Colorado CDPHE · Facility Report

FRONTIER VALLEY INDEPENDENT AND ASSISTED LIVING

📍 11265 E MISSISSIPPI AVE, AURORA, CO 80012

ID 2304B1Assisted Living Residence/Alternative Care Facility (Medicaid)Active
17
Inspections
4
Deficiencies
0
Actual Harm or Above
30
Occurrences
April 14, 2026
Last Inspection
S/S B/C Minimal potential

The most recent inspection of FRONTIER VALLEY INDEPENDENT AND ASSISTED LIVING on record is dated April 14, 2026. Across 17 published inspections, state surveyors cited 4 deficiencies, none of which reached the actual-harm level.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status
Active
Facility Type
Assisted Living Residence/Alternative Care Facility (Medicaid)
Administrator
Passanante, Stepheni
Owner
WINDSOR LAKE HEALTHCARE INC
Phone
(303) 341-1412
Payor Source
Medicaid, Private Pay
City
AURORA
ZIP
80012

Inspections & Citations

17 inspections · 4 deficiencies
4/14/2026Licensure (Re-licensure) · ID RE9O11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 4/14/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/2/2026Revisit: Licensure Complaint · ID O2YK12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint revisit survey was completed on 4/2/26 for all previous deficiencies cited on 9/16/25. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9/16/2025Licensure Complaint · ID C7WU11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO40864, was completed on 9/16/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9/16/2025Licensure Complaint · ID O2YK111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO40861 and #CO40863, was completed on 9/16/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
2810Env Pest Cntrl P/PS/S C▼
Findings
Based on observation, record review, and interview, the residence failed to have an effective pest control policy toensure eradication of pests, including bed bugs, affecting 111 residents. Specifically, the residence had a history of bed bug infestations. During the on-site survey, the residence failed tohave an effective pest control policy, and as a result, the bed bug infestation continued. The residence reportedthey were treating some residents' rooms; however, they were not treating all of the residents' rooms or thecommon areas, like the bathrooms and living rooms. During the onsite visit, active bed bugs were crawling on andunder the TV stand, on a chair, the living room wall and floor, bathroom wall, and between his bed mattress andbox springs. Resident # 1 reported he couldn't sleep in his bed and was sleeping on a chair in his living room. Theresidence had treated Resident #1's chair, and Resident #1 was wet from the treatment as he continued sleepingin it. Resident #1 reported anxiety and "stinging" pain from multiple bed bug bites, was shaky, and scared. Findings include:1. Records ReviewThe residence's July 2023 Pest Control Policy read in part, "It is the policy of this facilityto provide an environment free of pests. The residence's contracted pest control billing documents dated 8/8/25 read in part that bed bugs were observedin Resident #1's room, and it was recommended that Resident #1's room be "taken out of service". The residence's contracted pest control billing documents, dated 8/1 and 8/8/25, read in part, bed bugs inResident #1's room. Additionally, the residence provided pest control billing documents dated 6/19/24 through 8/13/25. Residence room tracking lists dated July, August and September 2025, read in part that the residence scheduled atreatment for Resident #1's room on 7/18, 8/1, 8/23, 9/5, 9/8 and 9/9/25. Also, the room tracking lists indicatedthat there were an additional 24 residents' rooms the residence was inspecting for suspected bed bugs. 2. ObservationsOn 9/16/25 at 11:11 a.m., a white powder was on the floor in both the living room and bedroom of Resident #1'sbedroom. Active bed bugs were crawling on and under the TV stand, on a chair, the living room wall and floor,bathroom wall, and between his bed mattress and boxsprings. Also, several brown spots, consistent in shape andsize with bed bugs, were smeared on the bed sheet. Additionally, multiple bed bug skeletons were foundthroughout the living room, bedroom, and bathroom. Resident #1 showed me multiple healing bed bug bites onhis chest and arms. On 09/16/25 at 1:09 p.m., several brown spots, consistent in shape and size with bed bugs, were smeared on the Resident #4's bed sheet. 3. InterviewsOn 9/16/25 at, Resident #1 stated he was wet from sitting in his chair, which the residence had treated for bedbugs on 9/15/25. He stated he was still itching from all the recent bed bugs on his arms and chest. Also, he statedhe could "feel them crawling all over, and it is really scary". He stated he was forced to sleep in his living roomchair due to the bed bugs in his bed. Additionally, he stated he was "shaky sometimes" and didn't know what toDo. He stated the residence hadn't treated the room or his personal belongings. On 9/16/25 at 11:47 a.m., the administrator stated the residence heat-treated, bagged the resident's personalItems, But not the residents' rooms. Additionally, she stated that the residence had vacated rooms 219 and 221and moved the residents to other rooms due to bed bugs. On 9/16/25 at 1:09 p.m., Resident #4 stated he had recently killed several bed bugs on his bed after they crawledinto his room through the electrical outlet in his living room. On 9/16/25 at approximately 3:20 p.m., the administrator stated the residence was conducting their owntreatments. She stated this was due to her request that the residence's contracted pest control company assign anew technician, as she was unsatisfied with the current technician.
