RIVARIA VISTA GRANDE

DESCRIPTION OF OCCURRENCE: On 12/16/23, a family member of a male resident (A) in his 60s reported resident (A)'s wallet was left in his pants that were taken to be laundered. The family member reported resident (A)’s wallet was returned missing $250.00 that was in there before his pants were washed. On 12/18/23, another family member said they gave resident (A) $200 and placed it in a white envelope in his drawer last week and that money was also missing. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and Adult Protective Services. The family is not accusing any specific caregiver. Caregiver (1) was assigned to resident (A) on 12/15/23. The caregiver confirmed the resident's laundry was completed but did not see a wallet. Additional caregivers involved with helping resident (A) said they did not see his wallet either. With the resident's permission, a search was conducted for the missing money and none of the mentioned money was found. The facility investigation was unable to identify the location of the missing money or potential assailant. To help prevent a recurrence, resident (A) was educated to keep his valuables in a secure place at all times and to lock his door as an added barrier. The family members were encouraged to add a security camera to his room and consider giving the resident smaller amounts of cash to keep in his possession. Staff were reminded of laundry procedures when personal items are found and to reporting any suspicious activity. 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.

DESCRIPTION OF OCCURRENCE: On 12/13/23, Resident A in her 80’s reported to Staff #2, that Staff #1 was verbally abusive, antagonistic, rough and was possibly trying to hurt her and other residents. Resident A also stated Staff #1 was impatient, argumentative and refused to care for her and other residents, and felt unsafe in his/her care. Resident B in her 80’s reported to Staff #3 that Staff #1 was argumentative, refused to provide care, had yelled at her and was not honoring her rights. Resident B described an incident with Staff #1 that left her tearful and emotionally distraught. Two additional residents voiced concerns regarding Staff #1: Resident C in his 80’s and Resident D in her 90’s. The interactions with Staff #1 made Resident D feel bad and to not want to use her pendant to summon assistance. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardians and adult protective services. Staff #1 was suspended and all four residents were assessed by staff #4 and #5. Resident A stated she never wanted Staff #1 to care for her again. She said s/he acted pleasant and caring when others were around, but described that as a front. When alone with her, Staff #1 was hostile and refused to help her with her needs. Staff #1 yelled at her and purposely tried to injure her ulcerated feet by slamming her feet into the couch or bed on multiple occasions. Resident A told Staff #1 that the rough treatment was hurtful. Resident A stated Staff #1 also rushed her to move, despite the resident telling her s/he was hurting her. Resident A stated staff #1 often lied and left trash on the floor that she could easily trip over which made her nervous. Resident A stated she was fearful of divulging these concerns about staff #1. Resident B stated that Staff #1 argued with her no matter what she asked him/her to do. She stated that Staff #1 had told her she was not being nice to the people who were trying to help her, was sweet to other residents, but not to her. Resident B stated that Staff #1 had yelled at her and directed her to go to the bathroom in her pants because s/he did not want to assist her. The resident stated she had to ask someone else to help her because she did not feel she should be yelled at or not allowed to use the toilet. Resident B stated she believed Staff #1 was taking her rights from her. Staff #3 stated s/he had recalled an incident when Resident B had called for assistance and Staff #1 had responded. Resident B wanted to be taken to the restroom, but Staff #1 insisted she go to the bathroom in her pants. Resident B got upset with Staff #1, so Staff #1 radioed for Staff #3 for help. When Staff #3 arrived, Staff #1 stated “You (expletive) deal with this (expletive)” and stormed out of the room, which caused Resident B to cry. Since this incident, Staff #1 had not answered the resident’s calls for assistance. Staff #3 stated that Staff #1 always wore earbuds and during phone conversations while working, s/he used profanity and inappropriate language, even when pushing a resident in a wheelchair, completing care or when in public areas where residents could overhear. Resident C stated that Staff #1 refused to use a gait belt when s/he transferred him, on two or three occasions, despite his reminders and was nearly dropped. Resident C stated Staff #1 was constantly on the phone, wearing earbuds and talking to someone else while caring for him. Resident D stated Staff #1 was rude when showering her, by not listening to her when she told her what she needed. Resident D stated Staff #1 consistently stated how tired s/he was, which made her feel bad and to not want to use her pendant to summon assistance. Staff #1 denied s/he had used profanity to or around residents, was neglectful or had refused to provide care. Staff #1 stated s/he did his/her job well at all times. From the investigation, the facility terminated Staff #1's employment. To help prevent a recurrence, the facility leadership retrained all of its associates on reporting requirements, elder abuse, neglect and policies and procedures. 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.

