Colorado CDPHE · Facility Report

MARYCREST ASSISTED LIVING

📍 2800/2850 COLUMBINE RD, DENVER, CO 80221

ID 2304STAssisted Living Residence/Alternative Care Facility (Medicaid)Active
29
Inspections
37
Deficiencies
0
Actual Harm or Above
31
Occurrences
July 14, 2026
Last Inspection
S/S A/B Minimal potential

The most recent inspection of MARYCREST ASSISTED LIVING on record is dated July 14, 2026. Across 29 published inspections, state surveyors cited 37 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
Opare, Gifty
Owner
LSS OF MARYCREST LLC
Phone
(303) 433-0282
Payor Source
Medicaid, Private Pay
City
DENVER
ZIP
80221

Inspections & Citations

29 inspections · 37 deficiencies
7/14/2026Licensure (Re-licensure) · ID N1KY11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 7/14/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/20/2026Licensure Complaint · ID 1YJQ111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO42247, was completed on 5/20/26. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0796PA Req-P/P-MANE▼
Findings
Based on record review and interviews, the facility (residence) failed to follow their written policy and procedures for mistreatment, abuse, neglect, and exploitation (MANE) affecting 132 members (residents) and one former resident (#1). Findings include:The residence's Investigation of Abuse, Neglect, and Exploitation policy, dated August 2025, read in part that residence staff would be educated annually and that, with any allegation of abuse, the residence would contact Adult Protective Services (APS), as required by state and federal law, and an investigation would be thoroughly conducted in accordance with state regulations. Former Resident #1 resided at the residence from 11/6/24 to 8/25/25. A progress note dated 8/7/25, documented by the former assistant executive director (FAED), read in part Former Resident #1 was observed on a recording to be speaking with Resident #2. Residents #1 and #2 were out of sight in the video due to a pillar. Resident #2 stumbled back and fell. Resident #2 stated that Former Resident #1 "flicked a cigarette" in his face, and Resident #2 admitted to staff that he pushed Former Resident #1. No further action was taken after local law enforcement had been to the residence, and case management was notified at 9:30 a.m. The residence's undated investigation of abuse, written by the assistant executive director (AED), failed to include documented resident and staff statements of what they had witnessed. It also failed to indicate whether APS had been notified after Former Resident #1 had alleged Resident #2 had abused her by pushing her down. A progress note on 8/8/25 "late entry" read "resident educated on staying away from [Resident #2]. Resident educated that if she goes to the smoking area, and [Resident #2] is already there, then she should go to a different smoking area. Resident verbalized understanding. Resident also educated on not going to the dining room over the weekend, as to separate her from [Resident #2]. Resident asked what if she goes to the door of the dining room. I stated that if she is not going to the dining room, then she does not need to go to the first floor. I let the resident know that the care staff will deliver her meals to her room and bring water if she requests it. Resident verbalized understanding. A progress note, dated 8/12/25, documented by the health and wellness director (HWD) read: "Resident has a small circular, healing bruise on her right arm." It does not appear to be related to the alleged push this past Friday."A department occurrence filed by the residence failed to have APS marked as being notified of the alleged abuse from Former Resident #1. On 5/20/26 at approximately 11:55 a.m., the health and wellness director failed to list APS when asked who she would call after an allegation of abuse. She acknowledged that APS should have been contacted for Former Resident #1. On 5/20/26 at 11:40 a.m., the administrator stated that if he had an allegation, he would contact the power of attorney, case managers, practitioner, regional director of operations, report an occurrence, notify law enforcement, and the ombudsman. However, the administrator did not state that APS would be contacted until asked by the surveyor. He stated he was not the administrator at the time of the incident on 8/7/25, and that the AED would be the one to ask as to why they had not been contacted. On 5/20/26 at 11:48 a.m., the AED acknowledged that Former Resident #1 had an allegation that Resident #2 had pushed her. She stated that the local law enforcement had been contacted, that the staff had notified the POA and caseworker, and that she had completed the occurrence report for the department and believed it was sufficient for the investigation. She stated that she did not contact APS and was unaware she needed to. On 5/20/26 at approximately 12:40 p.m., the administrator acknowledged understanding that an at-risk adult was over 70 years of age. He acknowledged the failure of the residence to report an alleged allegation of abuse to APS.
Plan of correction · submitted by the facility
The leadership team was educated on the occurrence reporting protocol on 6/4/26. Audit completed for all direct care staff on annual education around abuse/ neglect reporting. Date:6/11/26Annual education is completed for all direct care staff. Date: 6/30/26Weekly audits of state reportable events will be completed and reviewed during the weekly plan of correction (POC) meeting and monthly in quality assurance performance improvement (QAPI) for 3 months, or until fully in compliance and are to be documented on the monitoring form. The review will be of all reportable events and it will ensure the appropriate agencies are notified. Completion date of audits: Ongoing weekly audits started on 6/4/26 until 9/4/26.
5/20/2026Licensure Complaint · ID 0KL4111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO42246 was completed on 5/20/26. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1410Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S B▼
Findings
Based on record review and interviews, the residence failed to contact adult protective services and to include all required documentation in accordance with the residence's written policy, affecting 132 residents and one former (#1). Findings include:The residence's Investigation of Abuse, Neglect, and Exploitation policy, dated August 2025, read in part that residence staff would be educated annually and that, with any allegation of abuse, the residence would contact Adult Protective Services (APS), as required by state and federal law, and an investigation would be thoroughly conducted in accordance with state regulations. Former Resident #1 resided at the residence from 11/6/24 to 8/25/25. A progress note dated 8/7/25, documented by the former assistant executive director (FAED), read in part Former Resident #1 was observed on a recording to be speaking with Resident #2. Residents #1 and #2 were out of sight in the video due to a pillar. Resident #2 stumbled back and fell. Resident #2 stated that Former Resident #1 "flicked a cigarette" in his face, and Resident #2 admitted to staff that he pushed Former Resident #1. No further action was taken after local law enforcement had been to the residence, and case management was notified at 9:30 a.m. The residence's undated investigation of abuse, written by the assistant executive director (AED), failed to include documented resident and staff statements of what they had witnessed. It also failed to indicate whether APS had been notified after Former Resident #1 had alleged Resident #2 had abused her by pushing her down. A progress note on 8/8/25 "late entry" read "resident educated on staying away from [Resident #2]. Resident educated that if she goes to the smoking area, and [Resident #2] is already there, then she should go to a different smoking area. Resident verbalized understanding. Resident also educated on not going to the dining room over the weekend, as to separate her from [Resident #2]. Resident asked what if she goes to the door of the dining room. I stated that if she is not going to the dining room, then she does not need to go to the first floor. I let the resident know that the care staff will deliver her meals to her room and bring water if she requests it. Resident verbalized understanding. A progress note, dated 8/12/25, documented by the health and wellness director (HWD) read: "Resident has a small circular, healing bruise on her right arm." It does not appear to be related to the alleged push this past Friday."A department occurrence filed by the residence failed to have APS marked as being notified of the alleged abuse from Former Resident #1. On 5/20/26 at approximately 11:55 a.m., the health and wellness director failed to list APS when asked who she would call after an allegation of abuse. She acknowledged that APS should have been contacted for Former Resident #1. On 5/20/26 at 11:40 a.m., the administrator stated that if he had an allegation, he would contact the power of attorney, case managers, practitioner, regional director of operations, report an occurrence, notify law enforcement, and the ombudsman. However, the administrator did not state that APS would be contacted until asked by the surveyor. He stated he was not the administrator at the time of the incident on 8/7/25, and that the AED would be the one to ask as to why they had not been contacted. On 5/20/26 at 11:48 a.m., the AED acknowledged that Former Resident #1 had an allegation that Resident #2 had pushed her. She stated that the local law enforcement had been contacted, that the staff had notified the POA and caseworker, and that she had completed the occurrence report for the department and believed it was sufficient for the investigation. She stated that she did not contact APS and was unaware she needed to. On 5/20/26 at approximately 12:40 p.m., the administrator acknowledged understanding that an at-risk adult was over 70 years of age. He acknowledged the failure of the residence to report an alleged allegation of abuse to APS.
Plan of correction · submitted by the facility
The leadership team was educated on the occurrence reporting protocol on 6/4/26. Audit completed for all direct care staff on annual education around abuse/ neglect reporting. Date:6/11/26Annual education is completed for all direct care staff. Date: 6/30/26Weekly audits of state reportable events will be completed and reviewed during the weekly plan plan of correction (POC) meeting and monthly in quality assurance performance improvement (QAPI) for 3 months, or until fully in compliance and are to be documented on the monitoring form. The review will be of all reportable events and it will ensure the appropriate agencies are notified. Completion date of audits: Ongoing weekly audits started on 6/4/26 until 9/4/26.
4/30/2026Licensure Complaint · ID G5MJ11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO41510 and #CO41990, was completed on 5/1/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/30/2026Licensure Complaint · ID W0C311No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO41511 and #CO41991, was completed on 5/1/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/13/2026Revisit: Licensure Complaint · ID 2OCM12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 10/8/25. 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.
1/13/2026Revisit: Licensure Complaint · ID 4TDK12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 10/8/25. 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.
1/13/2026Revisit: Licensure Complaint · ID 8PRJ14No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 10/8/25. 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.
1/13/2026Revisit: Licensure and Licensure Complaint (Combined) · ID D3ZH13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 10/9/25. 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.
1/13/2026Revisit: Licensure Complaint · ID J2BS12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 10/8/25. 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.
1/13/2026Revisit: State Certification and State Certification Complaint (Combined) · ID QRME13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 10/8/25. 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.
1/13/2026Revisit: Licensure Complaint · ID TZ3L15No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 10/8/25. 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.
10/7/2025Revisit: Licensure and Licensure Complaint (Combined) · ID D3ZH122 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey and complaint revisit was completed on 10/8/25 for all previous deficiencies cited on 12/4/24. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.
Plan of correction
The state did not require a plan of correction for this citation.
1410Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S B▼
Findings
Based on record review and interview, the residence failed to thoroughly investigate allegations of abuse in accordance with the residence's written policy, affecting three of 22 sample residents (#19, #20, and former #24). This deficiency was cited previously during a complaint revisit on 12/4/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence policy, dated 11/2022, read in pertinent part that the residence will prevent, investigate and respond appropriately to allegations of suspected or actual resident abuse and neglect. This would include resident to resident, staff to resident, resident to staff or any other possible source of abuse or neglect. The administrator is responsible for the investigation, reporting, and follow-up of the abuse and neglect allegations."2. Record ReviewAll Investigations of abuse and neglect for the previous 90 days were requested on 10/7/25 at 11:24 a.m. A second request for investigations of abuse or neglect for the past 90 days was made on 10/7/25 at 4:30 p.m. A third request for investigations of abuse or neglect for the past 90 days was made on 10/8/25 at approximately 11:30 a.m. The residence provided no investigations of abuse or neglect on 10/7/25 and 10/8/25. Resident #19 was admitted to the residence on 12/30/20, with a diagnosis of cerebrovascular accident and neurological disorders. A progress note dated 7/30/25 read that the resident ran to the med room, bleeding from a head wound. He reported being struck by a beer bottle by a stranger by the residence smoking area. 3. InterviewOn 10/8/25, at approximately 1:30 p.m, the administrator stated the deficiency was not corrected because the residence failed to provide investigations of abuse and neglect. 4. Additionally, the residence demonstrated similar deficient practice for Resident #23 and Former Resident #24.
