Colorado CDPHE · Facility Report

ASPENS AT FORT COLLINS

📍 3150 ROCK CREEK DR, Fort Collins, CO 80528

ID 23G501Assisted Living Residence (Licensed Only)Active
11
Inspections
10
Deficiencies
0
Actual Harm or Above
20
Occurrences
July 15, 2026
Last Inspection
S/S B Minimal potential

The most recent inspection of ASPENS AT FORT COLLINS on record is dated July 15, 2026. Across 11 published inspections, state surveyors cited 10 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
Wilson, Kirstyn
Owner
FORT COLLINS MEMORY CARE LLC
Phone
(970) 244-0687
Payor Source
Private Pay
City
Fort Collins
ZIP
80528

Inspections & Citations

11 inspections · 10 deficiencies
7/15/2026Revisit: Licensure Complaint · ID I2EM12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was conducted on 7/15/26 for all previous deficiencies cited on 4/23/26. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
4/21/2026Licensure Complaint · ID I2EM112 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO39524, #CO41499, #CO41703, was completed on 4/22/26. Two deficiencies were cited
Plan of correction
The state did not require a plan of correction for this citation.
0722Stf Req-Stf Lvls Res NeedsS/S B▼
Findings
Based on observation, record review and interview, the residence failed to have staff sufficient in numbers to help residents needing or potentially needing assistance, affecting 45 current residents. (Cross-reference U1150)Findings include:1. ObservationDuring an environmental tour on 4/21/26 to 4/22/26 from 9:00 a.m. to 3:50 p.m. the following was observed:The waste baskets in Resident #6, #7, and #1's rooms overflowed with trash. Specifically Resident #6's bathroom trash was filled with incontinent diapers and an odor emanated from the restroom to the resident's room. There were 45 residents who resided in the residence and four staff members who worked and provided resident care. 2. Record ReviewThe December 2025 to February 2026 staff schedule revealed:From 12/31/25 through 1/6/26, staffing records indicated periods of understaffing within the care department. The most impacted dates were 1/2/26 and 1/3/26 in which there were only four staff members working within the entire residence, specifically two staff members each; in west and east units to provide all resident care and housekeeping for 42 residents. From 2/3/26 through 2/16/26, staffing records again indicated understaffing during the reviewed period. The most significant staffing shortages occurred on 2/13/26 and 2/14/26; there were only four staff working within the entire residence, specifically two staff members; each in west and east units to provide all resident care and housekeeping for 42 residents. The care plans for Resident #7, #6, and #1 read in part that the residence would provide the residents with housekeeping services. 3. InterviewOn 4/21/26 at 10:53 a.m., Staff #4 stated concerns related to staffing levels at the residence. Staff #4 reported that there were frequently insufficient staff scheduled for shifts, which impacted their ability to complete resident care tasks such as housekeeping. Staff #4 stated that while PRN (as needed) staff were available, they were often unreliable and did not consistently come in when the residence was shortstaffed. Staff #4 further indicated that staff were, routinely, required to manage multiple responsibilities simultaneously, which contributed to delays in providing care. Additionally, Staff #4 reported that at times the residence has operated without dedicated housekeeping requiring care staff to assume additional duties for all current residents. On 4/21/26 at 12:27 p.m., interview with Staff #3 revealed concerns regarding staffing levels and support from leadership. Staff #3 reported that staffing had been low and stated that on 4/20/26 there was only one staff member assigned to the west wing of the residence. Staff #3 expressed concern about resident safety when working alone, particularly in situations where immediate assistance may be required. Staff #3 further stated that, at times, staff members have left shifts due to workload demands leaving housekeeping as an uncompleted task for most if not all residents. Additionally, Staff #3 reported feeling unsupported by leadership when concerns about staffing are raised. On 04/21/26 at 3:42 p.m., interview with Staff #2 revealed concerns related to staffing levels and operational support. Staff #2 reported that staffing shortages were not consistently addressed by leadership and staff expressed that concerns were often not taken seriously. Staff #2 indicated that staffing limitations impacted the ability to complete assigned duties, particularly when staff were required to assume additional responsibilities such as housekeeping tasks for all current residents. Staff #2 further reported that housekeeping had not been consistently prioritized by management, resulting in care staff balancing both caregiving and housekeeping duties. Staff #2 stated that these staffing challenges interfered with the ability to effectively perform their primary job responsibilities. On 4/22/26 at 10:20 a.m., a family member of Resident #6 stated that external service providers waited up to 20 minutes to be let into the secured area due to insufficient staffing. Additionally, the family member of Resident #6 stated they had seen their parent ' s bathroom trash filled with incontinence products including incontinence briefs and hygiene products, with both urine and feces matter present on the products. They reported strong odors from urine and feces in the bathroom and living area of the studio apartment. On 4/22/26 at 11:22 a.m., a family member of Resident #6 reported they spent every Monday at the residence due to their witnessed pattern of poor staffing on that day. They stated they saw staff on their phones in common areas, residents left alone during meal times, and staff not opening the door into the secured area after multiple doorbell rings. They reported seeing a stain from feces on their parent ' s bathroom floor and requested a deep clean. They also sent the executive director several pictures and text messages about housekeeping before the floor was cleaned. On 4/22/26 at 2:16 p.m., the Executive Director (ED) stated metrics were used for staffing purposes based on care levels, staff training needs, and staff input. The ED stated if there was a need for more staff on a shift, they would offer other staff bonuses for coming in or the administration staff would come in. The ED noted agency staff could be used if needed. The ED reported that resident care was not affected by staffing levels.
