NEW MERCER COMMONS — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

December 16, 2025

Last Inspection

S/S E Potential for harm

The most recent inspection of NEW MERCER COMMONS on record is dated December 16, 2025. Across 2 published inspections, state surveyors cited 1 deficiency, 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 (Licensed Only)

Administrator

DIGIALLONARDO, GINA

Owner

THE WORTHINGTON INC

Phone

(970) 495-1000

Payor Source

Private Pay

City

FORT COLLINS

ZIP

80526

Inspections & Citations

2 inspections · 1 deficiencies

12/16/2025Revisit: Licensure and Licensure Complaint (Combined) · ID IY7V12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 12/16/25 for all previous deficiencies cited on 8/20/25. The facility is in compliance with all deficiencies that were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

8/19/2025Licensure and Licensure Complaint (Combined) · ID IY7V111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey and complaint investigation, prompted by #CO40182, #CO36848, and #CO35716 was completed on 8/20/25. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1194Res Care Srvs-Lift As Req DocS/S E▼

Findings

Based on interview and record review, the residence failed to implement effective actions that were to be taken by staff to prevent reocurrence of falls for one sample resident (#5) who fell. Findings include: Resident #5 was admitted to the residence on 9/3/24 with diagnoses including generalized weakness and left arm weakness. Progress notes for July and August 2025 revealed the following:On 7/12/25, Resident #5 had an unwitnessed fall in her room, which resulted in a 1.25-inch skin tear on her left elbow. Resident #5 attempted to self-transfer from the recliner to her wheelchair when she fell. On 8/9/25, Resident #5 had an unwitnessed fall in her room. Resident #5 attempted to self-transfer from her wheelchair to a chair when she fell and hit her head. On 8/12/25, Resident #5 had an unwitnessed fall in her room. Resident #5 attempted to self-transfer from her bed to her wheelchair when she fell. A care plan for Resident #5, last updated 8/13/25, revealed the resident was a fall risk and had a history of falls. The care plan contained the following individualized approaches to prevent falls: 10/8/24: Purposeful rounding program, give reminders not to ambulate/transfer without assistance. 2/1/25: Encourage to call for assistance with transfers. 7/14/25: Evaluation for transfer pole. Transfer pole was declined by resident. 8/13/25: Power of Attorney to look at wheelchair brakes. On 8/20/25 at 8:00 a.m., Staff #5 and Staff #6 were jointly interviewed. Staff #5 stated Resident #5 had a history of falls and that the most recent fall occurred on 8/12/25. She stated that Resident #5 had muscle weakness and utilized a wheelchair for ambulation. Staff #5 stated that all of Resident #5's falls occurred because she attempted to self-transfer to/from her wheelchair without staff assistance. She stated the only approaches she was aware of were to conduct safety checks every two hours and encouraging the resident to call staff for assistance before transferring. Staff #5 could not recall when the two-hour safety checks had been implemented, as this had always been something staff members had done. Staff #6 confirmed Staff #5's statements. On 8/20/25 at 8:12 a.m., the clinical coordinator (CC) stated the residence placed Resident #5 on frequent checks and had staff ensure the brakes on her wheelchair were locked. She further stated that staff were to encourage Resident #5 to use her call light when she needed transfer assistance. When asked to clarify what "frequent checks" were, the CC stated that staff were to check on Resident #5 every 30 minutes. The CC was unaware that staff were not performing 30 minute safety checks and only conducting checks every two hours. She acknowledged that this should have been documented more clearly in the care plan for Resident #5.

