9
Inspections
12
Deficiencies
0
Actual Harm or Above
9
Occurrences
July 20, 2026
Last Inspection
S/S B/C Minimal potential
The most recent inspection of HYLAND HILLS SENIOR LIVING on record is dated July 20, 2026. Across 9 published inspections, state surveyors cited 12 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
Hitzges, Marie
Owner
HSRE-DIAL X TRS LLC
Phone
(720) 805-9995
Payor Source
Private Pay
City
WESTMINSTER
ZIP
80031
Inspections & Citations
9 inspections · 12 deficiencies7/20/2026Licensure (Re-licensure) · ID 3G0D11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 7/20/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
6/4/2026Licensure Complaint · ID ER9111No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint survey, prompted by CO42354, was completed on 6/8/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/16/2025Licensure Complaint · ID B0GY11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO39039, #CO39080 and #CO39497 was completed on 12/16/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/1/2025Revisit: Licensure (Re-licensure) · ID K8QM13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 5/1/25 for all previous deficiencies cited on 12/3/24. 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.
12/3/2024Licensure Complaint · ID 9NI011No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO37273, was completed on 12/3/24. 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.
12/3/2024Revisit: Licensure (Re-licensure) · ID K8QM122 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure survey revisit was completed on 12/3/24 for the previous deficiencies cited on 6/13/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3050Sec Env-Re AsS/S B▼
Findings
Based on record review, and interview, the residence failed to re-assess residents to determine their continued need for a secure environment every six months and whenever the resident's condition changed from baseline status, affecting five of six sample residents (#1, #3, #4, #7 and #9). This deficiency was cited previously during a state licensure survey on 6/13/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Resident Assessment policy, dated September 2024, read in part: "Resident assessments to be completed every 6 months at minimum and with a significant change for all residents who reside within a secured unit."2. Resident #1 was admitted to the residence on 6/28/22, with essential (primary) hypertension and chronic obstructive pulmonary disease. A care plan dated 8/21/24, read in part Resident #1 had short-term memory impairment and required some redirection and reminding from others. A document titled Placement Consultation, dated 3/30/24, and signed by a practitioner, read in part that the resident "needs management of activities of daily living (ADLs), wander risk and oxygen (O2) management."No additional documentation was provided to demonstrate that Resident #1 was reassessed every six months to determine a continued need for a secure environment. Similar findings were found for Residents #3, #4, #7, and #9.3. InterviewsOn 12/3/24 at 1:10 p.m., the memory care director/assistant director of nursing (ADON) stated the secured environment placement assessment/reassessment needed to be completed prior to moving into the secured environment and reassessed annually or upon a change of condition. She stated these assessments/reassessments should be kept in the resident record. The ADON further stated that Residents#1, #3, #4, #7, and #9 may not have been reassessed as required. On 12/3/24 at 4:19 p.m., the director of nursing (DON) stated she was not sure of the frequency of reassessments for secured environment placement as she believed it was required annually and prior to moving into the secured environment. She further stated that these assessments should be kept in the resident record. Additionally, the DON stated she was not sure why the records for Residents #1, #3, #4, #7 and #9 were missing reassessments.
Plan of correction · submitted by the facility
S 3050 – 25.9 Sec Env-Res AsCorrective Action(s) to be accomplished:Executive Director or Designee will educate new Assistant Director of Nursing, when hired and new Director of Nursing, regarding Re-Assessment 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment. Identification/Corrective Action Taken:Executive Director or Designee will educate Director of Nursing and new Assistant Director of Nursing, when hired, regarding Re-Assessment 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment. Measures/systemic changes the community shall put into place to ensure the alleged deficient practice will not recur:Executive Director and Director of Nursing will randomly audit resident files once a month to ensure compliance beginning December 17, 2024. Regional Director of Nursing will randomly audit Resident Care Plans at least quarterly to ensure compliance beginning December 17, 2024. Assessment that are past due and have not had the 6-month reassessment will be completed by December 31, 2024. Residents #1, 3, 4, 7, and 9 listed on the survey results has been completed. Added a portion to the assessment scheduler to ensure we are collecting the information with the required 6- month assessment policy.
3142Sec Env-Phy Dsgn/Env/Sfty Crit-InS/S B▼
Findings
Based on observation, record reviews, and interviews the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting 27 current residents in the secure environment. This deficiency was cited previously during a state licensure survey on 6/13/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Alarmed Door for Locked Memory Unit policy, dated September 2024, read in part: "As part of the security system in this locked memory unit, all the doors leading to the outside are alarmed/coded and/or fobbed doors."2. ObservationOn 12/3/24 at 7:48 a.m., the secured environment of the residence had a fobbed door that led to the secure outdoor courtyard; the door was locked and only staff were able to open the door with a fob. On 12/3/24 at 9:46 a.m., the secure outdoor courtyard door was locked, and no residents were outside. On 12/3/24 at 11:48 a.m., the secure outdoor courtyard door was locked, and no residents were outside. 3. Record ReviewOn 12/3/24, a document dated 12/3/24 at 12:54 p.m. showed a service part titled "Wall Reader w/LCDU 6334 (Visionllne Remote Ctrl w/o GW Freight Out" had been ordered for the secured door. There was documentation of a quote for the part being requested on 10/23/24 with an expiration date of 11/22/24. On 12/3/24 an undated document titled "Documentation monitoring-QAPI Addendum November 2024" noted that Key Fob readers were broken. This document was signed by the administrator and the director of nursing (DON). 4. InterviewsOn 12/3/24 at 7:53 a.m., Staff #2 stated the door to the secure outdoor courtyard's south entrance was locked and unable to be opened due to a malfunctioning system. She also stated the main entrance to the secure outdoor courtyards was only able to be unlocked using a fob that the DON or DON could open. The secured door to the north was locked and needed to be key opened and only the DON or the memory care director/assistant director of nursing (ADON) had the key. On 12/3/24 at 11:24 a.m., a family member of Resident #1 stated the secured doors were locked and staff had to go outside with Resident #1 so that they could unlock the door. On 12/3/24 at 12:09 a.m., a family member of Resident #4 stated the doors were locked and if Resident #4 or family wanted to go to the courtyard, they needed to ask staff to unlock the door. On 12/3/24 at 1:11 p.m., the ADON stated she was not sure how long the doors had been broken and that she had a key as well as the DON.On 12/3/24 at 2:15 p.m., the maintenance director stated that he was aware the electronic locking system for the courtyard doors was not functioning. He clarified that they had to use a service part from one of the electronic key fob readers for the courtyard door to ensure the main entrance door was functioning properly. He stated this resulted in neither door to the courtyard working without a physical key. He stated that he had ordered the part earlier that morning and that the part should arrive in a week. On 12/3/24 at 4:20 p.m., the DON stated she was not sure when the secured doors broke. Additionally, the DON stated that the maintenance director stated the doors had been broken since 11/5/24. The DON stated that residents could ask staff to go outside and that the ADON had a key to open the doors.
