BRIDGE ASSISTED LVG AT LIFE CARE CTR OF CO SPRINGS, THE

Inspections

Deficiencies

Actual Harm or Above

Occurrences

January 14, 2026

Last Inspection

S/S B Minimal potential

The most recent inspection of BRIDGE ASSISTED LVG AT LIFE CARE CTR OF CO SPRINGS, THE on record is dated January 14, 2026. Across 5 published inspections, state surveyors cited 3 deficiencies, none of which reached the actual-harm level.

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

Provider Information

Status

Active

Facility Type

Assisted Living Residence (Licensed Only)

Administrator

Missing Admin Information

Owner

COLORADO SPRINGS RETIREMENT OPERATIONS, LLC

Phone

(719) 630-3330

Payor Source

Private Pay

City

COLORADO SPRINGS

ZIP

80910

Inspections & Citations

5 inspections · 3 deficiencies

1/14/2026Licensure Complaint · ID 0EUQ11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO41355, was completed 1/14/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

5/7/2025Revisit: Licensure (Re-licensure) · ID 0OPF12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 5/7/25 for all previous deficiencies cited on 3/4/25. 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.

9999Final ObservationsSurveyor note▼

Findings

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

3/4/2025Licensure (Re-licensure) · ID 0OPF113 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey was completed on 3/4/25. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1180Res Care Srvs-Fall Mgt PrS/S B▼

Findings

Based on record review and interview the residence failed to provide staff training related to fall prevention for three of eight sample residents (#1-#3). Findings include 1. Residence PolicyThe residence fall management policy, dated April 2024, read that staff would complete fall management training during orientation and on an annual basis. 2. Record ReviewResident #3 was admitted to the residence on 5/7/24 with a diagnosis of Parkinson's disease. A progress note dated 12/9/24 read that Resident #3 fell in the dining room. A progress note dated 12/18/24 read that following Resident #3's fall staff were to provide preventative support and assistance. A progress note dated 1/29/25 read that Resident #3 was found on the floor of her bathroom with no injuries. A progress note dated 2/8/25 read that Resident #3 was found on the floor in front of her recliner with no injuries. A care plan, with undated updates, read that Resident #3 fall interventions were as follows: "Educate resident on benefits of not lifting walker off the ground when walking, keep call pendant and most frequently used personal items within reach, keep room clear from clutter and hazards, make sure all staff members are aware that the resident is at risk for falls."3. InterviewsOn 3/4/25 at approximately 1:00 p.m., Staff #1 stated that the interventions he was aware of for Resident #3 were that she required standby staff assistance and that she needed staff to get her chair for her. On 3/4/25 at approximately 1:30 p.m., Resident #3 stated that she fell usually due to lifting her walker off of the ground and walking with it in the air and that she was told to prevent falls she should focus on walking with the walker on the ground. On 3/4/25 at 2:40 p.m., Staff #3 stated that the interventions she was aware of for Resident #3 was standby staff assistance. She stated that she was not certain where to find the interventions in the service plan and that that information would be known by the HWD. On 3/4/25 at approximately 4:00 p.m., the HWD stated that staff were expected to be trained on and understand the interventions in place for fall prevention. 4. Similar deficient practice was found for Residents #1 and #2.