Plan of correction · submitted by the facility
Aspens at Fort CollinsSurvey Completed: April 23, 2026Provider Number: 23G501DEFICIENCY U722 – Staffing LevelsRegulation: 6 CCR 1011-1 Chapter 7, Part 8.4 – Staff shall be sufficient in number to help residents needing or potentially needing assistance. Corrective Action for Affected Residents and Systemic ChangesImmediately upon identification of the cited concerns, the residence completed cleaning and sanitation of resident apartments #6, #7 and #1. Leadership conducted rounds to verify cleanliness and sanitation standards throughout the community. The community obtained approval for additional staffing support to better meet resident care and operational needs. Staffing schedules and assignments were reviewed and adjusted to improve resident supervision, response times, completion of care tasks and housekeeping services throughout the community. The community hired additional permanent staff to improve staffing coverage and better accommodate changing resident acuity, occupancy, and daily care needs. Agency staff were secured to provide additional support while recruitment and hiring efforts for permanent staff were completed. The community maintains dedicated housekeeping staff. All care staff were retrained regarding expectations for maintaining a clean, safe, and sanitary environment as part of their assigned job responsibilities. The community reenforced staffing contingency procedures, including the use of As Needed (PRN) staff, agency staffing, and leadership support coverage. Enhanced monitoring processes were implemented to ensure resident rooms, bathrooms, and common areas remain clean and sanitary. Monitoring PlanThe Executive Director, Director of Resident Services, or designee will conduct daily rounds for the next 30 days to monitor resident room cleanliness, sanitation, trash removal, odor control, and completion of assigned housekeeping tasks. Then go to weekly monitoring for an additional 3 months. These daily rounds will be documented via daily round sheets that are signed off. Staffing schedules and daily staffing coverage will be reviewed prior to each shift to ensure staffing levels remain sufficient to meet resident care needs. Leadership will review housekeeping completion logs and assignment sheets weekly to ensure required tasks are completed. Any identified concerns will be addressed through staff coaching, retraining, and corrective action. The monitoring will continue for 3 months and then go to biweekly after the 3 months are over for an additional 6 months to ensure procedures are being followed. Audits will be maintained by community leadership and reviewed during monthly Quality Assurance Performance Improvement (QAPI) meetings.
1150Res Care Srvs-Res CPS/S B▼
Findings
Based on record review and interview, the residence failed to follow specific personal service needs along with the staff tasks necessary to meet those needs, affecting three of three sample residents (#1, #6, #7). (Cross-reference U722)Findings include:1. Resident #1 was admitted to the residence on 4/30/25 with diagnoses including frontotemporal dementia, essential (primary) hypertension, allergic rhinitis, unspecified, depression, unspecified, anxiety disorder, unspecified. A care plan dated 3/12/26 read in part the resident required housekeeping services daily. 2. Resident #1 was admitted to the residence on 03/03/26 with diagnoses including frontotemporal Dementia, essential(primary) hypertension, allergic rhinitis, depression, anxiety disorder. A care plan dated 4/8/25 read in part the resident required housekeeping services daily. 3. Resident #6 was admitted to the residence on 4/23/25 with diagnoses including dementia and rhabdomyolysis. A care plan dated 3/25/26 read in part that the resident required housekeeping services one time a week. 4. Resident #7 was admitted to the residence on 3/22/26 with a diagnosis of Alzheimer ' s disease. A care plan dated 4/10/26 read in part the resident required housekeeping services daily. 5. InterviewsOn 4/21/26 at 10:53 a.m., an interview was conducted with Staff #4 regarding the provision of resident care. Staff #4 stated that all residents required housekeeping services, which were the responsibility of care staff. Staff #4 reported that, due to insufficient staffing, care plans were not consistently followed and required cares, including housekeeping tasks, were not always completed. Staff #4 indicated that staff were often unable to meet all resident needs during their shift. On 4/21/26, an interview was conducted with Staff #3 regarding care delivery and staffing. Staff #3 stated that they prioritized residents with higher mobility needs or more advanced memory impairment; however, when working alone, this impacted their ability to provide care to other residents. Staff #3 reported that extended time spent assisting one resident resulted in delays in care for others. Staff #3 further indicated that due to insufficient staffing, care plans were not consistently followed and required cares were not always completed, particularly when two-person assistance was needed but only one staff member was available. On 4/22/26 at 10:10 a.m., an interview was conducted with the Wellness Director regarding care planning and oversight. The Wellness Director stated they were responsible for overseeing care plans; however, they reported they were still in the process of verifying whether care plans were current and were unable to confirm that all care plans were up to date and being followed. The Wellness Director acknowledged that residents required housekeeping services as outlined in their care plans; however, due to lack of oversight and staffing challenges, these services were not consistently provided, resulting in care plans not being followed. On 4/22/26 at 2:17 p.m., an interview was conducted with the Executive Director regarding care tracking and oversight. The Executive Director reported that care tasks were not currently being formally documented, as the residence was awaiting activation of a care stream system feature. The Executive Director stated that, in the interim, staff relied on electronic communication, visual observation, and resident binders to guide care delivery. The Executive Director indicated that updates to care plans were communicated to staff through electronic communication; however, no formal system was identified to verify that care plan interventions were consistently implemented. As a result, required services outlined in care plans, including housekeeping tasks, were not consistently tracked or confirmed as completed.
