38
Inspections
29
Deficiencies
0
Actual Harm or Above
12
Occurrences
June 22, 2026
Last Inspection
S/S A/B/C Minimal potential
The most recent inspection of WANEKA PARK ASSISTED LIVING on record is dated June 22, 2026. Across 38 published inspections, state surveyors cited 29 deficiencies, none of which reached the actual-harm level.
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
Assisted Living Residence/Alternative Care Facility (Medicaid)
Administrator
Kobilan, Lori
Owner
LAFAYETTE OPCO LLC
Phone
(303) 666-0691
Payor Source
Medicaid, Private Pay
City
LAFAYETTE
ZIP
80026
Inspections & Citations
38 inspections · 29 deficiencies6/22/2026Revisit: Licensure Complaint · ID 4GBE13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 6/23/26 for the previous deficiency cited on 2/17/26. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
6/22/2026Revisit: Licensure Complaint · ID KS6H12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
The state listed this citation without publishing narrative text.
Plan of correction
The state did not require a plan of correction for this citation.
6/22/2026Revisit: Licensure Complaint · ID 7RDJ12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 6/23/26 for the previous deficiencies cited on 2/17/26. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
2/17/2026Revisit: Licensure Complaint · ID 4GBE121 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 2/17/26 for all previous deficiencies cited on 11/6/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼
Findings
Based on record review and interview, the residence failed to comply with the authorized practitioner's orders associated with medication administration, affecting one of three sample residents (#7). This deficiency was cited previously during a complaint survey on 11/6/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #7 was admitted to the residence on 7/2/21 with diagnoses including osteoarthritis, chronic pain and restless leg syndrome. A written practitioner's order, dated 12/22/25, directed the residence to administer oxycodone 5 mg four times daily. However, the January 2026 medication administration record (MAR) for Resident #7 read the medication was unavailable and not administered on 1/14/26; 4:00 p.m. dose. On 2/17/26 at approximately 3:30 p.m., the health and wellness director acknowledged the oxycodone medication was out of stock and not administered on 1/14/26. On 2/17/26 at approximately 4:30 p.m., the administrator said she expected medications to be administered according to their practitioner's orders and not run out of stock. The administrator said the reason this deficiency was not corrected was because of ongoing issues with an outside service provider that provided this resident's medications.
Plan of correction · submitted by the facility
1568 – Plan of CorrectionCorrective Action:Resident #7’s medical record and EMAR were immediately reviewed by the Health and Wellness Director, and review of the resident’s pain medication was conducted to ensure availability on hand. A medication error variance was completed and resident #7’s practitioner was notified of the medication error. Identification of Others:All residents residing in the community are at risk for this alleged deficient practice. Health and Wellness Director/designee will conduct a full house pain medication audit to ensure all residents residing at the community have pain medications in stock. Systemic Changes:The facility has implemented the following system changes to ensure practitioners’ orders for medications are as follows:Health and Wellness Director will re-educate Med Techs on the facility medication administration policy to ensure medications are available prior to administration times,Timely reordering of medicationsUse of emergency medication when medications are unavailable through alternative pharmacyImmediate notification to the physician and pharmacy when ordered medications are not available. On March 3, 2026, the Administrator and Health & Wellness Director met with the resident’s provider to discuss the ongoing challenges getting medications delivered timely in hopes of improving their response time to refilling medications. Med Techs were educated on the requirement to document medication variances and to notify the Health and Wellness Director and/or Resident Care Coordinator immediately if medications are not available. The facility reinforced procedures with the pharmacy provider to ensure timely medication delivery and use of emergency medication supplies when needed. Med Techs and Resident Care Coordinator will verify that medications are reordered prior to depletion. Monitoring:The Health and Wellness Director, or designee will conduct a random weekly medication audit for 4 weeks, then monthly for 3 months of the following:Medication Administration Record (MAR) of medications not givenMedication variance reportsMedication reorderingResults of the audits will be reviewed in the Quality Assurance and Performance Improvement (QAPI) Committee meetings. Additional education or corrective actions will be implemented if concerns are identified. ADDEMDUM: Health and Wellness Director will audit 100% of the residents that have this provider as their Primary Care Physician, which uses this third party pharmacy for medications. The total number of residents that are seen by this provider is 6.7% of the total census population.
