The nursing home administrator (NHA) was interviewed on 8/29/24 at 8:40 a.m. The NHA said he was not aware of the fly issues in the facility but he would look into it. He said the facility did have a mouse problem, but he said he did not know it was an ongoing issue. He said the mice dropping should have been cleaned with the cleaning schedule and he was surprised the droppings were still there. He said the residents were always spilling and making a mess on the floors in both units. He said cleaning these spills was an ongoing battle.
Plan of correction
The state did not require a plan of correction for this citation.
0695Respiratory/Tracheostomy Care and SuctioningS/S D▼
Findings
Based on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for three (#3, #2 and #7) of four residents reviewed for supplemental oxygen use out of 10 sample residents. Specifically, the facility failed to:-Administer oxygen in accordance with the physician's order for Resident #3 and #2; and,-Ensure a physician's order was in place for Resident #7's continuous use of oxygen. Findings include:I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 8/29/24 at 10:47 a.m. by the corporate consultant (CC). It read in pertinent part, "The purpose of this procedure is to provide guidelines for safe oxygen administration." II. Resident # 3 A. Resident status Resident #3, age 74, was admitted on 3/19/21. According to the August 2024 computerized physician orders (CPO), diagnoses included depression, delusional disorder, chronic obstructive pulmonary disease (COPD). According to the 7/17/24 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. The resident had no upper or lower body impairment. The assessment did not identify the resident used oxygen. B. Observations and interviews On 8/28/24 at 4:00 p.m. Resident #3 was observed in the hallway sitting in her wheelchair with her oxygen nasal cannula on and connected to a portable oxygen concentrator. The resident's portable oxygen concentrator was set on 2 LPM.Resident #3 said she had been out of her room since lunch. She said she could not remember when anyone checked her portable oxygen concentrator last. At 4:00 p.m. registered nurse (RN) #2 was asked to check the resident's oxygen saturation level (measure of oxygen in the blood) and the resident's portable oxygen concentrator. RN #2 checked Resident #3's oxygen saturation level which read 90 % (percent). RN #2 checked Resident 3's portable oxygen concentrator. RN #2 said the portable oxygen concentrator was empty. RN #2 wheeled the resident into her room and placed the resident on her room's oxygen concentrator. RN #2 exited the resident's room and proceeded to take the portable oxygen concentrator to fill it up with oxygen. At 4:10 p.m. Resident #3 said, "No wonder I was feeling a little loopy."C. Record review The care plan, initiated 3/22/21 and revised 8/25/24, identified the resident had oxygen therapy related to ineffective gas exchange due to COPD and impaired respiratory status related to hypoxia (low levels of oxygen in the body's tissues). Interventions included evaluating for signs and symptoms of respiratory distress and reporting to medical doctor (MD) as needed (respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough and, pleuritic pain). The August 2024 CPO included a physician's order dated 5/13/24 for the continuous use of oxygen at 2 liters per minute (LPM) via nasal cannula. D. Staff interview RN #2 was interviewed on 8/28/24 at 4:15 p.m. He said oxygen was a medication. RN #2 said Resident #3's oxygen concentrator was usually filled up in the morning and staff refilled all residents' portable oxygen concentrators again in the afternoon. RN #2 said a negative outcome for having an empty portable oxygen concentrator would be hypoxia and confusion. III. Resident #2 A. Resident status Resident #2, age 70, was admitted on 6/1/23. According to the August 2024 CPO, diagnoses included chronic respiratory failure whether with hypoxia or hypercapnia (too much carbon dioxide in the blood), schizoaffective disorder, bipolar, COPD. According to the 6/4/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of six out of 15. The resident had no behavioral symptoms. The assessment indicated the resident received oxygen therapy. B. Observation On 8/27/24 at 11:35 a.m. Resident #2 was sleeping with his nasal cannula on. His oxygen concentrator was at the foot of his bed and was set at 2 LPM.-However, the physician's order indicated the resident should be receiving 3 LPM of oxygen (see record review below). On 8/28/24 at 11:20 a.m. Resident #2 was lying in bed watching television in his room. He was wearing his nasal cannula with his oxygen concentrator set at 2 LPM.