Plan of correction · submitted by the facility
Aspens at Fort CollinsSurvey Completed: April 23, 2026Provider Number: 23G501Prepared in response to deficiencies cited in the Statement of Deficiencies dated April 23, 2026. DEFICIENCY U1150 – Resident Care PlansRegulation: 6 CCR 1011-1 Chapter 7, Part 12.10(A)-(F) – Resident care plans shall reflect current assessment information and detail specific personal service needs and staff tasks necessary to meet those needs. 1. Corrective Action for Affected Residents and Systemic ChangesImmediately upon the cited concerns, resident care plans for Residents #1, #6, and #7 were reviewed to verify required services, including housekeeping and personal service needs. A full audit of all resident care plans was initiated to verify care plans accurately reflected resident needs and service frequencies. The Wellness Director reviewed resident service assignments with all care staff to ensure understanding of resident-specific housekeeping and personal care expectations. A standardized care task tracking process was implemented pending full activation of the electronic care tracking system. Staff were educated on care plan implementation expectations, documentation requirements, resident-specific service delivery, and timely completion of assigned tasks. Leadership implemented oversight procedures requiring routine review of care plan updates and verification that required services are completed as assigned by auditing daily task sheets. Communication procedures were implemented requiring all care plan changes and resident service updates to be reviewed during shift report and documented for staff acknowledgment. Monitoring PlanThe Wellness Director and/or designee will conduct weekly audits of any updated resident care plans typically 5-8 per week and resident service completion documentation. Monitoring will verify care plans are current, resident service needs are identified, housekeeping services are completed, and care tasks are documented appropriately. These will be completed via spreadsheets and daily forms. Direct observation rounds and resident room inspections will verify services outlined in care plans are implemented. Weekly audits will occur for 8 weeks followed by bi-weekly audits for 4 additional weeks. Audit findings and corrective actions will be documented and maintained by the Wellness Director and/or Executive Director. Monitoring will continue for a minimum of 3 months and results will be reviewed during monthly Quality Assurance Performance Improvement (QAPI) meetings.
4/7/2026Licensure (Re-licensure) · ID ZFTU11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 4/7/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/3/2025Revisit: Licensure Complaint · ID 7ZN213No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 10/22/24. 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.
2/3/2025Revisit: Licensure Complaint · ID 8HVN13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 10/22/24. 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.
2/3/2025General Inspection · ID Q80S12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 10/22/24. 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.
10/22/2024Revisit: Licensure Complaint · ID 7ZN2121 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 10/22/24 for all previous deficiencies cited on 8/24/23. 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.
2512Ext Env HazS/S B▼
Findings
Based on observation and interview, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting 47 current residents. This deficiency was cited previously during a complaint revisit on 8/24/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 10/22/24 at approximately 8:00 a.m., an environmental tour of the common courtyard revealed the following:The courtyard was located in the central part of the building and was accessible to all residents. There was a cement walkway approximately three feet wide in the courtyard that led from one exit of the building to another exit on the opposite side of the courtyard. There were several ledges on the sides of the walkway that dropped approximately three to five inches from the walkway to a rock garden. On 10/23/24 at approximately 2:00 p.m., the acting administrator (AA) acknowledged the environment in the courtyard was unsafe. She said that a contractor was coming to make the repairs in the courtyard. The AA said she had been the administrator since October 2024 and was unsure why the residence did not fix it prior.
Plan of correction · submitted by the facility
Immediate Correction: Gravel and sand were used to fill all slopes, and holes near walkway as well as leveling all small gravel areas in both courtyards. Permanent Solution: The community will install an astroturf surface to replace the small gravel where ledges are present to eliminate any abrupt drops by January 2025. Routine grounds inspections: Grounds inspections will now include a checklist specifically for identifying hazards like slopes, holes, or uneven surfaces. Inspections will be conducted by the maintenance director and by the administrator to ensure ongoing safety. Accountability: The administrator will review inspection records and any needed repairs during monthly safety meetings. Completion date: repairs to the courtyard have been completed as of 11/4/2024. Modifications to the courtyard walkway will be completed by 01/30/2025.
10/22/2024Revisit: Licensure Complaint · ID 8HVN121 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 10/22/24 for all previous deficiencies cited on 5/4/22. 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.
1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼
Findings
Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting 47 current residents. This deficiency was cited previously during a complaint revisit on 5/4/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 10/22/24 at 8:00 a.m., quarterly medication audits were requested from the acting administrator (AA). On 10/22/24 at 9:00 a.m., the medication cart audits from August 2024 to October 2024 were provided by the AA; however, the medication cart audits had been completed and signed by a qualified medication administration person (QMAP). The medication cart audits revealed no evidence that audits were completed by the administrator and the QMAP supervisor as required per state regulations. On 10/22/24 at 3:30 p.m., the AA stated she was aware that the residence was required to conduct quarterly medication audits; however, she was not aware that the administrator was required to participate in the audits.
Plan of correction · submitted by the facility
Staff Training: Both the Senior Resident Care Director and the administrator received training on the quarterly audit form from company to ensure compliance with audit documentation requirements with signatures required from the Lead QMAP, Senior Resident Care Director, and Administrator on 11/4/2024. Ongoing Compliance Monitoring: A calendar system is established to alert the administrator and theSenior Resident Care Director when an audit is due. Accountability: The administrator will oversee compliance and will review and sign off on all completed audits going forward. Completion date: training was completed 11/04/2024, with the first dual-signed audit scheduled for 01/15/2024.
10/22/2024General Inspection · ID Q80S113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaints #CO36970, #CO37365, and #CO37873 was completed on 10/22/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0260LicProc-ContOblig LOI chngs-CpctyS/S B▼
Findings
Based on observation, record review, and interview the licensee failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting 47 current residents. Findings include:Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management, and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1. On 10/22/24 at 8:00 a.m., the acting administrator (AA) introduced herself as the current administrator. On 10/22/24, the department's database revealed that the AA was not listed as the administrator of record. On 10/22/24 at 8:00 a.m., the AA stated she began employment and took over the role of administrator on 10/8/24. She stated that the corporate office was responsible for submitting the application to the department and was unsure whether they had done so. On 10/22/24 at 10:42 a.m., an email from a department representative read in part: "(The department had) not received a change application for this residence. I do see a draft application that has not been submitted yet."