Plan of correction · submitted by the facility
S 3142 – 25.26 Sec Env-Phy Dsgn/Env. Sfty Crit-InCorrective Action(s) to be accomplished:Executive Director or Designee will educate Director of Nursing, new Assistant Director of Nursing, when hired, and Maintenance Director regarding the Secure Environment requirement 25.26 A secure environment shall meet the following criteria: (A) There shall be a multipurpose room for dining, group and individual activities, and family visits; (B) Resident access to appliances shall only be allowed with staff supervision; (C) There shall be a storage area which is inaccessible to residents for storage of items that could pose a risk or danger such as chemicals, toxic materials, and sharp objects; (D) The corridors and passageways shall be free of objects or obstacles that could pose a hazard; (E) There shall be documentation of routine monthly testing of all equipment and devices used to secure the environment. Identification/Corrective Action Taken:Executive Director or Designee will educate Director of Nursing, new Assistant Director of Nursing, when hired, and Maintenance Director regarding secure environment requirements 25.26 (F) (2) Is independently accessible to residents without staff assistance for entrance or exit. Maintenance Director was able to order, install and program key fob so residents can independently access for entrance or exit without assistance. Measures/systemic changes the community shall put into place to ensure the alleged deficient practice will not recur:Executive Director or Designee will inspect the neighborhood once a month to ensure requirements are being met. Will order parts and complete repairs as quickly as possible if the key fob reader stops working.
6/13/2024Licensure (Re-licensure) · ID K8QM118 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure survey was completed on 6/13/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0730Stf Req-First AidS/S B▼
Findings
Based on interviews and record review, the residence failed to have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization, affecting 128 current residents. Findings include:1. Residence policyThe residence's Staffing policy, dated March 2023, read in part: "The community will have on-site at least one team member who has current certification in first aid."2. Record Review A review of staff first aid certifications revealed that Staff #4 worked the third shift on dates; 5/31, 6/14, 6/7, and 6/8/24, and failed to have first aid certifications from a nationally recognized organization. 3. InterviewOn 6/13/2024 at 4:17 p.m., the administrator stated she was not aware there were four shifts that did not have a staff member onsite with first aid certification from a nationally recognized organization.
Plan of correction
The state did not require a plan of correction for this citation.
0812Pol/Proc VisitationS/S B▼
Findings
Based on observation, interview, and record review, the residence failed to develop and implement a visitation policy that described any restriction or limitation necessary to ensure the health and safety of residents, staff, and visitors, affecting 128 current residents. Findings include:During the on-site visit on 6/13/24 from 7:00 a.m. to approximately 4:30 p.m., visitors were observed entering the residence. On 6/13/2024 at 7:53 a.m. the residence's policy and procedures were requested from the administrator. However, a review of the policy and procedure binder revealed no evidence of a visitation policy. On 6/13/24 at 4:20 p.m., the administrator stated she was not aware of the requirement for the visitation policy until the day before the onsite visit.
Plan of correction
The state did not require a plan of correction for this citation.
0814Pol/Proc Visitation-LimitsS/S B▼
Findings
Based on observation, interview, and record review, the residence failed to develop and implement a visitation policy that described any restriction or limitation necessary to ensure the health and safety of residents, staff, and visitors, affecting 128 current residents. Findings include:During the on-site visit on 6/13/24 from 7:00 a.m. to approximately 4:30 p.m. visitors were observed entering the residence. On 6/13/2024 at 7:53 a.m. the residence's policy and procedures were requested from the administrator. However, a review of the policy and procedure binder revealed no evidence of a visitation policy. On 6/13/24 at 4:20 p.m., the administrator stated she was not aware of the requirement for the visitation policy until the day before the onsite visit.
Plan of correction
The state did not require a plan of correction for this citation.
0816Pol/Proc Dschrg GrievanceS/S B▼
Findings
Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy affecting 128 current residents. Findings Include:1. Residence PolicyThe residence's discharge policy, dated March 2023, read in part: When a current resident was either voluntarily or involuntarily discharged, the residence and resident would provide notice, and make proper notifications and arrangements for the discharge. The residence would provide a 30-day notice to the resident. The residence would provide a copy of any involuntary discharge notices to the department and/or local long-term care ombudsman, within five calendar days of the date provided to the resident or resident's legal representative. The residence would provide a discharge notification to the practitioner and pharmacy. The residence prepared discharge instructions for the resident upon discharge. Additionally, there would be a final notation in the resident record regarding the reason for discharge, discharge destination, date, time, and disposition of belongings. However, the policy failed to include the following required elements:a. The individual designated by the assisted living residence to receive involuntary discharge grievances. b. The ability for any of the persons the assisted living residence was required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. c. The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence.d. A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. 2. InterviewOn 6/13/24 at 3:55 p.m., the administrator stated the residence needed to update the resident agreement and house rules.