Plan of correction · submitted by the facility
How the deficiency was corrected for the residents affected:• The deficiency was corrected by staff education on proper procedure in the event of an allegation of abuse. Going forward, increased documentation of all incidents or allegations will allow us to maintain compliance with the written policy. How the facility will identify other residents who may have been affected:• Staff will perform an audit of past grievances to review past policy implementation to review adherence to said policy. What systemic changes will be made to ensure this deficient practice does not recur:• The education of staff on current written policy.• Staff will include the corporate office in all allegations of abuse.• Staff will implement increased documentation.• The policy will be reviewed with the QAPI/QMP Committee. Date of Compliance: 11/23/25
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼
Findings
Based on interviews and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting two of six sample residents whose medications were reviewed (#15, #18). This deficiency was cited previously during a complaint revisit on 12/4/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewResident #15 was admitted to the residence on 7/5/23 with a diagnosis including chronic pain. a. Keflex 500mgA written practitioner's order, dated 9/10/25, directed the residence to administer Keflex 500 mg by mouth three times daily for seven days to Resident #15. The September 2025 Medication Administration Record (MAR) read 500 mg of Keflex was not administered for the scheduled morning dose on 9/11/25. The MAR also showed Resident #15 was scheduled to receive Keflex 500 mg three times daily between 9/11-9/17/25.b. Acetaminophen 500mgA written practitioner's order, dated 8/19/25, directed the residence to administer two tablets of 500 mg acetaminophen by mouth three times daily. The August 2025 MAR read acetaminophen was not administered to Resident #15 for the scheduled morning and midday doses on 8/20/25. The MAR read acetaminophen was administered to Resident #15 with a "hold/nurse note" code for the scheduled morning and midday doses on 8/21/25. However, there was no practitioner's order to hold the medication. A late entry progress note, dated 8/21/25, read Resident #15 did not receive acetaminophen 8/20-8/21/25. The note further read Resident #15 did not receive the scheduled dose until 4:00 p.m. on 8/21/25.c. Lidocaine External Cream 4%A signed medication list, dated 8/19/25, read the residence was directed to administer Lidocaine External Cream 4% topically to Resident #15 ' s right thigh twice daily for pain. The July 2025 MAR showed Lidocaine External Cream 4% was not administered for the scheduled evening dose on 7/3/25. 2. Evidence obtained during the on site visit revealed the residence additionally failed to comply with authorized practitioner's orders for Resident #18.3. InterviewsOn 10/7/25, at approximately 3:48 p.m., the wellness director stated that there had been delays in residents receiving medications when admitted or readmitted to the residence when using an alternative pharmacy or when family did not pick up medication. The wellness director stated that residents had experienced up to a two day delay in receiving medications at times. The wellness director acknowledged that residents not receiving scheduled medication per the practitioner ' s order was not compliant with 1568 6 CCR 1011-10-09 Chapter 7, 14.21. On 10/8/25, at approximately 1:30 p.m., the administrator stated residents had come to her about not receiving medication and, when notified, she had followed up with qualified medication administration personnel (QMAP) to form a solution. The administrator acknowledged that there had been up to a two day delay in residents receiving medications when being admitted and readmitted to the residence. The administrator stated she was not aware Resident #15 and Resident #18 did not receive medications per the practitioner's order and acknowledged the deficiency had not been corrected and was not in compliance with 1568 6 CCR 1011-10-09 Chapter 7, 14.21.
Plan of correction · submitted by the facility
How the deficiency was corrected for the resident(s) affected:Affected residents were assessed by nursing staff for any adverse outcomesProvider was notified of lapse and provided updated clinical information. Orders were re-entered and verified in the electronic medical record (EMR)Staff involved received immediate re-education and corrective actionHow the facility will identify other residents who may have been affected:A 30 day lookback audit of all provider orders was conducted by the DOW/designee to focus on medication orders, lab and diagnostic testing, and therapy/treatment ordersAll discrepancies were communicated to providers as needed. Residents involved in any identified discrepancies were assessed to ensure their safety and well-being. What systemic changes will be made to ensure this deficient practice does not recur:Clinical staff received mandatory in-service training on practitioner order policy to include using the EMR to track pending orders and importance of prompt provider communication when clarification or concerns ariseA new order verification checklist was introduced for all shifts to confirm that new/changed orders are implemented, documented, and monitoredThe facility’s EMR alerts and tracking systems were reviewed and adjusted to flag incomplete or delayed orders. How the corrective action will be monitored to ensure the deficiency is corrected and does not recur:The RCC or designee will complete weekly audits of 5 new practitioner orders for 4 weeks, and then monthly for 3 months, to verify orders were carried out as written and timely follow-up occurred. Any missed or delayed orders found during audits will be reported to the DOW/designee immediately. Audit results will be submitted to the QAPI/QMP committee monthly. Date of Compliance: 11/23/25
10/7/2025Revisit: Licensure Complaint · ID TZ3L141 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 10/8/25 for the previous deficiency cited on 12/4/24. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on record review, observation, and interview, the residence failed to make a sanitary environment available, either directly or indirectly through a resident agreement, affecting two sample residents (#17 and #20) whose rooms were observed. This deficiency was cited previously during a state licensure survey 12/4/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:The residence's undated resident agreement read in part that the residence provided services as required by all applicable laws and regulations. Housekeeping checklists revealed Resident #17 and Resident #20 ' s rooms were scheduled to be cleaned on 10/7/25 yet, had not been cleaned during the onsite visit on 10/8/25. On 10/8/25 at approximately 9:00 a.m., an environmental tour of Resident #17 ' s room had dirt from plants on the ground next to the couch, on the air conditioning unit, and trailing around the room into the hallway. The trash cans in the living room and bathroom had not been emptied and the floors were cluttered with papers and personal items. On 10/8/25 at approximately 9:00 a.m., an environmental tour of Resident #20 ' s room, revealed that the tiled ground in the kitchen area had stains of spilled liquid that turned black, the living room and bedroom carpet had not been vacuumed and the floors were cluttered with Resident #20s personal items. Further, the trash cans in the kitchen area and bathroom had not been removed, and the room had a foul smell upon entering. On 10/8/25 at 1:48 p.m., the administrator stated that she was responsible for ensuring the housekeeping services had been completed on the days expected. She further stated, the deficiency had not been corrected because the person responsible for ensuring housekeeping was being completed had recently left the residence, leaving her responsible for housekeeping and there was a lack of oversight.
Plan of correction · submitted by the facility
How the deficiency was corrected for the residents affected:• The affected areas identified during the survey were immediately cleaned and shampooed. Residents do have a hx of refusing room cleans, and the care plan was updated on 10/27/25 to reflect that.• Housekeeping, maintenance, and clinical staff involved were re-educated on cleaning protocols and safety procedures. How the facility will identify other residents who may have been affected:• A facility-wide inspection was conducted by staff to identify any additional unsanitary or unsafe conditions, focusing on high-risk areas such as resident rooms, bathrooms and common areas.• Any areas found to be non-compliant were addressed immediately. What systemic changes will be made to ensure this deficient practice does not recur:• Staff education initiated proper cleaning and sanitization policy.• An environmental checklist / cleaning log was implemented• The ED/designee will conduct weekly environmental rounds with department heads for 12 weeks• All findings will be reviewed with the QAPI/QMP CommitteeDate of Compliance:11/23 /25
10/7/2025Revisit: State Certification and State Certification Complaint (Combined) · ID QRME123 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey and complaint revisit was completed on 10/8/25 for all previous deficiencies cited on 12/4/24. Deficiencies were cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 8/14/25.
Plan of correction
The state did not require a plan of correction for this citation.
0158Ind Rts-Adtl Crit-Prov Own/Ctrl-Res-Food▼
Findings
Based on observation, record review, and interview, the facility (residence) failed to provide access to food at all times, affecting 132 current members (residents). This deficiency was cited previously during a complaint revisit on 12/4/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence Policy:The residence agreement, dated 11/2022 read in pertinent part that Residents will have unrestricted access to the common Resident areas. 2. Observation:During the onsite observation on 10/7/25 and 10/8/25 staff served meals in the dining room of both Serenity and Harmony buildings. Snacks and hydration are available at the hydration station. On 10/8/25 at approximately 9:45 a.m., the Serenity building dining room doors were closed and locked, and the Harmony building dining room did not have snacks available to the residents. 3. Record Review:On 10/8/25 at approximately 9:45 a.m., the Serenity building dining room doors had a sign that read "Stop, do not enter, dining room (is) closed." 4. Interview:On 10/8/25 at approximately 11:10 a.m., the administrator acknowledged that the residence closed the dining rooms after every meal for cleaning and restocking. She further acknowledged that the dining room was not accessible at all times, and she was not aware that there were no snacks available at the Harmony building. The administrator stated the deficiency was not corrected because she was not aware the kitchen doors were locked while they were closed.
Plan of correction · submitted by the facility
Administrator educated Culinary and Environmental service teams that the dining area doors could not be locked on 10/17/25. Culinary team task checklist updated to reflect routine checks throughout the day to ensure snacks and hydration options are available in Harmony and Serenity. Administrator educated Culinary team on requirement on 10/17/25. How the facility will identify other residents who may have been affected:· Resident interviews were conducted by Culinary Director/designee on 10/17/25 to gather feedback on snack preferences, frequency, and accessibility.· Any gaps identified were immediately addressed and corrected. What systemic changes will be made to ensure this deficient practice does not recur:· Staff received in-service training on facility meals, snacks, and beverages being available to residents by Administrator/designee on 10/17/25· A standardized snack/beverage cart with labeled options was implemented on 10/17/25 for consistency and visibility. How the corrective action will be monitored to ensure the deficiency is corrected and does not recur:· The Culinary Director or designee will perform weekly audits of the availability of snacks at various times in the day. Audits to be performed three times weekly for twelve weeks.· Three resident interviews will be conducted per week by Administrator/designee to assess satisfaction and verify consistent delivery.· The Interdisciplinary Team will review audit results in monthly QAPI/QMP meetings to identify trends or compliance gaps. Date of Compliance: 11/23/25
0882PA Req-IR-Critical Incidents▼
Findings
Based on record review and interview, the facility (residence) failed to ensure case managers were notified after a member had a significant incident, affecting two of nine sample members (residents) (#22,#23) who were sent to the hospital after an incident. This deficiency was cited previously during a state licensure survey 12/4/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:Resident #22 was admitted to the residence on 5/27/25 with a diagnosis of epilepsy. An incident report dated 8/24/25 read in part, resident #22 had fallen and was taken to the hospital. There was no indication of the case manager being notified. An incident report dated 10/2/25 read in part, resident #22 had fallen and was taken to the hospital. There was no indication of the case manager being notified. On 10/8/25 at approximately 1:30 p.m., the administrator acknowledged that the case managers were not being notified after a resident's incident. The administrator stated she thought the deficiency had been corrected and was not overseeing that case managers were also being called. There was similar deficient practice for Resident #23.
Plan of correction · submitted by the facility
How the deficiency was corrected for the residents (s) affected:· Case Managers for Residents #22 and #23 were notified of prior incidents by DOW on 10/30/25. Medical record was updated to reflect case manager notification for affected residents.· Staff re-educated on notification policy, inclusive of case management notification by Administrator/designee on 10/31/25. How the facility will identify other residents who may have been affected:· A facility-wide audit was conducted for the past 30 days to identify any missed / delayed notifications by DOW on 10/31/25.· Any additional incidents noted where case manager was not previously notified were immediately addressed with appropriate notification, interventions, and documentation by DOW on 10/31/25. What systemic changes will be made to ensure this deficient practice does not recur:· Staff were re-educated on the notification policy by DOW on 10/31/25.· A Notification Checklist has been implemented for significant incidents/events to ensure compliance on 10/31/25How the corrective action will be monitored to ensure the deficiency is corrected and does not recur:Administrator/Director of wellness or designee will review 24-hour report entries to confirm that appropriate notifications have occurred as indicated. Negative findings will be addressed in Quality Assurance/Performance Improvement meeting for further recommendations. Date of Compliance: 11/23/2025
0920PA Req-Med Admin-Rx/PRN▼
Findings
Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting two of six sample residents whose medications were reviewed (#15, #18). This deficiency was cited previously during a complaint revisit on 12/4/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewResident #15 was admitted to the residence on 7/5/23 with a diagnosis including chronic pain. a. Keflex 500mgA written practitioner ' s order, dated 9/10/25, directed the residence to administer Keflex 500 mg by mouth three times daily for seven days to Resident #15. The September 2025 Medication Administration Record (MAR) read 500 mg of Keflex was not administered for the scheduled morning dose on 9/11/25. The MAR also showed Resident #15 was scheduled to receive Keflex 500 mg three times daily between 9/11-9/17/25.b. Acetaminophen 500mgA written practitioner's order, dated 8/19/25, directed the residence to administer two tablets of 500mg acetaminophen by mouth three times daily. The August 2025 MAR read acetaminophen was not administered to Resident #15 for the scheduled morning and midday doses on 8/20/25. The MAR read acetaminophen was administered to Resident #15 with a "hold/nurse note" code for the scheduled morning and midday doses on 8/21/25. However, there was no practitioner's order to hold the medication. A late entry progress note, dated 8/21/25, read Resident #15 did not receive acetaminophen 8/20-8/21/25. The note further read Resident #15 did not receive the scheduled dose until 4:00 p.m. on 8/21/25.c. Lidocaine External Cream 4%A signed medication list, dated 8/19/25, read the residence was directed to administer Lidocaine External Cream 4% topically to Resident #15 ' s right thigh twice daily for pain. The July 2025 MAR showed Lidocaine External Cream 4% was not administered for the scheduled evening dose on 7/3/25. 2. Evidence obtained during the on site visit revealed the residence additionally failed to comply with authorized practitioner's orders for Resident #18.3. InterviewsOn 10/7/25, at approximately 3:48 p.m., the wellness director stated that there had been delays in residents receiving medications when admitted or readmitted to the residence when using an alternative pharmacy or when family did not pick up medication. The wellness director stated that residents had experienced up to a two day delay in receiving medications at times. The wellness director acknowledged that residents not receiving scheduled medication per the practitioner's order was not compliant with 0920 10 CCR 2505-10 8.7414.a. On 10/8/25, at approximately 1:30 p.m., the administrator stated residents had come to her about not receiving medication and, when notified, she had followed up with qualified medication administration personnel (QMAP) to form a solution. The administrator acknowledged that there had been up to a two day delay in residents receiving medications when being admitted and readmitted to the residence. The administrator stated she was not aware Resident #15 and Resident #18 did not receive medications per the practitioner's order and acknowledged this deficiency had not been corrected and was not in compliance with 0920 10 CCR 2505-10 8.7414.a.
