6
Inspections
6
Deficiencies
0
Actual Harm or Above
22
Occurrences
March 13, 2026
Last Inspection
S/S A/B Minimal potential
The most recent inspection of TREANAS HAVEN on record is dated March 13, 2026. Across 6 published inspections, state surveyors cited 6 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
Stocke, Samantha
Owner
TERRA BLUFFS VENTURES OPCO, LP
Phone
(720) 798-3770
Payor Source
Private Pay
City
PARKER
ZIP
80134
Inspections & Citations
6 inspections · 6 deficiencies3/13/2026Licensure Complaint · ID PVQU11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO40397 was completed on 3/13/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/28/2025Revisit: Licensure Complaint · ID PZFD12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 5/28/25 for previous deficiencies cited on 3/25/25. The agency is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
3/24/2025Licensure Complaint · ID PZFD113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO36185, #CO36635, #CO37045, #CO37429, #CO39177 was completed on 3/25/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼
Findings
Based on observation, interview, and record review, the residence failed to comply with authorized practitioner's orders, affecting three of six sample residents (#2, #4, #5). Findings include: 1. Resident #4 was admitted to the residence on 2/13/25 with diagnoses including osteoporosis, Gastroesophageal reflux disease, and chronic kidney disorder. a. Metformin A written practitioner's order, dated 2/27/25, directed the residence to administer metformin 1000 mg one tablet twice daily. However, the March 2025 medication administration record (MAR) read that the medication was not administered from 3/1-3/5/25, as the medication was out of stock. A total of 10 doses were missed. b. Donepezil A written practitioner's order, dated 3/6/25, directed the residence to administer donepezil, five mg two tablets at bedtime (HS). However, the March 2025 MAR read that the medication was not administered from 3/8-3/9/25, as the medication was out of stock. A total of two doses were missed. c. Mirtazapine A written practitioner's order, dated 3/6/25, directed the residence to administer mirtazapine seven and a half mg at (HS). However, the March 2025 MAR read that the medication was not administered from 3/7-3/8/25, as the medication was out of stock. A total of two doses were missed. d. Sertraline A written practitioner's order, dated 3/6/25, directed the residence to administer sertraline 25 mg (0.5), one tablet daily. However, the March 2025 MAR read that the medication was not administered on 3/15/25 as the medication was out of stock. A total of two doses were missed. On 3/25/25 at 10:00 a.m., the director of wellness (DOW) stated she was aware that Resident #4 had been out of all the above medications. She stated she had contacted the pharmacy prior to the medications running out, and was informed they needed new orders from the practitioner before they could fill and deliver the prescriptions. She stated that Resident #4 had not any adverse reactions by not taking the scheduled medications. 2. Additional deficient practice was identified with Residents #2 and #5.
Plan of correction · submitted by the facility
Terra Bluffs will automatically reorder medications in advance of needed refill from pharmacy and ensure that orders are up to date and monitor the pharmacy dashboard to ensure that timely ordering is completed. Residents #2, #4, and #5 will be included in this sample. A call during business hours with Omnicare will be coordinated to review all medication statuses for any missing medications and to look 2-weeks in advance for needed refills. Director of wellness or designee will monitor reordered medications daily and follow up with pharmacy to ensure medications are delivered timely and no missed meds occur related to medications not being available. Physicians will be notified if pharmacy is unable to fill medications related to insurance issues or RX out of date to get updated RX or new orders. Resident care coordinators or designee will do weekly cart audits for three months to ensure medications are ordered. Audits will be documented and turned in weekly to Director of wellness or designee. All findings will be reported to QAPI.All medication staff will be educated on the above by May 9, 2025.
1622Med/Med Adm-Slf Adm Annly RvwS/S A▼
Findings
Based on interview and record review, the residence failed to review the resident's medication list with the resident and authorized practitioner, affecting one resident (#6) who self-administered medications. Findings include:1. Resident #6 was admitted to the residence on 8/30/24 with diagnoses including dementia, hypertension, type II diabetes, and osteoporosis. a. Record ReviewThe physician's admission form, dated 7/16/24, read in part, "Healthcare professionals administer medications. Medications are stored in a central location and administered by healthcare professionals only ..."The care plan for Resident #6, dated 8/31/24, read in part, "(Resident #6) requires assistance from family to set up, administer, and order all medications ..." The residence's Self-Administration of Medications Review Tool, dated 1/13/25, deemed Resident #6 fully capable and approved the resident to self-administer his medications. Additionally, the document read that the residence had obtained a physician order for the resident to self-administer; however, the residence was unable to provide the order as they had failed to contact the physician and review the medication list prior to the onsite visit. 2. Interviews On 3/25/25 at 10:00 a.m., the director of wellness (DOW) stated Resident #6's family wanted to maintain responsibility for his medications after he had moved in and had a private outside provider who came to the residence daily. She stated the self-administration evaluation was completed by the residence in January because they had noticed a cognitive decline; however, he was deemed capable of self-administering his medications but with supervision. The DOW stated the residence had reviewed the medication list with the resident but had not involved the resident's practitioner.