Plan of correction · submitted by the facility

S1180HWD immediately educated Staff #1 and Staff #3 on where to find the interventions for falls for Resident #1, #2 and #3 to ensure that staff is properly trained to fall prevention. HWD audited similar Residents with fall prevention service plans, to educate and make Care staff aware of the interventions placed for each and every individual Resident. ED in-serviced HWD and Care staff on the regulatory requirement for Fall Managment Programming, to include but not limited to a) provide fall management education and materials to residents and family members ; b) detailing each residents care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight or effects of medications as identified during the comprehensive resident assessment; c) Providing engagement activities to improve strength and balance; d) to routinely inspect and maintain a safe exterior and interior environment; and e) Providing staff training related to fall prevention. In-service to be completed by 3/20/25. HWD will monitor and provide weekly updates on fall prevention service plans with Care staff during weekly huddles and retention meetings for the next 90 days. HWD will report any observations of the weekly monitor during the regular scheduled monthly QMPI meetings to address any concerns that are trending for the next 3 months.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of eight sample residents (#4-#7). (Cross-reference S1596)Findings include:1. Resident #6 was admitted to the residence on 11/21/22 with diagnoses that included dementia, Parkinson's disease, and psychotic and mood disturbances. a. GabapentinA written practitioner's order dated 7/12/23 directed the residence to administer a 300 mg gabapentin oral capsule at bedtime. However, the January 2025 medication administration record (MAR) indicated that the residence did not administer the medication on 1/29/25.b. Carbidopa-levodopa A written practitioner's order dated 7/12/23 directed the residence to administer a 100 mg carbidopa-levodopa oral capsule three times a day for Parkinson's disease. However, the January 2025 MAR indicated that the residence did not administer the medication on 1/29/25 at 9:00 p.m. 2. InterviewsOn 3/4/25 at 2:29 p.m., the health and wellness director acknowledged that a blank MAR meant that the medication was not administered. She attributed the failure to a qualified medication administration person (QMAP), and she also acknowledged that she expected QMAPs to comply with the practitioner's orders. 3. Similar deficient practice was found for Residents #4, #5 and #7.

Plan of correction · submitted by the facility

S1568 - (Cross-reference to POCD for tag S1596)HWD brought to the immediate attention of QMAP staff about missing medications as indicated on MD orders dated 7/12/23 for Resident #6' Gabapentin 300mg & Carbidopa-Levodopa 100mg that was missed on 1/29/25, as well as other orders missed for Resident #4, #5, #7. HWD assessed other residents for concerns similar to Resident #4, #5, #6, #7, in order to provide further examples and training for all QMAPS to improve upon. HWD in-serviced QMAPS on the importance of complying with authorized practitioner orders associated with medication administration, except for those medications which a resident self- administers. HWD will monitor weekly during the Weekly Medication regimen review, to ensure that the authorized practitioner orders associated with medication administration are in compliance for the next 90 days. HWD will report any observed patterns from the weekly monitoring, to the regularly scheduled monthly QMPI meetings, for the next 90 days.

1596Med/Med Adm-Med Prep/Hnd Tr ICS/S B▼

Findings

Based on observation and interview the residence failed to ensure that qualified medication administration persons (QMAP) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting 54 current residents. (Cross-reference S1568)Findings include:On 3/4/25 at approximately 7:00 a.m., during the onsite visit Staff #1 was observed handling medication without gloves. Staff #1 touched the medication and crushed it to then return it to the cup to be administered. Additionally, an observation was made that there was no hand sanitizer on the medication cart. Staff #1 opened the drawer and there was not any hand sanitizer. Staff #1 was observed providing medication to multiple residents without washing their hands or using hand sanitizer before and after contact with the residents. Staff #1 was observed touching handles of doors, items in resident rooms and other objects before and after handling medication. On 3/4/25 at approximately 7:30 a.m., Staff #1 stated that the hand sanitizer was in the bottom drawer of the medication cart. Staff #1 was not sure if he should refill the hand sanitizer that was empty. On 3/4/25 at approximately 3:30 p.m., the HWD stated that staff were trained in infection control and that she expected staff to restock hand sanitizer if it was out. She stated that she told staff to have hand sanitizer both on the cart and a spare in the bottom drawer.

Plan of correction · submitted by the facility

S1596 - (Cross-reference S1568)HWD brought to the immediate attention of Staff # 1 the observation of handling the medications without gloves, crushing them and returning to the cup to be administered, without washing of the hands or using hand sanitizer before and after contact with multiple residents and that the medication cart was not properly equipped with hand sanitizer. HWD assess other carts to ensure that Hand sanitizers were proper stocked and filled and brought to the attention to all other Qualified Medication Administration Persons (QMAP), that protocols for basic infection control and prevention when preparing and administering medications are followed. HWD in-serviced all Qualified Medication Administration Person on applying nationally recognized protocols for basic infection control and prevention when preparing and administering medications to include, but not limited to, using of gloves, washing of hands, sanitizing of hands before and after contact with multiple residents, and to ensure that hand sanitizers are properly refilled and equipped on all medication carts. HWD will monitor during the weekly medication cart audit that Hand sanitizers are stocked on all med carts, and that QMAPs are properly practicing basic infection control and prevention when preparing and administering medications, for the next 90 days. HWD will report any observed patterns from the weekly monitoring, to the Regularly scheduled monthly QMPI meetings for the next 90 days.

