6
Inspections
3
Deficiencies
0
Actual Harm or Above
22
Occurrences
March 24, 2025
Last Inspection
S/S A/B Minimal potential
The most recent inspection of FOUNTAINS OF HILLTOP, THE on record is dated March 24, 2025. Across 6 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/Alternative Care Facility (Medicaid)
Administrator
Early, Lincoln
Owner
HILLTOP HEALTH SERVICES CORPORATION
Phone
(970) 243-8800
Payor Source
Medicaid, Private Pay
City
GRAND JUNCTION
ZIP
81506
Inspections & Citations
6 inspections · 3 deficiencies3/24/2025Revisit: Licensure and Licensure Complaint (Combined) · ID 1BQW14No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/24/25 for all previous deficiencies cited on 11/18/24. 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.
3/24/2025Revisit: Licensure and Licensure Complaint (Combined) · ID EPMY12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 3/24/25 for all previous deficiencies cited on 11/18/24. 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.
11/13/2024Revisit: Licensure and Licensure Complaint (Combined) · ID 1BQW131 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure and complaint revisit was completed on 11/18/24 for all previous deficiencies cited on 3/15/22. A deficiency was cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.
Plan of correction
The state did not require a plan of correction for this citation.
1180Res Care Srvs-Fall Mgt PrS/S A▼
Findings
Based on record review and interview, the residence failed to detail in each residents' care plan the individualized approach necessary to address fall risk related to deficits in strength and balance, affecting one of five sample residents (#19). This deficiency was cited previously during a state licensure survey on 3/15/22. 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 #19 was admitted to the residence on 4/11/22. The residence's fall report, dated 10/18/24-10/29/24, revealed Resident #19 fell on 10/18/24, 10/27/24, and twice on 10/29/24. The fall report indicated Resident #19 hit her head, had knee pain, and was sent to the local hospital after her fall on 10/27/24. Clinical notes for Resident #19 revealed that staff documented the initial fall report clinic note; however, the staff did not document any follow-up, including fall interventions for the falls Resident #19 had on 10/18/24, 10/27/24 and for both falls on 10/29/24. The care plan dated, 9/20/23, revealed that the residence failed to update the care plan after Resident #16 fell on 8/27/24, 10/18/24, 10/27/24, and two times on 10/29/24. The staff did not implement any additional interventions to prevent additional falls related to deficits in balance and strength, nor did the care plan include individual approaches necessary to address Resident #19's increased falls. 2. Interviews On 11/14/24 at 11:30 a.m., the assisted living nurse (ALN) stated the residence had not updated the care plan for Resident #19 ' s since 9/20/23. She stated that although the residence created a fall management spreadsheet, the residence did not create a fall management plan in an attempt to mitigate future falls. On 11/18/24 at 12:13 p.m., the administrator acknowledged the residence failed to follow their fall procedures after Resident #19 ' s falls in October 2024 due to tenured staff turnover in the care department.
Plan of correction · submitted by the facility
To address citation 1180, the following was put into place: A fall report must be completed for each resident fall. The report is completed by the employee/s involved in response to the fall. Each Fall report is reviewed by the Care Coordinator/s or nurse/s. The Care Coordinator/s or nurse/s will discuss and implement individualized fall prevention interventions with the resident/family members/Powers of Attorney. Agreed upon interventions will be documented on the resident’s care plan. This process will be monitored. As part of the monitoring, a fall spreadsheet is kept to ensure the following is captured: Time between most recent fall and last, cause of fall, whether or not the resident called for assistance with their pendant, whether there were injuries, if a clinical note was entered, if a follow up note was entered, if the fall form was completed, whether we are recommending they see their physician, intervention specific to the most recent fall, whether care plan was updated, if they were sent out to the hospital, if vitals were completed per our process, if there is any additional follow-up needed, and did the nurse contact the physician.?This spreadsheet will be reviewed and checked for completion at the Quality Management Program (QMP) meeting held at least 10 times per year, and with the first meeting following this PoC by 01/02/2025 The sample will include any residents will falls since the previous QMP meeting. The monitoring will occur at least 10 times per year with the first monitoring at the QMP meeting before 01/02/2025. The QMP meeting will be scheduled at least monthly and will occur at least 10 times in the year. The review date of the fall will be notated in the fall spreadsheet, and notes about the review will be kept in the QMP meeting notes. This monitoring will continue for at least three months from 01/02/2025. At that time an evaluation of the process and it’s effectiveness will take place to determine if continuation of the process as described is adequate or if other improvements are needed. The QMP meeting is a Quality Assurance and Process Improvement meeting. Review of the fall dashboard and any trends identified will be discussed and overall interventions explored during the review process. The review of items in the QMP meeting may result in Process Improvement projects, or interventions. Above will be in place no later than 01/02/2025. Training on this process will occur at the Staff meeting and Resident Council meetings in December 2024.