Plan of correction · submitted by the facility
The facility immediately addressed the issues identified by discussing with residents and or families were called and discussed for the 3 rooms identified as having pests. All residents identified in the 2567,except resident #2 who has moved, including residents #1, 3, and 5 were interviewed on 9/17/25 to ensure they felt comfortable and were no longer anxious or worried or feeling stinging. Resident #1 agreed to move to another room on 9/16/25 during survey. On 9/17/25 the other 2 residents moved rooms after permission from resident and/ or family. Ecolab Pest control being on site 9/16/25 as scheduled. Ecolab treated the 3 rooms identified prior to survey on 9/17/25. Maintenance Department doing a 100% house audit of all rooms in Lane building on 9/18/25, Kingston building 9/19/25 and spraying all Assisted Living rooms on those dates. All Assisted Living residents invited to an early Resident council meeting. The residents were met with in a resident council on 9/30/25 and reviewed the recent survey results, Bed bug procedure, Bed bug identification and provided a one on one meeting if they had concerns. The maintenance staff was verbally educated on Bed bug process on 9/17/25. On 9/25/25 at All Staff meeting the staff were re-educated on Bed bug process including the facility policy and procedure. All staff not in attendance, on vacation or PRN are educated before next worked shift. Pest control returned and rechecked and resprayed identified rooms with pest activity rooms 34, 135, and 121 on 9/17/25, 9/19/25, and 9/30/25 . Room 218 was excluded as no pest activity when checked on 9/17/25. As of 10/1/25 on in house audits found zero pest activity for identified rooms. 10/20/2025 those rooms remain unoccupied. Maintenance team will continue to inspect and spray every Tuesday until rooms are deemed 100% clear of any activity. New vendor for Pest Control put in place. Each occupied room is audited for evidence of pest infestation weekly with linen changes and maintenance team check all rooms and logged by the re-educated caregivers. Additionally, the facility administrator or director of maintenance (DOM)or designee will audit 9 rooms per week for evidence of pest activity and provide 1:1 education to caregiver staff as needed. Audits will be logged and completed for 3 months. The Endura Prime Life Safety and Maintenance resource will compete 9 monthly random room audits x 3 months to confirm continued improvement in effective control and eradication of insects, rodents, and other pests. Any evidence of pest activity in any of these audits, will be reported to pest control and addressed upon identification. Monitoring logs will be reviewed monthly in QMP for trends or opportunities for improvement. The facility is reporting substantial compliance as of DATE 9-25-25
5/14/2025Licensure and Licensure Complaint (Combined) · ID LQ3F11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO40016, #CO40036, #CO40066, #CO40070, and #CO40071, was completed on 5/14/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/14/2025Revisit: Licensure Complaint · ID LYMM12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 5/14/25 for the previous deficiency cited on 2/11/25. The facility is incompliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
5/14/2025Licensure Complaint · ID VQJ311No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO39803, #CO40014, #CO40037, and #CO40068, was completed on 5/14/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/11/2025Licensure Complaint · ID M1SO11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO39062 and #CO38195, was completed on 2/11/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/11/2025Licensure Complaint · ID LYMM111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO39061, #CO38194, and #CO36776 was completed on 2/11/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
2112Fd/Din Srvs-M/Dr/Sn M Incld/SubS/S B▼
Findings
Based on observation and interview, the residence failed to ensure that meals were appealing and served at a temperature that was appetizing, affecting 103 current residents. Findings include:1. ObservationsResident council notes, dated 8/24/24, read in part: " The council raises concern that meal passing doesn't always go smoothly and food is still cold. The former administrator responds that she will follow up with dietary and wellness managers."A sample of breakfast and lunch was evaluated. At breakfast, the eggs were found to be inedible due to unappetizing and bland taste. Multiple residents stated that they used the microwave located in the dining room to warm up food because the residence served food that was not hot enough. 2. InterviewsOn 2/11/25 at 8:00 a.m., Resident #6 stated, "The food is just okay. The temperature is usually not warm, and most of the time, I have to use the microwave to heat it to an acceptable temperature."On 2/11/25 at 8:30 a.m, Resident #4 stated, "Making my own frozen meals are better than what is coming out of the kitchen because the food is cold and unappealing. It ' s all pre-made unhealthy stuff."On 2/11/25 at approximately 3:00 p.m., the administrator stated that no complaints have been made regarding the food and that she ate lunch from the residence dining room almost every day. She stated that she liked the food.
Plan of correction · submitted by the facility
1. Resident Specific: Residents #4 and #6 were directly affected. A grievance completed for these residents, and grievance process followed. 2. Identification of Others: Facility interviewed additional residents, and none had concerns of food appearance or temperature. No other residents were noted to be affected. All residents had the potential to be affected. 3. Systematic Changes:(1) Dietary staff will check temperatures of all foods prior to meal service to ensure appropriate hot and cold holding temperatures are met. Temperatures will be recorded.(2) Dietary will serve hot meals on heated plates (using a plate warmer) to maintain temperatures. Room trays will be covered to maintain heat.(3) Any food found to be below the required temperature will be properly reheated prior to service.(4) All dietary staff will be trained on food holding temperatures and plate presentation. The kitchen team will be trained on best practices for food presentation and plating. All in-services to be completed by 3/1/25.4. Monitoring: DM or designee will utilize an audit tool to monitor all issues identified, beginning 2/28/25. Auditing will be completed 3 times each week for 12 weeks. The DM or designee will report audit results to QMP for three months to identify any opportunities for improvement. 5. Date of compliance: 03/1/25
12/19/2023General Inspection · ID DNFW11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey was completed on 12/19/23. No deficiencies were cited. A change of ownership occurred on 10/17/23.
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 7.7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items: (C) Orientation and training, including first aid and CPR certification, if applicable. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.
Plan of correction
The state did not require a plan of correction for this citation.
12/19/2023State Certification (Re-certification) · ID F8PM11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey was completed on 12/19/23. No deficiencies were cited.
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 10 CCR 2505-10 8.400.8.495.6(H)(2) Alternative Care Facility Providers shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations. Regulations governing assisted living residences, part 14.29, requires that all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.
Plan of correction
The state did not require a plan of correction for this citation.
9/19/2023Revisit: Licensure Complaint · ID QHCF12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 3/29/23. 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.
9/19/2023Revisit: Licensure Complaint · ID V5VD12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 3/29/23. 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.