Plan of correction · submitted by the facility
The facility will ensure that medication lists are reviewed with the resident and authorized practitioner at least once a year or upon change of condition for those who self-administer and will maintain documentation of this review. Resident #6’s regimen was reviewed with practitioner, and it was determined that the facility is to administer his medication. His care plan has been updated to reflect as such Facility will observe residents for self-administration of medication competency Medication staff will be educated on this requirement by May 9, 2025. Audits on residents who self-administer to be done weekly for three months by Director of Wellness or designee to ensure proper documentation and review are completed with residents and practitioners and that resident is still appropriate to self-administer. The results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed
1624Med/Med Adm-Slf Adm RprtS/S A▼
Findings
Based on interview and record review, the residence failed to report non-compliance of known medications by a resident who was self-administering to the resident's authorized practitioner. Findings include: 1. Resident #6 was admitted to the residence on 8/30/24 with diagnoses including dementia, hypertension, type II diabetes, and osteoporosis. a. Record ReviewThe physician's admission form, dated 7/16/24, read in part, "Healthcare professionals administer medications. Medications are stored in a central location and administered by healthcare professionals only ..."The care plan for Resident #6, dated 8/31/24, read in part, "(Resident #6) requires assistance from family to set up, administer, and order all medications ..." The residence's Self-Administration of Medications Review Tool, dated 1/13/25, deemed Resident #6 fully capable and approved the resident to self-administer his medications. Additionally, the document read that the residence had obtained a physician order for the resident to self-administer; however, the residence was unable to provide the order as they had failed to contact the physician and review the medication list prior to the onsite visit. 2. Interviews On 3/24/25 at approximately 7:52 a.m., Staff #2 stated, "We do not 'pop' his pills; he has an MRB." She stated later that morning when she realized medications had been left in Resident #6's MRB, she repeated, "That's not good, that's not good." Staff #2 stated she asked Resident #6 if he had been taking his medications and if there was a chance he was off on his days. Resident #6 admitted, "Yes, I could be." On 3/24/25 at 7:57 a.m., Staff #2 called the director of wellness (DOW), informed her of what she found in Resident #6's MRB, and asked if they should pull the medication from his room. The DOW stated that they should pull his medication. On 3/24/25 at 8:08 a.m., Staff #2 stated she thought it was 'crazy' that he got to keep his pills in his room. She continued to say that she was told to make sure he took the medication. On 3/24/25 at 8:21 a.m., Staff #2 stated that Resident #6 was self-administering when he first moved in in August 2024. She stated the residence had taken over supervising Resident #6 taking his medications in January 2025, but his medication stayed in his room. On 3/24/25 at 4:27 p.m., the DOW stated Resident #6's family and the outside care provider filled the MRB's. She stated, this was the first time she had heard about there being possible issues with Resident #6 self-administration of his medications. The DOW stated since learning of Resident #6 not taking his medications on 3/22/25 and 3/23/25, she had not yet contacted his practitioner as required by state regulations.
Plan of correction · submitted by the facility
The facility will ensure to report non-compliance of known medications to the resident’s authorized practitioner and ensure that the care plan accurately follows provider orders. Resident #6’s noncompliance was reported to practitioner and the facility has assumed responsibility for administering his medication, the care plan was updated to reflect this. All residents who self-administer will be re-assessed for appropriateness and provider will be notified of outcome, care plan will be updated. All medication administration staff will be educated on the policy and requirements of notifying the authorized practitioner of non-compliance by May 9th 2025. Audits to be done weekly for three months by Director of Wellness or designee to ensure proper documentation for safety to self-administer as well as any notification to provider. The results of these audits will be brought to the IDT for the monthly QAPI meeting and performance improvement plans will be developed as needed
7/30/2024Revisit: Licensure and Licensure Complaint (Combined) · ID VR1P12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 7/30/24 for all previous deficiencies cited on 5/28/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally
Plan of correction
The state did not require a plan of correction for this citation.