2/17/2026Licensure Complaint · ID 7RDJ112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO41482, was completed on 2/17/26. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0204Issuance-ConditionsS/S B▼
Findings
Based on interviews and record review, the residence failed to comply with conditions imposed by the department on the license, affecting 66 current residents. Findings include:The department completed a complaint survey on 7/23/25. The residence failed to ensure residents were treated with dignity and respect and was cited tag T1322 at a C level for harm. The department determined the residence violated statutory and regulatory requirements necessitating that the department impose an intermediate condition on 8/13/25. The residence was required to pay a civil fine of $500 by 9/12/25. The residence did not appeal the intermediate condition. Review of the department database revealed the residence had not yet paid the civil fine as of 2/17/26. A department representative confirmed that the residence had not paid the civil fine as of 2/12/26. On 2/17/26 at 4:20 p.m., the administrator stated she was aware of the fine issued in July 2025 but she was unaware that the residence failed to pay the fine by the due date.
Plan of correction · submitted by the facility
The deficient practice that was cited for a resident that is no longer at the residence. The staff member that conducted the deficient practice is no longer at the residence. The Executive Director will conduct resident rights training for all staff members to ensure understanding and compliance of residents rights on March 19, 2026. .This training will be conducted with all new hired employees, as well as on an annual basis for all staff members. The executive director will review Resident rights with residents at the town hall meeting March 19, 20206, to ensure residents understand their rights and the procedure to follow if they feel their rights have been violated in the residence by staff members or peers. Resident rights will be reviewed with all residents upon admission to the residence. Monitoring will occur weekly by the Executive Director and the Health and Wellness Director. Monitoring will be documented via spreadsheet and will be monitored for a minimum of 90 days. Any issues identified will constitute continued monitoring for an additional 90 days. The ongoing monitoring and the results of the monitoring will be discussed in the monthly QAPI meetings to identify any variances. Addendum:Fine was Paid in Full*Paid the fine on February 20, 2026*ED was re-educated by Director of Operations on monitoring, tracking and paying fines timely. Implementation of Others:No other outstanding invoices pendingSystematic Changes:Monitor and Track Invoices to ensure any future fines are paid in a timely mannerThe community has implemented the following systems:* Regulatory Tracking Log: A centralized log has been created to track: All deficiencies, associated fines/penalties, due dates, and payment status. Designated Responsible Party: The Executive Director (ED) is responsible for oversight of all regulatory compliance items, including fines. Calendar Alerts & Deadlines: All regulatory due dates are entered into an electronic calendar with alerts set at: 5 days prior, 3 days prior, and day of deadlineMonitoring:To ensure ongoing compliance:Monthly audit of the Regulatory Tracking log by the EDAudit results will be reviewed in QAPI meetings monthly. Any discrepancies identified will result in immediate corrective action. Date of Compliance February 28, 2026
1410Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S A▼
Findings
Based on interviews and records, the residence failed to investigate, report and document allegations of abuse, affecting two of four sample residents (#15 and #19). Findings include:1. ReferencesChapter 7 regulations governing assisted living residences, section 13.11 (C) (D) (E) (F) (G) reads in part, the assisted living residence shall investigate all allegations of abuse of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: The process for investigating such allegations; How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; A requirement that the resident shall be protected from potential future abuse while the investigation is being conducted; A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. 2. PolicyReview of the residents ' most recent abuse, neglect and exploitation prevention policy, dated 1/26/18, defines abuse as the willful infliction of injury, intimidation or punishment resulting in physical harm or mental anguish. Further the policy defines verbal abuse in part as threats of harm and physical abuse includes hitting, slapping, pinching and/or kicking. Further, review of the residents ' abuse, neglect and exploitation prevention policy and procedures read in part, should an incident or suspected incident of resident abuse, mistreatment, neglect or injury be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The facility's investigation will be documented on the required stated investigation form and the Administrator will provide the facility's completed documentation, including witness statements and other supporting documents to the state survey and certification agency within five working days of the reported incident. 