Colorado CDPHE · Facility Report

BROOKDALE MARIANA BUTTE

📍 215 SHUPE CIR, LOVELAND, CO 80537

ID 2303F3Assisted Living Residence (Licensed Only)Active
13
Inspections
10
Deficiencies
0
Actual Harm or Above
21
Occurrences
May 11, 2026
Last Inspection
S/S A/B Minimal potential

The most recent inspection of BROOKDALE MARIANA BUTTE on record is dated May 11, 2026. Across 13 published inspections, state surveyors cited 10 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 (Licensed Only)
Administrator
Mosley, Kelli
Owner
BKD STERLING HOUSE OF LOVELAND-ORCHARDS, LLC
Phone
(970) 622-0012
Payor Source
Private Pay
City
LOVELAND
ZIP
80537

Inspections & Citations

13 inspections · 10 deficiencies
5/11/2026Licensure Complaint · ID 60MX113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO41700 and #CO42029, was completed on 5/13/26. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0722Stf Req-Stf Lvls Res NeedsS/S B▼
Findings
Based on observations and interviews, the residence failed to have sufficient staff, specifically to ensure a physically sanitary environment. Findings include:ObservationsOn 5/11/26 at 7:50 a.m., the restroom near the residents ' dining room did not have any toilet paper. The restroom had been observed multiple times throughout the day of 5/11/26, beginning at 7:50 a.m. until 4:30 p.m., and there had been no available toilet paper each time the restroom was observed. Each observation revealed the same dead spider on the floor of the restroom. InterviewsOn 5/11/26 at 9:50 a.m., Staff #2 said the residence experienced staff shortages. Staff #2 said that when there had been staff shortages, the care for residents got ' back up, ' including slower meal service. Staff #2 said that there are shifts that do not complete all of their assigned tasks. On 5/12/26 at 10:55 a.m., Resident #5 said the staff was not consistent about taking out his trash. Resident #5 reported using incontinence briefs at all times, and his family purchased an enclosed diaper pail receptacle for his room to reduce odors because the staff was not consistent about taking out his trash. On 5/12/26 at 1:45 p.m., the executive director said the residence normally staffed two housekeepers, but one had recently quit without notice, and another had been hired with a start date for the week of 5/18/26.
Plan of correction · submitted by the facility
Manager on Duty will complete a daily walk through of all common areas and document any areaslacking cleanliness to give to Executive Director. They will also alert staff or clean area as needed. 77 apts havebeen divided between 9 members of management to conduct weekly apartment checks and visitwith residents about services. This will be given to Maintenance Manager and ED to meet anddiscuss weekly or as needed. Failure to complete and turn in weekly checks will result in coaching or other employment action as deemed appropriate by Executive Director and Human Resources Business Partner (“HRBP”). The ED will be responsible for checking that all audits are turned in weekly. We are currently fully staffed with a housekeeper. If staff shortages do happen in the future duties will be distributed and overnight shift will be responsible for the daily cleaning of common areas and trash pick up by care staff. This will take place for 30 days then resident apt checks will be done every two weeks for 3 months and reviewed. It will then be reviewed during the Quality Management Program quarterly meeting. Daily walk throughs are a Brookdale standard and will continue ongoing
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observation, interview, and record review, the residence failed to provide services to residents, specifically, housekeeping services to ensure a sanitary environment. Findings include:Observations Observations on 5/11/26 between 7:45 a.m. and 9:00 a.m. and 5/12/26 at approximately 10:15 a.m. revealed the residence had a strong odor of what smelled like urine and feces. The odor dissipated as staff completed morning care rounds between 9:00 a.m. and 11:00 a.m. The strong odors did not dissipate inside or outside the rooms of Residents #1 and #5. Record reviewThe residency agreement reads in pertinent part that housekeeping would be provided by the residence once a week. InterviewsOn 5/12/26 at 10:55 a.m., Resident #5 said the staff was not consistent about taking out his trash. Resident #5 reported using incontinence briefs at all times, and his family purchased an enclosed diaper pail receptacle for his room to dispose of his used briefs inside of to reduce odors in his room. On 5/11/26 at 9:50 a.m., Staff #2 stated that resident care can get backed up when there are staff shortages. Staff #2 said that staff shortages happened every other week up until April 2026, when the residence seemed to be better staffed.