11/13/2024Licensure and Licensure Complaint (Combined) · ID EPMY112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO36477 was completed on 11/18/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1150Res Care Srvs-Res CPS/S B▼
Findings
Based on interview and record review, the residence failed to ensure each resident care plan reflected current personal services needs and preferences along with staff tasks necessary to meet the needs of the resident, affecting two of two sample residents (#19 and 22) who required updates to the care plans. Findings include:1. Resident #19 was admitted to the residence on 4/11/22 with a diagnosis of urinary incontinence.a. Record ReviewThe residence's fall report, dated 10/18/24-10/29/24, revealed Resident #19 had fallen on 10/18/24, 10/27/24, and twice on 10/29/24. The fall report indicated Resident #19 hit her head, had knee pain, and was sent to the local hospital after she fell on 10/27/24. Clinical notes for Resident #19 revealed that staff documented the initial fall report clinic note; however, the staff did not document any follow-up, including fall interventions for the falls Resident #19 had on 10/18/24, 10/27/24 and for both falls on 10/29/24. The care plan dated, 9/20/23, revealed that the residence failed to update the care plan after Resident #16 fell on 8/27/24, 10/18/24, 10/27/24, and two times on 10/29/24. The staff did not implement any additional interventions to prevent additional falls related to deficits in balance and strength, nor did the care plan include individual approaches necessary to address Resident #19's increased falls.b. InterviewOn 11/14/24 at 11:30 a.m., the assisted living nurse (ALN) stated the residence had not updated the care plan for Resident #19 since 9/20/23. She stated the residence created a fall management spreadsheet to ensure fall interventions were put in place; however, the ALN discovered that while staff completed fall reports after each of Resident #19's falls, the residence did not follow up to create a fall management plan.c. Evidence revealed that the residence additionally failed to ensure the care plan for Resident #19 addressed services and resident preferences regarding incontinence care. 2. Additionally, record review and interview revealed that the residence failed to ensure the care plan for Resident #22 included pertinent and accurate information about behavioral expressions of paranoia and the individualized approaches to redirect him.
Plan of correction · submitted by the facility
To address citation 1150 the following will be in place: “Care plan updated” is part of the fall dashboard to ensure changes and interventions to the plan are captured related to falls. All care plan updates require a conversation with the resident and/or their responsible parties. These changes will typically be discussed during a Multi-Disciplinary Team meeting (MDT). Part of the required form completed in an MDT will include a notation that the care plan has been updated to ensure completion of the process and communication to employees about any changes. This process will be monitored. MDTs will be reviewed at the Quality Management Program (QMP) meeting held at least 10 times per year. The first of these reviews will take place prior to 01/02/2025. The sample will include any resident with an MDT/care plan changes since the previous QMP meeting. The monitoring will occur at least 10 times per year with the first of these taking place before 01/02/2025. The QMP meeting will be scheduled at least monthly and will occur at least 10 times in the year. The review date will be notated on the MDT form and the review will be documented in the QMP meeting notes. This monitoring will continue for at least three months from 01/02/2025. At that time an evaluation of the process and it’s effectiveness will take place to determine if continuation of the process as described is adequate or if other improvements are needed. The QMP meeting is a Quality Assurance and Process Improvement meeting. Review of these grievances and any trends identified will be discussed and interventions explored during the review process. The review of items in the QMP meeting may result in Process Improvement projects, or interventions. Above will be in place no later than 01/02/2025.