6/8/2023Licensure Complaint · ID BZ8511No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO31798, was completed on 6/8/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
6/8/2023State Certification Complaint · ID IUSM11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO31805, was completed on 6/8/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/29/2023Licensure Complaint · ID QHCF111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO30092 and #CO28632, was completed on 3/29/23. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1310Res Rghts Rghts/Rspn-Priv/ConfidentialS/S B▼
Findings
Based on interview and record review, the residence failed to observe a resident's right to privacy affecting five of seven sample residents. (#1, #4-#7)Findings include: 1. Residence policyThe residence's undated Resident Rights policy, read in part: "As a resident of our community, you have certain rights under state law. The rights are as follows: The right to privacy ..."2. Interviews On 3/29/23 at approximately 8:06 a.m., Resident #5 stated the evening and overnight staff often entered his room without knocking on the door. He confirmed he felt it violated his right to privacy. On 3/29/23 at approximately 8:06 a.m., Resident #6 stated the evening and overnight staff often entered her room without knocking on the door. She confirmed he felt it violated her right to privacy. On 3/29/23 at approximately 8:06 a.m., Resident #7 stated the evening and overnight staff often entered his room without knocking on the door. He confirmed he felt it violated his right to privacy. On 3/29/23 at 8:28 a.m., Resident #1 stated staff knocked on his door and entered without waiting for his permission. He stated it violated his right to privacy. On 3/29/23 at 8:50 a.m., Staff #2 stated staff were required to knock on resident doors prior to entering. She stated staff were only allowed to enter a resident's room without permission in an emergency. On 3/29/23 at 9:00 a.m., Resident #4 stated staff will sometimes knock but just barged in. She stated sometimes staff knocked, said hello, but then came in before she could acknowledge them. Resident #4 stated she did not like when staff barged into her room. On 3/29/23 at 1:15 p.m., Staff #1 stated staff were required to knock on resident doors prior to entering. She stated staff were only allowed to enter a resident's room without permission in an emergency. On 3/29/23 at 1:18 p.m., the corporate healthcare director stated staff were required to knock and wait for the resident to answer and to check after a few knocks to make sure they are okay. She stated it was not acceptable for staff to just knock and walk in without an answer. acknowledged it was an invasion of privacy if a staff member walked into a resident's room without permission. On 3/29/23 at 1:30 p.m., the administrator stated staff were to knock on the door, wait a minute, announce themselves, and then walk in. She stated it was not okay to walk in or walk in right after knocking. The administrator stated the only time it would be okay for staff to walk in was if they heard yelling. She acknowledged it would be a violation to privacy and irritating because it was the resident's home. Additionally, she stated she frequently educated staff on resident's right to privacy because it was a frequent complaint form residents.
Plan of correction · submitted by the facility
Resident Specific: Resident #5 is no longer at the facility. Resident #6, #7, #1, #2 #4 still reside at the facility. A grievance was filled out on behalf of these residents and the facility will follow the grievance process for resolution. Identification of Others: All residents have the potential to be affected. Systems and Measures: The Clinical Resource gave a written in-service to all staff about privacy, knocking on doors, and when it’s okay to enter a resident’s room by 6/16/21. Monitoring: The Administrator or designee will monitor 5 staff to resident encounters per week to ensure privacy is being upheld. The administrator or designee will also interview 3 residents a week to ensure they feel their privacy is being respected. This auditing will occurred weekly x 3 months. Issues and successes will be discussed during the QMP meeting. Actual compliance date 6/16/2023
3/29/2023State Certification Complaint · ID V5VD111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO28633 and #CO30093 was completed on 3/29/23. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0414Acf-Part Rts Infrm/Post/IncldS/S B▼
Findings
Based on interview and record review, the facility (residence) failed to ensure participants (residents) had the right to privacy, including in their living/sleeping units, affecting five of seven sample participants (#1, #4-#7). Findings include: 1. Residence policyThe residence's undated Resident Rights policy, read in part: "As a resident of our community, you have certain rights under state law. The rights are as follows: The right to privacy ..."2. Interviews On 3/29/23 at approximately 8:06 a.m., Resident #5 stated the evening and overnight staff often entered his room without knocking on the door. He confirmed he felt it violated his right to privacy. On 3/29/23 at approximately 8:06 a.m., Resident #6 stated the evening and overnight staff often entered her room without knocking on the door. She confirmed he felt it violated her right to privacy. On 3/29/23 at approximately 8:06 a.m., Resident #7 stated the evening and overnight staff often entered his room without knocking on the door. He confirmed he felt it violated his right to privacy. On 3/29/23 at 8:28 a.m., Resident #1 stated staff knocked on his door and entered without waiting for his permission. He stated it violated his right to privacy. On 3/29/23 at 8:50 a.m., Staff #2 stated staff were required to knock on resident doors prior to entering. She stated staff were only allowed to enter a resident's room without permission in an emergency. On 3/29/23 at 9:00 a.m., Resident #4 stated staff will sometimes knock but just barged in. She stated sometimes staff knocked, said hello, but then came in before she could acknowledge them. Resident #4 stated she did not like when staff barged into her room. On 3/29/23 at 1:15 p.m., Staff #1 stated staff were required to knock on resident doors prior to entering. She stated staff were only allowed to enter a resident's room without permission in an emergency. On 3/29/23 at 1:18 p.m., the corporate healthcare director stated staff were required to knock and wait for the resident to answer and to check after a few knocks to make sure they are okay. She stated it was not acceptable for staff to just knock and walk in without an answer. acknowledged it was an invasion of privacy if a staff member walked into a resident's room without permission. On 3/29/23 at 1:30 p.m., the administrator stated staff were to knock on the door, wait a minute, announce themselves, and then walk in. She stated it was not okay to walk in or walk in right after knocking. The administrator stated the only time it would be okay for staff to walk in was if they heard yelling. She acknowledged it would be a violation to privacy and irritating because it was the resident's home. Additionally, she stated she frequently educated staff on resident's right to privacy because it was a frequent complaint form residents.