Plan of correction · submitted by the facility

Resident #5 was admitted to New Mercer Commons 9/3/24. Resident is diagnosed with generalized weakness and left arm weakness, which increases her fall risk. On 7/12/25, 8/9/25, and 8/12/25 resident #5 had unwitnessed falls in her room when attempting to self-transfer. Per PT notes on 8/22/25 resident #5 has a significant increase in stability in standing and fear with performance. PT also notes that there are moderate gait deviations which can increase her risk of falling. Staff provided education to resident #5 about the importance of calling for assistance when self-transferring. Resident #5 acknowledged this education and has agreed to install a transfer pole next to her bed and another one next to her recliner. Physical and occupational therapies have been set up for resident #5. OT will help introduce the transfer pole to ensure resident #5 is using it correctly. PT notes from 8/22/25 state resident should be placed as stand by assistance; her care plan has since been updated to reflect this. A care conference has been held to review falls with resident #5, as well as fall prevention education. Education has also been provided to staff regarding anticipating resident needs, reviewing the fall section on the resident care plans and ensuring they fill out the fall form between the shift manager and the nurse so that we have better understanding of exactly how each fall is occurring. We review falls daily in IDT and review changes that may increase a residents fall risk. We then update the residents fall care plan and send fall prevention to our daily shift report for all staff to read. In addition, the residents primary care physician is always notified of each fall. Starting 9/8/25 IDT will be doing weekly rounds in rooms of our falls for that week. We will then document and reach out to resident/family/POA of our findings/suggestions for room safety. If the PCP deems it is appropriate to make an appointment to see the resident, our staff will help aid the resident in setting up that appointment.

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:(A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either:(1) The resident cannot explain how the injury occurred; or(2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries.(B) The assisted living residence shall document the following:(1) The investigation and identification of any injury identified in (A), above.(2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin: (a) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or (b) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse, neglect, or exploitation. Such steps may include, but not be limited to: (i) Staff or volunteer corrective action and/or additional training; or (ii) Modification of the assisted living residence ' s policies, procedures or physical environment.(3) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries. 14.33 The assisted living residence shall ensure that the resident ' s authorized practitioner and resident ' s legal representative are promptly notified of: (B) A resident ' s pattern of refusal. 18.9 The face sheet shall be updated at least annually and contain the following information:(H) Name, address, and contact information for resident ' s practitioner.

Plan of correction

The state did not require a plan of correction for this citation.

Reportable Occurrences

37 records

6/22/2026Physical Abuse · ID 2623036U009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/22/26, 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 observed client (A) on the floor reporting left arm pain. Client (A) alleged client (B) pushed them. During the course of the investigation, the healthcare entity increased supervision, contacted police and medical providers, conducted interviews, and reviewed records. Staff contacted emergency medical services, who transported client (A) to the emergency department. Client (A) reported to medical providers that client (B) punched their arm and kicked them after they fell. Medical providers assessed and treated client (A)'s injury. Due to cognitive impairment, client (B) was unable to provide detailed information about the incident, and client (A) had conflicting information. Staff did not observe an altercation between the two clients. The facility re-assessed their clients and discussed potential safety or behavioral concerns. Since the report, both clients were discharged due to needing a higher level of care. Due to the source of the injury being unknown, and no report of mishandling or an altercation, the event was not substantiated. This is the second report of physical abuse involving client (B). Please refer to the case ID 2623036U007 for details. 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 7/27/2026 · released to the public 8/4/2026.

6/18/2026Physical Abuse · ID 2623036U008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/18/26, 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 responded to yelling and observed client (A) and (B) having a verbal altercation that escalated to a physical altercation. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, and reviewed records. Due to cognitive impairment, both clients were unable to provide detailed information about the incident. Staff observed client (B) to be very anxious. No visible injuries or complaints of pain were indicated for either client when assessed. The facility increased supervision and behavior monitoring for client (A) and encouraged them to lock their door. Client (B)'s medical provider reviewed and adjusted their medications to assist with behaviors. The facility implemented 1:1 supervision during meal times and communicated any behavioral changes with the medical provider. Staff witnessed the incident. The event was substantiated. This is the third report of physical abuse involving client (A). Please refer to the case ID 2623036U002 and 2623036U005 for details. This is the third report of physical abuse involving client (B). Please refer to the case ID 2623036U004 and 2623036U005 for details. 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 7/27/2026 · released to the public 8/4/2026.