Plan of correction · submitted by the facility
How the deficiency was corrected for the resident(s) affected:• Affected residents were assessed by nursing staff for any adverse outcomes• Provider was notified of lapse and provided updated clinical information.• Orders were re-entered and verified in the electronic medical record (EMR)• Staff involved received immediate re-education and corrective actionHow the facility will identify other residents who may have been affected:• A 30 day lookback audit of all provider orders was conducted by the DOW/designee to focus on medication orders, lab and diagnostic testing, and therapy/treatment orders• All discrepancies were communicated to providers as needed.• Residents involved in any identified discrepancies were assessed to ensure their safety and well-being. What systemic changes will be made to ensure this deficient practice does not recur:• Clinical staff received mandatory in-service training on practitioner order policy to include using the EMR to track pending orders and importance of prompt provider communication when clarification or concerns arise• A new order verification checklist was introduced for all shifts to confirm that new/changed orders are implemented, documented, and monitored• The facility’s EMR alerts and tracking systems were reviewed and adjusted to flag incomplete or delayed orders. How the corrective action will be monitored to ensure the deficiency is corrected and does not recur:• The RCC or designee will complete weekly audits of 5 new practitioner orders for 4 weeks, and then monthly for 3 months, to verify orders were carried out as written and timely follow-up occurred.• All findings will be reviewed with the QAPI/QMP Committee. Date of compliance:11/23/25
10/7/2025Revisit: Licensure Complaint · ID 8PRJ131 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 10/8/25 for the previous deficiency cited on 12/4/24. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on record review, observation, and interview, the residence failed to make a sanitary environment available, either directly or indirectly through a resident agreement, affecting two sample residents (#17 and #20) whose rooms were observed. This deficiency was cited previously during a state licensure survey 12/4/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:The residence's undated resident agreement read in part that the residence provided services as required by all applicable laws and regulations. Housekeeping checklists revealed Resident #17 and Resident #20 ' s rooms were scheduled to be cleaned on 10/7/25 yet, had not been cleaned during the onsite visit on 10/8/25. On 10/8/25 at approximately 9:00 a.m., an environmental tour of Resident #17 ' s room had dirt from plants on the ground next to the couch, on the air conditioning unit, and trailing around the room into the hallway. The trash cans in the living room and bathroom had not been emptied and the floors were cluttered with papers and personal items. On 10/8/25 at approximately 9:00 a.m., an environmental tour of Resident #20 ' s room, revealed that the tiled ground in the kitchen area had stains of spilled liquid that turned black, the living room and bedroom carpet had not been vacuumed and the floors were cluttered with Resident #20s personal items. Further, the trash cans in the kitchen area and bathroom had not been removed, and the room had a foul smell upon entering. On 10/8/25 at 1:48 p.m., the administrator stated that she was responsible for ensuring the housekeeping services had been completed on the days expected. She further stated, the deficiency had not been corrected because the person responsible for ensuring housekeeping was being completed had recently left the residence, leaving her responsible for housekeeping and there was a lack of oversight.
Plan of correction · submitted by the facility
How the deficiency was corrected for the residents affected:• The affected areas identified during the survey were immediately cleaned and shampooed. Residents do have a hx of refusing room cleans, and the care plan was updated on 10/27/25 to reflect that.• Housekeeping, maintenance, and clinical staff involved were re-educated on cleaning protocols and safety procedures. How the facility will identify other residents who may have been affected:• A facility-wide inspection was conducted by staff to identify any additional unsanitary or unsafe conditions, focusing on high-risk areas such as resident rooms, bathrooms and common areas.• Any areas found to be non-compliant were addressed immediately. What systemic changes will be made to ensure this deficient practice does not recur:• Staff education initiated proper cleaning and sanitization policy.• An environmental checklist / cleaning log was implemented• The ED/designee will conduct weekly environmental rounds with department heads for 12 weeks• All findings will be reviewed with the QAPI/QMP CommitteeDate of Compliance:11/23 /25
10/7/2025Licensure Complaint · ID 4TDK111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO39229 and #CO40923, was completed on 10/8/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0920PA Req-Med Admin-Rx/PRN▼
Findings
Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting two of six sample residents whose medications were reviewed (#15, #18). Findings include:1. Record ReviewResident #15 was admitted to the residence on 7/5/23 with a diagnosis including chronic pain. a. Keflex 500mgA written practitioner ' s order, dated 9/10/25, directed the residence to administer Keflex 500 mg by mouth three times daily for seven days to Resident #15. The September 2025 Medication Administration Record (MAR) read 500 mg of Keflex was not administered for the scheduled morning dose on 9/11/25. The MAR also showed Resident #15 was scheduled to receive Keflex 500 mg three times daily between 9/11-9/17/25.b. Acetaminophen 500mgA written practitioner's order, dated 8/19/25, directed the residence to administer two tablets of 500mg acetaminophen by mouth three times daily. The August 2025 MAR read acetaminophen was not administered to Resident #15 for the scheduled morning and midday doses on 8/20/25. The MAR read acetaminophen was administered to Resident #15 with a "hold/nurse note" code for the scheduled morning and midday doses on 8/21/25. However, there was no practitioner's order to hold the medication. A late entry progress note, dated 8/21/25, read Resident #15 did not receive acetaminophen 8/20-8/21/25. The note further read Resident #15 did not receive the scheduled dose until 4:00 p.m. on 8/21/25.c. Lidocaine External Cream 4%A signed medication list, dated 8/19/25, read the residence was directed to administer Lidocaine External Cream 4% topically to Resident #15 ' s right thigh twice daily for pain. The July 2025 MAR showed Lidocaine External Cream 4% was not administered for the scheduled evening dose on 7/3/25. 2. Evidence obtained during the on site visit revealed the residence additionally failed to comply with authorized practitioner's orders for Resident #18.3. InterviewsOn 10/7/25, at approximately 3:48 p.m., the wellness director stated that there had been delays in residents receiving medications when admitted or readmitted to the residence when using an alternative pharmacy or when family did not pick up medication. The wellness director stated that residents had experienced up to a two day delay in receiving medications at times. The wellness director acknowledged that residents not receiving scheduled medication per the practitioner's order was not compliant with 0920 10 CCR 2505-10 8.7414.a. On 10/8/25, at approximately 1:30 p.m., the administrator stated residents had come to her about not receiving medication and, when notified, she had followed up with qualified medication administration personnel (QMAP) to form a solution. The administrator acknowledged that there had been up to a two day delay in residents receiving medications when being admitted and readmitted to the residence. The administrator stated she was not aware Resident #15 and Resident #18 did not receive medications per the practitioner's order and acknowledged this was not in compliance with 0920 10 CCR 2505-10 8.7414.a.
Plan of correction · submitted by the facility
How the deficiency was corrected for the resident(s) affected: · Residents #15 and #18 were assessed by nursing staff on 08/21/25 and 08/22/2025; no adverse outcomes noted.· Provider was notified of lapse and provided updated clinical information. by RCC on 08/21/25. · Staff involved received immediate re-education and corrective action by DOW on 08/21/25. How the facility will identify other residents who may have been affected: · A thirty day lookback audit of provider orders was conducted by the DOW/designee to focus on medication orders, lab and diagnostic testing, and therapy/treatment orders on 10/17/25· Identified discrepancies were communicated to providers as indicated by DOW/designee on 10/17/25. · What systemic changes will be made to ensure this deficient practice does not recur: · Clinical staff received re-education on 10/28/25 by DOW on practitioner order policy to include using the EMR to track pending orders and importance of prompt provider communication when clarification or concerns arise.· A new order verification checklist was introduced to confirm that new/changed orders are implemented, documented, and monitored on 10/17/25.· The facility’s EMR alerts and tracking systems were reviewed and adjusted to flag incomplete or delayed orders. How the corrective action will be monitored to ensure the deficiency is corrected and does not recur: · The RCC or designee will complete weekly audits of five new practitioner orders for four weeks, and then monthly for three months, to verify orders were carried out as written and timely follow-up occurred. A report will be presented to the Quality Assurance/Performance Improvement committee monthly for further recommendations. Date of compliance:11/23/25
10/7/2025Licensure Complaint · ID 2OCM113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO39228 and #CO40922, was completed on 10/8/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0540Admin-Dts RespS/S B▼
Findings
Based on record review and interview the administrator failed to ensure staff were trained, submit required reports to the department, and that the residence was in compliance with the involuntary discharge requirements of Section 25-27-104.3. C.R.S., affecting 136 current residents. Findings include:On 10/7/25 at approximately 9:00 a.m., the residence presented several incident reports. Four incident reports dated 7/30, 8/8, 8/23 and 10/2/25, included that residents had a physical altercation where residents were physically hurt. However, the residence failed to investigate the incidents after reporting the incident to the state department when the event occurred. On 10/8/25 at approximately 10:00 a.m., the residence presented their quarterly medication audits dated 10/2025 and 8/2025 completed by the lead Qualified Medication Administration Person (QMAP). On 10/8/25 at approximately 1:30 p.m., the residence presented the housekeeping schedule and the day of the week specific resident rooms were expected to be cleaned. Resident #17 and #20 ' s rooms were scheduled to be cleaned weekly on Tuesdays; however, during the onsite environmental tour, both rooms were visibly dirty and foul smelling. On 10/8/25 at 1:58 p.m., the Administrator stated she was unaware of the requirement to complete quarterly medication audits with the QMAP supervisor, that housekeeping and resident room cleaning had not been completed, and did not have access to the residences internal investigations.
Plan of correction · submitted by the facility
How the deficiency was corrected for the residents affected:• The deficiency was corrected with the resident affected by reaching out to the resident’s family and notifying them that incorrect information was given by the ombudsman regarding the proper procedure. The resident’s family was redirected to the appropriate step of the process by the state. How the facility will identify other residents who may have been affected:• The current discharge policy will be reframed in accordance with state guidelines and current corporate policy. What systemic changes will be made to ensure this deficient practice does not recur:• Staff will update the discharge policy and use that going forward.• Staff will include the corporate office in all discharge processes going forward.• The updated policy will be reviewed with the QAPI/QMP Committee. Date of Compliance:11/23 /25
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼
Findings
Based on interviews and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting two of six sample residents whose medications were reviewed (#15, #18). Findings include:1. Record ReviewResident #15 was admitted to the residence on 7/5/23 with a diagnosis including chronic pain. a. Keflex 500mgA written practitioner ' s order, dated 9/10/25, directed the residence to administer Keflex 500 mg by mouth three times daily for seven days to Resident #15. The September 2025 Medication Administration Record (MAR) read 500 mg of Keflex was not administered for the scheduled morning dose on 9/11/25. The MAR also showed Resident #15 was scheduled to receive Keflex 500 mg three times daily between 9/11-9/17/25.b. Acetaminophen 500mgA written practitioner's order, dated 8/19/25, directed the residence to administer two tablets of 500 mg acetaminophen by mouth three times daily. The August 2025 MAR read acetaminophen was not administered to Resident #15 for the scheduled morning and midday doses on 8/20/25. The MAR read acetaminophen was administered to Resident #15 with a "hold/nurse note" code for the scheduled morning and midday doses on 8/21/25. However, there was no practitioner's order to hold the medication. A late entry progress note, dated 8/21/25, read Resident #15 did not receive acetaminophen 8/20-8/21/25. The note further read Resident #15 did not receive the scheduled dose until 4:00 p.m. on 8/21/25.c. Lidocaine External Cream 4%A signed medication list, dated 8/19/25, read the residence was directed to administer Lidocaine External Cream 4% topically to Resident #15 ' s right thigh twice daily for pain. The July 2025 MAR showed Lidocaine External Cream 4% was not administered for the scheduled evening dose on 7/3/25. 2. Evidence obtained during the on site visit revealed the residence additionally failed to comply with authorized practitioner's orders for Resident #18.3. InterviewsOn 10/7/25, at approximately 3:48 p.m., the wellness director stated that there had been delays in residents receiving medications when admitted or readmitted to the residence when using an alternative pharmacy or when family did not pick up medication. The wellness director stated that residents had experienced up to a two day delay in receiving medications at times. The wellness director acknowledged that residents not receiving scheduled medication per the practitioner ' s order was not compliant with 1568 6 CCR 1011-10-09 Chapter 7, 14.21. On 10/8/25, at approximately 1:30 p.m., the administrator stated residents had come to her about not receiving medication and, when notified, she had followed up with qualified medication administration personnel (QMAP) to form a solution. The administrator acknowledged that there had been up to a two day delay in residents receiving medications when being admitted and readmitted to the residence. The administrator stated she was not aware Resident #15 and Resident #18 did not receive medications per the practitioner's order and acknowledged this was not in compliance with 1568 6 CCR 1011-10-09 Chapter 7, 14.21.