Plan of correction · submitted by the facility
Manager on duty will complete a daily walk through of all common areas and document any areaslacking cleanliness to give to ED. They will also alert staff or clean area as needed. 77 apartments havebeen divided between 9 members of management to conduct weekly apartment checks and visitwith residents about services. This will be given to Maintenance Manager and ED to meet anddiscuss weekly or as needed. Fresh Impression audits will be conducted. Failure to complete and turn in weekly checks will result in coaching or other employment action as deemed appropriate by Executive Director and Human Resources Business Partner (“HRBP”).. ED will be responsible for checking that all audits are turned in weekly. We are currently fully staffed with a housekeeper. This will take place for 30 days then resident apt checks will be done every two weeks for 3 months and reviewed. It will then be reviewed during the Quality Management Program quarterlymeeting. Daily walk throughs are a Brookdale standard and will continue ongoing
2680In Env-BR TP dspnsrS/S A▼
Findings
Based on observations and interviews, the residence failed to ensure toilet paper was available at all times in one of four common area bathrooms. Findings include:ObservationsOn 5/11/26 at 7:50 a.m., the restroom near the residents ' dining room did not have any toilet paper. The restroom had been observed multiple times throughout the day of 5/11/26, beginning at 7:50 a.m. until 4:30 p.m., and there had been no available toilet paper each time the restroom was observed. InterviewsOn 5/12/26 at 1:45 p.m., the executive director said the residence normally staffed two housekeepers, but one had recently quit without notice, and another had been hired with a start date for the week of 5/18/26.
Plan of correction · submitted by the facility
Manager on duty will complete a daily walk through of all common areas and document any areaslacking cleanliness to give to ED. They will also alert staff or clean area as needed. 77 apts havebeen divided between 9 members of management to conduct weekly apartment checks and visitwith residents about services. This will be given to Maintenance Manager and ED to meet and discuss weekly or as needed. On May 27, 2026 at all staff meeting training was completed with all staff to check public bathroom each shift to replenish supplies and clean as needed. Fresh Impressions (Maintenance cleaning) daily check includes all of the public restroom to check for supplies and cleanliness as well as checking the cleaning closets to ensure we have enough supplies. Fresh Impressions walk through was completed with all manager of how to complete the audits. Since audits have begun we are currently in compliance. Included in the daily audits of common areas both housekeeping closets are checked daily to monitor supplies.
4/15/2026Revisit: Licensure Complaint · ID JKQ412No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 4/15/26 for all previous deficiencies cited on 12/22/25. 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.
4/7/2026Licensure (Re-licensure) · ID ZI6111No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 4/8/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/22/2025Licensure Complaint · ID JKQ4111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO40907 and #CO41289, was completed on 12/22/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1192Res Care Srvs-Lift As Tr StffS/S B▼
Findings
Based on interview and record review, the residence failed to provide residents with lift assistance when determinedappropriate instead of relying on emergency medical responders, affecting two of six (#2 and #3). Findings include:1. Residence policyThe Lift Assistance policy, dated 2/2022, read in part:"To maintain quality care standards for our residents who experience a fall, the community will follow this policy and the Falls Checklist to determine when it is appropriate for an associate to assist a resident who has fallen and when local emergency medical responders should be contacted. If the resident is free of pain, able to move without pain or difficulty, and/or there is no change from baseline, the resident ' s mental status is unchanged from baseline, and there is no or minor bleeding or requests to be assisted to a standing position, the associate will physically perform the lift assistance using techniques provided in associate training and monitor the resident."The Health and Wellness Director (HWD)/nurse/Executive Director (ED)/or designee should call 911 if the resident:a. complains of pain, before or after attempting lift assist,b. experiences difficulty moving,c. has loss of consciousness,d. has a physical or mental decline from baseline,e. experiences a head injury,f. is bleeding,g. requests 911 be called or refuses lift assist,h. is found unresponsive outdoors in extreme weather."2. Record reviewResident #2 was admitted to the residence on 2/7/24, diagnoses included hypertension. A progress note, dated 11/6/25, revealed Resident #2 had a witnessed fall in his apartment and the residence contacted non-emergency services for lift assist. 3. InterviewOn 12/22/25 at 10:30 a.m., Resident #3 stated that on Saturday, 12/20/25, he fell in his bathroom while transitioning from the toilet to his wheelchair. Resident #3 stated the caregiver "couldn't help me get up," and paramedics were subsequently called to perform a lift assist. The resident noted he was not injured and stated that the paramedics "complained they see me too much" for these types of calls. On 12/22/25 at 11:20 a.m., Resident #2 said he fell in the bathroom while a caregiver was present (date unknown by resident). Resident #2 said he misjudged the distance of his wheelchair and ended up on the floor. Resident #2 said emergency medical response services (EMS) came out and "helped him up off the floor". Resident #2 said he was not injured or in pain when EMS was called. On 12/22/25 at 4:31 p.m., Staff #1 stated she called emergency medical services anytime a "bigger resident fell" after she injured herself lifting a resident in the past. Staff #1 said she called 911 for non-emergency lift assistance whether the residents were injured or not. On 12/22/25 at 5:48 p.m., the administrator reviewed the progress note for Resident #2, dated 11/6/25, and stated EMS should not have been called. The administrator stated that it was not appropriate to contact emergency responders for a lift assistance and that emergency services should not be called unless there is an injury, such as "hitting the head, bleeding, unconsciousness, pain, or a change in baseline." 4. Similar deficient practice occurred with Resident #3.