Plan of correction · submitted by the facility
S 0816 – 9.3 Sec Pol/Proc Dschrg GrievanceCorrective Action(s) to be accomplished:Executive Director or Designee will update policies and procedures to ensure compliance with 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. Identification/Corrective Action Taken:Executive Director or Designee will update policies and procedures to ensure compliance with 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. Will be completed no later than September 6, 2024. Executive Director or Designee will ensure residents, families, and visitors have access to a copy of the Colorado Assisted Living Regulations. Measures/systemic changes the community shall put into place to ensure the alleged deficient practice will not recur:Executive Director or Designee will ensure policies and procedures are updated no later than September 6, 2024, and will supply a copy to CDPHE. Executive Director or Designee will continually monitor Colorado Regulations for any additional changes and ensure their implementation. Addendum:The Executive Director or Designee will train facility staff on the updated involuntary discharge grievance policy starting September 6, 2024. The involuntary discharge grievance policy will be indicated in the resident agreement and house rules. Executive Director or Designee will supply a copy of the involuntary discharge grievance policy to the facility staff and will educate staff during stand-up meetings and new hire training starting August 14, 2024. Executive Director or Designee will audit staff files once a month to ensure all staff members are educated on the updated involuntary discharge grievance policy Documentation will be maintained in writing and kept on file at the community. This will be reviewed monthly for 3 months and ongoing with in QAPI meeting to ensure training remains up to date. The updated involuntary discharge grievance policy will be reviewed during this meeting to ensure appropriate training is complete and the community staff is up to date on the updated involuntary discharge grievance policy.
1146Res Care Srvs-Comp Res Asmnt Annl/Chng BslnS/S B▼
Findings
Based on record review and interview, the residence failed to complete a comprehensive assessment whenever a resident's condition changed from baseline status, affecting two of two sample residents (#6 and #7). Findings include:1. Residence policya. The residence's Practitioner Assessment policy, dated March 2023, read in part: "It is the policy of this community that each resident receives a comprehensive assessment prior to admission and no less than annually thereafter that includes an evaluation of the resident ' s physical, cognitive, and psychosocial condition completed by a physician.b. The residence ' s Resident Assessment policy dated March 2023, read in part: "It is the policy of this community to provide appropriate and quality healthcare services and to ensure that necessary documentation is on file at the community prior to a resident admission but not earlier than 30 days prior to admission to ensure that each resident is appropriately placed in assisted living and continues to meet admission criteria. On 6/13/24 at approximately 7:45 a.m., during the morning medication pass Staff #2 paused the medication pass to escort Resident #1 to his room. Staff #2 subsequently stated the resident did not know where his room was and required assistance as he would wander. A comprehensive assessment, dated 8/10/23, read in part Resident #1 "may wander at night and/or is a risk for falls."A progress note, dated 3/8/24, read in part: Resident #1 was lost looking for his room. He could not recollect how he got outside or how long he had been out there. The resident was completely disoriented to time, place, and day. Resident #1 was unable to direct himself to his room, staff subsequently escorted himA progress note, dated 4/16/24, read in part that Resident #1 was stable; however, he had started to have more confusion during the evening shift. A second note on 4/16/24 read the resident was observed locked outside the main entrance doors and was banging on them to get someone's attention. Resident #1 could not recall what door he exited through, why he went outside, or where his room was, the resident was subsequently escorted back to his room by staff. A comprehensive assessment, dated 4/17/24, read in part Resident #1 "does not have current or history of wandering. No wandering issues (Resident has current or history of occasional difficulty communicating and receiving information."A comprehensive assessment, dated 4/18/24, read in part Resident #1 "does not have a current or history of wandering. No wandering issues (Resident has current or history of occasional difficulty communicating and receiving information)."A progress note, dated 6/7/24, read in part that Resident #1 was doing fine today. He was confused during the night and tended to get lost. Around midnight Resident #1 had gone to bed. However, at 1:30 a.m., Resident #1 was seen fully dressed and outside. Resident #1 was escorted back to his room and stated he had felt confused and anxious regarding the time of day. 3. There were similar findings for Resident #6. On 6/13/24 at 2:50 p.m. and 4:02 p.m., the director of nursing and the administrator stated assessments should have been completed upon changes in condition.
Plan of correction
The state did not require a plan of correction for this citation.
