4
Inspections
2
Deficiencies
0
Actual Harm or Above
5
Occurrences
October 21, 2024
Last Inspection
S/S A/B Minimal potential
The most recent inspection of RETREAT AT CHURCH RANCH, THE on record is dated October 21, 2024. Across 4 published inspections, state surveyors cited 2 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Assisted Living Residence (Licensed Only)
Administrator
Short, Angelina
Owner
SIGNATURE - THE RETREAT, LLC
Phone
(303) 469-7178
Payor Source
Private Pay
City
WESTMINSTER
ZIP
80021
Inspections & Citations
4 inspections · 2 deficiencies10/21/2024Licensure Complaint · ID NHFD11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO37047 and #CO34750, was completed on 10/21/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/3/2024Revisit: State Certification (Re-certification) · ID 6M8T13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 4/3/24 for all previous deficiencies cited on 8/1/23. 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.
7/28/2023Licensure Complaint · ID 0IJ611No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO32002, was completed on 8/1/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
7/28/2023Revisit: State Certification (Re-certification) · ID 6M8T122 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 10/11/22. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0172LicProc-IntlApp CAPSS/S B▼
Findings
Based on record review and interview, the residence failed to ensure applicants completed the Colorado Adult Protective Data Systems (CAPS) requirements prior to hiring staff who provided direct care to at-risk residents for three of three sample staff (#6, #7, #8). This deficiency was cited previously during a state licensure survey on 10/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Referencesa. According to 2022 Colorado Revised Statutes (C.R.S.) Title 26 - Human Services Code Article 3.1 - 101 Protective Services for At-risk Adults - C.R.S 26-3.1-111. Access to CAPS - employment checks, read (1) The general assembly finds and declares that individuals receiving care and services from persons employed in programs or facilities described in subsection (7) of this section are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult. Subsection seven read (7) The following employers shall request a CAPS check pursuant to this section: (a) A health facility licensed pursuant to section 25-1.5-103, including those wholly owned and operated by any governmental unit. c. C.R.S. 26-3.1-101 (1.8) "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111. Retrieved from: https://cdhs.colorado.gov/aps 2. Record Reviewa. The personnel file for Staff #6 revealed a hire date of 5/11/23. However, the personnel file revealed that a CAPS check had been completed on 5/17/23.b. The personnel file for Staff #7 revealed a hire date of 7/14/23However, the personnel file revealed that a CAPS check had been completed on 10/18/22.c. The personnel file for Staff #8 revealed a hire date of 12/13/22However, the personnel file revealed that a CAPS check had been completed on 12/20/22.3. InterviewOn 7/28/23 At 9:58 a.m., the administrator stated she did not know CAPs check was required before hire. On 7/28/23 at approximately 12:30 p.m., the administrator admitted that Staff #6, #7, #8 files included CAPs checks dated after date of hire. She attributed the failure to the previous administration.
Plan of correction · submitted by the facility
Caps check, background checks, and TB test are all done before hire and start day. We do this for all staff that get hired on in the building. With new Administration, we have reviewed all employee files to fix any issues and correct future hires. A new policy on hiring protocols has been implemented for management. All background checks will be done after an interview, and CAPS checks will be done before hiring oncoming staff. We have created a checklist to be done every three months to ensure all paperwork in personnel files is up to date-and accurate. This includes new policies or state-regulated policies/needs. The administration assistant will be the first to check all personnel files, followed by a second check by the Administrator. Any missing paperwork will be collected immediately. This has been part of our qmp to better improve the onboarding process effectively and protect the residents under our care.
0246LicProc-IssueLic Cond LicS/S A▼
Findings
Based on record review and interview, the residence failed to immediately comply with conditions issued by the department, affecting 49 current residents. Findings include:The department concluded a revisit survey on 8/1/23. The original event dated 10/11/22 resulted in five deficiencies, which included TAG 1180 at a D-Level, a pattern of actual harm affecting one or more residents, regarding the facilities fall management program and individualized approach and staff training. Considering the risk of the challenging event, the department imposed a $750 civil fine payable by 12/1/22. As of the 7/28/23 onsite visit, the residence had not paid the required fine of $750 due to the department on 12/1/22. On 8/1/23 at 12:15 p.m.,the administrator stated the owner was unaware of a fine. On 8/1/23 at 12:17 p.m., the administrator stated that she would contact the owners and see if they knew of the fine. On 8/1/23 at 1:45 p.m., the owner stated the previous administrator had failed to inform her of a survey with deficiencies completed in October 2022.
Plan of correction · submitted by the facility
Fine has been paid by owners of the Retreat Cindy Avery and Robin Avery. Upon new management, COHFI will be monitored monthly to ensure nothing is missed. This will be done by all administration with access. There will be a sign-off monthly that all messages are read and responded to. As well as any fines or due dates for anything. The administration has been attending and training on COHFI or state regulation update meetings.
Reportable Occurrences
5 records6/21/2026Missing Person · ID 262304LF001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/21/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. Client (A), who was an at-risk adult, exited the facility and was missing for about one hour. During the course of the investigation, the healthcare entity conducted a search, contacted police, reviewed records, and conducted interviews. Client (A) was located and returned to the facility unharmed. Staff assessed client (A) with no abnormalities found. The facility implemented 1:1 supervision of client (A) until they were discharged to a higher level of care on 7/9/26. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/16/2026 · released to the public 7/23/2026.
5/20/2025Death · ID 252304LF004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/20/25, 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 the death of a client. The client became unresponsive but still breathing when being assisted to the toilet. Staff called emergency services and the client was taken to the hospital where they were pronounced deceased. During the course of the investigation the healthcare entity conducted interviews and record review. The client was not on hospice services and their death was not expected. The death was reported to the coroner. 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 10/28/2025 · released to the public 11/4/2025.
5/10/2025Brain Injury · ID 252304LF003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/10/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include; staff to provide assistance with a wheelchair and daily needs of the client. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 8/14/2025 · released to the public 8/21/2025.
2/8/2025Death · ID 252304LF002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/8/25, 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 the death of a client. During the course of the investigation, the healthcare entity conducted interviews and reviewed medical documentation. Staff noted the client was not feeling well and notified the client’s daughter. The daughter indicated she would come and take the client to the emergency department. Fifteen minutes later, the client’s condition worsened and they were struggling to breath, emergency services were called and the paramedics declared the client, who had a do not resuscitate order, dead shortly after they arrived. The client died from complications of pulmonary arterial hypotension. The facility provided education to staff regarding identifying early signs of medical distress. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 9/16/2025 · released to the public 9/23/2025.
5/10/2023Missing Person · ID 232304LF002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 5/10/23 at 4:00 a.m. a male resident (A) in his 90s was not in his room when staff member (1) checked. The facility was checked and resident (A)’s whereabouts were unknown. Staff member (1) contacted management.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the police, families/guardians, and physician. Management went to the facility to help look for resident (A) at the facility and the surrounding area. The police were called. Resident (A) was found at the gas station across the street from the community. Resident (A) was seen by his physician and not new symptoms were found. Resident (A) had confusion and can become disoriented. The facility investigation concluded resident (A) left the facility in the early morning hours without letting staff know. Staff were unaware she had left the facility. To help prevent a recurrence, resident (A) was provided with a one-to-one sitter until move out. Resident (A) was no longer appropriate for the current environment and would be transitioning to a secured environment.
DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 9/25/2023 · released to the public 10/2/2023.