Plan of correction · submitted by the facility
Immediate correction:Corporate home office has alerted CDPHE to the change in administration immediately upon notification of the citation and the annual review process will be in place by 01/30/2025. Verification process:A process was implemented to verify that the administrator’s information is updated in all relevant databases and systems upon any administrative changes. The HR manager and administrator will review and confirm these updates together. Annual view policy:An annual review will now be conducted every January by the HR manager and administrator to ensure all departmental records, databases, and state-required documents accurately reflect the current administrator and other key personnel.
1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼
Findings
Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting 47 current residents. Findings include:On 10/22/24 at 8:00 a.m., quarterly medication audits were requested from the acting administrator (AA). On 10/22/24 at 9:00 a.m., the medication cart audits from August 2024 to October 2024 were provided by the AA; however, the medication cart audits had been completed and signed by a qualified medication administration person (QMAP). The medication cart audits revealed no evidence that audits were completed by the administrator and the QMAP supervisor as required per state regulations. On 10/22/24 at 3:30 p.m., the AA stated she was aware that the residence was required to conduct quarterly medication audits; however, she was not aware that the administrator was required to participate in the audits.
Plan of correction · submitted by the facility
Staff Training:Both the Senior Resident Care Director and the administrator received training on the quarterly audit form from company to ensure compliance with audit documentation requirements with signatures required from the Lead QMAP, Senior Resident Care Director, and Administrator on 11/4/2024. Ongoing Compliance Monitoring:A calendar system is established to alert the administrator and the Senior Resident Care Director when an audit is due. Accountability: The administrator will oversee compliance and will review and sign off on all completed audits going forward. Completion date: Training was completed 11/04/2024, with the first dual-signed audit scheduled for 01/15/2024.
2512Ext Env HazS/S B▼
Findings
Based on observation and interview, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting 47 current residents. Findings include:On 10/22/24 at approximately 8:00 a.m., an environmental tour of the common courtyard revealed the following:The courtyard was located in the central part of the building and was accessible to all residents. There was a cement walkway approximately three feet wide in the courtyard that led from one exit of the building to another exit on the opposite side of the courtyard. There were several ledges on the sides of the walkway that dropped approximately three to five inches from the walkway to a rock garden. On 10/23/24 at approximately 2:00 p.m., the acting administrator (AA) acknowledged the environment in the courtyard was unsafe. She said that a contractor was coming to make the repairs in the courtyard. The AA said she had been the acting administrator since October 2024 and was unsure why the residence did not fix it prior.
Plan of correction · submitted by the facility
Immediate Correction:Gravel and sand were used to fill all slopes, and holes near walkway as well as leveling all small gravel areas in both courtyards. Permanent Solution:The community will install an AstroTurf surface to replace the small gravel where ledges are present to eliminate any abrupt drops by January 2025. Routine grounds inspections:Grounds inspections will now include a checklist specifically for identifying hazards like slopes, holes, or uneven surfaces. Inspections will be conducted by the maintenance director and by the administrator to ensure ongoing safety. Accountability:The administrator will review inspection records and any needed repairs during monthly safety meetings. Completion date:repairs to the courtyard have been completed as of 11/4/2024. Modifications to the courtyard walkway will be completed by 01/30/2025.
2/20/2024Licensure Complaint · ID Y4MZ11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO34988 was completed on 2/20/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
8/24/2023Licensure Complaint · ID 7ZN2113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO29540, #CO29876, #CO30049, #CO30363, and #CO33411, were completed on 8/24/23. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0410Rprt Rq-At Risk/Mndtry RprtS/S B▼
Findings
Based on interviews and record review, the residence personnel failed to report suspected physical abuse of at-risk residents to law enforcement within 24 hours of discovery, affecting 47 current residents. (Cross-reference Q1312)Findings include:Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), Colorado Revised Statutes (C.R.S.). Chapter VII regulations governing assisted living residences, part 2.1, defines "abuse" as any of the following acts or omissions: (A) The non-accidental infliction of bodily injury, serious bodily injury or death, (B) Confinement or restraint that is unreasonable under generally accepted caretaking standards, or (C) Subjection to sexual conduct or contact that is classified as a crime. The residence's Abuse policy, dated 12/2/22, read in part, "Resident abuse, neglect, and exploitation are prohibited. Should any resident experience abuse or when abuse is suspected, staff and volunteers are required to immediately provide notification to persons/agencies as described in this policy ... All staff members will receive training on abuse, neglect, and exploitation and the mandatory reporting requirements per state regulations during orientation and at least annually thereafter. Staff members, as mandated reporters, have a duty to report all suspected abuse, neglect and exploitation. Staff members will not be terminated nor reprimanded for reporting suspected or actual cases of resident abuse. Adherence to this policy is the responsibility of the executive director."The residence's At-risk Persons Mandatory Reporting policy, dated 12/2/22, read in part, "Assisted living residence personnel engaged in the admission, care or treatment of at risk persons shall report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement within 24 hours of observation or discovery pursuant to regulations. Per regulations an at-risk person is 70 years old or older and has one or more of the disabilities including blindness, mental impairment, cannot walk, see, hear, or speak, and several others."The residence operated as a secure environment serving at risk individuals with memory impairment and cognitive deficits. During staff interviews on 8/24/23 from approximately 8:00 a.m. to 4:00 p.m., five confidential staff members (#1, #4, #5, #6, #7) reported that Staff #6 was physically and verbally abusive to all residents she interacted with. The staff members stated they notified management at the residence on 7/28/23 and 7/30/23; however, did not report the abuse to local law enforcement. The staff members confirmed they were mandatory reporters; however, stated they were not aware they were required to report to law enforcement and thought the requirement fell on the management staff. On 8/24/23 at approximately 3:30 p.m., the administrator stated all staff were mandatory reporters and expected them to report abuse to the appropriate parties.