5/19/2026Physical Abuse · ID 2623036U007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/19/26, 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. Client (B) became agitated and slapped client (A) in the face. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, and reviewed records. No visible injuries were indicated for client (A) when assessed. Client (A) confirmed the incident. Due to cognitive impairment, client (B) was unable to provide detailed information about the incident. The facility implemented 1:1 supervision, behavior monitoring, and a meaningful activity for client (B). The facility contacted client (B)'s medical provider, who adjusted their medications. Staff increased supervision of client (A). Staff witnessed the incident. 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 7/27/2026 · released to the public 8/4/2026.

5/4/2026Physical Abuse · ID 2623036U006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/4/26, 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 heard client (A) report to client (B) that we do not hit each other. During the course of the investigation, the healthcare entity separated both clients, contacted police, and conducted interviews. No visible injuries or complaints of pain for both clients were indicated when assessed. Client (A) reported that both clients slapped each other. Neither client expressed fear. Due to cognitive impairment, client (A) was unable to provide detailed information about the incident. Staff reported not observing both clients slap each other. The facility encouraged both clients to sit at different tables in the dining room. Staff increased monitoring of client (B) and notified their medical providers. Due to the event not being witnessed and no visible injuries, the event was not substantiated. This is the second report of physical abuse involving the client (B). Please refer to the case ID 2523036U013 for details. 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.

4/18/2026Physical Abuse · ID 2623036U005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/18/26, 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 observed client (A) on the floor who reported that client (B) pushed them. Client (A) sustained an injury. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, and reviewed records. Emergency medical services transported client (A) to the emergency department for evaluation. Client (A) returned to the facility with a back brace and medical provider orders for treatment of the injury. Due to cognitive impairment, client (B) was unable to provide detailed information about the incident. The facility implemented frequent checks and separate seating in the dining room for both clients. For client (A), the facility implemented a keep out sign and reminders to keep their door locked to help prevent wandering. The facility reminded staff to provide redirection when client (B) was in proximity to others. 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 6/4/2026 · released to the public 6/12/2026.

4/15/2026Physical Abuse · ID 2623036U004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/15/26, 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 observed client (A) grab client (B), who responded by slapping client (A) and telling them to go away. During the course of the investigation, the healthcare entity separated both clients, contacted police, conducted interviews, and reviewed records. Due to cognitive impairment, both clients were unable to provide detailed information about the incident. No visible injuries or complaints of pain for client (A) were indicated when assessed. The facility implemented frequent checks and behavior monitoring of both clients. The facility implemented redirection techniques and 1:1 supervision during meals for client (A). The facility encouraged personal space for client (B). Staff witnessed the incident. The facility determined contact occurred, but it did not result in any visible injury or complaints of pain; therefore, 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 6/4/2026 · released to the public 6/12/2026.

2/25/2026Physical Abuse · ID 2623036U003Reported on time: Yes▼

Occurrence summary

On 2/25/26, 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. Client (B) slapped client (A) on the back of the head. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, and reviewed records. Client (A) reported pain when assessed and confirmed the incident. Due to cognitive impairment client (B) was unable to provide detailed information about the incident. The facility increased monitoring of both clients. Staff offered client (B) to sit in a different dining room and to take rest breaks. A lock was added to client (A)'s door to prevent unwanted visitors. Staff witnessed the incident. The event was substantiated. This is the second physical abuse report involving client (B). Please refer to case ID: 2523036U013 for further details. 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 4/24/2026 · released to the public 5/1/2026.

2/21/2026Physical Abuse · ID 2623036U002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/21/26, 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 observed a verbal altercation between client (A) and (B). Client (A) alleged that client (B) hit them. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, and reviewed records. No visible injuries or complaints of pain for both clients were indicated when assessed. Due to cognitive impairment, client (A) had conflicting details of the incident from what the staff observed. Client (B) reported that client (A) was trying to steal from them. No visible injuries or complaints of pain for both clients were indicated when assessed. The facility increased monitoring of both clients. The facility implemented a door lock and sign to keep unwanted visitors out for client (A). The facility implemented interventions for client (B) when they think items are missing. 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 4/22/2026 · released to the public 4/29/2026.