3. Records ReviewsResident #15 was admitted to the residence on 10/22/24 with diagnoses including Alzheimer ' s disease. Resident #19 was admitted to the residence on 7/29/25 with diagnoses including rheumatoid arthritis and osteoarthritis. Progress notes for Resident #15 and Resident #19, dated January 1, 2025 through February 17, 2026, were reviewed. These records revealed no documentation indicating that a threat of physical harm made by Resident #15 toward Resident #19 had been reported. Additionally, there was no incident report or further documentation to substantiate that an investigation into the abuse had been initiated or conducted by the Administrator or other staff members. An incident note dated 11/23/25 was provided by the administrator, written by former Staff #1, which read on part, Resident #15 called Resident #19 names in front of everyone in the dining room over a remote she believed Resident #19 stole from her. On 2/19/26 at approximately 3:30 p.m., all investigation reports related to the conflicts between Residents #15 and #19 were requested from the Administrator. The only record the Administrator provided was a progress note, dated 11/23/25, found in Resident #15 chart, documenting the incident when Resident #15 called Resident #19 names in front of everyone in the dining room for allegedly stealing Resident #15 remote control. No further evidence of investigation was provided. 4. InterviewsAn interview was conducted with Resident #19 at approximately 11:15 a.m. Resident #19 reported that since her former roommate, Resident #15, moved into the shared apartment in November 2025, Resident #15 had engaged in verbal altercations, including yelling and calling her derogatory names, related to disputes over the shared living space. Resident #19 further reported that in January 2026, Resident #15 threatened to inflict bodily harm upon her. According to Resident #19, she reported the threat to multiple staff members, including Staff #12. Resident #19 stated that Staff #12 advised her that the matter would be reported to the Administrator. Additionally, Resident #19 reported that she feared for her safety due to Resident #15 ' s behavior and, as a result, hid a kitchen knife to prevent Resident #15 from having access to it. An interview was conducted with Resident #15 at approximately 2:00 p.m. Resident #15 acknowledged that conflicts had occurred with her prior roommate, Resident #19. Resident #15 admitted to calling Resident #19 derogatory names and stated that she threatened to inflict bodily harm on Resident #19 if Resident #19 continued to report concerns about her to the Administrator. At approximately 4:15 p.m., an interview was conducted with Staff #12. Staff #12 confirmed that Resident #19 reported to her that Resident #15 had made a threat of physical harm and was frightened. Staff #12 further stated that she notified the Administrator of the reported incident via email or group text messageAt approximately 4:30 p.m., an interview was conducted with the Administrator. The Administrator stated she was aware of ongoing interpersonal conflicts between Resident #15 and Resident #19, and separated them when another private room became available; however, she reported that she had not been informed of any allegation that Resident #15 had threatened to inflict physical harm on Resident #19, so no investigation was initiated. Further, the Administrator stated it is her expectation that staff immediately notify her upon becoming aware of any alleged threat involving a resident and that such incidents be documented in the resident ' s progress notes in accordance with facility policy. Additionally, the Administrator acknowledged that a threat of physical harm constitutes alleged resident abuse and is required to be reported to the Administrator for appropriate investigation and follow-up.
Plan of correction · submitted by the facility
1410 - Plan of Correction:Corrective Action:Resident #15 and Resident #19 are no longer roommates. Resident #15 and Resident #19 were assessed by the Health and Wellness Director to evaluate any physical or psychological harm. Both residents were interviewed regarding the allegations. Implementation of Others:All residents residing in the community are at risk for this alleged deficient practice. A full house audit was conducted on March 5, 2026, to ensure no other residents residing at the facility are experiencing allegations of abusive behavior by other residents. Systemic Changes:Executive Director will be re-educated by the Director of Operations on the company’s abuse policy on or before March. The facility re-educated all staff on the abuse prevention policy, with emphasis on the requirement that resident-to-resident verbal or physical altercation must be immediately reported, investigated, and documented. The facility also implemented the following process improvement:A standardized abuse investigation checklist to ensure consistent investigation and documentation. Leadership review of all resident-to-resident altercations to determine if the incident meets criteria for abuse reporting. Reinforcement of behavior monitoring and individualized care planning for residents with known behavioral risks. Monitoring:The Administrator or designee will conduct a weekly audit times 4 weeks, then monthly for 3 months of incident and accident reports, allegations of abuse, resident-to-resident documentation, and investigation and reporting timelines. The audit will verify that all resident-to-resident incidents are immediately reported, investigations are completed timely, documentation is complete, and reported to CDPHE timely. Results of the audit will be reviewed during the facility’s Quality Assurance and Performance Improvement (QAPI) Committee monthly. Additional corrective action and education will be implemented if concerns are identified.