Plan of correction · submitted by the facility
As of 1/8/2026 all associates have been retrained on our lift assist policy by our HWD. The training has been provided to all associates on how to properly lift a resident off of the ground if there is no medical reason to contact EMS or the resident does not request it. HWD and HWC will review each post fall report if 911 was called to ensure it followed community policy and address any violations of this policy. We have included it in our new hire orientation to ensure associates are aware of policy and have the training to feel confident and comfortable assisting residents who have fallen. This policy will be reviewed with new associates during the 30-60-90 day conversation with ED/supervisor and reviewed at all staff meetings on a quarterly basis for the next year. Will be included in QMPTo monitor for on-going compliance the Health and Wellness Director and or designee will review each post fall report if 911 was called to determine if community policy was followed and address any violations of this policy for 90 days. Will be included in QMP
1/15/2025Revisit: Licensure and Licensure Complaint (Combined) · ID Y14U12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/15/25 for all previous deficiencies cited on 9/11/24. 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.
9/10/2024Licensure and Licensure Complaint (Combined) · ID Y14U113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO33648 was completed on 9/11/24. Deficiencies were cited
Plan of correction
The state did not require a plan of correction for this citation.
1204Res Care Srvs-Res Engmnt Outside OppS/S B▼
Findings
Based on observation and interview, the residence failed to ensure a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 25 current residents. Findings include:During the environmental tour on 9/10/24 at 9:37 a.m., the secured environment reception area, that all secure environment residents had access to, had carpets, chairs, and loveseats with stains. The carpet and love seat had several brown stains with a diameter of a half inch. The chair closest to the entrance door had a brown stain with pebble-like pieces of desiccated mass. On 9/10/24 at approximately 10:00 a.m., Staff #4 acknowledged the stains on the carpet, loveseat, and chair were unsanitary. On 9/10/24 at approximately 10:30 a.m., the regional health and wellness director and the administrator acknowledged the stains on the carpet, loveseat and chair were unsanitary.
Plan of correction
The state did not require a plan of correction for this citation.
1596Med/Med Adm-Med Prep/Hnd Tr ICS/S B▼
Findings
Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting four of four sample residents (#1-#3,#9) whose medications were administered. Findings include:On 9/10/24 at 7:37 a.m., Staff #4 washed her hands, walked over to the medication room, touched multiple keys on the key rings, unlocked the medication room, touched the door knob, unlocked the medication cart, touched the laptop, medication pack, and the medication cup. Staff #4 touched the door knob, closed the medication room door, set the key rings on the dining table and proceeded to administered the medications to Resident #2. Staff #4 repeated the previously described medication administration for Resident #1, #3 and #9. On 9/10/24 at approximately 11:30 a.m., the regional health and wellness director (RHWD) said she expected staff to wash or sanitize their hands before each medication administration. The RHWD stated she expected staff to sanitize their hands before touching the medication pack and administering medications.
Plan of correction
The state did not require a plan of correction for this citation.
3142Sec Env-Phy Dsgn/Env/Sfty Crit-InS/S B▼
Findings
Based on observation and interview, the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting 25 current residents. Findings include:On 9/10/24 at approximately 9:00 a.m., Resident #9 and three residents tried to access the outdoor secured environment but the door was double locked. The outdoor secured area was inaccessible to residents who tried to access the secured area without the assistance of staff. On 9/10/24 at approximately 9:15 a.m., Staff #3 stated the residence locked the main entrance door to the secured outdoor area because Resident #9 tried to elope. Staff #3 was unaware the residence was required to provide a year-round outdoor area that residents in the secure environment could independently access. On 9/10/24 at approximately 2:00 p.m., the regional health and wellness director and the administrator were unaware of the regulation that residence was required to provide a year-round outdoor area that residents in the secure environment could independently access.
Plan of correction
The state did not require a plan of correction for this citation.
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 7.13.8 Before the next regularly scheduled meeting, assisted living residence staff shall respond in writing to any suggestions or issues raised at the prior meeting.
Plan of correction
The state did not require a plan of correction for this citation.
5/29/2024Licensure Complaint · ID SMCX11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An involuntary discharge appeal survey, prompted by #CO34606, was completed on 5/29/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9/13/2023Revisit: Licensure Complaint · ID 6P5Q13No deficiencies▼
0000Initial commentsSurveyor note▼
Findings
A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 5/9/23. 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.
9/13/2023Revisit: CHOW and Licensure (Re-licensure) and Licensure Complaint (Combined) · ID Q0FX14No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 5/9/23. 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.