12/7/2025Brain Injury · ID 2523036U015Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/13/25, 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. A client experienced an unwitnessed fall, was transferred to the hospital for further assessment, and returned to the facility with no significant findings. Several days later, the client returned to the hospital due to increased pain, and repeated diagnostic imaging confirmed the presence of a brain bleed. During the course of the investigation, the healthcare entity reviewed records and notified the client’s medical provider. Following the initial fall, the client was placed on fall precautions and increased monitoring. After discharging from the hospital, the client moved to another facility based on their change in condition. 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 3/4/2026 · released to the public 3/11/2026.

10/30/2025Brain Injury · ID 2523036U014Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/30/25, 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. A client experienced an unwitnessed fall. A few days later, the client exhibited a change in behavior and was transferred to the hospital for further evaluation. Diagnostic testing confirmed the presence of a brain bleed. During the course of the investigation, the healthcare entity assessed the client, notified emergency services, and reviewed records. The client was placed on increased monitoring following the fall and prior to being sent to the hospital. Upon return from the hospital, the client continued on fall precautions and was evaluated by therapy and hospice services. The client’s medications were reviewed by the medical provider. 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 1/6/2026 · released to the public 1/15/2026.

9/21/2025Physical Abuse · ID 2523036U013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/21/25, 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. Staff heard yelling and found Client (B) in Client (A)'s room. Client (A) alleged Client (B) pulled their hair. Staff separated the clients. During the course of the investigation, the healthcare entity contacted police and medical providers, conducted interviews, reviewed records, and updated the care plans. Both clients confirmed that a physical altercation of hair pulling occurred. The facility implemented frequent checks on both clients, and environmental changes were completed to help deter others from wandering into client (A)'s room. An altercation did occur; however, it could not be determined who the aggressor was. 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 3/2/2026 · released to the public 3/9/2026.

8/10/2025Verbal Abuse · ID 2523036U012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/10/25, 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 verbal abuse of a client. A family member alleged verbal abuse from Staff #1 to Client (A) due to the client feeling rushed during care and the staff member's tone was cruel. During the course of the investigation the healthcare entity ensured the client felt safe. The investigation revealed the client was concerned they were weaker and needed more assistance and did not want Staff #1 to help them any longer. The family provided a care assistant to assist Client (A) due to weakness. Staff #1 was educated not to assist Client (A) any further and to ensure another staff assisted Client (A). Client (A) was not fearful. 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 1/6/2026 · released to the public 1/15/2026.

7/25/2025Brain Injury · ID 2523036U011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/25/25, 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. Client (A) had an unwitnessed fall. 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 and other injuries at the hospital. The client’s care plan will be updated to reflect safety interventions should they 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 9/23/2025 · released to the public 9/30/2025.

7/16/2025Brain Injury · ID 2523036U010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/16/25, 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. Client (A) had an unwitnessed fall. 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. The client’s care plan was updated to reflect safety interventions to include: stand by assistance with transfers, home health assistance, and frequent safety checks when they returned. 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 9/23/2025 · released to the public 9/30/2025.

4/26/2025Physical Abuse · ID 2523036U008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/26/25, 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 physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Other clients indicated Client (B) was bumping into Client (A) to get them to move. No staff witnessed the incident. No injuries. Additional seating was provided to make room for clients. Client (B). Staff will monitor, redirect the clients, provide one-to-one when needed and activities. The facility could not determine what happened and the event was inconclusive and 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 9/17/2025 · released to the public 9/24/2025.

4/26/2025Brain Injury · ID 2523036U009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/26/25, 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 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 before returning to the facility on hospice services. The client’s care plan was updated to reflect safety interventions to include; increased monitoring from the staff, and fall precautions were implemented. 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.

4/7/2025Physical Abuse · ID 2523036U007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/7/25, 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 physical abuse of a client. Client (A) alleged Client (B) grabbed their arm when they came into their room. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) stated maybe they were scratched. No injuries seen. The facility could not determine what happened in Client (A)’s room. However, interventions were implemented to include: Signage was put up, staff and Client (A) was reminded to lock their door, and frequent checks were implemented to monitor wandering clients. 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 9/16/2025 · released to the public 9/23/2025.