1400Res Rghts-Intrnl Griev/Compl Res PrS/S A▼
Findings
Based on interview and record review, the residence failed to develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates, affecting two of five sample residents (#21, #22). Findings include:1. Resident #21 was admitted to the residence on 3/7/22 with diagnoses of unilateral primary osteoarthritis and dementia.a. Record ReviewAn electronic message, dated 6/18/24 to the director from Resident #22, read in part that staff had served Resident #21 a sandwich that contained poison from the residence's kitchen resulting in loose stools and vomiting. b. InterviewsOn 11/13/24 at 12:24 p.m., the nurse stated that on 9/27/24, Resident #21 expressed concern about eating a sandwich prepared in the kitchen, claiming that it contained poison and made her ill. The nurse confirmed that both she and the administrator were present when Resident #21 voiced this concern. However, the nurse stated that neither of them documented the incident because they did not place "significant weight" on the Resident #21 ' s statement at the time. Both the nurse and the administrator believed the concern was not a serious issue, leading to their decision not to formally document the incident or investigate. On 11/13/24, at 4:18 p.m., the care director acknowledged that she was aware of Resident #21 ' s allegation involving a poisoned sandwich. The care director confirmed that no one at the residence conducted an investigation, nor did they document the grievance. She further stated that the residence should have conducted an investigation due to the seriousness of the allegation, emphasizing the importance of addressing such issues to ensure the safety and well-being of the residents. On 11/13/24 at approximately 12:15 p.m., the director stated that he was present when Resident #21 expressed her concern about being poisoned. He explained that the comment was made while another resident was receiving medical attention and that Resident #21 was not actively participating in the conversation at the time. The director stated he believed it was simply a remark rather than a grievance . However, he acknowledged that one of the staff should have investigated Resident #21's comment further, recognizing that it was a serious accusation that warranted proper attention and follow-up. 2. Record review and interview revealed similar deficient practice for Resident #22.
Plan of correction · submitted by the facility
To address citation 1400, the following was put into place: An updated grievance form to track receipt of the grievance, acknowledgment of receipt with the party submitting the grievance, tracking of investigation activities, and findings follow up within 30 days of the initial receipt of the grievance. Training will occur with at the staff meeting in December, and at the Resident Council meeting in December. A locked drop box will be installed for grievance submission, with access to the box limited to employees responsible for the grievance mechanism. Specific follow up and training will occur with the residents cited in the deficiency with documentation in a clinical note to ensure they have a description of the process for any future grievances. In the grievance process, employees are able to support residents or submit grievances based on conversations when a grievance is made verbally. Writing the grievance on the form and submitting it will start the investigation process. A numbered log of all grievances will be kept to ensure compliance with this process. All new employees will receive training about the grievance mechanism at new employee onboarding. New residents will receive a copy of the grievance policy and a grievance form in their welcome kit. The implementation of this process will be monitored. The grievance log and grievance forms will be reviewed at each Quality Management Program meeting. These meetings will occur at least 10 times per year. With the first meeting after this PoC held before 01/02/2025. All grievances received or with updates/conclusions since the previous QMP meeting will be reviewed. The monitoring will occur at least 10 times per year with the first monitoring at the QMP meeting before 01/02/2025. The QMP meeting will be scheduled at least monthly and will occur at least 10 times in the year. The review date of the grievance will be notated as part of the grievance log, and notes about the review will be kept in the QMP meeting notes. This monitoring will continue for at least three months from 01/02/2025. At that time an evaluation of the process and it’s effectiveness will take place to determine if continuation of the process as described is adequate or if other improvements are needed. The QMP meeting is a Quality Assurance and Process Improvement meeting. Review of these grievances and any trends identified will be discussed and interventions explored during the review process. The review of items in the QMP meeting may result in Process Improvement projects, or interventions. Above will be in place no later than 01/02/2025. Training on this process will occur at the Staff meeting and Resident Council meetings in December 2024.