9/13/2023Revisit: Licensure Complaint · ID SUK812No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 5/9/23. 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.
5/9/2023Revisit: Licensure Complaint · ID 6P5Q121 deficiency▼
0000Initial commentsSurveyor note▼
Findings
A licensure revisit was completed on 5/9/23 for all previous deficiencies cited on 4/18/22. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼
Findings
Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration affecting two of five sample residents (#23, #24). This deficiency was cited previously during a state licensure complaint completed on 4/18/22. Although the facility corrected the deficiency, based on the findings listed below, the residence has not maintained compliance with this regulation requirement. Findings include:1. Residence Policies The residence's Medications and Treatments - Availability policy read in part, It is (the residence's) policy that all currently ordered medications will be available to the resident. The community is responsible for obtaining newly ordered medication or refills for medications and treatment orders, unless otherwise agreed upon with the resident, family or legally responsible party in accordance with the Pharmacy Services Agreement Addendum to the Residency Agreement. In the event the resident or legally responsible party have signed the Pharmacy Services Agreement stating that they will have the responsibility for obtaining new ordered medication or re-ordering medications, but the medications are not delivered within two days prior to the depletion of the medication stock, the community will order or re-order the medications with the 'preferred provider' to insure no disruption takes place. 2. Resident #23 was admitted to the residence on 1/19/23 with multiple diagnoses including Alzhiemer's disease, atrial fibrillation and hypertension. a. DepakoteA written practitioner's order dated 1/30/23 directed the residence to administer Depakote 125 mg, twice daily. However the April 2023 medication administration record (MAR) revealed the medication was not administered on 4/24, 4/25, and 4/25/23 because the medication was not available. b. Potassium ChlorideA written practitioner's order dated 3/9/23 directed the residence to administer potassium chloride 10 meq, twice daily. However, the April 2023 MAR revealed the medication was not administered on the morning of 4/10 because the medication was not available. 3. Resident #24 was admitted to the residence on 9/22/20 with multiple diagnoses including carpal tunnel syndrome. a. WixelaA written practitioner's order dated 4/11/23 directed the residence to administer Wixela 100-50 mcg, one puff, twice daily. However, the April 2023 MAR revealed the medication was not administered on 4/26 and 4/27/23 because the medication was not available. b. Tylenol A written practitioner's order dated 1/10/23 directed the residence to administer Tylenol 325 mg, twice daily. However the April 2023 MAR revealed the medication was not administered on 4/27/23 because the medication was not available. On 5/9/23 at approximately 3:00 p.m., the regional registered nurse confirmed the medications for the above residents were out of stock.
Plan of correction · submitted by the facility
All sample residents medications have been available since 5/10/23. An audit of all current residents’ medications was completed on 6/19/23 and all medications are available as of 6/21/23. Re-education with QMAPS on how and when to order medications to be completed and documented by 7/10/2023. To monitor for on-going compliance, the Health and Wellness Director or designee will perform an audit of medication carts, to check that all medications that are running low have been re-ordered weekly for 3 months. The plan of correction will be fully integrated into our QMP program.
5/9/2023Revisit: CHOW and Licensure (Re-licensure) and Licensure Complaint (Combined) · ID Q0FX131 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 5/9/23 for all previous deficiencies cited on 4/18/22. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼
Findings
Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration affecting two of five sample residents (#23, #24). This deficiency was cited previously during a state licensure complaint completed on 4/18/22. Although the facility corrected the deficiency, based on the findings listed below, the residence has not maintained compliance with this regulation requirement. Findings include:1. Residence Policies The residence's Medications and Treatments - Availability policy read in part, It is (the residence's) policy that all currently ordered medications will be available to the resident. The community is responsible for obtaining newly ordered medication or refills for medications and treatment orders, unless otherwise agreed upon with the resident, family or legally responsible party in accordance with the Pharmacy Services Agreement Addendum to the Residency Agreement. In the event the resident or legally responsible party have signed the Pharmacy Services Agreement stating that they will have the responsibility for obtaining new ordered medication or re-ordering medications, but the medications are not delivered within two days prior to the depletion of the medication stock, the community will order or re-order the medications with the 'preferred provider' to insure no disruption takes place. 2. Resident #23 was admitted to the residence on 1/19/23 with multiple diagnoses including Alzhiemer's disease, atrial fibrillation and hypertension. a. DepakoteA written practitioner's order dated 1/30/23 directed the residence to administer Depakote 125 mg, twice daily. However the April 2023 medication administration record (MAR) revealed the medication was not administered on 4/24, 4/25, and 4/25/23 because the medication was not available. b. Potassium ChlorideA written practitioner's order dated 3/9/23 directed the residence to administer potassium chloride 10 meq, twice daily. However, the April 2023 MAR revealed the medication was not administered on the morning of 4/10 because the medication was not available. 3. Resident #24 was admitted to the residence on 9/22/20 with multiple diagnoses including carpal tunnel syndrome. a. WixelaA written practitioner's order dated 4/11/23 directed the residence to administer Wixela 100-50 mcg, one puff, twice daily. However, the April 2023 MAR revealed the medication was not administered on 4/26 and 4/27/23 because the medication was not available. b. Tylenol A written practitioner's order dated 1/10/23 directed the residence to administer Tylenol 325 mg, twice daily. However the April 2023 MAR revealed the medication was not administered on 4/27/23 because the medication was not available. On 5/9/23 at approximately 3:00 p.m., the regional registered nurse confirmed the medications for the above residents were out of stock.