Plan of correction · submitted by the facility
(Cross-reference Q1312)Each associate employed on 8/24/23 was trained individually and face to face by ED, GPD or designee on Mandatory Reporting by reviewing and signing ISL Policy GP 12: Resident Abuse, Neglect and Exploitation, Abuse, Physical – Statute and General Questions from the Health Facilities and Emergency Medical Services Division (HFEMSD) Occurrence Reporting Manual, and the Mandatory Reporting Section Three of our company’s new employee orientation (ISL You). Files were audited by ED, GPD or designee by 9/30/23 and all included these signed policies. These policies were also reviewed in the All-Staff Meeting on 9/21/2023. Starting on October 30, 2023, completing on January 30, 2024, ED, GPD or designee will audit 100% of all new employee files for training on Mandatory Reporting on the New Employee Orientation checklist and 50% of current employee files the first month, 25% the second month, and 10% the third month. The QMIP committee will meet monthly for the duration of this POC.Continued compliance will be measured by the ED, GPD or designee reviewing 10% of employee files quarterly. These reviews will be documented on the QMIP Meeting Notes. ED, GPD or designee will review mandatory reporting quarterly in department and/or staff meetings until the QMIP committee deems appropriate. Training will continue at new employee orientation and annually. Addendum: Staff #6 was immediately suspended after report of abuse from surveyor. Employee was separated from employment on 8/25/23. Employee last worked 8/19/23. The report was given to police about staff #6 on 8/24/23. Starting on October 30, 2023, completing on January 30, 2024, ED, GPD or designee will test employees on their knowledge of the Mandatory Reporting policy, specifically that they are required to report to law enforcement immediately and their supervisor or manager on duty immediately. This will be documented on the Mandatory Reporting Check in Form. 100% of all new within 30 days of hire, 33% current employees the first month, 33% the second month, and 33% the third month. The QMIP committee will meet monthly for the duration of this POC. Continued compliance will be measured by the ED, GPD or designee will review mandatory reporting quarterly in department and/or staff meetings by means of quizzes until the QMIP committee deems appropriate. Training will continue at new employee orientation and annually.
1312Res Rghts Rghts/Rspn-Civil/ReligS/S B▼
Findings
Based on interview and record review, the residence failed to ensure residents had the right to be free from abuse, affecting 47 current residents. Findings include:Chapter II regulations governing assisted living residences, part 1.1, defines "Abuse" as the willful infliction of injury, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. The residence's Resident Abuse, Neglect, and Exploitation policy, dated 12/2/22, read in part, "Abuse includes but may not be limited to physical abuse, failure to provide basic care services to a resident, sexual contact, theft or diversion, verbal abuse, mental abuse, financial abuse or involuntary seclusion." On 8/24/23 at approximately 12:40 p.m., Confidential Staff #4 stated s/he had witnessed Staff #6 to have screamed and cussed at the residents and considered it verbal abuse. S/he stated two staff members (Confidential Staff #6 and #7) reported the interactions to the program director. Confidential Staff #4 additionally stated s/he had witnessed Staff #6 roughly handled Residents #3 and #9 while providing personal care assistance such as showers and dressing. On 8/24/23 at approximately 1:50 p.m., Confidential Staff #5 stated s/he had witnessed Staff #6 being forceful with all residents and did not accept no as an answer. Confidential Staff #5 stated Staff #6 forced resident care and considered it abuse. She stated Staff #6 began treating residents forcefully approximately three weeks prior to the onsite visit. S/he stated Staff #6 cussed at residents and believed staff were afraid to report Staff #6 to management. On 8/24/23 at approximately 2:15 p.m., Confidential Staff #6 stated Staff #6 was forceful with her interactions with all residents. She stated s/he had seen Staff #6 verbally and physically force residents to the bathroom, to bed, and to get into bedtime clothing. Confidential Staff #6 stated Staff #6 told her the residents did not have a right to refuse since they resided in a secure residence. Confidential Staff #6 stated Staff #6 often cussed at residents and explicitly told them they stunk then forced them to take a shower. Confidential Staff #6 stated s/he considered Staff #6's interactions with the residents were abusive. Confidential Staff #6 stated s/he wrote a statement of what s/he had witnessed and sent it to the program director on 7/28/23; however, nothing had changed. On 8/24/23 at approximately 2:45 p.m., Confidential Staff #7 stated s/he provided a written statement to the program director regarding Staff #6's interactions with residents. Confidential Staff #7 stated s/he had witnessed Staff #6 aggressively trying to shower Resident #10 who did not want to take a shower. Confidential Staff #7 stated Staff #6 physically pulled Resident #10 out of her chair and cornered her in her bedroom to force a shower. Additionally, Confidential Staff #7 stated Staff #6 called residents abusive, derogatory, or insulting names and would not allow them to have choices regarding refusal of care. On 8/24/23 at approximately 3:00 p.m., Confidential Staff #1 stated s/he witnessed Staff #6 being forceful with resident care and would not allow a resident to refuse care approximately one month prior to the onsite visit and considered it abusive. She stated s/he reported the abuse to the program director and did not know if anything was done about it. On 8/24/23 at approximately 4:00 p.m., the administrator stated there was an all staff meeting regarding the treatment of residents and resident rights and she observed the care provided from Staff #6. S/he stated she received ambiguous verbal reports when she conducted her investigation and therefore was not able to substantiate that abuse had occurred at the time. Despite interviews with Confidential Staff #1, #4, #5, #6, #7 who had witnessed Staff #6 verbally and physically abuse residents and documentation that confirmed Confidential Staff #6 and #7 had reported their concerns to the program director, the administrator stated her investigation of the allegations of abuse were not substantiated. Record review revealed two different staff members (Confidential Staff #6 and #7) sent documentation and a text message to the program director regarding their concerns with Staff #6 on 7/28/23 and 7/30/23. Review of the Care Staff Assignment sheets revealed Staff #6 continued to work directly with residents on 7/28, 8/17, 8/18 and 8/19/23.