Plan of correction · submitted by the facility
How the deficiency was corrected for the resident(s) affected:· Resident #15 was assessed by nursing staff for any adverse outcomes; no negative outcomes noted.· Provider was notified of lapse and provided updated clinical information. How the facility will identify other residents who may have been affected:· A thirty day lookback audit of provider orders was conducted by the DOW/designee to focus on medication orders, lab and diagnostic testing, and therapy/treatment orders on 10/28/25.· Negative findings were communicated to providers as needed.· Residents involved in any identified discrepancies were assessed to ensure their safety and well-being. What systemic changes will be made to ensure this deficient practice does not recur:· Clinical staff received mandatory in-service training on practitioner order policy to include using the EMR to track pending orders and importance of prompt provider communication when clarification or concerns arise specifically in the event that medication can not be delivered timely on 10/28/2025 by Director of Wellness.· A new order verification checklist was introduced to confirm that new/changed orders are implemented, documented, and monitored by Director of Wellness on 10/28/25· The facility’s EMR alerts and tracking systems were reviewed and adjusted to flag incomplete or delayed orders. How the corrective action will be monitored to ensure the deficiency is corrected and does not recur:· The RCC or designee will complete weekly audits of 5 new practitioner orders for 4 weeks, and then monthly for 3 months, to verify orders were carried out as written and timely follow-up occurred.· Any missed or delayed orders found during audits will be reported to the DOW/designee for needed follow up.· Audit results will be submitted to the QAPI/QMP committee monthly. Date of Compliance: 11/23/25
1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼
Findings
Based on record review and interview the residence failed to document, investigate, and resolve irregularities of the medication administration record audit affecting 136 current residents. Findings include:On 10/7/25 at 8:00 a.m., the last two quarterly medication audits were requested from the residence; however, it was not provided. On 10/8/25 at 10:39 a.m., the administrator acknowledged that the residence had not completed medication audits per the regulation. She stated she does not participate in the quarterly medication audits and was unaware of the requirement.
Plan of correction · submitted by the facility
How the deficiency was corrected for the resident(s) affected:All identified reportable incidents not previously investigated were immediately reviewed and reported if reportable criteria met. Investigations were initiated for each event, with statements obtained from involved staff, residents, and witnesses. Affected residents were assessed for safety and psychosocial impact. Interventions were provided as appropriate. Staff were re-educated on incident reporting and investigation protocols. How the facility will identify other residents who may have been affected:A 30-day lookback audit was conducted by the ED/DOW or designee to review all incident reports, nurse’s notes, 24-hour reports, and grievance logs to identify any potential reportable events. Each identified incident was addressed through a full investigation, and state reporting was completed as needed. Residents involved were reassessed to ensure their safety and well-being. What systemic changes will be made to ensure this deficient practice does not recur:All staff received mandatory re-education on identifying and immediately reporting suspected abuse, neglect, misappropriation, or injury of unknown origin and the facility’s obligation to conduct and document a timely, thorough investigation. A workflow guide was implemented to assist staff through proper identification, categorization, and escalation of reportable events. How the corrective action will be monitored to ensure the deficiency is corrected and does not recur:The ED/DOW/designee will review all incident reports daily to ensure appropriate investigation has been initiated as needed, determination of reportability is made and documented, and state agency notifications (when required) are completed within regulatory timeframes. A weekly audit of all incidents will be conducted for 12 weeks by DOW/ED/designee. All findings will be reviewed in monthly QAPI/QMP meetings for trend analysis and further action if needed. Date of Compliance: 11/23
10/1/2025Licensure Complaint · ID J2BS112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An involuntary discharge appeal survey, prompted by #CO40871, was completed on 10/9/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0816Pol/Proc Dschrg GrievanceS/S B▼
Findings
Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S (A-I), affecting 137 current residents. Findings include: On 9/30/25 at 7:00 a.m., the Involuntary Discharge Grievance Policy was requested; however, the residence was unable to provide the policy. On 10/1/25 at 11:00 a.m., the administrator stated she was unaware of the state regulation which required the residence to have the Involuntary Discharge Grievance Policy, as the corporate office was responsible for creating the policies and procedures. On 10/1/25 at 11:00 a.m., the executive director confirmed the administrator's statement and stated that he was also unaware of the current state regulation.
Plan of correction · submitted by the facility
How the deficiency was corrected for the residents affected:The deficiency was corrected by staff education on proper procedure in the event of a grievance. Going forward, increased documentation of all incidents or allegations will allow us to maintain compliance with the written policy, as well as adherence to known timelines. We will continueHow the facility will identify other residents who may have been affected:Staff will perform an audit of past grievances to review past policy implementation to review adherence to said policy. What systemic changes will be made to ensure this deficient practice does not recur:The education of staff on current written policy and procedure. Staff will include the corporate office in the grievance process. Staff will implement increased documentation. The policy will be reviewed with the QAPI/QMP Committee. Date of Compliance: 12/3/2025
1072Res Ad/D/C-D/C Invol D/C-Wrtn Ntc ReqS/S A▼
Findings
Based on interview and record review, the residence failed to include on the discharge notice statements conveying that the individual receiving the notice had a right to file a grievance within 14 days of receiving the notice and that if a grievance was filed, the residence must provide a response within five business days, affecting one resident (#15). Findings include: Resident #15 was admitted to the residence on 2/7/24. A 30-day discharge notice, dated 8/26/25, read in part, Resident #15 was given a 30-day notice to vacate the residence related to repeated violation of the Resident Agreement and/or House Rules and violating the Behavioral Contract that was dated and signed on 5/19/25. However, the 30-day discharge notice did not include all of the required elements, which should have included statements conveying that the individual receiving the notice had a right to file a grievance within 14 days of receiving the notice, and that if a grievance was filed, the residence must provide a response within five business days. On 10/1/25 at 11:00 a.m., the administrator stated she was unaware that the above elements were a requirement and should have been included in the 30-day discharge notice. On 10/1/25 at 11:00 a.m., the executive director stated he was also unaware of the requirement.
Plan of correction · submitted by the facility
How the deficiency was corrected for the residents affected:The deficiency was corrected by staff education on proper procedure in the event of a grievance. Going forward, increased documentation of all incidents or allegations will allow us to maintain compliance with the written policy, as well as adherence to known timelines. We will continueHow the facility will identify other residents who may have been affected:Staff will perform an audit of past grievances to review past policy implementation to review adherence to said policy. What systemic changes will be made to ensure this deficient practice does not recur:The education of staff on current written policy and procedure. Staff will include the corporate office in the grievance process. Staff will implement increased documentation. The policy will be reviewed with the QAPI/QMP Committee.
12/3/2024Revisit: Licensure Complaint · ID 8PRJ121 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 12/4/24 for all previous deficiencies cited on 7/5/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S A▼
Findings
Based on observation and interview, the residence failed to make available a physically safe and sanitary environment, either directly or indirectly through a resident agreement affecting one of 13 sample residents (#3). This deficiency was cited previously during a licensure complaint survey 7/5/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #3 was admitted to the residence on 2/2/22. On 12/4/24 at approximately 8:30 a.m., Resident #3's room had a strong foul odor. On 12/4/24 at 8:35 a.m., Staff #6 stated the smell in Resident #3's room was urine and that Resident #3 sometimes had bladder accidents in her bed. On 12/4/24 at approximately 9:00 a.m., Staff #3 said Resident #3's room smelled like urine since she started working at the residents approximately two months prior to the onsite visit. On 12/4/24 at 10:45 a.m., Staff #5 said Resident #3's room smelled like urine because she had bladder accidents in her bed. She added she had just changed her sheets the morning of the onsite visit because they were soiled with urine. Staff #5 said Resident #3 sometimes refused to be changed and as a result she had bladder accidents in bed. On 12/3/24 at 11:19 a.m., an external service hospice representative said two months prior to the onsite visit, Resident #3's room smelled like urine because Resident #3 sometimes refused to let staff assist her to the bathroom. On 12/4/24 at approximately 12:00 p.m., the director of wellness said she was not aware Resident #3's room had a urine smell. She added Resident #3 refused showers and staff assistance with toileting. On 12/4/24 at 12:25 p.m., the administrator said staff checked on Resident #3 every two hours for incontinence reminders and that Resident #3 took herself to the restroom. She added she was not aware Resident #3's room smelled like urine and staff should have brought the concern to her attention.
Plan of correction · submitted by the facility
The facility will ensure that a physically safe and sanitary environment is made available to all residents by ensuring that residents follow the house rules. All staff will be educated about having a physically safe and sanitary environment and the process of ensuring residents are compliant with the house rules Audits of a sample of resident rooms will be completed monthly for three months by DOW or Designee. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
12/3/2024Revisit: Licensure Complaint · ID 17R813No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 12/4/24 for the previous deficiency cited on 7/5/23. The residence is in compliance with all regulations surveyed. The deficiency cited for Event 17R812 was cited prior to the regulation revision that was implemented on 7/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
12/3/2024Revisit: Licensure Complaint · ID 638U12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 12/4/24 for all previous deficiencies cited on 7/5/23. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event 638U11 were cited prior to the regulation revision that was implemented 3/16/24.
Plan of correction
The state did not require a plan of correction for this citation.
12/3/2024Licensure and Licensure Complaint (Combined) · ID D3ZH118 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaints #CO33315, CO34623, and CO38029 was completed on 12/4/24. Deficiencies were cited. The residence consisted of two separate buildings: Serenity and Harmony.
Plan of correction
The state did not require a plan of correction for this citation.
1382Res Rghts-House Rules Violation/InclS/S B▼
Findings
Based on observation, interview and record review, the residence failed to implement actions when a house rule was knowingly violated by a resident, affecting 89 residents in the Serenity house. (Cross-reference S2510) Findings include:On 12/3/24 at approximately 9:00 a.m., and on 12/4/24 at approximately 10:00 a.m., two residents were smoking in a non-designated smoking area within 25 feet of the front door of the residence. The residence ' s house rules, dated 1/31/23, read in part: "Smoking is not permitted, including the use of electronic cigarettes and vaporizers anywhere in the (residence) or in individual units by residents, guests, or employees. Smoking areas are located outside at either side of the buildings. Colorado law prohibits smoking within 25 (feet) of an entrance." The house rules did not list actions which the residence may take should any rule be violated by a resident. On 12/3/24 at approximately 8:00 a.m., the administrator stated that she was unaware the residence was required to list possible actions to take should house rules be broken. On 12/4/24 at approximately 2:00 p.m., the administrator acknowledged that residents smoked in areas not designated for smoking, despite the house rules, and she took no action except to ask the residents not to do so.
Plan of correction · submitted by the facility
(Cross-reference S2510)The residence will ensure that actions for violation of house rules be made evident and enforced for all residents, a notice of update house rules will be provided to each resident. Education for all directors will be provided on the house rules and actions that can be enforced. Monthly audit by ED or designee to ensure compliance with the house rules and actions being enforced. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
1410Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S A▼
Findings
Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one of 13 sample residents (#3). Findings include:1. Resident #3 was admitted to the residence on 2/2/22. A hand written external hospice note, dated 11/15/24, read Resident #3 had a new bruise to her left hand. Another external hospice note, dated 11/29/24, read Resident #3 had purple discoloration to her right hand. There was no documentation in the resident record for Resident #3 that the residence conducted an internal investigation regarding the bruising to her hands in November 2024. On 12/4/24 at approximately 2:00 p.m., the director of wellness said she was not aware of the external hospice documentation regarding bruising on Resident #3's hands. She added that the residence did not conduct an investigation into the injuries, as required. 2. InterviewOn 12/4/24 at 3:15 p.m., the administrator said when a resident had a bruise of unknown origin she expected the residence staff to investigate and document the findings. She added she was not aware of the bruises on Resident #3 that the external hospice provider documented in November 2024.
Plan of correction · submitted by the facility
The facility will ensure that all policies and procedures for identifying, reporting, and investigating injuries of unknown origin are followed. All care staff and outside providers will be educated on the policy and procedures for identifying, reporting, and investigating injuries of unknown origin. Monthly audit of resident skin sheets and hospice documentation will be completed by DOW or designee to ensure all injuries of unknown origin have a corresponding investigation and reporting requirements are being followed. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
1530Med/Med Adm-Gen Rq Pract OrdrS/S A▼
Findings
Based on record review and interview, the residence failed to only administer medications ordered by an authorized practitioner, affecting three of 13 sample residents (#3, #5, #10). Findings include:1. Resident #3 was admitted to the residence on 2/2/22. The November 2024 medication administration record (MAR) read to administer azithromycin two 250 mg tablets once daily then one 250 mg tablet daily for five days. The residence administered the medication on 11/4-11/9/24, for a total of seven doses administered. There was no corresponding signed practitioner's order for the azithromycin in Resident #3's record. On 12/4/24 at approximately 12:00 p.m., the director of wellness acknowledged the residence administered azithromycin to Resident #3 and did not obtain a corresponding signed practitioner's order. 2. Similar deficient practice was found for Residents #5 and #10.3. On 12/4/24 at 3:15 p.m., the administrator said she expected the residence to have corresponding signed practitioner's orders for all medications they administered to residents.