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 7.13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation;(C) The process for investigating such allegations;(D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted;(E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted;(F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and(G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.

Plan of correction

The state did not require a plan of correction for this citation.

7/30/2024Revisit: Licensure Complaint · ID WBET12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 7/30/24 for all previous deficiencies cited on 2/4/22. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 1/14/24. The deficiencies cited for event WBET11 were cited prior to the regulation revision that was implemented on 1/14/24.

Plan of correction

The state did not require a plan of correction for this citation.

7/30/2024Licensure Complaint · ID ZVL411No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO35704 and #CO29682, was completed on 7/30/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

Reportable Occurrences

17 records

3/16/2026Verbal Abuse · ID 2623052X004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/20/26, 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 (A) alleged that staff (1) yelled at them, was argumentative, and spied on them throughout the day. Client (A) expressed fear. During the course of the investigation, the healthcare entity suspended staff (1), ensured client (A) felt safe, contacted police, and conducted interviews. No visible injuries or complaints of pain for client (A) were indicated when assessed. Another client confirmed the incident. Staff (1) denied the incident; however, the facility terminated their employment. The facility monitored client (A) for emotional distress and reeducated staff on reporting and preventing abuse. Due to staff (1 )'s unprofessional conduct not being a threat or physical action, 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 6/1/2026 · released to the public 6/8/2026.

1/25/2026Misappropriation of Property · ID 2623052X003Reported 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 help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A)'s representative reported that client (A) assigned staff (1) as a beneficiary to receive $100,000. During the course of the investigation, the healthcare entity suspended staff (1), contacted police and adult protective services, conducted interviews, and reviewed records. Client (A) managed their own health and financial decisions. Staff (1) confirmed assisting with completing the beneficiary paperwork and obtaining client (A)'s signature. Client (A) confirmed they were aware of the beneficiary change, provided consent, and acted without coercion; however, their representative believed there was malicious intent from staff (1). Police were unable to investigate due to client (A) being their own responsible party. The facility terminated staff (1)'s employment, and the beneficiary was reversed. 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 4/13/2026 · released to the public 4/21/2026.

1/14/2026Misappropriation of Property · ID 2623052X002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/14/26, 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. The client reported their keys, glasses, and cash had been stolen. During the course of the investigation, the healthcare entity conducted a search and interviews. The keys and glasses were found in the client's apartment during an initial search. The client’s family confirmed a cash withdrawal had occurred in the previous weeks. The facility was unable to identify an alleged assailant. The facility encouraged the client to use the locking cabinet to secure their valuables and to keep receipts for purchases. 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 4/6/2026 · released to the public 4/13/2026.

5/28/2025Misappropriation of Property · ID 2523052X005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/28/25, 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 misappropriation of client property. Client (A) informed the facility they had a number of missing items and a family member may have taken them. During the course of the investigation the healthcare entity conducted a search, and interviews. The family member admitted to taking the items and stated they would bring them back. The police were notified and staff were informed to notify the police if they see this family member in the facility. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/19/2025 · released to the public 8/26/2025.

3/12/2025Misappropriation of Property · ID 2523052X003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/12/25, 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 misappropriation of client property. During the course of the investigation the healthcare entity conducted interviews. The police and other authorities were notified. Review of documentation revealed the responsible party for the client had not paid their rent since November 2024 and was being accused of financial exploitation. The client was taken to the bank to remove the responsible party from their financial accounts. The client will continue to work with Adult Protective Services regarding financial matters. 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 5/6/2025 · released to the public 5/13/2025.

2/22/2025Misappropriation of Property · ID 2523052X002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/24/25, 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 misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The client alleged a staff member stole $140.00 from their purse. The client and their responsible party had different stories and amounts of money alleged to be stolen. The police were notified and no assailant was identified. All staff working during that time frame denied taking any money from the client’s apartment. Staff temporarily stopped taking out the trash per the clients request to ensure nothing was taken and remained on mandatory reporting. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/29/2025 · released to the public 5/6/2025.