Sent to facility 1/22/2024 · released to the public 1/22/2024.

DESCRIPTION OF OCCURRENCE: On 11/16/23, a director of an independent living (IL) came to the facility to visit with Resident A in her 80’s. The resident used to reside in that community. During the visit, the director told Resident A she needed to move back to the independent living. The director proceeded to type up a 30-day discharge notice for this facility and had her sign it. The director also asked for her checkbook saying she owed money to the independent living. Allegedly, the director wrote out a check for the amount owed and directed Resident A to sign it. The resident reported she was unsure of what she signed in the director's presence. In addition, there was a report of another provider from the same community showing up and trying to get the resident to sign up for home care services associated with the IL community. Upon being notified of these actions, an investigation of financial exploitation and misappropriation of property was started for the resident, who was identified as an at-risk adult. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, physician and adult protective services. Attempts were made to speak to the director on multiple occasions, but the calls were not returned. The resident’s physician told the IL director that Resident A was not appropriate for an independent living situation. The facility staff were directed to monitor the visitors coming to see Resident A and to alert the administrator if visitors arrived. The facility was working with the resident, social workers, physician and the resident’s family member to secure a power of attorney or guardian, due to the resident’s mental status. Resident A stated a man came to her room and told her to sign multiple items, but she did not know what she signed. Resident A’s family member gained access to her financial documents and discovered multiple checks were written, not in Resident A’s handwriting, for services she was not receiving previously at the IL. The total amount of checks were approximately $32,000. Additionally, a car belonging to Resident A was no longer on the premises when the family member of Resident A went to the IL to retrieve it. From the investigation, the facility substantiated Resident A’s property had been misappropriated and were waiting to determine if a legal authority could be established for Resident A to prevent a future occurrence. The family member became more involved to assist with plans to ensure the safety of Resident A. The local police were aware of the allegations and investigating the missing money and car. 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.

Sent to facility 1/19/2024 · released to the public 1/19/2024.

DESCRIPTION OF OCCURRENCE: On 4/29/23 the facility received a call from a local restaurant stating that they had a patron at their site that lived at the facility. The resident was a female resident (A) in her 70s who at the restaurant and the facility was unaware she had left. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the physician, and families/guardians. The facility contacted resident (A)’s family and they went to pick her up from the local restaurant. Resident (A) had been gone for eight hours. Resident (A) has a diagnosis of dementia. Resident (A) was doing well when she returned to the facility and hourly checks were implemented. The facility investigation concluded resident (A) left the facility without letting anyone know. No previous elopement was indicated. To help prevent a recurrence the staff were provided with education again on the sign in and out process and to ensure the proper checklists were used. Resident (A) was provided with one-to-one staff until she is moved to a memory care as discussed with family. 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.

Sent to facility 9/25/2023 · released to the public 9/25/2023.

DESCRIPTION OF OCCURRENCE: On 03/29/23 female resident (B) reported male resident (A) had inappropriately touched her. Resident (B) said resident (A) had done the same thing to female residents (C) and (D). Residents (A) and (B) were in their 80s. Resident (A) had some cognitive impairment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police and families/guardians. Resident (C), in her 70s, had significant cognitive decline. She was out of the facility at the time this was reported and could not be interviewed. Resident (C)'s seat in the dining room was to be changed upon her return to separate her from resident (A). A safety plan for resident (C) will be developed. Resident (D) was in her 60s and cognitively intact. She was interviewed and reported the same issues as resident (B). She said resident (A) speaks to them inappropriately and has touched them inappropriately. Resident (A) denied the allegation. The facility determined that the allegation was substantiated. Resident (A) will have a staff member monitoring him at all times. He will only go to the gym when there are no female residents present. Seating arrangements in the dining will be rearranged to ensure the residents' safety. Care conferences were scheduled for all of the victims and will be updated upon their conclusion. 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.

Sent to facility 4/25/2023 · released to the public 4/28/2023.