1180Res Care Srvs-Fall Mgt PrS/S C▼
Findings
Based on observation, interview, and record review, the residence failed to implement a fall management program affecting two of two sample residents (#2, #6). Specifically, Resident #2 with a diagnosis of dementia had 11 falls within 35 days. On 5/7/24 the residence updated the care plan for Resident #2; however, Resident #2 sustained 10 falls after the update. Five of Resident #2's falls resulted in injuries such as skin tears and a bump on the head. Findings include:1. Residence policyThe residence's Fall Management policy dated March 2023, read in part: "It is with the intent of the community to monitor the environment and resident level of fall risk to maintain a safe environment and address any risk of resident falls proactively."2. Resident #2 was admitted to the residence on 7/12/23, with diagnoses including dementia, atrial fibrillation, and deep vein thrombosis (DVT). A progress note, dated 5/6/24, read in part: Resident #2 was standing up from her wheelchair and fell trying to sit. Resident #2 had no complaints of pain or discomfort and did not hit her head. Staff assisted Resident #2 off of the floor and back into her wheelchair. A progress note, dated 5/6/24, read in part: Resident #2 got out of her wheelchair and tried walking alongside the couch. Resident #2 fell and was complaining of left arm pain. Resident #2 was assisted into the wheelchair. The care plan for Resident #2, dated 5/7/24, read in part: Resident #2 required hands-on assistance for mobility and ambulation by staff inside her apartment, outside her apartment, to and from meals, and during activities. Resident #2 had three or more falls in 90 days and staff should assist with keeping a clutter-free apartment, encourage the resident to wear proper footwear, and remind the resident to ask for assistance as needed. Additionally, the care plan read Resident #2 required hands-on assistance with transferring and changing positions and a gait belt can be used to assist. A progress note, dated 5/12/24, read in part: Evening care staff reported the resident had a fall and was found with her head slightly under her bed. Resident #2 had a small bump on her head. Resident #2 was assisted back into her bed. A progress note, dated 5/16/24, read in part: Staff found Resident #2 on the floor next to her bed, lying on her fall mat. Resident #2 was subsequently assisted into her wheelchair. A progress note, dated 5/20/24, read in part: Resident #2's pendant alerted staff that Resident #2 was falling. When staff entered the room, Resident #2 was found on the floor of her bathroom with a large skin tear on her left shin. The wound was cleaned and wrapped. The resident was changed and put back into bed. A progress note, dated 5/23/24, read in part: The external hospice nurse documented Resident #2 experienced a fall on 5/18/24 and sustained a skin tear to her left leg. The hospice nurse cleansed the wound with wound cleanser and applied steri-strip bandage. A progress note, dated 5/26/24, read in part: During the first rounds by staff, Resident #2 was found on the floor in the hall of her room. No bumps or bruises were noticed. Resident #2 was assisted off the floor and back into bed. A progress note, dated 6/2/24, read in part: During midnight medication administration, upon entering Resident #2's apartment, Resident #2 was found lying on her hip on the floor in front of her bed. Staff observed an old scab on Resident #2's left shin that had reopened. First aid was provided with available supplies. A progress note dated 6/4/24 read in part: External hospice nurse assessment post fall. Resident #2 experienced a fall resulting in a skin tear to her right elbow. The skin tear was cleaned with wound spray and dressed. A progress note, dated 6/9/24, read in part: Resident #2 was observed on the floor in front of the bedroom door by care staff. Resident #2 was checked out for injuries and placed back in her wheelchair. No complaints of pain or discomfort were noted. A progress note, dated 6/9/24, read in part: Resident #2 was found on the floor of her room with a skin tear to the right leg and a slight bump on the back of her head. Resident #2 did not report any pain and was assisted off the floor. A progress note, dated 6/10/24, read in part: Resident #2 was found sleeping on the floor. Resident #2 was taken back to her bed and changed. No bruise could be seen and there were no complaints of pain or discomfort. A progress note dated, 6/10/24, read in part: Care staff walked in and found Resident #2 on the floor by her front door. Unsure if Resident #2 hit her head as no staff was present. Staff assisted the resident off of the floor and got her ready for the day. A progress note, dated 6/10/24, read in part: The residence contacted external hospice to discuss Resident #2's multiple falls, increased agitation, and how to prevent reoccurrences. External hospice was scheduled to see Resident #2 on 6/10/24. There were no other updated care plans in the record for Resident #2. On 6/13/24 at 4:02 p.m., the administrator stated that post-fall, residents were put on two-hour checks and vital checks for 48 hours. The administrator stated the residence would reach out to external physical therapy and or occupational therapy to prevent future occurrences. Additionally, the administrator stated all falls should been on the assessment, and addressed on the care plan. On 6/13/24 at 4:21 p.m., the director of nursing stated that if a resident had multiple falls the practitioner was contacted, and physical therapy or occupational therapy would have been ordered. The director of nursing stated for Resident #2 the residence along with external hospice should have been discussing interventions and updating the care plan. 3. Similar findings were revealed for Resident #6. On 6/13/24 at 4:01 p.m., the administrator stated for Resident #6 the care plan for Resident #6 should have been updated with further fall prevention information.
Plan of correction · submitted by the facility
S 1180 – 12.15 Res Care Srvs-Fall Mgt PrCorrective Action(s) to be accomplished:Executive Director or Designee will reeducate Director of Nursing on 12.15 regarding the requirement to update resident care plans with any individualized approaches that are necessary to address fall risk, as well as the residence Fall Management Policy. The training will include detailing in each resident’s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance. ED or Designee will also reeducate Community Business Manager on 7.9(C)(6) regarding the requirements for each staff member to receive training related to fall prevention and ways to monitor residents for signs of heightened fall potential. Identification/Corrective Action Taken:Executive Director or designee will reeducate Director of Nursing on requirements listed in 12.15 and the community Fall Management Policy. ED will also in-service the Community Business Manager on requirements listed in 7.9(C)(6) regarding the requirements for each staff member receiving training related to fall prevention and the community New Team Member Orientation and Continuing Education Policy dated 2/2024 prior to working independently by August 15, 2024. Measures/systemic changes the community shall put into place to ensure the alleged deficient practice will not recur:Executive Director or designee will randomly audit employee files at least quarterly to ensure compliance beginning August 15, 2024. Regional Director of Nursing will randomly audit Resident Care Plans at least quarterly to ensure compliance beginning August 15, 2024. Service plans will be updated with the appropriate interventions by August 31, 2024. Addendum:The care plan for Resident #6 has been updated. Resident #2 passed away on June 22, 2024. Implementation for Resident #6 to avoid or minimize falls: Resident has a history of falls. Staff to assist in keeping a clutter free apartment, encourage resident to wear proper footwear, and remind resident to ask for assistance as needed. PT/OT Activity tolerance, UE strengthening, Balance and safety. Also care conference completed with POA regarding adding additional servicesThe Executive Director, Director of Nursing and Assistant Director of Nursing are auditing resident files to ensure updated care plans are being maintained. Executive Director, Director of Nursing and Assistant Director of Nursing will audit all resident files to ensure the fall management programs progress notes are followed. Executive Director, Director of Nursing, and Assistant Director of Nursing will review the incident log tracker to ensure all residents needing a change of condition have been completed and care plan updated. Documentation will be maintained in writing and kept on file at the community. This will be reviewed monthly for 3 months and ongoing with in QAPI meeting to ensure fall management progress notes are followed. Resident file audits will be reviewed during this meeting to ensure resident fall management progress notes are being followed.