-However, the physician's order indicated the resident should be receiving 3 LPM of oxygen (see record review below). C. Record Review The care plan, initiated 6/3/23 and revised, on 8/1/24, identified the resident had altered respiratory status, difficulty breathing/ shortness of breath (SOB) related to COPD, chronic respiratory failure, unspecified and asthma. Interventions include providing oxygen as ordered. -The August 2024 CPO included a physician's order dated 7/27/23 for the continuous use of oxygen at 3 LPM via nasal cannula to maintain an oxygen saturation level at or above 88% percent. D. Staff interview RN #1 interviewed on 8/28/24 at 11:20 a.m. RN #1 said oxygen was a medication. She said Resident #2 was supposed to be on 3 LPM of oxygen continuously. RN #1 said she adjusted Resident #2's oxygen to 3 LPM per the physician's order, instead of 2 LPM. She said a negative outcome of receiving the wrong amount of oxygen could be the resident getting confused and hypoxic. IV. Resident #7Resident #7, age 69, was admitted on 8/1/23 and readmitted on 7/26/24. According to the August 2024 CPO, diagnoses included respiratory arrest, schizoaffective disorder, bipolar, COPD, acute respiratory failure with hypoxia, major depression. According to the 7/4/24 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident had verbal behaviors directed at others. The assessment indicated the resident received oxygen therapy. C. Record review The care plan, initiated 8/1/23 and revised 7/22/24, identified the resident had COPD related to smoking. The resident was encouraged to wear his oxygen and stated that staff were idiots and he did not need his oxygen. Interventions included administering 10 LPM of oxygen continuously as the resident allowed, observing for difficulty breathing on exertion, and reminding the resident not to push beyond his tolerated endurance. -The August 2024 CPO did not include a physician's order for oxygen. C. ObservationOn 8/27/24 at 10:35 a.m. Resident #7 was sleeping in his room. The resident was wearing an oxygen nasal cannula and an oxygen concentrator was next to his dresser and set to 3 LPM.On 8/28/24 at 8:50 a.m. Resident #7 was lying down in his bed. The resident was wearing an oxygen nasal cannula and his oxygen concentrator was set at 3 LPM. D. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 8/29/24 at 9:00 a.m. LPN #1 said oxygen was a medication and required a physician's order. LPN #1 checked her computer to verify the physician's order for oxygen for Resident #7. She said Resident #7 did not have a physician's order for his oxygen. She said the resident should have had a physician's order to receive oxygen. V. Additional staff interviewThe assistant director of nursing (ADON) was interviewed on 8/29/24 at 12:13 p.m. The ADON said oxygen was a medication. She said staff should be checking all portable oxygen concentrators for all residents to ensure they were not empty. She said staff should ensure all oxygen was being administered in accordance with the physician's orders and all residents who were on oxygen should have a physician's order in place for the use of oxygen. The ADON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls and hypoxic events. She said not receiving the correct amount of oxygen could put the residents in respiratory distress.
Plan of correction
The state did not require a plan of correction for this citation.
0925Maintains Effective Pest Control ProgramS/S F▼
Findings
Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the facility. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated 2/15/19, pp. 94-95, retrieved on 9/5/24 from https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf, "Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. "From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Eliminating food sources, indoor habitats, and other conditions that attract pests;-Excluding pests from entering the indoor environments; and,-Applying pesticides as needed. "Insect habitats are characterized by warmth, moisture, and availability of food." II. Observations/resident interviews:On 8/27/24 at 9:50 a.m. room #100 was observed. The resident who resided in the room was lying in bed. The resident was swatting flies away from his face. On 8/27/24 at 9:55 a.m. room #113 was observed. One of the residents who resided in the room was sitting on the end of his bed and his roommate was sleeping. Flies were observed throughout the room flying on or around the residents' faces. There was a fly glue ribbon hanging from the ceiling. The fly trap was full of dead flies. On 8/27/24 at 9:57 a.m. room #101 was observed. Flies were observed throughout the room landing on resident's personal items, such as drinking cups. On 8/27/24 at 10:00 a.m. room #102 was observed. The resident who resided in the room was lying in bed with flies landing on his head and face. On 8/27/24 at 10:04 a.m. room #111 was observed. The resident who resided in the room was sitting on her bed and was swatting flies away from her face. The room had two glue fly ribbons on each side of the room. The fly traps were full of dead flies. On 8/27/24 at 10:07 a.m. room #103 was observed. Flies were observed throughout the room landing on the residents' personal belongings. On 8/27/24 at 10:12 a.m. room #108 was observed. The room had two glue fly ribbons hanging from the ceiling. The glue traps were full of flies. On 8/27/24 at 10:16 a.m. room #104 was observed. The resident who resided in the room was lying in bed sleeping with flies landing on his head and pillows. The resident had a drinking cup on his dresser with dead flies in the bottom of the glass. On 8/27/24 at 10:21 a.m. room #105 was observed. Flies were observed throughout the room landing on personal items. On 8/27/24 at 10:35 a.m. room #9 was observed. The resident who resided in the room was eating her breakfast and swatting flies away from her food. The resident said the