Plan of correction · submitted by the facility
Starting on October 30, 2023, completing on January 30, 2024, ED, GPD or designee will audit 100% of all new employee files for training on Resident Rights on the New Employee Orientation checklist and 50% of current employee files the first month, 25% the second month, and 10% the third month. The QMIP committee will meet monthly for the duration of this POC. Additionally, an all-staff training on Resident Rights will take place by 11/16/23. Continued compliance will be measured by the ED, GPD or designee reviewing 10% of employee files quarterly. These reviews will be documented on the QMIP Meeting Notes. ED, GPD or designee will review Resident Rights quarterly in department and/or staff meetings until the QMIP committee deems appropriate. Training will continue at new employee orientation and annually. Addendum: Staff #6 was immediately suspended after report of abuse from surveyor. Employee was separated from employment on 8/25/23. Employee last worked 8/19/23. The report was given to police about staff #6 on 8/24/23. Starting on October 30, 2023, completing on January 30, 2024, ED, GPD or designee will test employees on their knowledge of Resident Rights, specifically that residents have the right to be free of abuse, and they are required to report to law enforcement immediately and their supervisor or manager on duty immediately. This will be documented on the Mandatory Reporting Check in Form. 100% of all new within 30 days of hire, 33% current employees the first month, 33% the second month, and 33% the third month. The QMIP committee will meet monthly for the duration of this POC. Continued compliance will be measured by the ED, GPD or designee will review resident rights quarterly in department and/or staff meetings by means of quizzes until the QMIP committee deems appropriate. Training will continue at new employee orientation and annually.
2412Ext Env HazS/S B▼
Findings
Based on observation and interview, the residence failed to maintain grounds to protect residents from slopes, holes, and other hazards, affecting 47 current residents. Findings include:On 8/24/23 during an environmental tour of the common use courtyard at approximately 3:30 p.m. slopes and hazards were identified as follows:The courtyard was located in the central part of the building and was accessible to all residents. There was a cement walkway approximately three feet wide in the courtyard that led from one exit door of the building to the other exit door on the opposite side of the courtyard. There were several drops on the sides of the walkway that dropped approximately three to five inches from the walkway into a rock garden. Additionally, the corners of the courtyard had a drainage grate that was surrounded with rocks that dropped down approximately 18 inches from the adjacent walkway. There was a landscaping border that was not secured down and protruded up approximately three inches adjacent to the inner side of the walkway, which caused a tripping hazard. On 8/24/23 at approximately 12:40 p.m., Staff #4 stated the rocks in the courtyard were dangerous and residents had tripped on them and fell into bushes. On 8/24/23 at approximately 1:50 p.m., Staff #5 stated she felt the rocks in the courtyard were dangerous because they were a tripping hazard for residents. On 8/24/23 at approximately 2:10 p.m., Staff #6 stated "the rocks are scary"because they were a tripping hazard for residents. On 8/24/23 at approximately 3:00 p.m., the program coordinator stated she was concerned about the rocks because they were a tripping hazard for residents and had brought her concerns to management; however, they did not want to change anything.
Plan of correction · submitted by the facility
The courtyard has three entrances. Two entrances were locked on 8/24/23 following the survey. By 8/25/23, the areas at issue were blocked by a plastic and concrete barrier, giving residents access only to one entrance to a paved patio. All portions where rock mulch meets the patio or sidewalk are blocked by the barrier. Photos are available upon request. Bids to flatten the courtyards and make them safe are being reviewed as of this writing. The barriers will stay in place until repairs commence. Starting on October 30, 2023, completing on January 30, 2024, ED, GPD or designee will inspect the courtyards and ensure barriers are in place and undisturbed and courtyard doors leading to the sidewalks are locked. These inspections will occur 5x per week the first month, 3x per week the second month, 2x per week the third month and thereafter until work commences. These checks will be documented on the Courtyard Duty Checklist. If repairs begin during this POC period, it will be documented on the Courtyard Duty Checklist and in QMIP meeting notes. The QMIP committee will meet monthly for the duration of this POC.Continued compliance will be measured by the ED, GPD or designee checking the courtyard for safety weekly and documented on the Community Rounding form. Reviews will include process improvements and action steps needed and will be documented in the QMIP meeting notes.

Reportable Occurrences

20 records
5/7/2026Physical Abuse · ID 2623G501003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/7/26, 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 physical abuse of a client. Client (B) pushed client (A), causing them to fall. Client (A) sustained an injury and reported pain. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, and reviewed records. Emergency medical services assessed client (A) and recommended that they be transported to the emergency department; however, client (A) refused. Client (A)'s medical provider assisted with treatment and medication for the pain. Client (A) confirmed client (B) shoved them. Due to cognitive impairment, client (B) was unable to provide detailed information about the incident, but was observed to be in an aggressive mood by staff. The facility coordinated care with both clients' medical providers. Client (B)'s medical provider increased their medication to assist with behaviors. Staff increased checks and 1:1 supervision for behavioral redirection. The event was substantiated. This is the second report of physical abuse involving the client (B). Please refer to the case ID 2623G501002 for details. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/24/2026 · released to the public 7/31/2026.
5/5/2026Verbal Abuse · ID 2623G501004Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/5/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Client (A) alleged staff (1) verbally abused them by speaking loudly and aggressively. During the course of the investigation, the healthcare entity separated client (A), suspended staff (1), ensured they felt safe, contacted police, reviewed records, and conducted interviews. Staff witnessed client (A) become agitated and physically aggressive by attempting to hit staff (1) with objects. Staff assessed client (A), who expressed agitation; however, no visible injuries or complaints of pain or fear were indicated. The facility terminated staff (1)'s employment. The facility increased monitoring of client (A) and reminded staff of client (A)'s behavioral triggers, redirection approaches, and de-escalation interventions. The facility retrained staff on abuse prevention and de-escalation techniques. From the evidence revealed by the facility’s investigation, 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 7/21/2026 · released to the public 7/28/2026.