3050Sec Env-Re AsS/S B▼
Findings
Based on record review, and interview, the residence failed to re-assess residents to determine their continued need for a secure environment every six months and whenever the resident's condition changed from baseline status, affecting three of three residents sample residents (#1, #2,#4). Findings include:1. Residence PolicyThe residence ' s Resident Assessment policy, dated March 2023, read in part: "Resident assessments to be completed every 6 months at minimum and with a significant change for all residents within a secured unit."2. Resident #1 was admitted to the residence on 6/28/22, with diagnoses including angina pectoris, chronic obstructive pulmonary disease, and hypertension. A comprehensive assessment, dated 8/10/23, read in part Resident #1 "may wander at night and/or is a risk for falls."A comprehensive assessment, dated 4/17/24, read in part Resident #1 "does not have current or history of wandering. No wandering issues (Resident has current or history of occasional difficulty communicating and receiving information."A comprehensive assessment, dated 4/18/24, read in part Resident #1 "does not have a current or history of wandering. No wandering issues (Resident has current or history of occasional difficulty communicating and receiving information."No additional documentation was provided to demonstrate that Resident #1 was reassessed every six months to determine a continued need for a secure environment. 3. Resident #2 was admitted to the residence on 7/12/23, with diagnoses including dementia, atrial fibrillation, and deep vein thrombosis (DVT). A document titled Colorado Pre-placement Consultation, dated 7/7/23, and signed by a practioner, read in part that the resident "habitually wanders or would wander and be unable to find own way back, needs a more structured environment, needs close supervision for personal safety/possibility or danger to self, has a history of multiple falls, Alzheimer ' s and atrial fibrillation."A comprehensive assessment, dated 7/8/23, read in part that Resident #2 had a "current or history of wandering within the residence or facility and may wander outside, but does not jeopardize health or safety."A comprehensive assessment, dated 4/16/24, read in part that Resident #2 had a "current or history of wandering within the residence or facility and may wander outside, but does jeopardize health or safety."A comprehensive assessment, dated 5/7/24, read in part that Resident #2 had a "current or history of wandering within the residence or facility and may wander outside, but does not jeopardize health or safety."No additional documentation was provided to demonstrate that Resident #2 was reassessed every six months to determine a continued need for a secure environment. Similar findings for Resident #44. InterviewsOn 6/13/24 at 4:02 p.m., the administrator stated the secure environment assessment was prompted in the residence's electronic medical record, and residence staff, and family work on updating the assessment into the electronic medical record. The assessment should have been completed every six months by the assistant director of nursing.
Plan of correction · submitted by the facility
S 3050 – 25.9 Sec Env-Res AsCorrective Action(s) to be accomplished:Executive Director or Designee will reeducate Director of Nursing and Assistant Director of Nursing regarding Re-Assessment 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment. Identification/Corrective Action Taken:Executive Director or Designee will reeducate Director of Nursing and Assistant Director of Nursing regarding Re-Assessment 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment. Measures/systemic changes the community shall put into place to ensure the alleged deficient practice will not recur:Executive Director and Director of Nursing will randomly audit resident files once a month to ensure compliance beginning August 15, 2024. Regional Director of Nursing will randomly audit Resident Care Plans at least quarterly to ensure compliance beginning August 15, 2024. Assessment that are past due and have not had the 6-month reassessment will be completed by August 31, 2024. Addendum:The community has requested documentation for Resident #1 and Resident #2 from their physicians to determine a continued need for a secure environment. Resident #2 passed away June 22, 2024. The Executive Director, Director of Nursing and Assistant Director of Nursing reviewing assessment tracker to ensure assessments are up to date including documentation to determine a continued need for a secure environment. Documentation will be maintained in writing and kept on file at the community. This will be reviewed monthly for 3 months and ongoing with in QAPI meeting to ensure Resident file audits will be reviewed during this meeting to ensure residents assessments are completed every 6 months to include documentation to determine a continued need for a secured environment.
3142Sec Env-Phy Dsgn/Env/Sfty Crit-InS/S B▼
Findings
Based on observation and interview, the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting 19 current residents in the secure environment. Findings include:1. Residence policyThe residence's Alarmed Door for Locked Memory Unit policy, dated March 2023, read in part: "As part of the security system in this locked memory unit, all the doors leading to the outside are alarmed/coded and/or fobbed doors."2. ObservationOn 6/13/24 at 7:31 a.m., the secured environment of the residence had a fobbed door which led to the secure outdoor courtyard; the door was locked and only staff were able to open the door with a fob. On 6/13/24 at 2:35 p.m., the secure outdoor courtyard door was locked and no residents were outside. 3. InterviewsOn 6/13/24 at 7:32 a.m., Staff #5 stated the secure outdoor courtyard was locked and for residents to access the courtyard a staff member had to use a fob. On 6/13/24 at 2:28 p.m., Resident #1 stated the secure outdoor courtyard doors were locked and that if he wanted to go outside, staff would go with him when he asked them to go outside. On 6/13/24 at 2:35 p.m., Staff #6 stated the doors for the courtyard were locked as the residence wanted residents to stay inside. On 6/13/24 at 4:02 p.m., the administrator stated all residents needed to be fobbed in or out of the courtyard for safety reasons and inclement weather she stated it had been like the residence opened four years prior. On 6/13/24 at 4:22 p.m., the director of nursing stated that for safety reasons the residence fobbed the residents in and out of the secure outdoor courtyard. She further stated the doors to the secure outdoor courtyard had been locked for the four years the residence was in operation.
