CLERMONT PARK ASSISTED LIVING

SUMMARY OF FINDINGS:On 5/26/26, 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 misappropriation of client property. Client (A)'s representative alleged staff had stolen two of client (A)'s rings and reported it to law enforcement. The rings were last observed on client (A) on 5/26/26. During the course of the investigation, the healthcare entity searched for the items and conducted interviews. Staff reported awareness of the rings and hearing an altercation between client (A) and their representative, with client (A) requesting the representative to return the rings to them. Staff observed client (A) wearing their rings before the altercation with their representative and then no rings after. The facility increased safety checks on client (A) and advised clients not to bring valuables into the facility. Since the incident, client (A) moved out of the facility. The facility was unable to identify any alleged assailants; the item is still missing. 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.

Sent to facility 7/23/2026 · released to the public 7/30/2026.

SUMMARY OF FINDINGS:On 5/26/26, 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 (A)'s representative became aggressive and had an inappropriate emotional outburst towards client (A). Staff observed client (A)'s representative wrench two rings off client (A)'s hand, then left the facility. Client (A) sustained an injury. During the course of the investigation, the healthcare entity separated client (A), contacted police, conducted interviews, and reviewed records. Staff assessed and treated client (A)'s injury and provided emotional support. Client (A) reported being mortified by their representative's behavior and requested not to see them. Client (A)'s representative acknowledged their behavior was inappropriate. The facility and law enforcement instructed client (A)'s representative not to have contact with client (A) nor behave in a threatening manner in the facility. The facility discussed a negotiated risk agreement and implemented supervised visits with client (A)'s representative. The facility increased supervision of client (A) and encouraged them to participate in a day program. The event was substantiated. Client (A) was identified in another occurrence case. Please refer to case ID: 26230463005 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 7/24/2026 · released to the public 7/31/2026.

SUMMARY OF FINDINGS:On 4/23/26, 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 verbal abuse of a client. A visitor witnessed staff (1) talking loudly, aggressively, and very close to client (A)'s face. Client (A) stated they didn't want that person near them repeatedly. During the course of the investigation, the healthcare entity suspended staff (1), ensured client (A) felt safe, contacted police, and conducted interviews. Staff assessed client (A) with no changes in behaviors or injuries indicated. Due to cognitive impairment, client (A) was unable to provide detailed information about the incident, nor describe which person they didn't want near them. Staff (1) reported talking loudly to client (A) due to a hearing impairment, as well as working on improving their demeanor. Other clients and staff reported concerns about staff (1)'s demeanor. No fear, threats, or injuries reported. The facility instructed staff (1) not to provide care to client (A) and to complete educational training on communication, dementia, courtesy, conflict management, and culture. 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.

Sent to facility 6/17/2026 · released to the public 6/24/2026.

SUMMARY OF FINDINGS:On 4/9/26, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. A visitor witnessed client (B) become aggressive by putting their hands around client (A)'s head and screaming at them. During the course of the investigation, the healthcare entity separated both clients, contacted police, conducted interviews, and reviewed records. Client (A) denied being assessed for injury by staff. Client (A) shrugged when asked questions about the incident, stated they could not hear client (B) due to a hearing impairment, and denied their head being grabbed. Client (B) demonstrated how they grabbed client (A )'s head and stated it was not harmful, but agreed to be more patient. Client (B)'s medical provider reviewed medications for mood stabilization. The facility implemented increased safety checks of both clients and asked client (B) to be more empathetic when feeling impatient. 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.

Sent to facility 5/28/2026 · released to the public 6/4/2026.

SUMMARY OF FINDINGS:On 12/17/25, 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. Reportedly, client (B) wandered into client (A)’s room and when asked to leave hit client (A) in the arm. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and assessed the clients. Client (A) did not have visible injuries and reported no pain. Client (B) could not recall the event. Staff witnessed client (B) in the other client’s room but did not witness physical contact between them. The facility updated care plans to reflect keeping client (A)’s door closed, keeping the clients separated in common areas, increased private caregiver supervision for client (B), and medication adjustments for client (B). The healthcare entity was unable to confirm physical abuse occurred based on inconclusive evidence. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 3/26/2026 · released to the public 4/2/2026.

SUMMARY OF FINDINGS:On 9/12/25, 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) hit client (A) in the face and put their hands around their neck. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and assessed the clients. Client (B) did not sustain any visible injuries. Due to cognitive impairment neither client could provide details about the event. The facility provided direct supervision when client (A) is in common areas, and will continue to re-direct client (B). 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.

Sent to facility 12/18/2025 · released to the public 12/25/2025.