3/24/2026Physical Abuse · ID 2623G501002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/24/26, 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 physical abuse of a client. Client (B) pushed client (A), causing them to fall. Client (A) sustained an injury. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, and reviewed records. Emergency medical services transported client (A) to the emergency department for treatment of their injuries. Client (A) returned to the facility with wound care and medication to assist with pain. Client (A) confirmed being pushed. Due to cognitive impairment client (B) was unable to provide detailed information about the incident, but stated being mad. The facility increased monitoring of client (B)'s behaviors, and their medical provider reviewed medications. Staff witnessed 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 5/5/2026 · released to the public 5/12/2026.
3/9/2026Sexual Abuse · ID 2623G501001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/9/26, 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 sexual abuse of a client. Client (A) reported they had been raped by client (B). During the course of the investigation, the healthcare entity separated both clients, ensured they felt safe, contacted the police and medical providers, and conducted interviews. Both clients had no physical concerns with bruising or harm to their bodies when assessed. Staff reported that client (B) attempted to enter client (A)'s room, but they did not want them in their room, so they slammed the door. Client (A) denied being raped; however, they reported feeling scared of client (B) attempting to enter their room. Client (B) denied the allegation. The facility increased monitoring and contacted both clients' medical providers to review medications and discuss occupational therapy to assist with behaviors. 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 5/12/2026 · released to the public 5/19/2026.
9/17/2025Physical Abuse · ID 2523G501008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/23/25, 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 physical abuse of a client. Client (B) threw a chair at staff and then pushed Client (A), which caused them to fall. During the course of the investigation, the healthcare entity separated the clients, assessed for injury, contacted police, and conducted interviews. No visible injuries were reported. Due to cognitive impairment, both clients were unable to provide detailed information about the event. The facility implemented increased behavior monitoring of Client (B) and the family was actively looking for a company to provide Client (B) with one-to-one services. Staff witnessed the altercation. 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 3/2/2026 · released to the public 3/9/2026.
9/7/2025Physical Abuse · ID 2523G501007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/7/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) hit client (A) across the face. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, and conducted interviews. Client (A) did not have any visible injuries and did not recall the event. Client (B) expressed they were frustrated because client (A) moved their walker. The facility started therapy services and increased safety monitoring. The facility determined contact occurred but did not cause injury. 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 12/18/2025 · released to the public 12/25/2025.
6/28/2025Physical Abuse · ID 2523G501006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/28/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) alleged they were hit on the head by Client (B). During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) did not have any visible injuries but was agitated and upset they were allegedly hit. There were no witnesses and the facility could not determine what happened, however, Client (A) gave specific details and identified Client (B) as the one who hit them. Staff increased safety monitoring for both clients. 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 11/16/2025 · released to the public 11/24/2025.
6/27/2025Physical Abuse · ID 2523G501005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/30/25, 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) grabbed Client (A)’s arm causing a skin tear that was treated by staff. Client (B) has a tendency to lead other clients without harm. The injury was accidental in nature. Staff increased safety checks for the clients and a one-to-one caregiver was discussed with Client (B)’s family member if their condition continues to decline. 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 11/16/2025 · released to the public 11/24/2025.
6/24/2025Physical Abuse · ID 2523G501004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/24/25, 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 Client (A) and the alleged assailant (family member) were separated before the police were notified. Staff witnessed Client (A) try to leave the memory care unit following the family member who proceeded to push Client (A) back inside. No visible injuries to Client (A), they just called the family member an explicit name. The family member stated they did not want Client (A) to leave and did not intend to cause harm. The family member was educated on other redirection techniques or to ask for staff assistance. Contact was made, however no injury and the family member action was stated for the safety of Client (A). 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 10/29/2025 · released to the public 11/5/2025.
5/19/2025Physical Abuse · ID 2523G501003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/20/25, 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. Client (A) stated they were hit by Client (B). Client (B) could not be interviewed due to cognitive impairment. The facility could not determine what happened, there were no witnesses or an injury. 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 11/11/2025 · released to the public 11/18/2025.
3/10/2025Physical Abuse · ID 2523G501002Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/10/25, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, after client (A) misunderstood a conversation client (B) was having, they pushed client (B) which resulted in a physical altercation between the clients. During the course of the investigation, the healthcare entity notified law enforcement, separated the clients, completed assessments and conducted interviews. Both clients sustained injuries requiring first aid treatment. The facility implemented increased safety monitoring of interactions between the clients. 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 8/13/2025 · released to the public 8/21/2025.
9/4/2024Physical Abuse · ID 2423G501006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/4/24, 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. Client (B) walked up to Client (A) and kicked them in the leg. No visible injuries seen. Both clients have cognitive impairment and did not recall the event. Client (B) was sent to the hospital for agitation and returned without any new orders. Client (B)’s primary physician made changes to their medication regime. Staff increased safety checks. Staff witnessed the event. 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 5/7/2025 · released to the public 5/14/2025.
8/16/2024Physical Abuse · ID 2423G501004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/16/24, 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 member (1) during safety checks found Client (B) in Client (A)’s apartment with oxygen tubing wrapped around Client (A)’s neck. No visible injuries. Neither client could recall what occurred due to cognitive impairment. One-to-one oversight was implemented during overnight hours. Staff will monitor for behaviors and to ensure apartments are locked. 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 4/28/2025 · released to the public 5/5/2025.
6/14/2024Sexual Abuse · ID 2423G501003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/14/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported sexual abuse of a client. During the course of the investigation the healthcare entity ensured the client was safe. Staff member (1) alleged Staff member (2) was acting inappropriately with Client (A). The police were notified and Adult Protective Services. Staff member (2) stated they treated the clients like their grandparents when showing gestures of affection. There was no ill intent. All staff were provided additional training by management and Adult Protective 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 submitted within the required timeframe.