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 2.4.2.2 (B)(1) The following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (B) Any occurrence that results in any of the following serious injuries to a client: (1) Brain or spinal cord injuries; 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 7.9.2 The assisted living residence shall have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S. Such policies and procedures shall: (A) Set forth the visitation rights of the resident, consistent with 42 CFR 482.13(h); 42 U.S.C. 1396r(c)(3)(C); 42 U.S.C. 1395i(c)(3)(C); 42 CFR483.10(a), (b), and (f); and Section 2527-104, C.R.S., as applicable to the facility type; (B) Describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the reasons for such restriction or limitation; (C) Be available for inspection at the request of the Department; (D) Be provided to residents and/or family members upon request; and (E) Include the right of each resident of an assisted living residence to have at least one visitor of the resident's choosing during their stay at the residence, unless restrictions or limitations under federal law or regulation, other state statute, or state or local public health order apply. This visitation right shall be exercised in accordance with the following: (1) A visitor to provide a compassionate care visit to alleviate the resident's physical or mental distress. (2) For a resident with a disability: (a) A visitor or support person, designated by the resident, orally or in writing, to support the resident during the course of their residency. The support person may visit the resident and may exercise the resident's visitation rights even when the resident is incapacitated or otherwise unable to communicate. (b) When the resident has not otherwise designated a support person and the resident is incapacitated or otherwise unable to communicate their wishes, an individual may provide an advance medical directive designating the individual as the resident's support person or another term indicating that the individual is authorized to exercise visitation rights on behalf of the resident. Pursuant to Section 15-18.7-102(2), C.R.S., "(2) 'Advance medical directive' means a written instruction concerning medical treatment decisions to be made on behalf of the adult who provided the instruction in the event that he or she becomes incapacitated. An advance medical directive includes, but need not be limited to: (a) A medical durable power of attorney executed pursuant to Section 15-14-506; (b) A declaration executed pursuant to the "Colorado Medical Treatment Decision Act", article 18 of this title; (c) A power of attorney granting medical treatment authority executed prior to July 1, 1992, pursuant to Section 15-14-501, as it existed prior to that date; or (d) A CPR directive or declaration executed pursuant to article 18.6 of this title." (3). For a resident who is under eighteen years of age, the parent, legal guardian, or person standing in loco parentis to the resident is allowed to exercise these visitation rights pursuant to any limitations described in Parts 9.2(F) and (G). (F). The policies and procedures may impose limitations on visitation rights. During a period when the risk of transmission of a communicable disease is heightened, an assisted living residence may: (1) Require visitors to enter the residence through a single, designated entrance; (2) Deny entrance to a visitor who has known symptoms of the communicable disease; (3) Require visitors to use medical masks, face-coverings, or other personal protective equipment while on the assisted living residence premises or in specific areas of the residence; (4) Require visitors to sign a document acknowledging: (a) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and (b) That menacing and physical assaults on health-care workers and other employees of the residence will not be tolerated; (5). Require all visitors, before entering the residence, to be screened for symptoms of the communicable disease and deny entrance to any visitor who has symptoms of the communicable disease; (6) Require all visitors to the residence to be tested for the communicable disease and deny entry for those who have a positive test result; and (7) Restrict the movement of visitors within the residence, including restricting access to where immunocompromised or otherwise vulnerable populations are at greater risk of being harmed by a communicable disease. (8) If an assisted living residence requires that a visitor use a medical mask, face covering, or other personal protective equipment or to take a test for a communicable disease in order to visit a resident at the assisted living residence, nothing in these regulations: (a) Requires the residence allow a visitor to enter, if the required equipment or test is not available due to lack of supply; (b) Requires the residence to supply the required equipment or test to the visitor, or bear the cost of the equipment for the visitor; or (c) Precludes the health-care residence from supplying the required equipment or test to the visitor. (G). The policies and procedures may impose additional limitations for the visitors of a resident with a communicable disease who is isolated. In this case, the residence may impose additional restrictions including: (1) Limiting visitation to essential caregivers who are helping to provide care to the resident; (2). Limiting visitation to one caregiver at a time per resident with a communicable disease; (3) Scheduling visitors to allow for adequate time for screening, education, and training of visitors and to comply with any limits on the number of visitors permitted in the isolated area at the time; and (4) Prohibiting the presence of visitors during aerosol-generating procedures or during collection of respiratory specimens. (H) Any limitations imposed shall be consistent with applicable federal law and regulation and other state statutes. 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (A) Providing fall management education and materials to residents and family members; (B) Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment; (C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C); (D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and (E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6).
Plan of correction
The state did not require a plan of correction for this citation.
11/13/2024General Inspection · ID U5S114No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A COVID-19 Infection Control focused revisit was completed on 11/18/24 for the previous deficiency cited on 3/15/22. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
11/13/2024State Certification and State Certification Complaint (Combined) · ID Y64F11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey with complaint #CO36478 was completed on 11/18/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
The state listed this citation without publishing narrative text.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
22 records4/10/2026Missing Person · ID 262311QA003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/10/26, 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 considered at risk, left the facility with numerous personal belongings and was missing for five hours. During the course of the investigation, the healthcare entity conducted a search, contacted client (A)'s family, and conducted interviews. A family member located client (A) and transported them to the emergency department for evaluation. Medical providers treated client (A)'s changes in condition, adjusted their medications, and provided mental health support. Client (A) returned to the facility. The facility implemented safety checks and daily walks. 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 5/21/2026 · released to the public 5/28/2026.