12/14/2024Physical Abuse · ID 2423052X006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/14/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant (family #1) were separated before the police were notified. Staff witnessed Family #1 hit Client (A) in the back of the head during medication administration, when they did not respond to a question. Family #1 was asked to leave the facility. Client (A) could not recall being slapped due to cognitive impairment. No visible injury. Family #1 will be required to check in at the front desk to have staff oversight during visits. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/16/2025 · released to the public 7/23/2025.

12/1/2024Physical Abuse · ID 2423052X005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/4/25, 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 assessed and ensured the client’s safety. In addition, a staff member fitting the description was suspended pending the outcome of the investigation. The client alleged that an unknown staff member was rough when assisting them to bed. They were able to give some physical description of the alleged assailant; however, they were not certain what date it occurred. The client did not show any signs of injury and was provided with wellness checks and emotional support. Staff interviews were conducted and the suspected staff member denied being rough with the client. Additional client interviews were conducted and no concerns were reported. The healthcare entity was unable to confirm the event occurred based on inconclusive evidence. All staff were provided education. 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 6/24/2025 · released to the public 7/1/2025.

11/3/2024Misappropriation of Property · ID 2423052X004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/3/24, 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 conducted a search, and interviews. The police were notified and no assailant was identified. An unknown individual entered through the clients window and stole their phone and glasses. All windows were checked and locked. Staff were educated on assisting clients with locking their windows for security purposes. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/24/2025 · released to the public 3/31/2025.

5/9/2024Misappropriation of Property · ID 2423052X002Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 5/14/23 resident (A) alleged staff member (1), who was given $50.00 by resident (A) to purchase three items, only purchased two and they did not receive the change either. Additionally, resident (A) is reporting staff member (1) may have taken five blank checks. Staff member (1) was suspended and stated they made the purchases and was notified by resident (A) one of the purchases was incorrect. The receipt was kept by staff member (1) in order to make the return. Staff member (1) also stated they used some of their money as $50.00 was not enough. Staff notified the police and they were able to find the blank checks. The facility investigation concluded no theft had occurred and the item will be returned to the store for the right one. To help prevent a recurrence staff were educated on making personal shopping tasks for residents that involve money transactions despite being given consent by the resident. Staff were educated not to accept this additional task. 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 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 facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/27/2024 · released to the public 12/4/2024.

4/12/2024Missing Person · ID 2423052X001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 4/12/24 resident (A) was found outside in the early morning by a visitor who called the paramedics. The paramedics assessed resident (A) and brought them inside the facility. The staff were unaware resident (A) was not in the facility. Resident (A) was identified to be an at risk adult. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and the physician. Resident (A) has a diagnosis of dementia and was taken back to his apartment by staff. A one-to-one staff member was placed with resident (A) for safety. Resident (A) did not recall leaving the facility and requires additional support until a determination could be made on why he left. The facility investigation concluded resident (A) left the facility without staff being aware and could not remember doing so. To help prevent a recurrence, staff were educated on identifying residents with exit seeking behaviors and the importance of doing wellness visits for the residents safety. Resident (A) had his care plan updated to reflect frequent safety checks in addition to the one-to-one private caregiver. 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 11/25/2024 · released to the public 12/2/2024.

11/2/2023Misappropriation of Property · ID 2323052X007Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 11/2/23 a family member of a male resident (A) in his 80s confirmed resident (A)’s laptop had been hacked and alleged money had been stolen. The alleged assailant was reported to also have access to the residents' laptop camera and could see his current living situation. The family notified the police. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman and Adult Protective Services. The family member was able to disable the laptop after confirming the cyber breach. The laptop was last accounted for in November 2023. The family was not able to confirm any monetary loss. No other residents had concerns of missing items. The facility investigation concluded cyber breach had occurred. No finance evidence was provided of any loss. To help prevent a recurrence, the laptop was disabled to protect resident (A) from further cyber attack. Resident (A)’s browsing data was limited and restricted by his family. Resident (A) was encouraged to bring concerns to management immediately in the future. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