Publication
Sent to facility 4/2/2025 · released to the public 4/9/2025.
5/1/2024Verbal Abuse · ID 2423G501001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. 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 agency/facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.
Publication
Sent to facility 4/1/2025 · released to the public 4/9/2025.
12/28/2023Brain Injury · ID 2323G501006Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 12/28/23, a female resident (A) in her 80s was found on the floor lying on a pillow unresponsive when staff member (1) arrived at her room. Staff member (1) entered resident (A)’s room at 6:10 p.m. Resident (A) was transported to the hospital and diagnosed with a brain bleed/injury. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family. Resident (A) was admitted to the hospital with a brain bleed. Resident (A) was newly admitted to the facility on the day she fell 12/28/23. Staff indicated she was last seen around 5:45 p.m. seated in her wheelchair. Resident (A) was last checked on by staff within 30 minutes of her falling. Resident (A) did not return to the facility as she passed away on 12/29/23. The facility investigation concluded resident (A) had an unwitnessed fall sustaining a brain injury. Per facility findings, staff responded appropriately and followed her care plan prior to her fall. The facility will continue to follow the residents care plan in place. 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 11/18/2024 · released to the public 11/25/2024.
10/20/2023Misappropriation of Property · ID 2323G501005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 10/20/23, a family member of a female resident (A) in her 80s reported resident (A)’s ring was missing. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Staff were interviewed and staff member (1) stated they saw the husband who would visit resident (A) take the ring off on 10/10/23 and put it in his shirt pocket. Resident (A) has dementia and the husband did as well. The ring was last seen by family on 10/4/23 or 10/5/23. Staff filled out a concern form on 10/8/23 indicating the ring was missing. On 10/10/23 staff member (1) stated the item was found and the husband had taken it. The missing item form had not been submitted until this investigation on 10/20/23. The facility investigation concluded there was no evidence to state the husband took the ring or not. Staff member (1)’s story was the same each time. No assailant was identified. Resident (A)’s ring was still missing. To help prevent a recurrence, the husband's personal caregiver was asked to stay with him during the visit. Families are still asked to take valuables home. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.
Publication
Sent to facility 9/30/2024 · released to the public 10/7/2024.
9/2/2023Brain Injury · ID 2323G501004Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 9/2/23, a resident (A), in her 80s, was found on the floor by staff around 2:20 p.m. Resident (A) stated she struck her head after falling forward and was experiencing pain. Resident (A) was on hospice services and the hospice staff was notified. Resident (A) was assessed and made comfortable with medication. Per staff, resident (A) was talking and walking normally. She remained in the facility after the fall. A day later, resident (A) had a change in condition. Resident (A) was provided end of life care on hospice services according to her wishes and passed away two days later. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family and physician. The facility investigation concluded the circumstances of the fall were unclear and it was unknown if she suffered an internal brain bleed. No diagnostic tests were completed. Staff continued following policies in regards to resident wishes and protocols post falls. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 8/12/2024 · released to the public 8/19/2024.
8/24/2023Physical Abuse · ID 2323G501003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 8/24/23, during an onsite survey conducted by a representative from the health department, the facility was made aware of concerns regarding the actions of a qualified medication administration person (QMAP) (1). The allegations included QMAP (1) being too fast, rough with care and forcing care on residents. Per the facility, these allegations had not been previously reported and involved seven at-risk residents with varying care needs. All the residents had diagnoses of dementia. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families, ombudsman, Adult protective Services and physician. QMAP (1) denied the allegations. QMAP (1) was immediately suspended pending the investigation. All the residents were assessed without any visible injuries or unexplained bruising. The residents had cognitive impairments and were unable to participate in a follow up interview about their care. Staff reported the residents did not exhibit signs of distress, fear or anxiety. Other staff reported they have heard QMAP (1) use inappropriate language, and insult residents but did not report these concerns to management. The staff also reported witnessing QMAP (1) allegedly force care on residents that refused such as, pulling residents into the shower, pulling them out of bed, or dressing or undressing them when they verbally refused. After reviewing documentation, there were no entries of allegations or resident injuries. Based on the facility's investigation, they facility concluded the allegations against QMAP (1) were founded. QMAP (1)’s employment was terminated. The staff were educated on mandatory reporting expectations, resident rights, and resident abuse. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department. In addition to this off-site occurrence review, an onsite investigation was conducted. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 8/24/23.
Publication
Sent to facility 7/24/2024 · released to the public 7/24/2024.
1/5/2023Physical Abuse · ID 2323G501001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/5/23 a male resident (A) in his 90s was at the end of life and experiencing pain. The power of attorney (POA) was refusing needed medications that were recommended by hospice and resident (A)’s physician. After several attempts to communicate and educate the POA, the allegation was made due to mismanagement and neglecting to give proper medical care to resident (A) by the POA. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, Adult Protective Services and ombudsman. Resident (A) was complaining of pain to his coccyx area. Balm was applied, a cushion was provided and Tylenol was implemented. The interventions became ineffective and hospice contacted the POA to discuss other pain medications. The POA would not approve other pain medications. The POA was also refusing proper bandages for resident (A)s skin breakdown. The facility made multiple attempts to speak with the POA, however the POA would hang up the phone. The POA took resident (A) to the emergency room for a cough and was discharged with no new diagnoses and stated the red area to resident (A)’s coccyx was from antibiotics that were completed a week ago. The facility investigation concluded the POA was denying resident (A) proper medical care during the end stages of his life. To help prevent a recurrence, the staff and hospice will continue to provide care for resident (A) according to the medical provider(s). The POA for resident (A), who lives out of state, will not be allowed to visit or take resident (A) out of the facility until supervisory visitations could be established. Staff will monitor in house visits when POA is in the facility. 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 7/24/2023 · released to the public 7/31/2023.