Plan of correction · submitted by the facility
Resident Specific: Resident #5 is no longer at the facility. Resident #6, #7, #1, #2 #4 still reside at the facility. A grievance was filled out on behalf of these residents and the facility will follow the grievance process for resolution. Identification of Others: All residents have the potential to be affected. Systems and Measures: The Clinical Resource gave a written in-service to all staff about privacy, knocking on doors, and when it’s okay to enter a resident’s room by 6/16/21. Monitoring: The Administrator or designee will monitor 5 staff to resident encounters per week to ensure privacy is being upheld. The administrator or designee will also interview 3 residents a week to ensure they feel their privacy is being respected. This auditing will occurred weekly x 3 months. Issues and successes will be discussed during the QMP meeting. Actual compliance date 6/16/2023

Reportable Occurrences

30 records
8/22/2025Physical Abuse · ID 252304B1007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/22/25, 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 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) stated they were hit with a towel in the face by Client (B) but was not injured. Staff witnessed the event as well. Client (B) was immediately placed on increased supervision due to the need for higher level of care; they already had a discharge date of 8/29/25. Client (B) was discharged from the facility the evening of 8/22/25. The incident did occur, however, there was no injury to Client (A). 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 1/18/2026 · released to the public 1/26/2026.
6/27/2025Physical Abuse · ID 252304B1006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/27/25, 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) was safe before the police were notified. Client (A) alleged they were hit in the chest with an oxygen tank requesting to go to the hospital. Client (A) was assessed in the hospital without any injuries, their story changed multiple times, and they were sent back to the facility. Staff #1 and #2 stated they assisted Client (A) at the same time with their oxygen and denied the allegations. Client (A) later stated they felt safe and declined a room change or increased safety checks by staff. Management will assist with Client (A) finding alternative housing, care will be provided in pairs, and the clients care plan was updated to indicate a history of false allegations. 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 11/16/2025 · released to the public 11/26/2025.
3/11/2025Physical Abuse · ID 252304B1003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client .Reportedly, client (A) pushed client (B) causing them to lose balance and fall. During the course of the investigation, the healthcare entity separated the clients, notified law enforcement, conducted interviews, and reviewed medical documentation. As client (B) complained of back pain, they were transported to the hospital for evaluation, and returned to the facility with no new diagnosis. Both clients indicated a misunderstanding occurred between them about coffee and expressed no intent to harm each other. The facility implemented increased safety monitoring. 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 8/19/2025 · released to the public 8/26/2025.
2/20/2025Sexual Abuse · ID 252304B1002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/20/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported sexual abuse of a client. During the course of the investigation the healthcare entity ensured the client was safe. Client (C) sent an email to management alleging Client (B) tried to rape Client (A) by drinking together. The police were notified. Both Client (A) and (B) denied the allegations of sexual contact as well as staff. Client (A) and (B) did share a drink months ago. Temporary monitoring was implemented for the clients to monitor for any changes. Staff were educated on abuse and reporting. 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 8/21/2025 · released to the public 8/29/2025.
11/30/2024Equipment Malfunction · ID 242304B1017Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/30/24, 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 equipment malfunction. During the course of the investigation, the healthcare entity assessed the client and ensured their safety. Reportedly, the client sustained an unwitnessed fall and reported they tried using their call pendant and it was not working. The client did not sustain any injuries. The pendant call system was inspected by maintenance and the pendant call system was reset and tested to confirm it was working properly. Additional client interviews were conducted and all said their pendants were working appropriately. The healthcare entity implemented weekly pendant system checks. 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 6/24/2025 · released to the public 7/1/2025.
11/28/2024Verbal Abuse · ID 242304B1016Reported 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 verbal abuse of a client. During the course of the investigation the healthcare entity ensured the client felt safe. Client (A) initially alleged Staff #1 threatened them with discharging from the facility and then state on another date while at the hospital for an unrelated concern, that Staff #1 grabbed their arm. The investigation revealed. Staff #1 denied the allegations and stated they did educate the client on consequences of not following their dietary recommendations. No other clients that were interviewed had any concerns with Staff #1. Client (A) is hard of hearing and acknowledge later Staff #1 was speaking loudly to get their attention. Staff #1 has been reassigned and will not be working with Client (A) to prevent further allegations. 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 7/16/2025 · released to the public 7/23/2025.
9/29/2024Equipment Malfunction · ID 242304B1014Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/2/24, 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 equipment malfunction. The client chose to ignore signs regarding the elevator not functioning property and got on and began jumping up and down before the elevator jerked. The client was sent to the hospital due to complaints of pain, however the hospital sent them back without any findings. During the course of the investigation the healthcare entity ensured the elevator was removed from service on 9/29/24 and serviced. The facility conducted interviews and reviewed documentation. The elevator was back in service on 9/30/24 after two inspections. Staff were educated to be on both floors when equipment failure is present to ensure no clients can access the equipment. Signs were made available at all times to prevent a delay in shutting down the elevator immediately. 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 5/28/2025 · released to the public 6/4/2025.
9/8/2024Physical Abuse · ID 242304B1013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/8/24, 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 Client (A) and the alleged assailant (staff member 1) were separated before the police were notified. Client (A) sent an email alleging Staff member (1) bumped their walker and injured their knee. Client (A) refused to be fully assessed but showed a fading bruise to their knee. Client (A) refused safety measures and speaking to the police after 4:00 p.m. No others stated any concerns with staff member (1) and no one witnessed the alleged event. Staff member (1) was moved to another facility as Client (A) would benefit from a higher level of care due to paranoia and had not been accepted at the time of this report. 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 5/13/2025 · released to the public 5/20/2025.