Plan of correction
The state did not require a plan of correction for this citation.
5/9/2023Licensure Complaint · ID SUK8111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO31118, #CO31705, #CO31908 was completed on 5/9/23. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼
Findings
Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration affecting two of five sample residents (#23, #24). Findings include:1. Residence Policies The residence's Medications and Treatments - Availability policy read in part, It is (the residence's) policy that all currently ordered medications will be available to the resident. The community is responsible for obtaining newly ordered medication or refills for medications and treatment orders, unless otherwise agreed upon with the resident, family or legally responsible party in accordance with the Pharmacy Services Agreement Addendum to the Residency Agreement. In the event the resident or legally responsible party have signed the Pharmacy Services Agreement stating that they will have the responsibility for obtaining new ordered medication or re-ordering medications, but the medications are not delivered within two days prior to the depletion of the medication stock, the community will order or re-order the medications with the 'preferred provider' to insure no disruption takes place. 2. Resident #23 was admitted to the residence on 1/19/23 with multiple diagnoses including Alzhiemer's disease, atrial fibrillation and hypertension. a. DepakoteA written practitioner's order dated 1/30/23 directed the residence to administer Depakote 125 mg, twice daily. However the April 2023 medication administration record (MAR) revealed the medication was not administered on 4/24, 4/25, and 4/25/23 because the medication was not available. b. Potassium ChlorideA written practitioner's order dated 3/9/23 directed the residence to administer potassium chloride 10 meq, twice daily. However, the April 2023 MAR revealed the medication was not administered on the morning of 4/10 because the medication was not available. 3. Resident #24 was admitted to the residence on 9/22/20 with multiple diagnoses including carpal tunnel syndrome. a. WixelaA written practitioner's order dated 4/11/23 directed the residence to administer Wixela 100-50 mcg, one puff, twice daily. However, the April 2023 MAR revealed the medication was not administered on 4/26 and 4/27/23 because the medication was not available. b. Tylenol A written practitioner's order dated 1/10/23 directed the residence to administer Tylenol 325 mg, twice daily. However the April 2023 MAR revealed the medication was not administered on 4/27/23 because the medication was not available. On 5/9/23 at approximately 3:00 p.m., the regional registered nurse confirmed the medications for the above residents were out of stock.
Plan of correction · submitted by the facility
All sample residents medications have been available since 5/10/23. An audit of all current residents’ medications was completed on 6/19/23 and all medications are available as of 6/21/23. Re-education with QMAPS on how and when to order medications to be completed and documented by 7/10/2023. To monitor for on-going compliance, the Health and Wellness Director or designee will perform an audit of medication carts, to check that all medications that are running low have been re-ordered weekly for 3 months. The plan of correction will be fully integrated into our QMP program.

Reportable Occurrences

21 records
6/9/2026Brain Injury · ID 262303F3008Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/9/26, 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 prevent a future recurrence. The healthcare entity reported a brain injury of a client. Client (A) had an unwitnessed fall. The staff suggested to the responsible person to send the client to the hospital by ambulance. The responsible party declined and transported Client (A) to the hospital. During the course of the investigation the healthcare entity monitored the clients progress in the hospital. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include: encouraging the client to turn on the overhead light when walking at night and checking for any tripping hazards will continue by the staff. Additionally, staff were trained on timely reporting. 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 not submitted within the required timeframe.
Publication
Sent to facility 6/22/2026 · released to the public 6/29/2026.
6/2/2026Missing Person · ID 262303F3007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/2/26, 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 prevent a future recurrence. The healthcare entity reported a missing client. Client (A) was an at risk adult missing for approximately 15 minutes. During the course of the investigation, the healthcare entity notified the family and physician. Staff completed a head count to ensure all clients were accounted for. Due to their cognitive ability, Client (A) resided in a secured unit. The client was observed by staff outside of the facility. To prevent a recurrence, the healthcare entity provided monitoring of the back door to the courtyard and supervision of the clients. A service order to have the gate magnet repaired or replaced was submitted. Documented daily checks of exit doors and gate as well as weekly alarm checks for the gate were completed. 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’s occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/23/2026 · released to the public 6/30/2026.