2/17/2026Revisit: Licensure Complaint · ID 9TQR12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 2/17/26 for all previous deficiencies 11/6/25. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
2/17/2026Revisit: Licensure Complaint · ID HO3O12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 2/17/26 for all previous deficiencies cited on 11/18/25. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
2/17/2026Revisit: Licensure Complaint · ID JMLV12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 2/17/26 for the previous deficiency cited on 11/18/25. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
2/17/2026Licensure Complaint · ID KS6H111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO41483, was completed on 2/17/26. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0796PA Req-P/P-MANE▼
Findings
Based on interviews and records, the facility (residence) failed to investigate, report and document allegations of abuse, affecting two of four sample members (residents) (#15 and #19)Findings include:1. ReferencesChapter 7 regulations governing assisted living residences, section 13.11 (C) (D) (E) (F) (G) reads in part, the assisted living residence shall investigate all allegations of abuse of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: The process for investigating such allegations; How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; A requirement that the resident shall be protected from potential future abuse while the investigation is being conducted; A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. 2. PolicyReview of the residents ' most recent abuse, neglect and exploitation prevention policy, dated 1/26/18, defines abuse as the willful infliction of injury, intimidation or punishment resulting in physical harm or mental anguish. Further the policy defines verbal abuse in part as threats of harm and physical abuse includes hitting, slapping, pinching and/or kicking. Further, review of the residents ' abuse, neglect and exploitation prevention policy and procedures read in part, should an incident or suspected incident of resident abuse, mistreatment, neglect or injury be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The facility's investigation will be documented on the required stated investigation form and the Administrator will provide the facility's completed documentation, including witness statements and other supporting documents to the state survey and certification agency within five working days of the reported incident. 3. Records ReviewsResident #15 was admitted to the residence on 10/22/24 with diagnoses including Alzheimer ' s disease. Resident #19 was admitted to the residence on 7/29/25 with diagnoses including rheumatoid arthritis and osteoarthritis. Progress notes for Resident #15 and Resident #19, dated January 1, 2025 through February 17, 2026, were reviewed. These records revealed no documentation indicating that a threat of physical harm made by Resident #15 toward Resident #19 had been reported. Additionally, there was no incident report or further documentation to substantiate that an investigation into the abuse had been initiated or conducted by the Administrator or other staff members. An incident note dated 11/23/25 was provided by the administrator, written by former Staff #1, which read on part, Resident #15 called Resident #19 names in front of everyone in the dining room over a remote she believed Resident #19 stole from her. On 2/19/26 at approximately 3:30 p.m., all investigation reports related to the conflicts between Residents #15 and #19 were requested from the Administrator. The only record the Administrator provided was a progress note, dated 11/23/25, found in Resident #15 chart, documenting the incident when Resident #15 called Resident #19 names in front of everyone in the dining room for allegedly stealing Resident #15 remote control. No further evidence of investigation was provided. 4. InterviewsAn interview was conducted with Resident #19 at approximately 11:15 a.m. Resident #19 reported that since her former roommate, Resident #15, moved into the shared apartment in November 2025, Resident #15 had engaged in verbal altercations, including yelling and calling her derogatory names, related to disputes over the shared living space. Resident #19 further reported that in January 2026, Resident #15 threatened to inflict bodily harm upon her. According to Resident #19, she reported the threat to multiple staff members, including Staff #12. Resident #19 stated that Staff #12 advised her that the matter would be reported to the Administrator. Additionally, Resident #19 reported that she feared for her safety due to Resident #15 ' s behavior and, as a result, hid a kitchen knife to prevent Resident #15 from having access to it. An interview was conducted with Resident #15 at approximately 2:00 p.m. Resident #15 acknowledged that conflicts had occurred with her prior roommate, Resident #19. Resident #15 admitted to calling Resident #19 derogatory names and stated that she threatened to inflict bodily harm on Resident #19 if Resident #19 continued to report concerns about her to the Administrator. At approximately 4:15 p.m., an interview was conducted with Staff #12. Staff #12 confirmed that Resident #19 reported to her that Resident #15 had made a threat of physical harm and was frightened. Staff #12 further stated that she notified the Administrator of the reported incident via email or group text messageAt approximately 4:30 p.m., an interview was conducted with the Administrator. The Administrator stated she was aware of ongoing interpersonal conflicts between Resident #15 and Resident #19, and separated them when another private room became available; however, she reported that she had not been informed of any allegation that Resident #15 had threatened to inflict physical harm on Resident #19, so no investigation was initiated. Further, the Administrator stated it is her expectation that staff immediately notify her upon becoming aware of any alleged threat involving a resident and that such incidents be documented in the resident ' s progress notes in accordance with facility policy. Additionally, the Administrator acknowledged that a threat of physical harm constitutes alleged resident abuse and is required to be reported to the Administrator for appropriate investigation and follow-up.