flies were terrible but they were even worse when it was hotter. She said they got on her face and her food and they were just a bother. On 8/27/24 at 10:42 a.m. room #2 was observed. Flies were observed throughout the room landing on the resident who resided in the room and his personal belongings. The resident said the flies were a problem because they were all over the place. On 8/27/24 at 10:55 a.m. room #23 was observed. Flies were observed throughout the room landing on personal items of the resident who resided in the room. The resident had a fly swatter at the foot of his bed. The resident said the flies were the worst, especially since they got on his food. On 8/27/24 11:00 a.m. room #30 was observed. Flies were observed throughout the resident's room landing on the personal items of the resident who resided in the room. The resident said the flies were a problem but felt like the flies were only in his room. III. Building observations Throughout the survey (8/27/24 to 8/29/24) flies were observed in all areas of the secure unit and long term care living environment of the facility. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 8/28/24 at 11:20 a.m. RN #1 said the flies had been getting worse ever since the area had been getting a high amount of rain. She said the flies were mainly in the residents' rooms. Licensed practical nurse (LPN) #1 was interviewed on 8/28/24 at 11:40 a.m. LPN #1 said the flies had been getting worse in the secure unit. She said staff had been trying to keep the main doors closed to try to keep the flies from coming into the building. Housekeeper (HSK) #1 was interviewed on 8/28/24 at 11:58 a.m. HSKP #1 said the flies had been a problem and they seemed to be getting worse. She said facility staff tried not to let the doors stay open for any long periods of time but it was hard to keep them closed with the residents frequently going in and out. LPN #2 was interviewed on 8/29/24 at 8:59 a.m. LPN #2 said the flies seemed to be in the residents' rooms much more than anywhere else in the building. She said the facility had a blue light in the dining areas and that appeared to keep the flies out of the dining room. LPN #2 said the flies were bad in the residents' rooms. She said some residents' families got the residents fly swatters for their rooms. The maintenance supervisor (MS) was interviewed on 8/28/24 at 11:06 a.m. The MS said the flies were a problem because of the area the facility was located in. He said the weather had also been a factor in the increase of flies. He said the facility had placed glue fly traps in three rooms. He said the fly traps were high enough to be out of the residents' way and they were supposed to be changed regularly. The MS said the fly traps should have been changed monthly or as needed when they were full of dead flies. The NHA was interviewed on 8/29/24 at 8:40 a.m. The NHA said he was not aware of the fly issues in the facility but he would look into it.
Plan of correction
The state did not require a plan of correction for this citation.
8/16/2024Revisit: Recertification Survey · ID 7VIA22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
69 records6/8/2026Physical Abuse · ID 26020256008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/8/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client(B) make physical contact with client (A). During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, conducted interviews, and initiated increased safety monitoring. Client (A) sustained two scratches on their forearm. Client (B) was not able to recall the event due to cognitive impairment. Staff witnesses indicated client (B) became aggressive with client (A) in an attempt to protect staff, as client (B) thought client (A) was being verbally aggressive with staff. The facility implemented a room change, provided client (B) with a less stimulatory dining environment, and educated staff regarding environmental triggers and redirection. The event was substantiated. Client (B) was identified in another physical abuse occurrence, please see case ID 26020256007 for additional information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/30/2026 · released to the public 8/6/2026.
5/14/2026Physical Abuse · ID 26020256007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/14/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) hit client (A) in the back of the head with a closed fist after a verbal altercation. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, conducted interviews, and started increased safety monitoring. Client (A) did not sustain any visible injuries. Client (B) did not recall the event due to cognitive impairment. The facility initiated a plan for increased supervision during meals and in common areas, initiated behavior monitoring, adjusted staffing assignments to support ongoing supervision needs, and educated staff regarding increased monitoring requirements. The event was substantiated. This is the second physical abuse occurrence involving these two clients, please see case ID 25020256015f for additional information. Client (A) was identified in two additional physical abuse occurrences, please see case IDs 26020256003 and 25020256024 for additional information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/17/2026 · released to the public 7/24/2026.