4/29/2026Diverted Drugs · ID 262303F3006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/29/26, 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 prevent a future recurrence. The healthcare entity reported diverted drugs. Narcotics were removed from the secured medication cart and placed in a location that was not as secure, by Staff #1. It was identified before the medications were to be destroyed 58 pills were missing. During the course of the investigation the healthcare entity attempted to locate the missing medication. The medications were last counted in January 2026, and a number of staff members had access to the area. The remaining medications that were also removed from the medication cart were placed back until they were destroyed and counted every shift. The medications were never found, and no assailant was identified, however the medication had been diverted. Staff #1 violated facility policy regarding medication destruction and their employment was terminated. 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 6/23/2026 · released to the public 6/30/2026.
4/13/2026Sexual Abuse · ID 262303F3005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/13/26, 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 sexual abuse of a client. Client (A) reported to their medical provider that staff (1) got close to their face and touched an intimate body part when providing care. Client (A) reported feeling fearful and sexually harassed. During the course of the investigation, the healthcare entity suspended staff (1), ensured the client was safe, contacted police, and conducted interviews. No visible injuries or complaints of pain for client (A) were indicated when assessed. Staff (1) did not recall the allegation nor any intention if it did occur. Law enforcement investigated the incident and determined that it was unintentional. Other clients denied being fearful and staff (1) ever touching them inappropriately. The facility implemented a same sex staff member to provide care to client (A) and provided additional training to staff (1) on body space awareness. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/12/2026 · released to the public 6/19/2026.
3/24/2026Brain Injury · ID 262303F3004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/24/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. Client (A) leaned over too far when attempted to pick up something off the floor and fell hitting their head. 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 placed on hospice care instead of having surgical intervention. The client’s care plan was updated to reflect comfort measures until the client subsequently passed away on 3/26/26. 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 4/27/2026 · released to the public 5/4/2026.
2/25/2026Physical Abuse · ID 262303F3003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: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) hit client (A) in the face, then punched them on the arm. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, reviewed records, and conducted interviews. Client (B) stated that client (A) deserved it, but was unable to provide further details. Due to cognitive impairment, client (A) was unable to provide detailed information about the event. No visible injuries for both clients were indicated when assessed. The facility implemented engagement for client (A) to assist with disruptive behaviors and moved client (B) to a quieter area during meals to help prevent overstimulation. 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 4/24/2026 · released to the public 5/1/2026.
12/29/2025Physical Abuse · ID 252303F3011Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed a verbal altercation between two clients culminating in one client being pushed by the other, and one client attempting to hit the other. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, assessed the clients, and started increased safety monitoring. Neither client sustained visible injuries. The facility implemented adjustments to staff tasks and schedules to increase supervision for both clients and educated staff. The facility determined physical contact occurred but did not result in any injury. 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 4/10/2026 · released to the public 4/17/2026.
12/3/2025Physical Abuse · ID 252303F3010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/3/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed Client (B) strike Client (A) on the side of Client (A)’s face, causing pain. During the course of the investigation, the healthcare entity separated and assessed the clients, notified law enforcement, and conducted interviews. Neither client was able to accurately speak to the incident due to diminished cognitive functioning. Per the facility’s report, Client (B) was in pain and experiencing discomfort, potentially leading to increased behaviors. Medications were adjusted. Staff received education on monitoring nonverbal signs to reduce the risk of recurrence. 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 3/12/2026 · released to the public 3/19/2026.
11/18/2025Neglect · ID 252303F3009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/18/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. The facility received an allegation that Client (A) was left on the ground overnight after falling, and staff did not respond to the Client (A)’s call light. During the course of the investigation, the healthcare entity assessed the client, notified law enforcement, conducted interviews, and evaluated equipment functionality. The client was transferred to a higher level of care, diagnosed with an underlying infection, and was admitted with an altered mental status. Documentation review and interviews indicated the client was checked by staff multiple times throughout the night and was found in bed. The facility believed the client was found shortly after falling the following morning. Per the facility’s investigation, Client (A) did press their call light, but the device malfunctioned and did not alert staff. The client was issued a new call light, and the facility implemented weekly checks of all call lights to ensure optimal functionality. Upon the client’s return, therapy services were initiated, and the facility increased staff assistance as needed. 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 2/24/2026 · released to the public 3/3/2026.
7/24/2025Misappropriation of Property · ID 252303F3005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/22/25, 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 client alleged $75.00 had been stolen from them and the last time they saw it was a few weeks prior. During the course of the investigation the healthcare entity conducted a search, and interviews. The client received services from staff and third party agency staff. Only Staff #1 collaborated the client had money in the amount of $73.00 but did not know where the client put hid their money. The client was encouraged to lock their apartment instead of leaving it unlocked. The police were notified and no assailant was identified. The event was inconclusive and 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 9/23/2025 · released to the public 9/30/2025.