Plan of correction · submitted by the facility
0796 - Plan of Correction:Corrective Action:Resident #15 and Resident #19 are no longer roommates. Resident #15 and Resident #19 were assessed by the Health and Wellness Director to evaluate any physical or psychological harm. Both residents were interviewed regarding the allegations. Implementation of Others:All residents residing in the community are at risk for this alleged deficient practice. A full house audit was conducted on March 5, 2026, to ensure no other residents residing at the facility are experiencing allegations of abusive behavior by other residents. Systemic Changes:Executive Director will be re-educated by the Director of Operations on the company’s abuse policy on or before March. The facility re-educated all staff on the abuse prevention policy, with emphasis on the requirement that resident-to-resident altercations must be immediately reported, investigated, and documented. The facility also implemented the following process improvement:A standardized abuse investigation checklist to ensure consistent investigation and documentation. Leadership review of all resident-to-resident altercations to determine if the incident meets criteria for abuse reporting. Reinforcement of behavior monitoring and individualized care planning for residents with known behavioral risks. Monitoring:The Administrator or designee will conduct a weekly audit times 4 weeks, then monthly for 3 months of incident and accident reports, allegations of abuse, resident-to-resident documentation, and investigation and reporting timelines. The audit will verify that all resident-to-resident incidents are immediately reported, investigations are completed timely, documentation is complete, and reported to CDPHE timely. Results of the audit will be reviewed during the facility’s Quality Assurance and Performance Improvement (QAPI) Committee monthly. Additional corrective action and education will be implemented if concerns are identified.
11/17/2025Licensure Complaint · ID JMLV111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO41105, was completed on 11/18/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1770Ben/Svc Req-ACF-PA-PCSP▼
Findings
Based on interview and record review, the facility (residence) failed to ensure that each resident care plan reflected the member (resident) goals, choices, preferences, and needs and incorporation of these elements into the supports and services described in the Person-Centered Support Plan, affecting one former resident (#18). Findings include:1. Former Resident #18 was admitted to the residence on 12/6/24 with a diagnosis of parkinsonism, abnormalities of gait and mobility. The care plan for Former Resident #18, dated 10/1/24, read she required two person assistance with transferring. 2. InterviewsOn 11/17/25 at 10:44 a.m., Staff #11 stated Former Resident #18 was in the hospital following a fall. Staff #11 said Former Resident #18 was a fall risk and fell often. She added Staff #7 lifted up Former Resident #18 by herself. On 11/17/25 at 1:37 p.m., Staff #6 stated Staff #11 called for help and said Former Resident #18 fell on the floor. Staff #6 said she had not used the sit to stand lift with Former Resident #18's for transfers. On 11/17/25 at 2:14 p.m., Resident #18 ' s family member said Former Resident #18 did not require two staff members to transfer her, as he was told by the administrator that the residence did not provide two person transfer assistance and that is why he bought the sit to stand mechanical lift so that one staff member could use the lift to transfer Former Resident #18. On 11/18/25 at 2:23 p.m., the administrator stated staff were required to read and follow resident care plans. She added care plans should be updated any time there was a change in a residents' condition. The administrator stated Former Resident #18 was a two person assist and was not aware staff were transferring Resident #18 with only one person. She added she encouraged Former Resident #18's family member to purchase a sit to stand mechanical lift. The administrator said she was not aware that staff were not using the sit to stand mechanical lift, as required.
Plan of correction · submitted by the facility
1770– Corrective Action:Resident #18 – no longer resides at the facilityIdentification of Others:Full house service plan audit was completed. No other residents were identified. Systemic Changes:H& W Director will ensure residents’ transfer service plans are accurate. H& W will validate the need for mechanical lifts with all residents requiring to be transferred using a mechanical lift. Monitoring:H&W Director will review with QA any identified trends/concerns over the next 3 months. H&W Director is responsible for any follow-up recommendations made in QA.HWD & RCC will monitor staff completing a 2 person transfer to ensure staff are completing the transfer correctly, safely, and according to training they received. HWD & RCC will complete spot checks weekly on the 2 person transfers. The monitoring of the task will be documented on spreadsheet.
9999Final ObservationsSurveyor note▼
Findings
THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10, Chapter 8.7000. 8.7411. A Incident reportingProvider Agencies shall complete the timely reporting, recording, and reviewing of incidents which shall include, but not be limited to: 2. Hospitalization of Member receiving services; 3. Medical emergencies, above and beyond first aid, involving Member receiving services; 5. Injury to Member or illness of Member.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
12 records12/21/2025Physical Abuse · ID 25230322007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/21/25, 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. Client (B) allegedly hit Client (A) in the forehead three times during a verbal interaction, causing Client (A) pain. During the course of the investigation, the healthcare entity separated and assessed the clients, notified law enforcement, and conducted interviews. Client (A) received treatment for their pain and was placed on increased monitoring following the event. Client (B)’s care plan was updated to include staff interventions for de-escalation to reduce the risk of recurrence. Staff monitored both clients in common areas to encourage separation. Client (B) was later discharged from the facility. 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 4/2/2026 · released to the public 4/9/2026.