8/25/2024Physical Abuse · ID 242304B1012Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/25/24, 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. Video footage revealed Client (A) was the aggressor and not the visitor from another part of the campus. Both were in an altercation and stated they were friends and were just playing. Neither had any injuries. Both the client and the visitor have been given warning letters for their actions. The police indicated no crime had occurred. 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 5/6/2025 · released to the public 5/13/2025.
8/20/2024Misappropriation of Property · ID 242304B1011Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/21/24, 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 misappropriation of client property. During the course of the investigation the healthcare entity reviewed security footage, conducted a search, interviewed others who were in the immediate area, and the client was educated not to leave valuables unattended. 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 3/3/2025 · released to the public 3/10/2025.
6/25/2024Brain Injury · ID 242304B1009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/25/24, 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 will be updated to reflect safety interventions when they return to the facility after receiving rehabilitation therapy. 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 2/4/2025 · released to the public 2/11/2025.
6/12/2024Physical Abuse · ID 242304B1010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/1/24, 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 victim was safe and the police were notified. The client alleged during their hospital stay around 6/12/24, the hospital told them must have been assaulted but no documentation was provided. The client alleged they had a bite mark, bruising to her stomach and sore ribs. The client stated they did not recall any assailant, they did not make a report with the hospital and did not want to speak to the police. After reviewing the documentation at the hospital, the client (A) reported bumping their own stomach on a counter and also got injections to her stomach to explain the bruising. Client (A) refused safety checks, however does have some metal health concerns that were addressed with medication and a therapist. The facility believed no abuse occurred, and the police did not find a report of assault from the hospital. The client has reported installing a camera in their room and was educated to report any concerns. 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 3/30/2025 · released to the public 4/6/2025.
6/5/2024Misappropriation of Property · ID 242304B1008Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 6/6/24 the facility was made aware Resident (A)’s money was gone from their account in the amount of $765.00 when he went to pay his rent. Staff notified the police. The facility investigation concluded, a person from social media had convinced Resident (A) to buy gift cards, send photos of his Social Security card and a photo of his identification card. No staff were involved. Staff assisted Resident (A) with blocking the social media account and deactivated his account. To help prevent a recurrence, Resident (A) was encouraged to attend the class on scamming. His debit card was cancelled. Resident (A) was also encouraged to do direct deposit for his rent to be paid and the facility would assist with that. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 1/16/2025 · released to the public 1/23/2025.
4/19/2024Neglect · ID 242304B1006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/9/2024, 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 after the family complained about concerns with weight loss and a delay in palliative care because the facility would not release medical records. During the course of the investigation, the healthcare entity provided medical records to the family after receiving the proper paperwork from the newly appointed medical durable power of attorney (MDPOA). The client was admitted to the hospital a month prior due to spending more time in his/her room and not eating despite being offered 3 meals and snacks per day. The client’s physician was aware of the client’s behavior and diagnosed him/her with unknown weight loss. 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 2/26/2025 · released to the public 3/7/2025.
3/14/2024Verbal Abuse · ID 242304B1004Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 3/5/24 resident (A) and his son wanted to know about the results of an assault that was alleged to have taken place. Resident (A) had only called and reported the incident to his son. Resident (A) stated a female resident allegedly hit him before he fell possibly on 2/29/24. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Management attempted to locate a female resident who was involved with resident (A). Resident (B) was identified as the possible assailant, however, she mentioned having a discussion with resident (A) about his dog barking and resident (A) was very verbally aggressive, so she walked away. Resident (A) had old scabs on his hands stating it is from when he fell down. The facility investigation was inconclusive and abuse could not be substantiated. Both residents gave a different account of what happened and the one witnessed did not recall anything physical between resident (A) and (B). Resident (A) did not report the incident timely. To help prevent a recurrence, resident (A) was educated to report any concerns immediately and staff were made aware of the allegation. Resident (A)’s dog will be walked more frequently to help avoid excessively barking. Resident (B) was educated on verbal abuse and reporting any concerns to staff. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 12/9/2024 · released to the public 12/16/2024.
2/21/2024Brain Injury · ID 242304B1003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 2/23/24, the facility reported that while out on pass on 2/21/24, they received a notice that their resident had been admitted to the hospital due to low oxygen. Reportedly, the resident told staff at the hospital he had experienced a fall prior to going there. The resident received a CT scan of the head and was diagnosed with a brain bleed. AGENCY/FACILITY ACTION: The facility conducted an internal investigation and notified the physician and family/guardian. The record review showed the resident was admitted to the hospital for treatment and was subsequently discharged back to this living facility several days later. He was alert, oriented and independent upon readmission. The record review showed the resident had not been taking his self-administered medications properly which may have contributed to his reported fall. The physician reviewed the resident’s medications upon his readmission and he agreed to allow staff to administer them to him going forward. The facility concluded that the resident did experience a fall days prior to taking himself to the hospital where it was determined he had a brain injury. At the closing of this report, the facility provided additional follow up. They said the resident did have a fall in the facility on 2/16/24 with a laceration to his head; however, the resident declined to be sent out to the hospital at that time. While in the hospital the resident told hospital staff he had fallen in the facility on 2/19/24; however, this was incorrect. The facility reported that between 2/16/24 and 2/19/24 the resident did not present with any issues indicating he had a brain injury. 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 11/25/2024 · released to the public 12/2/2024.
