BROOKDALE MONUMENT VALLEY PARK

SUMMARY OF FINDINGS:On 8/5/26, 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 prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Staff witnessed Client (B) in client (A)’s room touching their breast over the top of their shirt. During the course of the investigation the healthcare entity ensured the client was safe. The police were notified. Client (A) indicated they were scared of Client (B). Client (B) ran out of the room when staff entered. Both clients reside in a memory care unit so other clients were checked as well without any concerns. Staff implemented a sitter around the clock for Client (B) and medication review with changes to reduce Client (B)’s impulsive behaviors. Client (A) was educated and staff will assist them in locking their door. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 1/6/2026 · released to the public 1/13/2026.

SUMMARY OF FINDINGS:On 2/7/25, 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 neglect of a client. The client’s daughter alleged the facility neglected to properly care for wounds, causing them to get worse. During the course of the investigation, the healthcare entity reviewed medical documentation and conducted interviews. Medical documentation indicated that the client attended a third party wound clinic weekly and received visits in the facility from another wound provider 3 times a week. Documentation revealed consistent refusal of hygiene care and wound care on the part of the client. On the date of the allegation the client was transferred to the hospital for an unrelated issue and ultimately passed away. The facility will continue to document refusal of care for all clients. 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.

Sent to facility 8/6/2025 · released to the public 8/13/2025.

SUMMARY OF FINDINGS:On 1/28/25, 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 a brain injury. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client’s care plan was updated to reflect safety interventions to include; safety checks every four hours, and encouraged to use their assistive device. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 2/10/2025 · released to the public 2/17/2025.

DESCRIPTION OF OCCURRENCE:On 3/5/24 resident (A) had an unwitnessed fall and was found on their back next to their bedside with a small abrasion to the right eye and had a cognitive decline. Resident (A) was assessed and transported to the hospital and was placed in a coma on 3/6/24. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the family, and the physician. Staff member (1) found resident (A) on the floor during medication administration. The resident was assessed, a cerebral vascular accident (CVA) protocol was initiated and they were sent to the hospital as s/he did not respond to verbal stimulation only physical touch. Resident had seizure activity along with other concerns and was in a coma before the family placed resident (A) under hospice care. The facility investigation concluded resident (A) had an outcome that may have been caused by a brain injury. This was not ruled out. To help prevent a recurrence with independent residents, staff have increased safety rounds and report any abnormalities found with residents. 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 11/25/2024 · released to the public 12/2/2024.

DESCRIPTION OF OCCURRENCE: On 1/12/23 a male resident (A) in his 90s reported that $235.00 that was in an envelope in his sock drawer was gone. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians and district director of operations. Resident (A) stated he placed the money in his drawer last Saturday night and when he got up this morning it was gone. He stated the only person that was in his room was the housekeeper. The client called the police to file a report and did not want any help looking for the money. Staff members were interviewed and did not reveal any misconduct. A family member of resident (A) believes resident (A) may have spent the money and has had a decline in cognitive states. The facility investigation could not determine if the money was taken by someone or the resident spent the money and did not remember. To help prevent a recurrence the resident has been educated to keep his personal items locked up. Resident (A) was provided with a lock box and the family member of resident (A) will encourage resident (A) not to keep a lot of cash with him. 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 6/14/2023 · released to the public 6/14/2023.