Plan of correction · submitted by the facility
S 3142 – 25.26 Sec Env-Phy Dsgn/Env. Sfty Crit-InCorrective Action(s) to be accomplished:Executive Director or Designee will reeducate staff regarding the Secure Environment requirement 25.26 A secure environment shall meet the following criteria: (A) There shall be a multipurpose room for dining, group and individual activities, and family visits; (B) Resident access to appliances shall only be allowed with staff supervision; (C) There shall be a storage area which is inaccessible to residents for storage of items that could pose a risk or danger such as chemicals, toxic materials, and sharp objects; (D) The corridors and passageways shall be free of objects or obstacles that could pose a hazard; (E) There shall be documentation of routine monthly testing of all equipment and devices used to secure the environment. Identification/Corrective Action Taken:Executive Director or Designee will reeducate staff regarding secure environment requirements 25.26 (F) (2) Is independently accessible to residents without staff assistance for entrance or exit. Maintenance Director will reach out to vendor to assist in reprogramming key fob readers so the doors to the courtyard remain unlocked for accessibility to the residents without staff assistance. Measures/systemic changes the community shall put into place to ensure the alleged deficient practice will not recur:Executive Director or Designee will inspect the neighborhood once a month to ensure requirements are being met. Addendum:Documentation will be maintained in writing and kept on file at the community. This will be reviewed monthly for 3 months and ongoing with in QAPI meeting to ensure the policy is being to ensure the secure outdoor area is available year-round and independently accessible to the residents without staff assistance for entrance or exit. The policy that the secure outdoor area is available year-round and independently accessible to the residents without staff assistance for entrance or exit will be reviewed during this meeting to ensure compliance.
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 7.14.21 The assisted living residence shall be responsible for complying with authorized practitionerorders associated with medication administration except for those medications which a residentself-administers. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administrationrecord (MAR) which contains the name and date of birth of the resident, the resident ' s roomlocation, any known allergies, and the name and telephone number of the resident ' s authorizedpractitioner.(A) The medication administration record shall reflect the name, strength, dosage, and modeof administration of each medication, the date the order was received, the date and timeof administration, any special considerations related to administration, and the signatureor initial of the person administering the medication.(B) As part of the medication administration record, the assisted living residence shallmaintain a legible list of the names of the persons utilizing the record for medicationadministration, along with each of their signatures and, if used, their initials.(C) Each qualified medication administration person, nurse, or practitioner shall accuratelydocument each medication administration or monitoring event at the time the event iscompleted for each resident.(D) Each qualified medication administration person, nurse, or authorized practitioner shalldocument accurate information in the medication administration record including anymedication omissions, refusals, and resident reported responses to medications. 18.8 Resident records shall contain, but not be limited to, the following items:(A) Face Sheet;(B) Practitioner order;(C) Individualized resident care plan;(D) Progress notes which shall include information on resident status and wellbeing, as wellas documentation regarding any out of the ordinary event or issue that affects aresident ' s physical, behavioral, cognitive and/or functional condition, along with the actiontaken by staff to address that resident ' s changing needs;(1) The assisted living residence shall require staff members to document, beforethe end of their shift, any out of the ordinary event or issue regarding a residentthat they personally observed, or was reported to them.(E) Medication Administration Record;(F) Documentation of on-going services provided by external service providers including, butnot limited to, caregivers, essential caregivers, aides, podiatrists, physical therapists,hospice and home care services, and other practitioners, assistants, and care providers;(G) Advance directives, if applicable, with extra copies; and(H) Final disposition of resident including, if applicable, date, time, and circumstances of aresident ' s death, along with the name of the person to whom the body is released.
Plan of correction
The state did not require a plan of correction for this citation.
9/15/2023Revisit: CHOW and Licensure Complaint (Combined) · ID ISY812No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 9/15/23 for all previous deficiencies cited on 2/7/23. 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.
2/7/2023CHOW and Licensure Complaint (Combined) · ID ISY8112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO30269, was completed on 2/7/23. Deficiencies were cited. A change of ownership occurred on 10/17/22.
Plan of correction
The state did not require a plan of correction for this citation.
0522Admin-Qual RqS/S B▼
Findings
Based on record review and interview, the residence failed to ensure a newly hired administrator met requirements related to supervising the delivery of personal care and services to residents, affecting 72 current residents. Findings include:1. Record ReviewOn 2/7/23 the department's database read the administrator had been the administrator since 10/17/22. The administrator provided her resume, which revealed the administrator did not met requirements for newly hired administrators. 2. InterviewsOn 2/7/23 at 9:15 a.m., the administrator stated that prior to becoming the residence administrator, she had worked for the residence as a sales director since 2011. The administrator confirmed she had not had at least one year supervising the delivery of personal care services that included activities of daily living, prior to hire as the administrator. The administrator also confirmed she had not met any of the alternative requirements, so as to be qualified to be the administrator. On 2/7/23 at 11:00 a.m., the regional director stated he had been unaware of requirements for administrators, beyond a background check and administrator training, when the administrator was hired for the administrator position.