1/5/2024Missing Person · ID 242304B1002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/5/23 a male resident (A) in his 60s was not in the facility after dinner. He had left the facility without notifying any staff and left his bike, backpack and phone behind. A search was conducted on foot and by vehicle and residents (A)’s whereabouts were unknown. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, and physician. Resident (A) is alert and oriented and was allowed to go into the community. At midnight the facility reported resident (A) missing to the police and continued to check local hospitals, jails and outside agencies. The next morning by 8:00 a.m. resident still had not returned and multiple phone calls were made again to locate him. The prior facility was called and indicated resident (A) had a history of leaving the facility for days at a time around the beginning of the month. On 1/6/23 about 1:00 p.m. resident (A) returned to the facility and stated he was in the hospital but declined to provide any further information. Resident (A) is new to the facility, and has a history of leaving without notice. The facility was unaware of this behavior prior to admission. The facility investigation concluded resident (A) left on his own without signing out or notifying staff. To help prevent a recurrence, staff and management have been made aware of resident (A)’s behaviors and habits. Staff will inquire if resident (A) intends to leave the facility. Resident (A) was educated again on the sign out process and reporting his whereabouts to not cause concern in the future. 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 11/14/2024 · released to the public 11/21/2024.
12/31/2023Misappropriation of Property · ID 242304B1001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/1/24, a family member of resident (A) a female in her 70s, reported the resident’s wallet was missing and either misplaced or stolen on 12/31/23. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Resident (A) had a history of misplacing items, but it could not be located. The facility was unable to determine what happened to the wallet. Management noted this was a second report of misappropriation, suggesting a potential pattern. To help prevent a recurrence, the facility notified all residents to secure their valuables and keep their doors locked when not in their apartment. 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 5/31/2024 · released to the public 6/7/2024.
12/17/2023Misappropriation of Property · ID 232304B1020Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/3/23 a female resident (A) in her 70s reported that when she moved to another room, a $100.00 bill went missing and her Christmas wreath. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police. Resident (A) stated on 12/17/23 she put her bank bag containing her money in her pajama bin. She did not count the money prior but stated it was paperclipped together and when she checked, the paperclip was gone. Management conducted a search, and the money or wreath were not found. Staff reported resident (A) had an abundance of items and needed to change her room because of saving things. The family had unloaded a storage unit into resident (A)’s room which was now over packed. The manager who assisted resident (A) to move, had no complaints on their personnel record and worked for the last 10 years. The facility investigation concluded, resident (A) had so much stuff in her room, the facility was unable to determine if the items were misplaced or missing. No assailant was identified. To help prevent a recurrence, residents have been reminded not to store large amounts of cash in their rooms. Resident (A) was also reminded to lock her door, and will be downsizing due to concerns with the amount of personal possessions that are in her room. 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.
12/6/2023Sexual Abuse · ID 232304B1018Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 12/7/23, a female resident (A) in her 60s alleged a male resident (B) in his 60s made unwanted sexual advances towards her. She reported it has happened a few times in the past that resident (B) touched her breast and made comments to her. Resident (A) stated she was not fearful, but did not want to have a friendship with resident (B) anymore. She reported resident (B) would go to her apartment to hangout as friends but on a few occasions he was intoxicated and made unwanted gestures and advances towards her. FACILITY/AGENCY ACTION: The facility conducted an internal investigation and notified the police. Resident (A) stated they also went out to smoke together and will not be doing that any longer. Resident (B) was informed to not have any contact with resident (A) as he lived in the independent section of the facility. Resident (B) denied the allegations but stated he may have been drinking and understood the seriousness of the accusation and would never mean anyone any harm. No other incidents or patterns of behaviors were identified for resident (B). The facility investigation concluded resident (A) was possibly touched on her breast by resident (B) without giving consent. To help prevent a recurrence, resident (B) was counseled and given a written notice to have no contact with any residents in the assisted living side of the facility. Staff monitored resident (A) to ensure resident (B) was not visiting other residents. Resident (A) was offered a room change but declined and educated to keep her door locked. Additionally, residents will smoke in different areas of the facility. 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.
11/30/2023Physical Abuse · ID 232304B1019Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 12/11/23, the administrator received an email from an outside agency social worker. The email asked for documentation regarding an incident where it was alleged Staff #1 had squeezed the hand of Resident A, in her 60’s. The facility was not aware of this allegation and talked to Resident A. Resident A stated she had written a grievance pertaining to the allegation that occurred on 11/30/23, but had not turned it in yet. Resident A then provided the grievance form, but it did not include that her hand had been squeezed. Resident A amended it to include her hand had been squeezed by Staff #1 and it caused her pain. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police and physician. Staff #1 was not working in the facility during the investigation. Staff #1 stated Resident A often slept through medication passes and needed to be awakened to receive medications. Resident A refused to drink the facility water and preferred to take her pills with juice that she provided. Staff #1 recalled an incident where Resident A was awakened to take medications and to prepare her juice. Resident A came to receive her medications when she began to yell, and spit some of the pills to the floor. She then directed Staff #1 to pick them up. Resident (A) started to leave the area but still had a cup of remaining medications in her possession. Due to Resident A's history of pocketing medications, Staff #1 said they did attempt to retrieve the cup but denied squeezing the resident’s hand. Resident A then started screaming loudly, which was not attributed to any physical contact. Other staff collaborated Staff #1's account of the interaction and said resident A had a behavioral episode. Other residents had no concerns regarding medication administration or the need for QMAPS to observe the ingestion of medications. From the investigation, the facility was unable to substantiate the allegation of Staff #1 intentionally squeezing Resident A's hand during the interaction. To help prevent a recurrence, Staff #1 will not work on the unit where Resident A resides. The facility continued to address Resident A’s concerns and grievances. 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 1/22/2024 · released to the public 1/29/2024.