11/3/2025Neglect · ID 25230322006Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/5/25, the healthcare entity investigated a reportable event of neglect of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 11/6/25, Event IDs 4GBE11 and 9TQR11. 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. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 2/2/2026 · released to the public 2/9/2026.
5/26/2025Misappropriation of Property · ID 25230322004Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/26/25, 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 prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) alleged $100.00 was missing from their wallet. During the course of the investigation the healthcare entity conducted a search, and interviews. No staff were aware of the money. Client (A) had a safe fastened to the wall in their closet to use. The police were notified and no assailant was identified. 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 8/19/2025 · released to the public 8/26/2025.
4/10/2025Brain Injury · ID 25230322003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/11/25, 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 prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital and was discharged to a rehabilitation facility where they fell. The client’s care plan will be updated to reflect safety interventions should they return to the facility. The client was currently back at the hospital at the time the report was submitted. 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 8/14/2025 · released to the public 8/21/2025.
1/17/2025Misappropriation of Property · ID 25230322002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/11/25, 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 prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted interviews and reviewed documentation which revealed the client wrote a check for $500 to staff member (1) back in January 2025. The police were notified and Staff member (1) had already had their employment terminated on 3/7/25 for other concerns. All staff were educated again they can not take gifts from clients and not to discuss personal issues with the clients. The clients have been educated not to give gifts to employees and this client was given back their money by the facility. 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 4/20/2025 · released to the public 4/27/2025.
12/7/2024Sexual Abuse · ID 24230322007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 12/9/25, 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 prevent a future recurrence. The healthcare entity reported sexual abuse of a client. During the course of the investigation, the healthcare entity, ensured client safety. Client (A) reported that client (B) came into the laundry room area, cornered them and attempted to "grope" them; however, no contact was made. Client (A) said they yelled at client (B) and client (B) left the room. Client (B) was placed under close staff supervision to keep them separated from client (A). Client (B) denied any wrongdoing. A staff member witness said they saw client (B) in the laundry pulling clothes out of a machine and throwing them on the floor. Then they saw client (A) come by and yell at client (B) that those were their clothes and to leave until they finished washing their clothes. The healthcare entity was unable to confirm sexual abuse occurred based on inconclusive evidence. 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 7/10/2025 · released to the public 7/17/2025.
12/5/2024Brain Injury · ID 24230322006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/5/24, 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 prevent a future recurrence. The healthcare entity reported a brain injury. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client’s care plan was updated to reflect safety interventions should the client return to the facility after their rehabilitation stay. 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 2/19/2025 · released to the public 2/26/2025.
6/19/2024Physical Abuse · ID 24230322004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/20/24, 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 prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) yelled out “ouch” indicating pain when their hair was pulled by Client (B). The event was witnessed by staff. Client (B) was educated to keep to themselves and it was not appropriate to touch others. Staff will continue to redirect clients. 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 4/3/2025 · released to the public 4/10/2025.
6/7/2024Misappropriation of Property · ID 24230322003Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 6/7/24 a manager saw staff member (1) place a 50 cent piece in their pocket while in Resident (A)’s room. Other residents mention missing items that would later show up. Staff notified the police. Staff member (1) admitted to taking the 50 cent piece and had it in their pocket. Staff member (1) stated they took it to ask Resident (A) where they got it from. The facility investigation concluded staff member (1)’s actions were witnessed and they did not have any reason to place the money in their pocket and leave the apartment. To help prevent a recurrence, staff member (1)’s employment was terminated. No further concerns have been identified.
DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 1/16/2025 · released to the public 1/23/2025.
4/22/2024Brain Injury · ID 24230322002Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 4/22/24 resident (A) had an unwitnessed fall hitting his head on an electronic device and had complaints of head and neck pain. Resident was sent to the hospital and diagnosed with a brain injury and a fracture to his neck. The facility’s investigation concluded resident (A) attempted to sit down and missed the chair falling and striking his head. Resident (A) was admitted to the hospital. If resident (A) returns to the facility his safety plan will be updated to reflect his current needs.
DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 12/2/2024 · released to the public 1/14/2025.