4/28/2025Physical Abuse · ID 252303F3003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/28/25, 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. Staff witnessed Client (B) yell at and hit Client (A) with their cane in the shin during a shared activity. Client (A) had discoloration to their shin that later faded. Neither client could recall the incident due to cognitive impairment. Staff will provide oversight of the clients and ensure activity supplies are set out for the clients. A walker has been ordered for Client (B) to use instead of a cane. 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 9/17/2025 · released to the public 9/24/2025.
11/12/2024Brain Injury · ID 242303F3003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/12/24, 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, 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 2/11/2025 · released to the public 2/18/2025.
4/13/2024Physical Abuse · ID 242303F3001Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 4/13/24 resident (A) was hit by resident (B) in the face until she fell on the floor and could get away. This occurred in resident (B)’s room as seen on video footage. Resident (B) was sent to the hospital for his behaviors. Resident (A) was assessed and no visible injuries seen. Both residents have cognitive impairment, and resident (A) was unable to express pain. Staff notified the police. The facility investigation concluded resident (B) became physically abusive after finding resident (A) in his room. The incident was substantiated. To help prevent a recurrence, resident (B) returned from the hospital after being treated for potential causes of his behaviors and was provided with a one-to-one staff oversight for safety. Resident (B)’s room was also moved across the facility. Staff will monitor and redirect resident (A) when she is in other residents’ rooms. 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 12/4/2024 · released to the public 12/11/2024.
12/30/2023Physical Abuse · ID 232303F3009Reported on time: Yes▼
Occurrence summary
Summary of Findings:On 12/30/23, management became aware of an alleged physical abuse incident involving resident (B) and staff (1). Video of the interaction was captured during review of a fall detection camera footage. Reportedly, staff (1) physically pushed resident (B) to the ground and then held the resident’s hands from behind. Resident (B) complained of soreness but no visible injuries were observed. Resident (B) had wandered into another resident’s apartment. The incident happened as staff (1) attempted to remove her from the apartment. The police arrested staff (1). Door codes were changed immediately after staff (1) was escorted off the property. Resident (B) recalled being pushed but could not report any additional details due to her cognitive impairment. No additional residents reported having any concerns of staff mistreatment. Staff (1)’s employment was terminated. Resident (B)’s plan of care was updated to help redirect her wandering habits. Staff received re-training on working with residents with dementia, challenging behaviors and to continue monitoring and report any instances of alleged abuse or neglect. The facility indicated a police investigation was ongoing with former staff (1) and this alleged incident. 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. 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. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency.
Publication
Sent to facility 11/18/2024 · released to the public 11/25/2024.
9/14/2023Physical Abuse · ID 232303F3008Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 9/18/23, the facility was informed caregiver (1) had restrained a male resident (A) in his 70s with a bear hug from behind stating this was done for safety reasons. However, it was not an approved intervention technique. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Caregiver (1) was placed on suspension pending the investigation. Resident (A) had dementia and did not recall the event. No visual injuries were observed; however, they were sent to the emergency room for an evaluation. Caregiver (1) acknowledged their act of restraining resident (A) and then proceeding to lower resident (A) to the floor. Afterwards, they assisted him up to sit on a bench but did not take their hand off resident (A)’s leg until resident (A) was calm. Resident (A) returned from the emergency room without any new orders. The facility investigation concluded caregiver (1) did not follow policies by restraining the resident in this manner. Caregiver (1)’s employment was terminated. To help prevent a recurrence, resident (A) was assessed for another placement as a higher level of care and staff received additional training. 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 8/29/2024 · released to the public 9/5/2024.
7/26/2023Missing Person · ID 232303F3007Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 7/26/23, a resident (A), in her 80s, eloped from a secured unit without staff awareness. A citizen found the resident out in the community and solicited the help of a Park Ranger. The Park Ranger brought resident (A) back to the facility. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family/guardian and physician. Resident (A) was returned to the facility without any injuries. She had a diagnosis of dementia and was newly admitted to the facility. Management reviewed the details and discovered the resident had punched numbers on the code pad that allowed the door to open without an alarm sounding. She left and walked up the street. Staff members were assisting other residents at the time. The facility investigation concluded resident (A) successfully exited the secured unit and left the facility. To help prevent a recurrence, the door codes were immediately changed. Resident (A) remained on frequent safety checks and staff was directed to encourage resident (A) to participate in group activities during the evening hours. 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 5/28/2024 · released to the public 6/4/2024.