4/5/2025Brain Injury · ID 2523036U006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/5/25, 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 will go to a rehabilitation facility before returning. The client’s care plan will be updated should the client return to include safety precautions. 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.

3/7/2025Misappropriation of Property · ID 2523036U004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/7/25, 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. The responsible party indicated the client was missing $100.00. During the course of the investigation the healthcare entity conducted a search, and interviews. The police were notified and no assailant was identified. The responsible party was educated to utilize the locking drawer or have the money placed in an account that the facility manages. Staff were educated to report to management if the client left valuables unsecured. The money was not found. 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 5/6/2025 · released to the public 5/13/2025.

3/6/2025Brain Injury · ID 2523036U003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/7/25, 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. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client had an unwitnessed fall and was diagnosed with a brain injury at the hospital and received aftercare treatment. The client’s care plan will be updated to reflect safety interventions should they return to 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 4/10/2025 · released to the public 4/18/2025.

2/15/2025Physical Abuse · ID 2523036U002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/15/25, 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 physical abuse of a client. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant (Companion #1) were separated before the police were notified. Client (A) stated they were assaulted by Companion #1 and was touched all over. No findings of abuse during the assessment. No staff indicated witnessing the allegation. It was revealed Client (A) had a history of delusions and hallucinations. Companion #1 was educated to notify management if Client (A) appeared anxious or refused care. Staff implemented frequent checks, and stress reliever interventions were added to the clients plan of care. 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 7/30/2025 · released to the public 8/6/2025.

11/29/2024Neglect · ID 2423036U015Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/29/24, 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 neglect of a client. A family member who was present in the facility alleged Staff #1 did not provide services to the client when requested and stated, the client was alright. No negative concerns to the client. During the course of the investigation the healthcare entity conducted interviews. Staff #1 indicated the client was requesting more assistance than normal, reassured the client but denied assisting the client. The family member and the client were informed the facility would no longer use the agency #staff #1. The client was encouraged to continue using their call light and requesting assistance. 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 7/17/2025 · released to the public 7/24/2025.

10/12/2024Brain Injury · ID 2423036U013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/14/24, 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 of a client. During the course of the investigation the healthcare entity did an assessment, obtained medical treatment and updated the client's care plan to reflect increased safety changes if the client returned. The client was placed on comfort care at the hospital. 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 2/6/2025 · released to the public 2/13/2025.

9/23/2024Physical Abuse · ID 2423036U012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/23/24, 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 was safe before the police were notified. The client alleged someone hit them multiple times. The client had no injuries and could not identify the person. Staff increased monitoring of all client interactions and others. A family member visited with the client on the night of the allegation and noticed the client becomes agitated when another client is around. No interaction occurred. The family member also stated they may get a new one-to-one person to be with the client due to agitation and to add support. 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 5/28/2025 · released to the public 6/4/2025.

6/26/2024Physical Abuse · ID 2423036U011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/26/24, 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) alleged they were pushed by Client (B) striking their head on the door and leg on a walker before complaining of pain that resolved. Staff implemented frequent safety checks and encouraged participation in activities due to both clients have cognitive impairment. Client (B) actions were reckless as they did not want Client (A) to walk closely to their room door. 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.

6/23/2024Physical Abuse · ID 2423036U010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/23/24, 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) alleged Client (B) hit them in the chest when trying to redirect them. Staff will monitor the clients interactions and staff placed a stronger magnet on the door Client (B) was able to get through. No staff witnessed the event. Client (A) did not have any injuries from this event and it 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 4/3/2025 · released to the public 4/10/2025.

6/6/2024Physical Abuse · ID 2423036U008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/6/24, 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. The staff witnessed the clients hitting each other in the hands with silverware. Client (A) was the aggressor. The staff monitored the clients closer due to cognitive impairment and to keep others safe. No visible injuries to either client. 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 3/26/2025 · released to the public 4/2/2025.