10/25/2023Sexual Abuse · ID 2323052X006Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/25/23, a male resident (B) in his 80s allegedly unzipped his pants and exposed himself to a female resident (A) in her 80s while seated in front of the dining room. Resident (B) zipped his pants up when he saw staff member (1) pass by. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult protective services and physician. The residents were immediately separated from each other. There was no report of any physical touch. Resident (A) stated she saw the act of resident (B) and stated something is wrong with him. She stated she was not afraid of him or what he did. Resident (B) has a diagnosis of dementia and did not recall the act that occurred. Staff member (1) stated resident (B) was seated in his wheelchair about 10 feet from resident (A) and exposed himself and only zipped his pants when he saw staff. The facility investigation concluded the incident of resident (B) exposing himself was witnessed by resident (A) and a staff member. Even though resident (B) had a cognitive impairment, staff reported he did understand to stop exposing himself when staff were present. To help prevent a recurrence, staff will monitor resident (B) for any further behaviors. Resident (B) was also assessed for any immediate medical concerns related to behaviors. Resident (A) was provided with mental support if needed for any distress that maybe expressed. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 9/30/2024 · released to the public 10/7/2024.

8/19/2023Misappropriation of Property · ID 2323052X005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 8/18/23, resident (A), in his 60s, reported missing two pillow cases, one measuring cup and one mirror. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman and physician. Resident (A) was adamant about these items missing; however, he was unsure of the last time he saw these items. A family member of resident (A) was not sure if these items were brought to the facility. Staff members did not indicate seeing these items. The facility investigation concluded it was unclear if the items were brought with the resident or even if they were missing. To help prevent a recurrence, a log of the resident items will be kept and resident (A) was encouraged to lock his door. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 7/26/2024 · released to the public 8/2/2024.

6/3/2023Misappropriation of Property · ID 2323052X004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/3/23, a family member of a resident (A), in her 90s, reported resident (A)’s wallet and $300 was missing. The family member stated they searched the room and found $100 in the closet. Recently, there was a $400 bank withdrawal on behalf of the resident. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police and ombudsman. The last time the money had been accounted for was on 5/28/23. Staff reported they did not know about the cash or the whereabouts of the wallet. From the facility's investigation, the facility was unable to determine what happened to the wallet or money. The family helped the resident replace the items in her wallet. To help prevent a recurrence, residents were encouraged to lock their doors and keep valuables in a locked cabinet. 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 3/4/2024 · released to the public 3/11/2024.

6/2/2023Misappropriation of Property · ID 2323052X003Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/2/23, a resident (A), in her 80s, reported a $20.00 bill, $10.00 bill, and three one dollar bills were missing from her wallet that her daughter gave her two weeks ago. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and ombudsman. Staff helped search for the money with the residents permission and the only money that was found was a single dollar bill in her wallet. The resident’s daughter confirmed giving the resident the money. Resident (A) stated she never took the money out of her wallet after her daughter gave it to her a few weeks ago. The family reported this was the second time money has gone missing in the last month. No staff stated seeing the money that was alleged to be missing. The facility investigation concluded no assailant could be identified. To help prevent a recurrence, resident (A) was offered a locked drawer in her room which she would be the only one to have the key to. She was advised to keep her door locked. The daughter of resident (A) stated she would no longer leave cash with the resident. 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 3/4/2024 · released to the public 3/11/2024.

1/18/2023Diverted Drugs · ID 2323052X001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/18/23 qualified medication administration person (QMAP) (1) was thought to be under the influence and was sent because of a panic attack. During the narcotic count with QMAP (1), QMAP (2) noticed that a resident who did not normally ask for pain medications had a Hydrocodone 5mg-325mg(milligram) signed out. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians and Adult Protective Services. It was discovered that a female resident (A) in her 80s was given another resident's medication that was different and not the same dose. Resident (A) was monitored without side effects. No harm to any residents. QMAP(1) was sent for a drug test that came back negative. The facility investigation concluded QMAP (1) already had three corrective actions on her/his record. It was determined QMAP (1) was not fit to administer medications and their employment was terminated. To help prevent a recurrence staff will continue to report any discrepancies right away. A communication message was sent via a platform to the QMAPs to carefully read the medication record to avoid making mistakes. 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 8/24/2023 · released to the public 8/25/2023.