MANOR ON MARSTON LAKE LLC, THE

SUMMARY OF FINDINGS:On 7/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. A client signed out of the facility in the afternoon and did not return to the facility. Staff were unable to locate the client the next morning. During the course of the investigation, the healthcare entity completed a search of the grounds, notified law enforcement, contacted the client’s family, reviewed records, and conducted interviews with staff. The client was located outside near a family member’s house and presented with a significant change in physical condition. The client was transported to the hospital for further medical care. The client was placed on increased monitoring upon returning to the facility and later moved to a secured unit to reduce the risk of recurrence. Although the facility reported the client was not at risk at the time of the incident, the client was missing for more than eight hours. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 1/14/2026 · released to the public 1/21/2026.