5/23/2024Physical Abuse · ID 2423036U007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/23/24, 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) was found on the floor with Client (B) close by. Due to both clients having cognitive impairment and Client (A) having an additional language barrier, the facility could not determine if the Client (A) was or was not pushed by Client (B). Both clients were placed on safety checks and increased monitoring for behaviors. 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 3/3/2025 · released to the public 3/10/2025.

3/12/2024Neglect · ID 2423036U005Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 3/12/24 staff member (1) was alleged to be neglectful by not weighing and documenting accurately for resident (A). Staff member (1) was suspended and stated they may not have subtracted the wheelchair weight from the residents weight but was adamant about weighing resident (A). The facility’s investigation concluded the weights were inaccurate and the allegation was substantiated. To help prevent a recurrence, staff member (1)’s employment was terminated. The dietary manager will monitor weights and request a new weight for any variances 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 12/2/2024 · released to the public 12/10/2024.

1/24/2024Brain Injury · ID 2423036U003Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE:On 1/24/24 resident (A) informed staff s/he had fallen in the bathroom after losing their balance. Resident (A) stated s/he hit their head and had back pain. Resident (A) was sent out to the hospital and was diagnosed with a closed brain injury-contusion to the right side of their head. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family, ombudsman and physician. Resident (A) had on shoes when s/he was found and their cane was on the floor. No one witnessed the fall occur. The facility investigation concluded resident (A) had an unwitnessed fall and got themselves up before reporting to staff. To help prevent a recurrence, resident (A)'s care plan was updated to reflect more support care from staff. Resident (A) was provided with more safety checks and s/he will work with therapy as ordered. 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 11/25/2024 · released to the public 12/3/2024.

1/19/2024Physical Abuse · ID 2423036U002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/19/24, resident (A) fell and struck her head. Resident (B) admitted to pushing resident (A). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. The residents were separated. Resident (A) was sent to the emergency room for an evaluation and treatment before returning to the facility. Resident (B) stated she was trying to get resident (A) out of her room when resident (A) fell after she stepped backwards. The facility investigation concluded it was unclear if the push caused resident (A) to fall. To help prevent a recurrence, a sign was placed outside of resident (B)'s door to keep others out of her room. She was reminded to lock her door. The resident care plans were updated with interventions for both individuals and staff would continue to monitor all residents to ensure their safety. 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 11/25/2024 · released to the public 12/3/2024.

1/15/2024Sexual Abuse · ID 2423036U001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/15/24, resident (A)'s family member reported resident (A) alleged they were touched inappropriately by resident (B). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Resident (A) resided on an all female unit and interactions with male residents were limited. Resident (B) denied the allegations. Staff indicated resident (A) showed an increase in confusion lately and needed redirection. The facility investigation could not conclude if any inappropriate behavior occurred as alleged by the resident and her family member. To help prevent a recurrence, staff have been educated to seat the resident away from male residents. Staff would continue to monitor all interactions between residents. 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 11/25/2024 · released to the public 12/3/2024.

12/15/2023Brain Injury · ID 2323036U011Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 12/15/23, the spouse of Resident A in his 90’s, yelled for assistance. Staff #1 responded and found Resident A down in the bathroom, in his room. His head and upper torso were in the shower and the lower torso was stretched out on the bathroom floor. Staff #1 observed blood under the resident’s head. An administrative staff member notified emergency medical services and Resident A was transported to a hospital. The hospital staff conducted an assessment and completed two computed tomography (CT) scans and neurological evaluations. The CT scans revealed a small subdural hematoma. A head laceration was closed with staples. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family/guardian and physician. Frequent checks were implemented following his return to facility, and therapy services was ordered. From the investigation, the facility confirmed the documentation review showed Resident A sustained a brain bleed with the fall. To help prevent a recurrence, the facility updated the care plan of Resident A to encourage him to call for assistance when ambulating and to limit distractions. Signs were placed in the resident’s room to remind him to call for assistance. 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 2/8/2024 · released to the public 2/9/2024.