Plan of correction · submitted by the facility
Dial Home Office updated requirements within system to ensure any new administrator starting will meet qualifications. We will be looking into hiring an interim ED until our current ED can complete required regulatory compliance. Executive director file will be reviewed annually to ensure accuracy with required regulatory compliance such as but not limited to job qualifications and on-going training. Addendum 6/22/2023Interim Administrator in place, administrator has completed course and has certificate of her licensure. She will provide oversight at the community until current administrator meets the requirements by regulations. Interim Administrator will be meeting weekly with community administrator to review any community specific items ensuring regulations are being met. Interim Admin will also provide education and training to the administrator. Team member files will be reviewed, ensuring all regulated requirements are met. Files are reviewed on site and with in HR education platforms. HR updated requirements with in system to ensure regulations are met prior to hiring new team members moving forward. Admin file will be reviewed monthly for 3 months and annually there after. Documentation will be conducted on paper and/or computer. information will be kept on site at the community with in QAPI folder. This will be reviewed monthly for 3 months, we will also review team member files annually to ensure all training/education remains up to date. Team member files will be reviewed during QAPI monthly for 3 months, this will include administrator and director level files to ensure appropriate training/education is in place for roles.
0540Admin-Dts RespS/S B▼
Findings
Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 72 current residents. Findings include: 1. Referencesa. The Ninth Amended State Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response, dated 10/11/22, required residences to:-Maintain a COVID-19 vaccination and treatment plan as outlined in CDPHE Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidance. The plan must be readily available for review by county and state disease control staff and state health facility inspectors.-Report to the department information pertaining to their available resources to respond to the COVID-19 pandemic. Items that may be reported include, but are not limited to, residence bed capacity, supply of personal protective equipment and available staffing for the facilities. The department will provide the reporting platforms and the form and format for submission of the required information, which may be modified as the response to this pandemic evolves. Facilities must adhere to reporting requirements as specified in the Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidanceb. The CDPHE Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidance, dated 11/3/22, required residences to:-Establish and maintain a COVID-19 mitigation, vaccine, and treatment plan that promotes vaccine confidence and acceptance. At a minimum, this plan must include: How the facility assesses and addresses the vaccination status of new staff and residents; the identification of designated staff who coordinate vaccination information, administration, and tracking and reporting (e.g., EMResource) of the vaccination status of staff and residents on an ongoing basis; ongoing measures to promote vaccine confidence and acceptance; the vaccination status of all current staff and residents; and the name and location of the COVID-19 vaccine and treatment provider(s) that will be used by your facility to get vaccines and treatments (antivirals and monoclonal antibodies).-Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one) and (period two). not meet requirements for future reporting periods. Reporting period one (defined as days 1-14 of each month): complete all facility questions. Reporting period two (defined as days 15-31 of each month): complete all facility questions. Update reporting when changes occur: vaccine information (see vaccination clinics section).-Assign at least one staff member to complete training in infection prevention and control (IPC) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The designated person must complete the Colorado RCF Infection Prevention Training using CO.TRAIN within two weeks of the assignment of duties and each following calendar year thereafter. 2. COVID-19 Mitigation, Vaccine, and Treatment PlanOn 2/7/22 at approximately 8:30 a.m., the residence's COVID-19 Mitigation, Vaccine, and Treatment Plan was requested. However, no such plan was provided. On 2/7/22 at 2:30, the regional nurse confirmed the residence had not established a COVID-19 Mitigation, Vaccine, and Treatment Plan prior to the onsite visit. 3. EMResource ReportingOn 2/7/22 at 12:20 p.m., the administrator stated she had not reported EMResource reporting since her hire as the residence administrator in October 2022. On 2/7/22 at 12:42 p.m., a department representative provided the residence's EMResource reporting. Review of the reporting revealed no information had been provided since 10/1/22. Additionally, the last EMResource revealed the residence had 103 residents; however, the resident roster provided during the on-site investigation read there were 72 current residents. 4. Infection Prevention and Control (IPC)On 2/7/22 at approximately 12:20 p.m., the administrator stated she was responsible for the residence's IPC program. She stated the training she received for the program had been provided by the residence. The administrator confirmed she had not completed the Colorado RCF Infection Prevention Training using CO.TRAIN, as required.
Plan of correction · submitted by the facility
Executive Director is on CDPHE emails to receive any updates that may occur related to regulatory requirements. Dial Home Office reviews Policy/Procedures and any compliance requirements annually to ensure accuracy and compliance. The community has completed the Covid Mitigation, Vaccine and treatment plan as outlined by CDPHE. The executive director will continue to monitor if any changes come forth from CDPHE and new information is needed or changes in regards to this reporting. The executive director has completed the CO-Train as of March 1st. The executive director will remain up to date on any covid trainings as outlined by CDPHE. The executive director is reporting at least two times a month to the CDPHE reporting portal related to covid-19. All items related to this citation were corrected as of March 1st. The community will continue to monitor for any updated changes related to Covid-19 as directed by CDPHE and address/complete these changes as needed. Addendum 6/22/2023 Documentation will be maintained in writing and kept on file at the community. This will be reviewed monthly for 3 months with in QAPI meetings to ensure training remains up to date. QAPI's are reviewed monthly. Infection control QAPI will be reviewed during this meeting to ensure appropriate trainings is completed and community is up to date on all infection control practices.
Reportable Occurrences
9 records1/7/2026Physical Abuse · ID 2623B428002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/8/26, 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 physical abuse of a client. Client (A) alleged Staff #1 was rough during care they felt they did not need assistance with. During the course of the investigation the healthcare entity ensured Client (A) was assessed, Staff #1 was suspended, interviews and record reviews were conducted, and the police were notified. Staff #1 admitted to possibly going into the wrong client's room to provide care, and indicated they did things correctly. The facility determined, Staff #1 actions did not align with policy and their employment was terminated. The incident was inconclusive to indicate abuse occured. 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 4/27/2026 · released to the public 5/4/2026.
