MONARCH MANOR

SUMMARY OF FINDINGS:On 7/19/24 around 5:30 a.m., a resident (A) alerted staff about resident (B) being found outside unresponsive. Staff called 911 and resuscitative efforts were unsuccessful. The death was unexpected to an apparent healthy young person. Earlier that morning, video footage showed the resident had been pacing outside until he stopped to sit on a facility bench. It appeared he fell asleep on the bench around 3:30 a.m. and remained outside on the bench until staff discovered him without vital signs. On 10/28/24, the facility provided a follow up regarding the medical examiner findings: Multiple medications (prescribed and non-prescribed) with combined toxic effects were discovered in resident (A)’s system that subsequently contributed to his passing. The facility was unable to determine when and how the resident accessed these medications for self-ingestion. 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.

Sent to facility 2/6/2025 · released to the public 2/13/2025.

DESCRIPTION OF OCCURRENCE: On 5/21/23, a staff member went to a resident’s room to administer his bedtime medications. There was no response and staff found the door partially blocked. Additional force was used to open the door and the staff member found the resident on the floor with apparent self-inflicted injuries. He was unresponsive with no pulse or breaths. Staff called 911 services for support. The resident, who was in his 50s, was pronounced deceased. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, case managers, and ombudsman. Furniture items had been placed in front of the door to partially block entry, and the room was in disarray. One staff member indicated they saw him about three hours earlier, and he appeared normal mentally and was unharmed. Some staff indicated resident (A) was not his usual happy playful self the past few days, but they had observed this mood several times in the past so it was not alarming to the staff. Other residents heard furniture moving but no screaming or yelling. The findings indicated the resident passed away from injuries suffered from an apparent suicide. Staff reported he had made no comments about ending his life. The facility took the opportunity to review current policies and house rules about adding information on securing sharp objects. 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 2/22/2024 · released to the public 2/22/2024.