10/13/2023Misappropriation of Property · ID 232304B1017Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 10/13/23, a female resident (A) called the police regarding an allegation of being scammed and that items were missing from her apartment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, Veterans administration intensive mental health and Adult Protective Services. The police came out to the facility and were able to confirm resident (A) had a history of reporting missing items, professional theft and participating in gift card scams willingly. Per the facility, the police saw no concerns and left the facility. Afterwards, resident (A) reported a television was missing from her apartment. Another resident did have multiple televisions in his room and when questioned, he indicated the television was his although resident (A) identified one of the televisions as possibly hers. Documentation revealed resident (A) had a history of making false accusations regarding misappropriation. No staff indicated seeing anyone enter the resident (A)’s apartment. There were no findings related to other missing items or being a victim of scam event. The facility investigation concluded it was unclear if resident (A)’s television was stolen or sold to the other resident. To help prevent a recurrence, resident (A) did not have a phone so she could not participate in scams. Resident (A) had a new lock placed on her door. Resident (A) will continue to be encouraged to not sell or borrow items or money. 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 9/27/2024 · released to the public 10/4/2024.
10/10/2023Physical Abuse · ID 232304B1016Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 10/10/23, a female resident (B) in her 70s and a male resident (A) in his 70s got into a disagreement. Resident (B) began to throw items at resident (A) and hit him with the objects. Resident (A)’s necklace was broken and he suffered two scratches on his cheek during the altercation. The incident was witnessed by staff members (1) and (2) in the dining room. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, ombudsman and physician. Both residents were separated. The police arrived. Resident (B) did not want to press charges. Staff stated resident (B) was displeased with seeing resident (A) participating in a group activity interacting with another female resident and became angry, and threw items at him, poured water on him and hit him before staff could intervene. Resident (A) stated he had no idea why resident (B) would act that way over knitting but was not concerned. Resident (B) stated she did not touch resident (A) and she was not certain she should be sorry for pouring water on him. The facility investigation concluded the incident was witnessed by multiple staff members, which resulted in a minor injury to resident (A). However, resident (A) continues to want to have a relationship with resident (B) and states it was a misunderstanding. The other female resident stated the accusations were foolish. To help prevent a recurrence, both residents were placed on safety checks. Both residents declined the offer to move rooms. Staff were educated to notify management of any further concerns. Resident (B) was provided with a written warning regarding her actions and rule violations. 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 9/26/2024 · released to the public 10/3/2024.
9/13/2023Physical Abuse · ID 232304B1013Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 9/13/23, female resident (A) in her 60s was in the community on pass drinking with another resident (B) and family member. Resident (B)'s family member (family 1) alleged asked resident (A) for a dollar and when she said no, family (1) allegedly pushed resident (A) to the ground where she scraped her elbow. The manager of the facility was driving by the area and saw resident (A) on the ground and called 911. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, Adult Protective services and the physician. Resident (A) was transported to the hospital for an evaluation and no other injuries were seen. Resident (A) declined to press charges. Both residents were encouraged not to interact with the visitor. The other resident who witnessed the incident gave the same information as resident (A). Family (1) returned the next day and the police were called and he was arrested. The facility investigation concluded the allegation resident (A) being pushed to the ground by family (1) while out in the community. To help prevent a recurrence, resident (A) filed a restraining order against the family (1). The facility will be locking the doors at night. Both residents were encouraged to have safe practices while drinking and/or to stop drinking. All staff were notified to call 911 if the assailant was seen on campus. 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 8/26/2024 · released to the public 9/2/2024.
8/27/2023Physical Abuse · ID 232304B1012Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 8/27/23, two male residents had a disagreement in a hallway that led to a physical altercation. Resident (B) in his 60s shoved resident (A) in his 60s in the chest. Residents were separated by off duty staff who witnessed the altercation. Resident (A) had a red mark to his chest and reported his shoulder hurt and wanted to go to the hospital. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Staff stated the two were discussing a pair of shoes resident (B) was not wearing when resident (A) was shoved. Resident (A) returned from the hospital with a different account of what was witnessed. Resident (A) stated he was punched in the month and lost 10 teeth, but hospital assessments did not support this allegation. Resident (A)’s teeth were intact. He had chronic shoulder pain and no acute findings were noted. The hospital recommended Tylenol for pain. Staff reported the two residents have been getting on each others' nerves at times that require redirection. Staff was also monitoring resident (B)'s behaviors that might be upsetting to peers. The facility investigation concluded resident (B) did shove resident (A) during an argument. To help prevent a recurrence, staff sought another placement for resident (B) and until his discharge, staff continued to monitor and redirect him away from others. Both residents were instructed to have no interaction with each other. 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 7/22/2024 · released to the public 7/29/2024.
7/2/2023Equipment Malfunction · ID 232304B1010Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 7/2/23, a shower bench broke while a resident was independently showering. The incident caused the resident to slide on the floor, and he called for help. When staff arrived, he denied hitting his head and had no other complaints. He declined a hospital assessment. Staff assisted him to get up from the floor. The resident said he was leaning back on the shower chair in an unsafe manner and that was when it broke. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the physician. The broken shower bench was removed and discarded. Maintenance conducted a full house audit on all shower chairs to ensure they were all in good working condition. Management obtained a new shower chair for the resident with proper parameters for their weight. The patient was asked not to lean back when using the shower chair and that staff was available to assist when needed. 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 1/9/2024 · released to the public 1/16/2024.