SUMMARY OF FINDINGS:On 4/29/25, 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 prevent a future recurrence. The healthcare entity reported the death of a client. The client was not on hospice services and their death was not expected. Client (A) sustained an unwitnessed fall in the facility and was sent to the hospital for an evaluation and treatment. During the course of the investigation the healthcare entity assessed the client, conducted interviews and reviewed documentation. Client (A) declined while at the hospital and passed away about a week later. Staff followed fall protocols. Staff were educated on early hospice evaluations as there may have been an opportunity to evaluate Client (A) sooner. 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.

Sent to facility 9/23/2025 · released to the public 9/30/2025.

SUMMARY OF FINDINGS:On 9/16/24, 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. Staff witnessed Client (B) grab and pull Client (A) towards them before punching them in the shoulder. Client (A) was able to get away after screaming. Client (A) sustained a bruise to their forearm. Staff assisted with keeping the clients separated. Client (B)’s medications were reviewed to assist with stabilizing their mood. Client (B) did not recall due to cognitive impairment, however Client (A) recalled the event. 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.

Sent to facility 5/28/2025 · released to the public 6/4/2025.

DESCRIPTION OF OCCURRENCE:On 4/21/24, resident (A) was sitting in a car outside the facility when s/he observed an incident involving resident (B) and an unknown individual. Resident (A) saw the unknown person walking alongside resident (B), grabbing her arm three times, and appearing to yell or scold her. Although resident (A) could not hear the conversation, she reported the incident to an administrative staff member on 4/25/24 and described the alleged assailant. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and informed the police, the family/guardian, the ombudsman, and Adult Protective Services. It was determined that the description of the alleged assailant matched that of resident (B)’s family member, who had been with her at the time. The facility requested that the family member refrain from visiting during the investigation. Two licensed staff members assessed resident (B0 and found no physical injuries or behavioral changes. During interviews, resident (B) did not recall the incident and reported that the visit had been pleasant. S/he described the family member as their only support, their best support, and someone who was good to them. Resident (B), who has Alzheimer's disease with significant dementia, had become upset and was shouting when informed by the family member that their external caregiver had resigned. The family member had tried to calm resident (B) and assist them into the facility. The family member submitted a written response to the incident, stating that while s/he might have raised her voice, s/he did not strike resident (B). The witness also provided a written report that corroborated their verbal account to the administrative staff member. Review of resident (B)’s care chart showed no changes in behavior or evidence of physical abuse following the incident. The facility concluded that the incident did not constitute abuse, as the witness saw one point of time in a period of dementia-related behavior. The investigation also revealed that resident (B) had been distressed during the investigation due to the family member's absence. To prevent future occurrences, the facility plans to work with resident (B)’s providers on strategies to manage their anxiety and agitation and will meet with the family member to discuss approaches for avoiding or ending direct contact with resident (B) when their behaviors were escalated. 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 acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 11/20/2024 · released to the public 11/26/2024.

DESCRIPTION OF OCCURRENCE: On 2/12/23 the concierge reported via email that two women were seen in the parking lot in a car “screaming and hitting” by a visitor. One woman who left the car and slammed the door was identified as the daughter of a female resident (A) in her 80s who then entered the facility. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, Adult Protective Services, families/guardians and ombudsman. On 2/13/23 after the email was read, the facility contacted the daughter who reported that her mother (resident A) did not want her to leave and held onto her arm and would not let go so she had to pry her hand off of her. The daughter stated she did leave the day in question after notifying staff resident (A) would not be taken to church. Resident (A) was assessed and had bruises to her arm and did not remember the details by the afternoon due to cognitive impairment. The visitor who originally witnessed the altercation and reported it to the concierge was left multiple message via phone without any return call. The daughter was informed not to visit with resident (A) at this time, but had already had a visit today on 2/13/23 but acknowledged the request and until resident (A) has her medical appointment on 2/16/23. Staff indicated they heard yelling during the visit. Resident (A) reported they did not fight. The facility investigation concluded the bruising may have been from the daughter's tight grasp and was a plausible reason, however at the time of the final report could not rule out what the witness reported initially "screaming and hitting". To help prevent a recurrence the daughter was asked to bring along a third party for the appointment on 2/16/23 to buffer any situations as resident (A) had a history of combative behavior. Staff will monitor interactions between resident (A) and the daughter and redirect as needed if resident (A) became agitated. The daughter was asked to notify staff for assistance with resident (A)’s behaviors. 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.

Sent to facility 9/6/2023 · released to the public 9/6/2023.