8/21/2023Physical Abuse · ID 2323036U009Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 8/21/23, staff (1) was in the dining room and heard resident (B) call another resident (A) stupid. Resident (B) was then heard saying she was going to punch resident (A). Staff (1) turned around and saw resident (B) pushing resident (A) away with a closed fist and pushing resident (A) on the face. The alleged incident occurred in the memory care unit. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Residents were separated. Resident (A) was assessed without any visible injuries. Both residents had cognitive impairments and did not recall the incident. Staff indicated resident (B) told resident (A) she needed to keep the juice in her mouth and saw her grab resident (A)’s nose and push her on the face. The facility investigation concluded resident (B) got upset and reacted in a physical manner towards resident (A). To help prevent a recurrence, frequent checks will continue on both residents for safety. Resident (B) was offered another room to interact with residents with similar cognition; however, she declined. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility 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 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 7/29/2024 · released to the public 7/31/2024.

6/11/2023Sexual Abuse · ID 2323036U007Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/11/23, a staff member (1) witnessed resident (B), in her 90s, walk up to another resident (A), in her 70s. Resident (B) proceeded to lift up resident (A)'s shirt and grabbed her breasts. Resident (A) said “no” and began to swat the hands of resident (B). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, ombudsman, Adult Protective Services and physician. Both residents were separated and placed on frequent safety checks. There were no reported injuries. Resident (A) stated she was fine and asked why the nurse was bothering her. Resident (A) did not recall the event. Resident (B) appeared confused thinking she was gong to engage in sexual relations. She was unable to recall the incident with resident (A). A medical provider assessed resident (B) and she was diagnosed with a urinary tract infection with increased confusion. The facility investigation concluded resident (B), in her confusion, touched resident (A) without consent and without an understanding of her intentions. Staff continued monitoring the residents with a plan to redirect resident (B) back to her room or offer other activities if she started showing signs of sexually inappropriate behaviors. Staff contacted resident (A)'s responsible party to offer a room change if they would like. 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 3/25/2024 · released to the public 3/25/2024.

3/5/2023Physical Abuse · ID 2323036U004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 3/5/23 as witnessed by qualified medication administration person (QMAP) (1) a female resident (B) in her 70s was in the dining room at a dinner table and self-propelled in her wheelchair over to another female resident (A) in her 80s and grabbed her arm causing a bruise. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, Adult Protective Services and ombudsman. Resident (A) yelled out, “why don’t you just stop” and QMAP (1) separated the two residents. Resident (A) had a dime sized bruise to her right wrist. Resident (A) stated “Did you see that rough woman grab and squeeze my arm?” Resident (B) stated “the young girls are doing that and we can’t stop them. I am trying to help and I know you are”. Both residents have cognitive impairment. The facility investigation concluded the action of resident (B) to resident (A) was witnessed and resident (A) sustained a bruise to her wrist. To help prevent a recurrence, safety checks were implemented by staff. Both residents will be redirected as needed to participate in activities and will be monitored for overstimulation. 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 8/14/2023 · released to the public 8/16/2023.

1/28/2023Physical Abuse · ID 2323036U001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/28/23 staff member (1) witnessed a female resident (A) in her 90s in the dining room at the same table as another female resident (B) in her 80s. Resident (A) was seen coughing and trying to clear her throat when resident (B) told her that was gross and got up from her chair and went over to resident (A) and pulled her hair while stating “stop it.” FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, Adult Protective Services and ombudsman. Both residents have cognitive impairments. Resident (A) when reminded of the incident asked why resident (B) pulled her hair. Resident (B) stated she pulled resident (A)’s hair on accident as she was trying to get other residents to leave. Resident (A) had no visible injuries. The facility investigation concluded the incident was witnessed, resident (B) did not like what resident (A) was doing so she went over to her and pulled her hair before staff could intervene. Also identified, the on call did not report the occurrence within the 24 hour time frame. To help prevent a recurrence, resident (B)’s care plan was updated to include physical aggression, and to move resident to another table if other residents are agitating her. Staff will continue to monitor residents for behaviors. Education was provided to staff regarding timely reporting criteria. 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 8/22/2023 · released to the public 8/22/2023.