Plan of correction · submitted by the facility
The facility will ensure each resident medication order corresponds with a signed practitioner’s order. All medication administration staff will be educated on the policy and requirements of ensuring a signed practitioner order corresponds for medication that is being administered. Audits will be done monthly by DOW or designee for three months on resident orders to ensure a corresponding signed practitioner order is provided for each resident. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
1566Med/Med Adm-Ordrs Ordr ClrfctnS/S A▼
Findings
Based on record review and interview, the residence failed to contact the authorized practitioner for clarification of unclear orders and failed to obtain new orders in writing, affecting one of 13 sample residents (#2). Findings include:1. Resident #2 was admitted to the residence on 2/1/11 with diagnoses including chronic pain.a. Lidocaine 5% CreamA written practitioner's order, dated 9/16/24, directed the residence to administer lidocaine 5% cream to affected areas once daily at bedtime. However, the practitioner's order did not list how much was to be applied and to what affected area. b. Diclofenac Sodium Gel 1%A written practitioner's order, dated 9/11/24, directed the residence to administer 2 grams of diclofenac sodium 1% gel to affected areas four times daily. However, the practitioner's order did not list the affected area for staff to apply the medication. On 12/4/24 at 11:39 a.m., the director of wellness said the residence should have contacted the practitioner and clarified the lidocaine and diclofenac orders for Resident #3. On 12/4/24 at approximately 3:15 p.m., the administrator said she expected the staff to contact practitioners to clarify all unclear practitioners orders.
Plan of correction · submitted by the facility
The facility will ensure clarification for unclear orders is obtained in writing for all residents. Education for medication administration staff will be provided on obtaining clarification on unclear orders. Audits will be done monthly by DOW or designee for three months on resident orders being clear. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼
Findings
Based on interview and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting two of 13 sample residents (#2, #4). Findings include:1. Resident #2 was admitted to the residence on 12/1/11 with diagnoses including chronic pain.a. Lidocaine 5% CreamA written practitioner's order, dated 9/16/24, directed the residence to administer lidocaine 5% cream to affected areas once daily. However, the September and October 2024 medication administration records (MARs) for Resident #2 read the residence failed to administer the medication on 9/16, 10/8-10/12, 10/14-10/16/24 because the medication was unavailable, for a total of nine missed doses. On 12/4/24 at approximately 11:45 a.m., the director of wellness (DOW) acknowledged that the residence did not administer the medication, as required. b. DuloxetineA written practitioner's order, dated 9/11/24, directed the residence to administer duloxetine 30 mg daily. However the October 2024 MAR for Resident #2 read the residence failed to administer the medication on 10/16 and 10/17/24 because it was unavailable, for a total of two missed doses. On 12/4/24 at approximately 11:45 a.m., the DOW acknowledged the medication was not administered, as required. c. XareltoA written practitioner's order, dated 9/11/24, directed the residence to administer Xarelto 10 mg daily. However, the October 2024 MAR for Resident #2 read the residence failed to administer the medication on 10/16/24 because it was not available. On 12/4/24 at approximately 11:45 a.m., the DOW acknowledged the medication was not administered, as required. d. Lidocaine 4% PatchA written practitioner's order, dated 9/11/24, directed the residence to apply Lidocaine patch 4% between the resident's shoulders. However, the October 2024 MAR read the residence failed to administer the medication on 10/14/24 because it was not available. On 12/4/24 at approximately 11:45 a.m., the DOW acknowledged the medication was not administered, as required. e. Hydrocodone-AcetaminophenA written practitioner's order, dated 9/11/24, directed the residence to administer hydrocodone-acetaminophen 5-325 mg four times daily. However, the December 2024 MAR read the residence failed to administer the medication for one dose because Resident #2 was absent from the residence. On 12/4/24 at approximately 11:45 p.m., the DOW acknowledged the residence did not pack up Resident #2's medications when she went out for the day. 2. Similar deficient practice was found for Resident #4.3. On 12/4/24 at approximately 3:15 p.m., the administrator said she expected the residence to administer resident medications as ordered and not run out of stock.
Plan of correction · submitted by the facility
The facility will ensure that medication required to be administered per physician orders is available to the resident. All medication administration staff will be educated on the policy and requirements of ensuring stock of medication on-site and notification of low-stock. Audits to be done weekly for three months by DOW or designee to ensure proper stock of medication on site for residents. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
1600Med/Med Adm-Rcrd Kpng MARS/S A▼
Findings
Based on interview and record review, the residence failed to accurately document each medication administration event at the time the event was completed and failed to document accurate information in the medication administration record (MAR), including omissions and refusals, affecting one of 13 sample residents (#2). Findings include:1. Resident #2 was admitted to the residence on 12/1/11.a. TorsemideA written practitioner's order, dated 9/11/24, directed the residence to administer torsemide 20 mg daily. However, the November 2024 MAR read that the residence did not administer the medication on 11/16/24. On 12/4/24 at 11:39 a.m., the director of wellness said she was unaware whether the medication was administered.b. HydrocodoneA written practitioner's order, dated 9/11/24, directed the residence to administer hydrocodone 5-325 mg four times daily. However, the October 2024 MAR had a blank space on 10/14/24 at 5:00 a.m. On 12/4/24 at 11:30 a.m., the director of wellness said she was unaware whether the medication was administered. On 12/4/24 at approximately 3:15 p.m., the administrator said she expected staff to accurately document medication administration in the MARs.
Plan of correction · submitted by the facility
All medication will be administered and documented accurately on the MAR.All medication administration staff will be educated on the policy and requirements of accurately documenting medication administration on the MAR. Audits will be done monthly for three months by DOW or designee to ensure accurate documentation is provided on resident MARs. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
2230HIR-Cntnt IncldS/S A▼
Findings
Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed or was reported to them and retain documentation of on-going services by an external provider for two of 13 sample residents. (#3, #6)Findings include:1. Resident #2 was admitted to the residence on 2/22/22. On 12/4/24 at approximately 12:00 p.m., the director of wellness said that one month prior to the onsite visit, Resident #2 had some symptoms of a urinary tract infection (UTI); a urinalysis confirmed she did have a UTI and was prescribed antibiotics. Resident #2's record did not contain any progress notes about Resident #2's UTI symptoms or diagnosis in November 2024. On 12/24/24 at 12:25 p.m., the administrator said she expected staff to document in the progress notes about Resident #2's UTI symptoms and diagnosis. 2. There was similar deficient practice for Resident #6.
Plan of correction · submitted by the facility
The facility will ensure that all outside provider documentation is obtained by the facility to be included in the resident record in a timely manner after any outside visits. Staff members will document prior to the end of their shift any out of the ordinary event or issue they observed and follow up. All care staff will be educated on the expectation of obtaining documentation after any outside visits for residents as well as completing their own documentation on any out of the ordinary event or issues observed on shift. Resident documentation audits will be completed monthly by DOW or designee for three months. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed
2720In Env-Smkng CCIAAS/S B▼
Findings
Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act and maintain a smoke free entryway, affecting 89 residents who resided in Serenity house. On 12/3/24 and 12/4/24, two residents were observed smoking in the non designated smoking area within 25 feet of the residence's front entrance door. On 12/4/24 at approximately 8:00 a.m., the administrator acknowledged awareness of residents smoking in the non-smoking area and reported having asked them to refrain from doing so. Resident council notes from September 2024 reflected resident frustration about residents smoking by the front door.
Plan of correction · submitted by the facility
The facility will ensure compliance with the Colorado Clean Indoor Air Act. All staff will be educated on the Colorado Clean Indoor Air Act and its implications. Audits of residents smoking in designated smoking areas will be performed for three months by ED or Designee. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 12.10 Each resident care plan shall:(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence's visitation policy as required by Part 9.2, along with care coordination arrangements. 13.4 The house rules shall list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident. House rules shall not supersede or contradict any regulation herein, or in any way discourage or hinder a resident's exercise of his or her rights. House rules shall address, at a minimum, the following items: Consumption of alcohol and marijuana.
Plan of correction
The state did not require a plan of correction for this citation.
12/3/2024State Certification and State Certification Complaint (Combined) · ID QRME116 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey with complaints #CO38030, CO34624, and CO33316 was completed on 12/4/24. Deficiencies were cited. The residence consisted of two separate buildings: Serenity and Harmony.
Plan of correction
The state did not require a plan of correction for this citation.
0140Ind Rts-AdtlCrit-ProvOwn/Ctrl-Res-Wrtn Agrmnt▼
Findings
Based on interview and record review, the facility's lease agreement failed to specify the services to be provided, the charges associated with the services, and written disclosures of that information, affecting nine sample members. Findings include: On 12/4/24 a review of the resident agreements for Members #1-#4 and #8-#12 revealed a fluctuation in room and board fees that were not reviewed nor acknowledged by members. On 12/4/24 at 12:29 p.m., the administrator said resident agreements were not being reviewed and updated annually because she was not aware of the requirement.
Plan of correction · submitted by the facility
The residence will record and review the facility’s lease agreement specifying the services provided, charges associated with the services and written disclosure of that information for all ACF residents annually with documented signature of member. All affected residents will have documented review with signature in their charts by January 17th, 2025. An audit of all other ACF resident charts to ensure compliance will be conducted by ED or designee. Residents without written review with signature will be provided the form for signature. Rate changes and care changes for all ACF residents will be audited monthly by Administrator or Designee to ensure compliance with signature of notification and documentation of review of change for 3 months. The results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed.
0882PA Req-IR-Critical Incidents▼
Findings
Based on interview and record review the facility failed to notify a member's case management agency case manager of a critical incident within 24 hours of discovery of the actual or alleged Incident. Findings include:8.7000 regulations, governing alternative care facilities, defines a critical incident as an actual or alleged event to include abuse. Resident #7 was admitted to the facility on 12/4/24 with diagnoses which included alcohol abuse, mixed confusion, and post traumatic stress syndrome (PTSS). An occurrence report, dated 9/12/24, revealed Member #7 was named as the victim of an alleged abuse allegation. The occurrence did not indicate that staff notified Member #7's case manager. On 12/4/24 at 3:00 p.m., the administrator said that staff did not notify Member #7's case manager or the case management agency of the critical incident. The administrator said she was not aware of this requirement.
Plan of correction · submitted by the facility
Facility will ensure notification to a member’s case manager within 24 hours of discovery of alleged or actual critical incidents. All incidents involving ACF residents will be audited monthly for three months to ensure compliance with notification requirements by ED or Designee. Education for directors of notification requirements will be provided. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼
Findings
Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting two of 13 sample residents (#2, #4). Findings include:1. Resident #2 was admitted to the residence on 12/1/11 with diagnoses including chronic pain.a. Lidocaine 5% CreamA written practitioner's order, dated 9/16/24, directed the residence to administer lidocaine 5% cream to affected areas once daily. However, the September and October 2024 medication administration records (MARs) for Resident #2 read the residence failed to administer the medication on 9/16, 10/8-10/12, 10/14-10/16/24 because the medication was unavailable, for a total of nine missed doses. On 12/4/24 at approximately 11:45 a.m., the director of wellness (DOW) acknowledged that the residence did not administer the medication, as required. b. DuloxetineA written practitioner's order, dated 9/11/24, directed the residence to administer duloxetine 30 mg daily. However the October 2024 MAR for Resident #2 read the residence failed to administer the medication on 10/16 and 10/17/24 because it was unavailable, for a total of two missed doses. On 12/4/24 at approximately 11:45 a.m., the DOW acknowledged the medication was not administered, as required. c. XareltoA written practitioner's order, dated 9/11/24, directed the residence to administer Xarelto 10 mg daily. However, the October 2024 MAR for Resident #2 read the residence failed to administer the medication on 10/16/24 because it was not available. On 12/4/24 at approximately 11:45 a.m., the DOW acknowledged the medication was not administered, as required. d. Lidocaine 4% PatchA written practitioner's order, dated 9/11/24, directed the residence to apply Lidocaine patch 4% between the resident's shoulders. However, the October 2024 MAR read the residence failed to administer the medication on 10/14/24 because it was not available. On 12/4/24 at approximately 11:45 a.m., the DOW acknowledged the medication was not administered, as required. e. Hydrocodone-AcetaminophenA written practitioner's order, dated 9/11/24, directed the residence to administer hydrocodone-acetaminophen 5-325 mg four times daily. However, the December 2024 MAR read the residence failed to administer the medication for one dose because Resident #2 was absent from the residence. On 12/4/24 at approximately 11:45 p.m., the DOW acknowledged the residence did not pack up Resident #2's medications when she went out for the day. 2. Similar deficient practice was found for Resident #4.3. On 12/4/24 at approximately 3:15 p.m., the administrator said she expected the residence to administer resident medications as ordered and not run out of stock.