7/13/2023Diverted Drugs · ID 232303F3006Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 7/13/23 during a medication count, a qualified medication administration personnel (QMAP) (1) identified six prefilled liquid Morphine syringes were missing. The medications had been secured inside a locked box, inside a locked refrigerator that was inside a locked medication room. Staff had access to the medications. The medications had been prescribed to a resident, who had recently passed away. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police. The facility indicated resident (A) did not miss any doses of medication as she had passed away prior to the medication being discovered missing. All staff, who had access to the medication, indicated they had no knowledge of where the medication went or when it went missing. The facility investigation concluded the allegation of a drug diversion was substantiated; however, an assailant could not be identified. All QMAPs received re-training on the expectations to secure medications and perform narcotic counts at shift change. 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 reported to be accurate and complete at this time. 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 State Agency.
Publication
Sent to facility 4/22/2024 · released to the public 4/22/2024.
7/5/2023Brain Injury · ID 232303F3005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 7/5/23. a staff member found a resident (A) in his 90s on the floor with a bump to their head. Emergency services was called and resident (A) was transported to the hospital. He was diagnosed with a brain bleed and urinary tract infection. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family/guardian and physician. There was a reported functional decline the first 24 hours, but then his status improved. He was transferred to a rehabilitation facility for further strengthening. When reviewing the event of the fall, the facility concluded the resident got up to use the bathroom and did not call for assistance. He suffered an accidental fall and suffered a brain bleed. If he returned, staff planned to reassess his mobility and safety 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 reported to be accurate and complete at this time. 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 State Agency.
Publication
Sent to facility 4/12/2024 · released to the public 4/12/2024.
4/21/2023Missing Person · ID 232303F3004Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 4/21/23 the door alarm went off and staff member (1) checked the doors. A male resident (A) in his 80s was not seen by staff member (1) outside of the facility. A passerby found resident (A) walking on the sidewalk unsteadily with a cane and suffered a fall. Resident (A) resided in a locked memory care unit. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, and families/guardians. Emergency medical services were called and resident (A) was transported to the hospital. The family took resident (A) home after being discharged from the hospital. Staff member (1) stated they did not continue to look outside or do a head count after the door alarm sounded. The facility investigation concluded staff member (1) did not follow procedures fully when the door alarm sounded for the memory care unit as resident (A) pressed the door bar and went outside unattended. To help prevent a recurrence, staff member (1) and other staff were provided with retraining and elopement drills were performed. Staff will do periodic head counts of residents to ensure an accurate person count. 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 9/26/2023 · released to the public 9/26/2023.
4/2/2023Brain Injury · ID 232303F3003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 4/2/23, the facility reported staff observed a resident in her 90’s on the floor with noted injury to her forehead and above both eyes. Staff provided first aid treatment while awaiting for the ambulance to arrive. She was transported to the hospital for further evaluation and treatment. Diagnostic test results showed the findings of a small brain bleed. AGENCY/FACILITY ACTION: The facility conducted an internal investigation and notified the physician and family/guardian. Once she was stabilized, she returned to the facility. Staff reassessed her safety needs, and a referral for therapy services was made. There were no reported changes to her functional status. It was also noted that the resident had tested positive for COVID-19 and her oxygen needs had increased. When reviewing the fall, the facility reported she was independent with ambulation. Staff saw the resident leave the dining room approximately 45 minutes prior to the fall. From the findings, the facility was unable to determine what caused the fall. The resident was reminded to use her call pendant if she was feeling unsteady and to use her walker for all transfers and ambulation for fall 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 facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 1/4/2024 · released to the public 1/5/2024.
2/26/2023Physical Abuse · ID 232303F3001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 2/27/23 as witnessed by qualified medication administration person (QMAP) (1) a male resident (C) in his 80s was talking with another male resident (A) in his 80s when resident (C) grabbed resident (A) by the shoulders and threw him to the ground. Resident (C) then walked over to QMAP (1) and told them he was the government and they needed to tell him everything before proceeding to grab QMAP (1), push him/her into the medication cart and before falling to the ground. This is when a female resident (B) walked over and clapped in resident (C)’s face calling him a “bad boy”. Resident (C) then grabbed resident (B) by the shoulders and threw her to the ground. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. Resident (C) was separated from other residents and the family was called immediately to provide 1:1 safety oversight. Resident (B) complained of pain in her shoulder and was sent to the hospital and her left shoulder was broken and casted. Resident (A) complained of pain and was sent to the hospital and was treated for a broken rib. Both victims/residents returned to the facility. Neither could recall the details of the event because of cognitive impairment. The facility investigation concluded resident (C) was a danger to himself and others and was issued an immediate discharge. To help prevent a recurrence resident (C) was discharged from the facility the same evening this took place. No further incidents. Residents (A) and (B) were monitored for after care. 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 8/21/2023.