11/23/2025Physical Abuse · ID 2523B428006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/22/25, 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 a physical abuse event. Staff reported client (A) did not want to get out of bed despite multiple attempts. When staff notified staff (2) about client (A)’s wishes, staff alleged staff (2) forcefully made client (A) get out of bed causing her to experience pain. In addition, staff (2) failed to treat client (A) with respect and dignity. During the course of the investigation, the healthcare entity conducted an assessment and interviews and notified the police. Staff (2) left the building. With client (A)’s severe cognitive impairment, she did not recall the incident when asked. No visible injuries were observed with client (A). Staff (2) acknowledged the incident and their actions. Staff (2) resigned from their position as well as management terminating staff (2)’s employment. The facility notified staff (2)’s oversight licensing board with the findings. 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 3/25/2026 · released to the public 4/1/2026.
8/27/2025Neglect · ID 2523B428005Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/28/25, 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 help prevent a future recurrence. The healthcare entity reported neglect of a client. Staff allegedly did not follow a client’s fall prevention care plan, resulting in the client experiencing another fall and subsequent hospitalization. During the course of the investigation, the healthcare entity transferred the client to a higher level of care, conducted interviews, reviewed records, and notified the client’s medical provider. Per the facility’s investigation, staff completed and documented the fall prevention care plan at the time of the incident, including two hour safety checks. Staff also increased monitoring of the client in common areas when possible to reduce the risk of falls. The facility completed an assessment upon the client’s return. Their care plan was updated to include increased fall prevention interventions and therapy services. 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 not submitted within the required timeframe.
Publication
Sent to facility 1/18/2026 · released to the public 1/31/2026.
8/24/2025Physical Abuse · ID 2523B428004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/24/25, 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 physical abuse of a client. Client (A) alleged Client (B) was verbally aggressive with them before pushing them into a table. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) had two abrasions to their right arm which were treated by staff. Client (B) was transported to the hospital for behavioral and medication evaluation. Video footage confirmed the allegation. Client (B)’s room has been moved to another area of the facility and will be monitored for behaviors once they return from the hospital. 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 12/22/2025 · released to the public 12/30/2025.
6/8/2025Neglect · ID 2523B428003Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/13/25, 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. Reportedly, the client did not receive two days worth of a specific medication due to being out of the medication. During the course of the investigation, the healthcare entity notified the medical provider, obtained the medication from the pharmacy, conducted interviews, reviewed medical documentation, and removed staff from medication administration tasks. The client was unharmed. The facility was aware the medication was needed and had asked staff to follow up on the request, staff did not complete follow up, and documented administering the medication. Staff reported they mistakenly documented the medication as being given. The facility determined staff did not follow proper procedure when administering medications nor with ordering medications. The facility removed staff from medication administration duties for a minimum of 90 days for re-education and demonstrated competency of medication administration procedure. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 11/4/2025 · released to the public 11/11/2025.
2/23/2025Physical Abuse · ID 2523B428002Reported 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 physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (B) assault Client (A). Client (A) sustained an abrasion under their eye that was treated. Both clients have cognitive impairment. Client (B)’s medications were reviewed for necessary changes, behavior tracking was updated and staff were instructed to keep the two clients separated and to remove Client (B) from a situation with having negative behaviors. 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.
5/16/2024Physical Abuse · ID 2423B428003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/16/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (A) slapped Client (B) in the face and sustained a scratch to their face that was treated. Staff will monitor the assigned seating in the dining room as this was the cause of the incident. 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 3/26/2025 · released to the public 4/2/2025.
3/19/2024Neglect · ID 2423B428002Reported on time: No▼
Occurrence summary
SUMMARY FINDINGS: On 3/19/24 resident (A) was sent to the hospital for episodes of increased confusion, being disoriented, lethargic and unresponsive. Resident (A) received a new order for a topical patch, however, staff member (1) failed to remove the old topical patch from the medication cart. Resident (A) was administered both patches. Resident (A) returned from the hospital at her baseline and the old patch was removed from the medication cart. The facility’s investigation concluded neglect was substantiated. Staff member (1) was given a written corrective action. To help prevent a recurrence, staff were educated on ensuring the previous patch is removed before placing a new one.
DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 12/2/2024 · released to the public 12/9/2024.
1/17/2024Physical Abuse · ID 2423B428001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/17/24, staff member (1) allegedly got into a verbal and physical altercation with a female resident (A) in her 90s. Resident (A) attempted to get staff member (1) to help her before they left and asked again 30 minutes later without providing assistance. Resident (A) accessed her wheelchair and waited in her doorway. About 10-15 minutes later, staff member (1) came by resident (A)’s room, yelled at her, and pushed resident (A) back into her room. Resident (A) tried to stand up and was pushed back down by staff member (1)’s hand on her chest. Resident (A) directed the staff member to not push her again before staff member (1) left. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman and physician. Staff said staff member (1) poked resident (A)’s hand while yelling at her. Staff member (1) was suspended and denied the allegations. Staff member (1) eventually admitted to telling resident (A) if she could get herself out of bed, she could turn off the television and the lights. Other staff on the same shift reminded staff member (1) that the resident was a fall risk. The facility investigation concluded there were no witnesses, however resident (A)’s statement remained consistent when telling staff members. To help prevent a recurrence, staff member (1)’s employment was terminated on 1/28/24. Staff were provided additional training on customer service and expectations for providing residents care.
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.