Plan of correction · submitted by the facility
The facility will ensure that medication required to be administered per physician orders is available to the resident. All medication administration staff will be educated on the policy and requirements of ensuring stock of medication on-site and notification of low-stock. Audits to be done weekly for three months by DOW or designee to ensure proper stock of medication on site for residents. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
0924PA Req-Med Admin-Rx/PRN-Orders▼
Findings
Based on interview and record review the facility (residence) failed to ensure the licensed medical provider's order was maintained in the member's (resident's) record, affecting three of 13 sample residents (#3, #5, #10). 1. Resident #3 was admitted to the residence on 2/2/22. The November 2024 medication administration record (MAR) read administer azithromycin two 250 mg tablets once daily then one 250 mg tablet daily for five days. The medication was administered on 11/4-11/9/24, for a total of seven doses administered. There was no corresponding signed practitioner's order for the azithromycin in Resident #3's record. On 12/4/24 at approximately 12:00 p.m., the director of wellness acknowledged the residence administered azithromycin to Resident #3 and did not obtain a corresponding signed practitioner's order. 2. Similar deficient practice was found for Residents #5 and #10.3. On 12/4/24 at 3:15 p.m., the administrator said she expected the residence to have corresponding signed practitioner's orders for all medications they administered to residents.
Plan of correction · submitted by the facility
The facility will ensure each resident medication order corresponds with a signed practitioner’s order. All medication administration staff will be educated on the policy and requirements of ensuring a signed practitioner order corresponds for medication that is being administered. Audits will be done monthly by DOW or designee for three months on a sample of resident orders to ensure a corresponding signed practitioner order is provided for each resident. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
0926PA Req-Med Admin-Rx/PRN-Records▼
Findings
Based on record review and interview, the facility (residence) failed to ensure each qualified medication administration person (QMAP) accurately recorded all medications administered, affecting one of 13 sample members (residents) (#2). Findings include:1. Resident #2 was admitted to the residence on 12/1/11.a. TorsemideA written practitioner's order, dated 9/11/24, directed the residence to administer torsemide 20 mg daily. However, the November 2024 MAR read that the residence did not administer the medication on 11/16/24. On 12/4/24 at 11:39 a.m., the director of wellness said she was unaware whether the medication was administered.b. HydrocodoneA written practitioner's order, dated 9/11/24, directed the residence to administer hydrocodone 5-325 mg four times daily. However, the October 2024 MAR had a blank space on 10/14/24 at 5:00 a.m. On 12/4/24 at 11:30 a.m., the director of wellness said she was unaware whether the medication was administered. On 12/4/24 at approximately 3:15 p.m., the administrator said she expected staff to accurately document medication administration in the MARs.
Plan of correction · submitted by the facility
All medication will be administered and documented accurately on the MAR.All medication administration staff will be educated on the policy and requirements of accurately documenting medication administration on the MAR. Audits will be done monthly for three months by DOW or designee to ensure accurate documentation is provided on resident MARs. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
1350Ben/Svc Req-ACF-PA-Env Standards▼
Findings
Based on observation and interview, the residence (facility) failed to provide access to nutritious food and beverages at all times affecting 89 current residents (members) who resided in Harmony. The residence is split into two homes; house one and house two. The residence failed to provide residents independent access to nutritious food and beverages (including water) in House two. During an environmental tour of house two on 12/4/24 from 10:30 a.m. to 3:30 p.m., the residence only had black coffee and tea available for the residents to drink. On 12/4/24 at 10:30 a.m., an unknown dining staff member stated that sugar and creamer were stored in the kitchen refrigerator behind a locked door, only accessible by the kitchen staff. On 12/4/24 at approximately 10:45 a.m., seven residents stated that they did not have independent access to snacks, coffee condiments, and water. They continued to say they had to ask a kitchen staff member when they needed those items. On 12/4/24 at approximately 3:00 p.m., the administrator confirmed that residents had not had independent access to snacks and beverages at all times for at least one week prior to the onsite visit due to the chef resigning. She said that she was aware of the requirement but chose to stop allowing residents independent access to snacks and coffee condiments after staff reported hoarding behaviors.
Plan of correction · submitted by the facility
The facility will ensure to always make snacks and beverages available for all residents. All directors and culinary staff will be educated on the requirement to ensure beverages and snacks are always available. Audits of this will be done monthly for three months by ED or Designee The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
12/3/2024Revisit: Licensure Complaint · ID TZ3L131 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 12/4/24 for the previous deficiency cited on 7/5/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S A▼
Findings
Based on observation and interview, the residence failed to make available a physically safe and sanitary environment, either directly or indirectly through a resident agreement affecting one of 13 sample residents (#3). This deficiency was cited previously during a complaint revisit on 7/5/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #3 was admitted to the residence on 2/2/22. On 12/4/24 at approximately 8:30 a.m., Resident #3's room had a strong foul odor. On 12/4/24 at 8:35 a.m., Staff #6 stated the smell in Resident #3's room was urine and that Resident #3 sometimes had bladder accidents in her bed. On 12/4/24 at approximately 9:00 a.m., Staff #3 said Resident #3's room smelled like urine since she started working at the residents approximately two months prior to the onsite visit. On 12/4/24 at 10:45 a.m., Staff #5 said Resident #3's room smelled like urine because she had bladder accidents in her bed. She added she had just changed her sheets the morning of the onsite visit because they were soiled with urine. Staff #5 said Resident #3 sometimes refused to be changed and as a result she had bladder accidents in bed. On 12/3/24 at 11:19 a.m., an external service hospice representative said two months prior to the onsite visit, Resident #3's room smelled like urine because Resident #3 sometimes refused to let staff assist her to the bathroom. On 12/4/24 at approximately 12:00 p.m., the director of wellness said she was not aware Resident #3's room had a urine smell. She added Resident #3 refused showers and staff assistance with toileting. On 12/4/24 at 12:25 p.m., the administrator said staff checked on Resident #3 every two hours for incontinence reminders and that Resident #3 took herself to the restroom. She added she was not aware Resident #3's room smelled like urine and staff should have brought the concern to her attention.
Plan of correction · submitted by the facility
The facility will ensure that a physically safe and sanitary environment is made available to all residents by ensuring that residents follow the house rules. All staff will be educated about having a physically safe and sanitary environment and the process of ensuring residents are compliant with the house rules. Audits of a sample of resident rooms will be completed monthly for three months by DOW or Designee. The results of these audits will be brought to the IDT for monthly QAPI meeting and performance improvement plans will be developed as needed.
7/5/2023Licensure Complaint · ID 8PRJ112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO32502, was completed on 7/5/23. Deficiencies were cited. The residence consisted of two separate buildings: Serenity and Harmony.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observations and interviews, the residence failed to provide a physically safe and sanitary environment affecting 21 residents on the first floor of the Serenity building. Findings include:On 7/5/23 from approximately 7:30 a.m. to 12:00 p.m. an environmental tour of the Serenity building revealed the following:The carpeting in the common hallways on the first floor was heavily soiled with dark staining approximately two feet wide in the middle of the hallways throughout the entire first floor. The carpeting leading into Resident #2's room had dark colored soiling approximately two feet by one foot in size. Maintenance logs dated 4/1/23 to 7/1/23 read the hallway on the first floor of the serenity building was shampooed due to carpet smelling of urine. There was a build up of dust and debris on the flooring throughout Resident #1's room. On 7/5/23 at approximately 8:30 a.m. Resident #1 stated housekeeping was supposed to clean his room once per week; however, they did not clean the floors. Resident #1 further stated the last time his room was cleaned was by his family member approximately two weeks prior to the onsite visit. On 7/5/23 at approximately 2:30 p.m. the administrator stated Resident #1's room was cleaned every other week and was not sure why there was a build up of dust. Additionally the administrator acknowledged that the carpeting throughout the first floor was stained.
Plan of correction · submitted by the facility
Quarterly carpet extraction schedule to be implemented immediately to ensure cleanliness of hallway carpeting. Monthly audits of the hallway by maintenance or designee will be conducted for three months to ensure cleanliness of hallway carpeting. The results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed.
2520In Env-H/L/VentS/S A▼
Findings
Based on observations and interviews the residence failed to provide sufficient ventilation sufficient to meet the needs of the residents affecting one of two sample residents (#1). Findings include:On 7/5/23 at approximately 8:45 a.m. Resident #1 was laying in his bed without any covers and a fan pointed at him. On 7/5/23 at 9:07 a.m. the temperature in Resident #1's room was 81.3 degrees Fahrenheit. On 7/5/23 at approximately 9:10 a.m. Resident #1 stated his air conditioner had not been functioning for approximately one week. He stated that the air conditioning unit was replaced with a brand new one; however, there was an electrical problem and they were not able to connect the air conditioner to power. Resident #1 further stated he was told that they would connect the air conditioner to power; however it was not completed. He stated if he stayed still and kept the fans on he was ok; however, would be more comfortable if the air conditioner was working properly. On 7/5/23 at approximately 9:10 a.m. the surveyor attempted to turn on Resident #1's air conditioning unit; however, it was not functional. On 7/5/23 at approximately 11:30 a.m. the temperature in Resident #1's room was 82.9 degrees. On 7/5/23 at approximately 2:00 p.m. the administrator confirmed that Resident #1's air conditioner was not functional; however, she thought it had been repaired over the weekend prior to the onsite visit. At 2:30 p.m. the administrator confirmed with maintenance personnel that the air conditioner remained nonfunctional as there was an electrical problem.
Plan of correction · submitted by the facility
The unit for resident #1 was repaired by an electrician on 7/5/2023. EVS staff will be provided with education regarding expectations and notification to administrator around ventilation not operating sufficiently. Weekly random room audits of at least five rooms will be conducted by maintenance or designee for three months to ensure proper ventilation is kept throughout the rooms. The results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed
7/5/2023Revisit: Licensure Complaint · ID 17R8121 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 7/5/23 for all previous deficiencies cited on 12/29/22. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0626Acf-Prov Role/Resp Env StndsS/S A▼
Findings
Based on observations and interviews the facility (residence) failed to ensure participant (resident) rooms never exceeded 80 degrees affecting one of two sample participants (#1). This deficiency was cited previously during a state licensure complaint on 12/29/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:On 7/5/23 at approximately 8:45 a.m. Resident #1 was laying in his bed without any covers and a fan pointed at him. On 7/5/23 at 9:07 a.m. the temperature in Resident #1's room was 81.3 degrees Fahrenheit. On 7/5/23 at approximately 9:10 a.m. Resident #1 stated his air conditioner had not been functioning for approximately one week. He stated that the air conditioning unit was replaced with a brand new one; however, there was an electrical problem and they were not able to connect the air conditioner to power. Resident #1 further stated he was told that they would connect the air conditioner to power; however it was not completed. He stated if he stayed still and kept the fans on he was ok; however, would be more comfortable if the air conditioner was working properly. On 7/5/23 at approximately 9:10 a.m. the surveyor attempted to turn on Resident #1's air conditioning unit; however, it was not functional. On 7/5/23 at approximately 11:30 a.m. the temperature in Resident #1's room was 82.9 degrees. On 7/5/23 at approximately 2:00 p.m. the administrator confirmed that Resident #1's air conditioner was not functional; however, she thought it had been repaired over the weekend prior to the onsite visit. At 2:30 p.m. the administrator confirmed with maintenance personnel that the air conditioner remained nonfunctional as there was an electrical problem.
Plan of correction · submitted by the facility
This A/C Unit was repaired by an electrician on 7/5/2023Staff will be provided with education regarding expectations and notification to administrator or designee around rooms exceeding temperatures of 80 degrees Weekly random room audits of at least five rooms will be conducted by maintenance or designee for three months to ensure proper room temperaturesThe results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed
7/5/2023State Certification Complaint · ID 638U112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO32503, was completed on 7/5/23. Deficiencies were cited. The facility consisted of two separate buildings: Serenity and Harmony.
Plan of correction
The state did not require a plan of correction for this citation.
0626Acf-Prov Role/Resp Env StndsS/S B▼
Findings
Based on observations and interviews the facility (residence) failed to ensure participant (resident) rooms never exceeded 80 degrees affecting one of two sample participants (#1). Findings include:On 7/5/23 at approximately 8:45 a.m. Resident #1 was laying in his bed without any covers and a fan pointed at him. On 7/5/23 at 9:07 a.m. the temperature in Resident #1's room was 81.3 degrees Fahrenheit. On 7/5/23 at approximately 9:10 a.m. Resident #1 stated his air conditioner had not been functioning for approximately one week. He stated that the air conditioning unit was replaced with a brand new one; however, there was an electrical problem and they were not able to connect the air conditioner to power. Resident #1 further stated he was told that they would connect the air conditioner to power; however it was not completed. He stated if he stayed still and kept the fans on he was ok; however, would be more comfortable if the air conditioner was working properly. On 7/5/23 at approximately 9:10 a.m. the surveyor attempted to turn on Resident #1's air conditioning unit; however, it was not functional. On 7/5/23 at approximately 11:30 a.m. the temperature in Resident #1's room was 82.9 degrees. On 7/5/23 at approximately 2:00 p.m. the administrator confirmed that Resident #1's air conditioner was not functional; however, she thought it had been repaired over the weekend prior to the onsite visit. At 2:30 p.m. the administrator confirmed with maintenance personnel that the air conditioner remained nonfunctional as there was an electrical problem.