4/10/2026Death · ID 26020256006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/10/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported the death of a client. The client choked during a meal, received life saving measures, and ultimately died. During the course of the investigation, the healthcare entity conducted interviews and reviewed records. Interviews indicated the client choked, staff responded immediately and performed multiple life saving measures and called emergency services. Record review showed the client had no dietary restrictions and an inspection of the food indicated proper consistency and size. The facility determined the event was a sudden and unforeseen choking incident despite appropriate care planning, diet management, and staff response. The facility completed an audit of all diet orders, reviewed all food preparation procedures, and educated staff. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/28/2026 · released to the public 5/5/2026.
4/5/2026Physical Abuse · ID 26020256005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/5/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) hit client (A), their roommate, in the chest with an open hand after a verbal altercation. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, conducted interviews, and reviewed records. Client (B) denied the allegations. Client (A) did have any visible injuries and declined to discuss the event. Staff indicated the two clients had multiple verbal altercations throughout the day requiring client (B) to be redirected multiple times. The facility implemented a room change, supervised visits, completed a medication review and adjustment, and increased monitoring. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/26/2026 · released to the public 7/3/2026.
4/3/2026Physical Abuse · ID 26020256004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/3/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, staff was rough when providing care. During the course of the investigation, the healthcare entity notified law enforcement, suspended staff, assessed the client, and conducted interviews. The client did not sustain any visible injuries. Staff reported they were specifically requested by the client and provided care several times during their shift with no issues. Record review showed the client had a history of similar unsubstantiated allegations. The facility relocated staff to a different work area, continued the existing two person care model, and educated the client on the importance of the two person care model. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/29/2026 · released to the public 7/6/2026.
3/10/2026Physical Abuse · ID 26020256003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/10/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, staff #1 used their foot to push the client’s foot onto the lift device during a negative interaction with the client. During the course of the investigation, the healthcare entity notified law enforcement, suspended staff, conducted interviews, and assessed the client. The client did not have any visible injuries. The client reported staff #1 was mean and pushed their leg but denied being harmed and was unable to describe specific instances of the staff being mean. Staff #1 denied the allegations and reported a normal care routine. Staff witness indicated the interaction with the client caused the client to be upset. The facility determined staff #1’s actions did not meet facility expectations for appropriate caregiving practices related to technique and professionalism but did not result in physical abuse. The facility terminated staff #1’s employment, educated all staff, and implemented increased supervisory observation of staff-to-client interactions. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/12/2026 · released to the public 6/19/2026.
1/24/2026Physical Abuse · ID 26020256002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/24/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed two clients have a verbal altercation culminating in physical contact between the clients. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, conducted interviews, and reviewed records. Client (A) reported being hit in the face and chest area and was found to have a bruise on their finger. The facility determined both clients have significant cognitive impairment and triggers related to loud noises which seemed to cause the altercation. The facility implemented increased safety monitoring, requested a psychiatric evaluation, made environmental changes to reduce triggers, and completed referrals for alternative placement. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/14/2026 · released to the public 5/21/2026.
10/4/2025Physical Abuse · ID 25020256024Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/4/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed a physical altercation between two clients resulting in one client being scratched on the arm and neck. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and started increased safety monitoring. The facility determined staff heard a verbal altercation between the clients and ultimately did not act fast enough to intervene and suspended the staff member. The facility educated staff and updated care plans to include increased safety monitoring. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 1/12/2026 · released to the public 1/22/2026.
9/26/2025Neglect · ID 25020256023Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/26/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. The client alleged staff left them without access to their call light and did not answer their call light for over 30 minutes. During the course of the investigation, the healthcare entity provided additional staffing to the unit, conducted interviews, reviewed records, and completed a call light audit. The client, who has a history of unsubstantiated allegations and aggressive behaviors towards staff, did not sustain any injuries. Record review revealed the client had access to their call light, response times were appropriate, and the client received appropriate care as outlined in the care plan. The facility scheduled an intake appointment with behavioral therapy services and continued to provide behavioral interventions. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 1/20/2026 · released to the public 1/27/2026.
9/8/2025Brain Injury · ID 25020256022Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/8/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a brain injury of a client. The client attempted to go to the bathroom without assistance, had an unwitnessed fall, experienced a change of condition, and was later diagnosed with a brain injury. During the course of the investigation, the healthcare entity assessed the client, conducted interviews, and reviewed records. The client had several fall interventions in place at the time, all of which were implemented appropriately. The facility reviewed and revised the care plan, educated staff, and encouraged the client to use their call light. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/31/2026 · released to the public 4/13/2026.