3/20/2026Brain Injury · ID 262311QA002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/23/26, 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 a brain injury of a client. Client (A) had a witnessed fall by a family member. Client (A) had changes to their condition. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital requiring surgery. The client had not returned to the facility at the time of the initial report. They will be reassessed for safety interventions once medically cleared to return. 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 4/14/2026 · released to the public 4/21/2026.
3/20/2026Misappropriation of Property · ID 262311QA001Reported 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 misappropriation of client property. Client (A)'s representative reported missing items from client (A)'s apartment while they were out of the facility. The representative reported that the five items were there on 3/12/26, and when they returned on 3/20/26, some were missing. During the course of the investigation, the healthcare entity searched for the items, contacted police, and conducted interviews. Staff (1) reported seeing a box of the items, but did not look inside. Staff (2) reported seeing three of the items on 3/12/26. The facility implemented a double lock on unoccupied apartments to secure belongings. The facility was unable to identify any alleged assailants and was unable to determine if the items were lost, or stolen. Due to the staff's awareness of the items, 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 5/6/2026 · released to the public 5/13/2026.
12/3/2025Verbal Abuse · ID 252311QA014Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/5/25, 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 verbal abuse of a client. Client (A) alleged Staff #1 made degrading statements towards Client (A), including telling them they will be removed from the facility if Client (A) did not behave appropriately. During the course of the investigation, the healthcare entity removed Staff #1 from the client’s care schedule, notified law enforcement, reviewed records, and conducted interviews. During the alleged incident, Client (A) did not report fear of injury and continued to reside in the facility with no further concerns. Staff #1 denied the allegations, and no other claims of abuse have been reported against Staff #1. All staff, to include Staff #1, were re-educated on appropriate service and care for clients and communicating concerns to leadership. 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 3/4/2026 · released to the public 3/11/2026.
9/28/2025Brain Injury · ID 252311QA013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. Client (A) reported they had an unwitnessed fall and got themselves off the floor. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include the client wearing non-slip socks. 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 12/8/2025 · released to the public 12/17/2025.
8/10/2025Missing Person · ID 252311QA012Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/10/25, 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 prevent a future recurrence. The healthcare entity reported a missing client. Client (A) did not sign out of the facility and was missing for more than 10 hours. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The police were notified. The client was found in the community and transported to the hospital and admitted for high blood pressure, pneumonia, weakness and difficulty speaking. It was revealed two staff members falsified tasks for the client when the client had already left the facility which delayed the search for the client. Client (A) was independent and will be educated on signing out when they return along with the other clients and staff. The employees were terminated. 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 12/10/2025 · released to the public 12/17/2025.
7/24/2025Diverted Drugs · ID 252311QA011Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/31/25, 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. Staff reported medications were unaccounted for with a client who manages their own medication, and the client could not recall taking them. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, and reviewed records. The facility determined medication delivery procedures were followed, and interviews did not indicate staff involvement. However, the client’s annual self-medication assessment had not been completed per policy. Due to diminished cognitive functioning, the facility reported the client may have taken the medications outside of the scheduled regimen. The facility now administers the client’s medications to reduce the risk of recurrence. The facility’s findings 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 1/6/2026 · released to the public 1/13/2026.
6/4/2025Brain Injury · ID 252311QA010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/4/25, 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 a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include; reminders to use their pendant and walker. 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 8/26/2025 · released to the public 9/2/2025.
5/9/2025Brain Injury · ID 252311QA009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/14/25, 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 prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include; the client and family were educated to use the pendant for assistance and communication will continue with the family regarding the client moving to a memory care setting in the future. 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 8/14/2025 · released to the public 8/21/2025.
4/7/2025Diverted Drugs · ID 252311QA008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/8/25, 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 diverted drugs. Specific medications for the Client (A)’s comfort were missing. The facility did not administer these medications the hospice staff did. During the course of the investigation the healthcare entity attempted to locate the missing medication. The client was not currently taking the medications. They were delivered back on 3/27/25 according to documentation. All staff who had access were questioned and no individual was identified to divert the medications. It was unclear what happened to the medications, however the facility increased their documentation process for receiving medications and tracking. 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 9/30/2025 · released to the public 10/7/2025.