Plan of correction · submitted by the facility
This A/C Unit was repaired by an electrician on 7/5/2023Staff will be provided with education regarding expectations and notification to administrator or designee around rooms exceeding temperatures of 80 degrees Weekly random room audits of at least five rooms will be conducted by maintenance or designee for three months to ensure proper room temperaturesThe results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed
0646Acf-Prov Role/Resp-Staff Req MinS/S B▼
Findings
Based on record review and interview the facility failed to ensure there was at least one staff member for every 10 participants during the daytime hours and one staff member for every 16 participants during the nighttime shift, affecting 134 current participants. Findings include:1. ReferenceRegulations governing alternative care facilities 10 CCR 2505-10 section 8.495.6. I.3 read, an approved staffing waiver is only applicable for nighttime hours, with the exception for secured environments. b. A staffing waiver expires five years from the date of approval. Continuance of staffing waiver requires Department approval. The resident agreement read the the facility's designated daytime hours were from 5:00 a.m. to 5:00 p.m. and the designated nighttime hours were from 5:00 p.m. to 5:00 a.m. The resident agreement additionally read, "absent circumstances beyond the facility's reasonable control, the usual staffing ratio is as follows: a.m. 1:10, p.m. 1:15 and HS (night) 1:24 (in the Harmony building) 1:30 (in the Serenity building). Please note: HS ratio is an approved waiver from the Colorado Department of Health Care Policy and Financing. The residence had a staffing waiver dated 9/9/08, 14 years old, for 1:24 staff to residents in the Harmony building between the hours of 11:00 p.m. and 6:00 a.m. and 1:30 staff to residents in the Serenity building between the hours of 11:00 p.m. and 6:00 a.m. On 7/5/23 the resident roster revealed there were 87 current residents in the Serenity building and 47 current residents in the Harmony building for a total of 134 residents at the facility which would require 14 staff members during the daytime and nine during the nighttime. The May, June and July 2023 staff schedules revealed there were seven staff scheduled between 6:00 a.m. and 6:00 p.m. with an additional three staff working from 2:00 p.m. to 10:00 p.m. and five staff working from 6:00 p.m. to 6:00 a.m. in both buildings. On 7/5/23 at approximately 2:00 p.m. the administrator stated she was not aware of the required staffing ratios and thought she only needed to provide sufficient staff to meet the residents' needs.
Plan of correction · submitted by the facility
All staff have been educated and signed off on how to provide direct care as well as the requirements as it relates to staff to resident ratio. They are to call administrative on call or designee if needed for staffing issues. During daytime hours there is at least one staff member for every 10 participants. During nighttime hours there is at least one staff member for every 16 participants. The schedule will be audited weekly for three months to ensure that the one staff member for every 10 participants is maintained during the day and one staff member for every 16 participants is maintained during the nightThe results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed A staffing waiver application has been submitted, if this is accepted, the nighttime staffing ratio will be one staff member for every 20 participants.
7/5/2023Revisit: Licensure Complaint · ID TZ3L121 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 7/5/23 for all previous deficiencies cited on 12/29/23. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1110Res Care Srvs-Min Srvs Res AgrS/S B▼
Findings
Based on observations and interviews, the residence failed to provide a physically safe and sanitary environment affecting 21 residents on the first floor of the Serenity building. This deficiency was cited previously during a state licensure complaint on 12/29/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:On 7/5/23 from approximately 7:30 a.m. to 12:00 p.m. an environmental tour of the Serenity building revealed the following:The carpeting in the common hallways on the first floor was heavily soiled with dark staining approximately two feet wide in the middle of the hallways throughout the entire first floor. The carpeting leading into Resident #2's room had dark colored soiling approximately two feet by one foot in size. Maintenance logs dated 4/1/23 to 7/1/23 read the hallway on the first floor of the serenity building was shampooed due to carpet smelling of urine. There was a build up of dust and debris on the flooring throughout Resident #1's room. On 7/5/23 at approximately 8:30 a.m. Resident #1 stated housekeeping was supposed to clean his room once per week; however, they did not clean the floors. Resident #1 further stated the last time his room was cleaned was by his family member approximately two weeks prior to the onsite visit. On 7/5/23 at approximately 2:30 p.m. the administrator stated Resident #1's room was cleaned every other week and was not sure why there was a build up of dust. Additionally the administrator acknowledged that the carpeting throughout the first floor was stained.
Plan of correction · submitted by the facility
Quarterly carpet extraction schedule to be implemented immediately to ensure cleanliness of hallway carpeting Monthly audits of the hallway by maintenance or designee will be conducted for three months to ensure cleanliness of hallway carpeting The results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed

Reportable Occurrences

31 records
6/5/2026Misappropriation of Property · ID 262304ST011Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/5/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) reported their necklace had been missing from their apartment since 5/28/26. During the course of the investigation, the healthcare entity searched for the item, contacted police, and conducted interviews. Client (A)'s representative confirmed seeing it last on 5/28/26. Staff reported unawareness of the necklace. The facility educated client (A) on storing their valuables in their locked box. The facility was unable to identify any alleged assailants; the item is still missing. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 7/13/2026 · released to the public 7/20/2026.
5/15/2026Missing Person · ID 262304ST009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/15/26, 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, signed out and left the facility. Client (A) did not return at the communicated time and was missing for 6.5 hours. During the course of the investigation, the healthcare entity conducted a search, contacted police, client (A)'s personal telephone, and medical providers, reviewed records, and conducted interviews. Client (A) had a history of client (A) being an unhoused person. Client (A) returned to the facility unharmed and was assessed by their medical provider with no abnormalities found. The facility educated client (A) on their sign-out process and medication safety if going to be away for long periods of time. 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 7/15/2026 · released to the public 7/22/2026.
4/1/2026Misappropriation of Property · ID 262304ST008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/1/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) reported that a pair of earrings was missing from their apartment and was unable to recall when they last saw them. During the course of the investigation, the healthcare entity searched for the item, conducted interviews, and reviewed records. Client (A) confirmed locking their door when leaving and storing the earring in their locked cabinet. Staff reported being unaware of the item. The facility offered to replace the earrings; however, client (A) denied the offer. The facility educated client (A) on continuing to store their valuables in their locked box and locking their door when leaving. The facility was unable to identify any alleged assailants and was unable to determine if the items were lost or stolen. Due to the results of the investigation being inconclusive, 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 5/19/2026 · released to the public 5/26/2026.
3/18/2026Misappropriation of Property · ID 262304ST006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/19/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) reported that a bottle of perfume was missing from their apartment and last saw it on 3/18/26 in the evening. During the course of the investigation, the healthcare entity searched for the item and conducted interviews. Client (A)'s family confirmed the item being in client (A)'s possession. Staff reported unawareness of the perfume or what happened to it. The facility replaced the item and client (A) to store their valuables in their locked box. The facility was unable to identify any alleged assailants and was unable to determine if the items were lost or stolen. Due to the results of the investigation being inconclusive, 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 5/8/2026 · released to the public 5/15/2026.
3/3/2026Diverted Drugs · ID 262304ST005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/3/26, 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 prevent a future recurrence. The healthcare entity reported diverted drugs. Staff #1 signed for 60 Oxycodone pills from a pharmacy delivery, did not secure them leaving them out and they were gone when they returned from assisting Client (A). During the course of the investigation the healthcare entity attempted to locate the missing medication. The medication was not located, the pharmacy confirmed delivery and provided replacement medications. Staff #1 stated the medications were gone and they requested assistance with looking for them, however, they did not follow policies regarding securing medication. Staff were educated on proper delivery and storage of medications and notifying management of any discrepancy or missing medications. 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 6/23/2026 · released to the public 6/30/2026.
2/11/2026Verbal Abuse · ID 262304ST004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/11/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Client (B) yelled and called client (A) inappropriate names. During the course of the investigation, the healthcare entity separated both clients, ensured they felt safe, contacted police, and conducted interviews. Staff stated they witnessed client (B) raise their cane at client (A). Both clients denied client (B) raising their cane. No injuries were sustained by either client. The facility educated clients on walking away when upset or obtaining staff support. Staff increased monitoring. From the evidence revealed by the facility’s investigation, 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 4/28/2026 · released to the public 5/5/2026.
1/3/2026Verbal Abuse · ID 262304ST002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/2/26, 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 prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Staff #1 reported, Client (A) alleged Staff #2, stated “if you fall I will not help you.” During the course of the investigation the healthcare entity ensured the client felt safe and Staff #2 was suspended during the investigation. The investigation revealed Staff #2 denied the allegation and indicated they are supportive to the clients needs and will continue. Client (A) and their daily report being happy with the services provided. 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 6/9/2026 · released to the public 6/16/2026.
12/23/2025Misappropriation of Property · ID 252304ST010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/30/25, 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 misappropriation of client property. Client (A) alleged a sum of money was stolen from their room. During the course of the investigation, the healthcare entity conducted interviews and contacted police. Client (A) refused to have the facility assist with a search of their room and stated that the money was kept in a locked box in their locked room and that the box did not appear to have been tampered with. Client (A) stated they were the only one with a key and could not identify an assailant. The facility verified that the only second set of keys was with maintenance in a double-locked cabinet. The facility was unable to determine whether the client had that sum of money in their possession or determine what might have happened. No other clients reported concerns with missing items. 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 3/13/2026 · released to the public 3/20/2026.
11/26/2025Diverted Drugs · ID 252304ST009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/26/25, 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 diverted drugs. Client (A)'s medication was missing from the facility upon returning from the hospital on 11/16/25. Client (A) reported giving staff (1) their medication on 11/14/25 prior to going to the hospital. During the course of the investigation, the healthcare entity searched for the medication, conducted interviews, reviewed records, and contacted police and medical providers. Client (A) had no adverse effects when assessed from not receiving their medication. Staff (1) confirmed receiving the medication from client (A) putting it in the locked medication cart, and was unaware of where it went. The facility retrained staff on the procedure when receiving delivered medication, and reordered client (A)'s medication. Client (A) was provided their new medication when delivered. 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 4/2/2026 · released to the public 4/9/2026.
11/14/2025Sexual Abuse · ID 252304ST008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/14/25, 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 sexual abuse of a client. Female Client (A) alleged male Client (B) had sexually assaulted her, including frequent touching without Client (A)’s consent. During the course of the investigation, the healthcare entity separated and assessed the clients, notified law enforcement, and conducted interviews. Client (A) exhibited no visible injuries. Staff confirmed seeing Client (B) touch Client (A)’s back, and both clients confirmed Client (B) would rub Client (A)’s back, occasionally kissing her. Client (A) stated she never asked Client (B) to stop the behaviors, and Client (B) reported he knew to stop if Client (A) requested it. When asked to go to the hospital for further assessment, Client (A) declined and recanted the sexual assault allegation. Both clients were placed on increased monitoring for safety, and staff will provide oversight when the clients are in common areas. Client (A) reported feeling safe in the facility and near Client (B). The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 2/24/2026 · released to the public 3/3/2026.
9/10/2025Diverted Drugs · ID 252304ST007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/10/25, 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 help prevent a future recurrence. The healthcare entity reported diverted drugs. Client (A), who was alert and oriented, requested his as-needed narcotic medication from staff (2), but medication records indicated staff (1) had already administered it on the prior shift. Reportedly, client (A) denied receiving that medication. During the course of the investigation, the healthcare entity suspended staff (1), conducted assessments and interviews, and reviewed records. Management also conducted medication audits, contacted the police, and the medical provider. Client (A) reported no current complaints of pain. Staff (1) reported they administered the medication to client (A). Medication records showed that staff (1) did not document administrations accurately or according to their training. The facility identified three narcotic pills in question as to whether they were administered or not by staff (1). The facility planned to complete weekly medication audits, compare medication records for accuracy, and retrained staff on medication policies and procedures when administering narcotic medications. Staff (1)'s employment was terminated. The findings of a deliberate diversion were inconclusive, and 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 2/27/2026 · released to the public 3/6/2026.
8/23/2025Verbal Abuse · ID 252304ST006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/23/25, 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 verbal abuse of a client. Client (A) stated they were hit with a walker of Client (B). During the course of the investigation the healthcare entity ensured Client (A) felt safe. The investigation revealed no physical touching occurred, however Client (B) did threatening gestures to Client (A) which caused Client (A) to reach in a motion to defend themselves. Video footage revealed this information and other witnesses. Both clients were placed on frequent safety checks. The clients will be kept separated and due to previous behaviors, Client (B) had a discharge date within a week on 8/27/25. 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 1/6/2026 · released to the public 1/15/2026.