6/27/2023Missing Person · ID 232304B1008Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 6/27/23 around 6:30 p.m., staff was unable to locate a resident in the facility and he had not signed out per facility expectations. When asking the wife about his whereabouts, she indicated he was at the store and had not returned. Staff had not seen the resident since lunch time. Attempts to contact the resident by phone were unsuccessful. The facility initiated a campus and community search and then called police to issue a BOLO alert. The resident was in his 60s and was not identified to be at-risk. Although, he did have a history of alcoholism. FACILITY / AGENCY ACTION: Around 11:44 p.m., the police contacted the facility to report they found the resident asleep in the grass about a 1/4 mile away and he was highly intoxicated. He was transported to the hospital for an evaluation. The following day he returned. There were no reported injuries beyond his initial intoxication. Administration gave notice to the resident regarding alcohol use and behaviors while drinking. In addition, administration reported he was aware of the consequences of being evicted for not following the rules. The facility reported the resident was able to leave the facility on his own and had been aware of the expectation to sign out. Re-education was provided regarding the expectations to sign out prior to leaving the facility and staff asked him to take his phone. The facility concluded the resident left the facility without notifying staff and his whereabouts were unknown for approximately 5 hours. Staff notified his physician regarding the alcohol use to help with management. 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 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 4/8/2024 · released to the public 4/15/2024.
4/8/2023Diverted Drugs · ID 232304B1006Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 4/8/23, as two staff conducted a narcotic count, staff discovered two different types of tablets inside a medication bottle. The resident had an order for three - 10 mg tablets of Methadone at bedtime. There were 60 Methadone tablets and 12 Trazadone tablets noted inside the bottle. It appeared someone removed the prescribed Methadone tablets and replaced it with Trazadone tablets. The facility reported 12 Methadone tablets had been diverted. There was another finding of an alleged drug diversion on this day - refer to event #232304B1005 for further information. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, ombudsman, and physician. The resident received his medications as ordered and did not miss a dose. Education was provided to staff to ensure they are looking at each individual pill when counting medications to ensure no pills had been switched or swapped out. The medication bottles had been secured in a locked medication cart, accessible only by staff. No residents reported having any concerns of uncontrolled pain or not receiving their prescribed medications. One of the staff members (1), whose employment was terminated recently for an unrelated incident, could not be reached for a statement. All other staff denied taking the medications. Management concluded there was high suspicion of staff member (1) being responsible for the drug diversion; however, there was no tangible evidence to prove it was this staff member. The allegation of a drug diversion was substantiated. The facility paid to have the medications replaced for the resident. Management was attempting to have medications placed in blister packs versus bottles. 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 1/8/2024 · released to the public 1/15/2024.
4/8/2023Diverted Drugs · ID 232304B1005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 4/8/23, as two staff conducted a narcotic count, staff discovered two different types of tablets inside a medication bottle. The resident had an order for one - 150 mg tablet of Lyrica twice a day. There were 35 Lyrica tablets and 54 gabapentin tablets noted in the bottle. It appeared someone removed the prescribed Lyrica tablets and replaced it with Gabapentin tablets. The facility reported 54 Lyrica tablets had been diverted. There was another finding of an alleged drug diversion on this day - refer to event #232304B1006 for further information. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, ombudsman, and physician. The resident received his medications as ordered and did not miss a dose. Education was provided to staff to ensure they are looking at each individual pill when counting medications to ensure no pills had been switched or swapped out. The medication bottles had been secured in a locked medication cart, accessible only by staff. No residents reported having any concerns of uncontrolled pain or not receiving their prescribed medications. One of the staff members (1), whose employment was terminated recently for an unrelated incident, could not be reached for a statement. All other staff denied taking the medication. Management concluded there was high suspicion of staff member (1) being responsible for the drug diversion; however, there was no tangible evidence to prove it was this staff member. The allegation of a drug diversion was substantiated. The facility paid to have the medications replaced. Management was attempting to have medications placed in blister packs versus bottles. 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 1/8/2024 · released to the public 1/15/2024.
1/8/2023Sexual Abuse · ID 232304B1001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/8/23 a female resident (A), reported that she and a male resident (B) from a different part of the facility (independent living) went to the store. Resident (A) alleged that on the way back from the store resident (B) asked her for oral sex. Upon returning to the facility resident (A) accompanied resident (B) to his apartment where he locked the door behind them and she stated she was made to perform oral sex on resident (B). Both residents were in their 60s. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police. Both residents (A) and (B) are cognitively intact. Resident (B) was told not to leave his room without a chaperone after the allegation was made. Resident (A) stated later that there was no force or threat used towards her and only that resident (B) told her to do it and she performed oral sex and did not like it. Resident (A) was assessed without any visible injuries, does suffer from anxiety, was transferred to the hospital by her request and was admitted for unknown reasons. Additional information was not proved to the facility by the hospital due to resident (A) being assessed by a forensic nurse at the hospital. The police were onsite to ensure there was no immediate threat, no evidence was found to arrest resident (B), however indicated the door was locked during the action. Resident (A) returned to the facility without any additional concerns. Upon review of documentation, resident (A) had a pattern of hospital visits, multiple consensual intimate relationships with men on campus as well as a history of behaviors of making false accusations of theft and relationship idealizations with multiple male residents. The alleged assailant stated that the action between (A) was consensual, no force or threat was made and resident (B) stated that he liked resident (A) and wanted her to be his girlfriend. Resident (B) stated, he and resident (A) had previous sexual interactions and no concerns were expressed. Resident (B) stated he did nothing wrong. The facility investigation concluded that both resident (A) and (B) stated there was no force or threat made for the sexual interaction between the two. Resident (A) felt she was told to perform oral sex and resident (B) stated they did have a sexual encounter. To help prevent a recurrence, both residents will be and on safety checks and staff will monitor their location. Resident (B) was given a written warning, and would not be allowed into the assisted living facility, where resident (A) resided, for any reason and to report any action that was initiated by resident (A) in the future. Based on the history of resident (A) being easily influenced, a care conference was held with the family and others to discuss if a move to a smaller facility would be more appropriate for resident (A) as the setup of the current facility left resident (A) vulnerable to initiating relationships. 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 8/11/2023 · released to the public 8/18/2023.