8/8/2025Physical Abuse · ID 252304ST005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/8/25, 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 prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) alleged they were pushed by Client (B). Client (B) indicated Client (A) flicked their cigarette in their face before they pushed them. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Video footage only captured the two clients in close proximity and Client (A) falling backwards onto the grass. A pole obstructed the camera's view. Client (A) declined the need for medical services. Client (A) had previously been given a 30 day notice because of negative behaviors. Both clients will stay away from each other, smoke in different designated areas, and earth in their rooms. Staff implemented frequent checks. The case manager and the ombudsman are aware Client (A) will be discharged. 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 12/16/2025 · released to the public 12/23/2025.
7/30/2025Physical Abuse · ID 252304ST004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/30/25, 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. A client was struck in the head while outside on the grounds by an unknown person that wandered onto the property, causing injury. During the course of the investigation, the healthcare entity notified law enforcement, assessed the clients, reviewed video footage, and conducted interviews. Upon review, video footage corroborated the reported incident. The client was placed on frequent safety checks following the incident for monitoring. The facility reported law enforcement increased patrols in the area to reduce the risk of recurrence. A photo of the alleged assailant was posted in the facility and staff have been instructed to contact law enforcement if seen in the area. All clients have been encouraged to move inside if the individual is observed on the grounds. 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 12/23/2025 · released to the public 12/30/2025.
5/9/2025Physical Abuse · ID 252304ST003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/9/25, 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. A client not involved in the event stated Client (A) and (B) were in an altercation. Client (A) stated they bumped into Client (B) on accident before Client (B) swung their cane and they felt contact in their armpit but no pain. Client (B) thought they were defending themselves. Client (B) was educated on walking away when upset or obtaining staff support. The police indicated there was no abuse. 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 10/30/2025 · released to the public 11/6/2025.
3/15/2025Physical Abuse · ID 252304ST002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/15/25, 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. Client (A) alleged Client (B) closed the door on them multiple times. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) had no visible injuries. The camera footage was reviewed and the clients had no interactions with each other. Client (A) was discharged from the facility as previously scheduled on 3/16/25. Staff will continue to report suspected abuse. 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 8/26/2025 · released to the public 9/2/2025.
10/9/2024Verbal Abuse · ID 242304ST010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/9/24, 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 Client (A) felt safe. Client (A) alleged they and Client (B) had a verbal disagreement before Client (B) threatened them. This incident was witnessed by others who denied a threat was made or a gesture. Client (B) denied the threat. The investigation revealed Client (A)’s allegation could not be corroborated. The clients had increased monitoring, frequent checks implemented and were instructed to use different areas of the facility. 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 7/5/2025 · released to the public 7/12/2025.
9/12/2024Sexual Abuse · ID 242304ST009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/12/24, 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 sexual abuse of a client. During the course of the investigation the healthcare entity ensured the client was safe. The client alleged a man was in their bed attempting to pull their pants down. The client could not identify who it was and went to get staff. No one was in the clients room when staff arrived; however the screen on their window was undone. The police were notified and conducted a search. No assailant was identified and they were asked to increase their presence. No staff matched the description provided. Safety devices were added to the clients windows on the first floor. The client refused additional support and the evidence was inconclusive. 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 4/24/2025 · released to the public 5/1/2025.
8/11/2024Physical Abuse · ID 242304ST008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/12/24, 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. Client (B) started a verbal altercation with Client (A) who pushed Client (B). Frequent safety checks were implemented and the clients were instructed to smoke on opposite sides of the facility. Client (B) fell to the ground however stated they were not injured. 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 4/28/2025 · released to the public 5/5/2025.
8/2/2024Verbal Abuse · ID 242304ST007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/5/24, 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. The investigation revealed staff member (1) was witnessed by a family member verbally threatening Client (A). The incident was corroborated by others. Staff member (1)’s employment was terminated. Client (A) was provided with trauma support. All staff were educated on resident rights. 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 5/21/2025 · released to the public 5/28/2025.
7/28/2024Misappropriation of Property · ID 242304ST006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/28/24, 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 suspended staff member (1), conducted interviews, offered reassurance and education on safety to the client, and the use of a lock box for her valuables. 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 2/6/2025 · released to the public 2/13/2025.
5/6/2024Verbal Abuse · ID 242304ST004Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 5/6/24 staff witnessed resident (B) leaving the lobby after staff deescalated a situation. Resident (B) proceeded to tell resident (A) “I want to rape you.” The residents were separated. Staff stayed with resident (A) for her safety. Resident (B) was kept in line of sight by a staff member. Staff notified the police. Resident (B) was transferred to a higher level of care. Resident (A) felt safe after resident (B) left the premises. The facility investigation concluded the incident occurred and resident (A) was provided with support and medication as needed to help with anxiety. To help prevent a recurrence staff were educated on abuse and resident (B) no longer resided in the facility. 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 12/11/2024 · released to the public 12/18/2024.
1/6/2024Physical Abuse · ID 242304ST003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/7/24, resident (A) complained of pain in her hip. The resident alleged she was rushed during cares by caregiver (1) last night and as a result, fell forward and hit her hip on a chair. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. No visible marks were found on the resident’s skin. Caregiver (1) was suspended pending the investigation. Caregiver (1) stated resident (A) complained of hip pain related to an exercise class before care was provided. Caregiver (1) admitted to providing care to the resident without another staff member present although two person assistanced was individualized to the resident's care need for making false allegations against other staff members. Additional staff members that assisted resident (A) on the evening of 1/7/24 indicated resident (A) did not report or complain of pain. The facility investigation concluded the abuse allegation was not substantiated, however caregiver (1) did not follow the resident's care plan to work in pairs. To help prevent a recurrence, caregiver (1) was educated to follow care plans in place. All staff would assist resident (A) in pairs as written in her care plan. 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 11/22/2024 · released to the public 11/29/2024.
1/5/2024Physical Abuse · ID 242304ST002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/5/24, a family member of female resident (A) in her 80s alleged caregiver (1) was rough with resident (A) on 1/4/24. Resident (A) stated caregiver (1) was rough when assisting her with care and she did not want the caregiver to provide her with anymore assistance. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Resident (A) was assessed and found to have healing bruises on her right buttock and right inner thigh. Caregiver (1) was identified after resident (A) provided the facility a description of the individual. The facility suspended the caregiver pending the outcome of the investigation. The caregiver (1) stated they assisted resident (A) while she was in bed on 1/1/24. The caregiver said on 1/4/24, resident (A) did not want her help. Caregiver (1) stated they repositioned their hands when resident (A) complained they were hurting her while providing care. The facility investigation concluded there was no substantiated abuse. Resident (A) is on medication that could cause bruising. To help prevent a recurrence, caregiver (1) was removed from the agency staff coverage pool and no longer allowed to work in the facility. Resident (A) was happy with the results of the investigation. 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 11/13/2024 · released to the public 11/20/2024.
1/2/2024Missing Person · ID 242304ST001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/2/24, Residents A and B were out of the facility in Resident B’s vehicle. Resident A in her 50’s was dropped off in the community as she wanted to buy cigarettes and see a friend. Resident A did not return to the facility. She was her own responsible person with a diagnosis of mental illness and was not identified to be at-risk to self. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian and physician. A complete search of the facilities, the surrounding neighborhood, local businesses, including the area where Resident B dropped off Resident A, were searched. Resident A’s physician checked hospitals for a possible admission of Resident A to an emergency room, however, none were found. Staff reported resident A had not expressed an interest to leave. A family member of Resident A stated the resident had a history of going off on her own. At the time of the incident, Resident A exhibited normal and usual behavior. Resident A had still not returned to the facility as of 1/22/24 and her whereabouts were unknown. 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 1/22/2024 · released to the public 1/22/2024.
12/25/2023Misappropriation of Property · ID 232304ST010Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 12/26/23, a female resident (A) in her 90s alleged another female resident (B) in her 60s took her Christmas decoration she placed on a table in the hallway. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police and families. Resident (A) stated she last saw the snowman decoration on 12/25/23 and believed resident (B) stole it and gave it to a family member. Resident (B) denied taking the item initially and later admitted to taking the item and thought it was available for anyone as it was out on the table in the hallway. Resident (B) stated she would return the item. Resident (A) did not want to press charges. The facility investigation concluded resident (A) did take the item but stated she did not know it belonged to someone. To help prevent a recurrence, residents were educated on not moving items in public areas. 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 11/18/2024 · released to the public 11/25/2024.
9/1/2023Missing Person · ID 232304ST008Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 9/1/23, a female resident (A) in her 50s signed herself out of the facility for the day and did not return for her night time medications. The whereabouts of resident (A) were unknown after a search of the facility and surrounding areas were conducted. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police. Resident (A) was alert and oriented and had a known history of noncompliance and being unhoused. Other residents indicated resident (A) had discussions with them about seeing her boyfriend. The identity of this person was not known. The facility investigation concluded resident (A) signed herself out of the facility and has made no contact with the facility. Resident (A) was unable to be located and she was discharged from the facility. Follow up, resident (A) was picked up by the paramedics on 9/9/23 for strange behaviors. Resident (A) admitted to doing illicit drugs and stated she did not want to return to the facility. She requested her belongings and management helped arrange that request. 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 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 8/5/2024 · released to the public 8/5/2024.
7/1/2023Diverted Drugs · ID 232304ST005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 7/1/23, staff discovered an agency staff member signed out as needed (prn) pain medications for a resident, who stated they did not request or receive the medication. Upon further investigation, the facility identified the same circumstances involving a second resident. Neither resident had cognitive impairments. The facility initiated an investigation for possible drug diversion. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, case manager and physician. Review of the medication administration records showed two tablets of 5 mg of Oxycodone medication and one tablet - 50 mg Tramadol medication had been administered during the shift. Facility staff reported they noticed these prn medications had been administered when typically the residents did not request pain medications. Management suspended the suspected agency staff member. The facility notified the staffing agency and all further shifts were cancelled. The agency staff member stated one resident requested pain medication and they administered the medication according to physician orders. No follow up drug test occurred as the person was not an employee of the facility. The facility investigation concluded the residents did not request or receive the pain medication and it was unknown what the agency staff member did with the medication. The agency staff member was placed on the do not return list. 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 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 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 State Agency.
Publication
Sent to facility 4/11/2024 · released to the public 4/11/2024.
3/25/2023Physical Abuse · ID 232304ST003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 3/25/23 multiple residents witnessed two males playing poker and got into an argument. Resident (B) in his 80s stood up and punched resident (A) in his 60s in the shoulder. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, and families/guardians. The residents were separated, resident (A) complaint of mild pain. No bruises were seen. Resident (A) stated that staff cleaned up and resident (B) came back to play more poker, he did not want to play poker and accidentally backed into resident (B)’s wheelchair because he was behind him and resident (B) hit him and stated, “I didn’t think I could hit that hard”. Resident (A) did not want to file charges. Resident (B) stated he did not mean to hit resident (A). Staff indicated they were unaware of what words were exchanged but did see resident (B) strike resident (A). The facility investigation concluded the incident did occur, and was witnessed. To help prevent a recurrence, staff implemented frequent checks and a care conference was held to see if resident (B) needed a higher level of care. Both residents will be kept separated. 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 11/7/2023 · released to the public 11/7/2023.
3/15/2023Verbal Abuse · ID 232304ST002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 03/15/23 female resident (B) reported male resident (A) threatened to hit her with his cane. Both residents were in their 70s. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were separated and put on frequent checks. Resident (B) refused an assessment. Resident (B) said she was trying to tell resident (A) the elevator was not working but he told her she did not know everything and raised his cane above his head and said "I'm going to biff you in the head". Resident (B) said she was frightened and back away. Resident (A) said he was using his cane to push the elevator buttons because of COVID and resident (B) came and took his cane out of his hand. The said he asked her to step away and that was when staff arrived. The facility could not determine who initiated the incident but both residents were put on frequent checks. 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 9/19/2023 · released to the public 9/19/2023.
3/3/2023Missing Person · ID 232304ST001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 3/3/23 a male resident (A) in his 30s was not available to take his medications. The staff searched for resident (A) and called his phone. Resident (A)’s whereabouts were unknown and for approximately 24 hours. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians. Resident returned to the facility alert and oriented and stated that he had gone to his mother’s house. Resident stayed with his mothers for a few days. The facility investigation concluded resident (A) came and left the facility, this time he left he did not sign out or let staff know. To help prevent a recurrence resident (A) was educated again on signing in and out when he wanted to leave the facility. He was also reminded to charge his cell phone and carry it with him. Staff will do frequent checks on resident (A) for safety. 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 8/7/2023 · released to the public 8/7/2023.