5/8/2024Licensure and Licensure Complaint (Combined) · ID VR1P113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO34898, and #CO35649 was completed on 5/8/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1412Res Rts-Inv Ab/Neg Alleg or Inj Unk Org IUOS/S B▼
Findings
Based on record review and interview, the residence failed to develop and implement policies and procedures with all of the required elements for the identification, reporting, and investigation of injuries of unknown origin, affecting 19 current residents residing in the secure environment and one former resident (#6). Findings include:1. Residence PolicyThe residence's January 2023 Abuse, Neglect, and Exploitation Reporting policy read in part: "Injuries of unknown source: An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person, and the source of the injury could not be explained by the resident. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time." However, the residence failed to include that the investigation was documented with outcomes and ongoing monitoring when the residence failed to determine the source of the injury and the steps taken to monitor the resident in an effort to identify and prevent similar injuries. Further, the residence failed to include in the policy the retention and availability of the investigation, as well as updates required to the policy after the investigation. 2. Former Resident #6 was admitted to the residence on 2/29/24 with a diagnosis of Parkinson's disease. A progress note, dated 4/1/24, read: "Resident returned with family, and family reported that they noticed a bruise on Resident's inner thigh. Thinking it is night care team being too rough." However, the March 2024 resident's medication administration record read the resident was out of the residence beginning on 3/22/24 and returned on 3/26/24. An incident report, dated 4/1/24, read: "Resident returned to the [residence] from a trip from [out of state], and the resident's family made the care team aware of a bruise to the resident's inner thigh. It is unknown where the bruise came from, and the resident has a workout bike and other [exercise] equipment in his room. The injury was not present or seen before the trip took place. The resident was unable to give a description, but the resident's [family member] stated that 'the night shift caregivers are too rough with the resident."Further, the report read that the resident had a baseline mental status, the bruise was on the resident's right front thigh, and the resident continued to ambulate independently. The residence's investigation, dated 4/1-4/2/24, read in part that the residence investigated the injury of unknown origin. The residence was unable to determine specific staff member involvement, if it was related to falls or use of exercise equipment, and when or where it occurred. Therefore, the residence could not determine the cause of the injury. However, the investigation failed to include several required elements, such as ongoing monitoring and steps taken to ensure the resident did not experience similar injuries in the future. On 5/8/24 at 9:30 a.m., a family member of the former resident stated that the resident reported to another family member that the residence staff was rough with him, and the resident sustained a bruise to the thigh at the end of March 2024. She stated that the resident had also sustained several falls at the residence from February 2024 until the resident moved from the facility in early April 2024. She stated the resident fell on 4/7/24 and sustained a different injury; however, she stated that the hospital identified a hairline fracture to the resident's right thigh from the previous injury at that time. She added that she was not aware if the residence investigated the cause of the injury, including whether the residence investigated the staff. On 5/8/24 at 12:07 p.m., the director of health and wellness (DHW) stated thatthe residence identified that Former Resident #6 had an injury of unknown origin and that the wellness nurse (WN) and the executive director (ED) investigated the incident. She added she was not working at the residence when the family member of the former resident reported the injury or during the investigation. On 5/8/24 at 12:37 p.m., the WN stated that the former resident care coordinator (RCC) reported the bruise and concern to her approximately one week after the resident returned from being out of the residence on a trip. She stated that she and the ED conducted an investigation of staff and involved staff and residents; however, the investigation was late due to the late notification. She added she believed that the resident bruised his thigh when he used his exercise bicycle; however, the residence failed to evaluate the way the resident used the exercise bicycle or the placement of the bicycle to avoid future injuries. She added that the residence did not update the resident's care plan or implement ongoing monitoring of the resident. She stated she was unaware of the requirements of investigating an injury of unknown origin. On 5/8/24 at 1:48 p.m., the ED stated she believed that the former resident had an injury of unknown origin as the family member of the former resident reported general staff roughness, and the family member reported no specific instance or named staff member. In a later interview, at 3:35 p.m., the ED stated that she and the WN conducted the investigation approximately one week after the family member reported the concern to the former RCC. She added they investigated secure environment (SE) staff through staff and resident interviews, reviewed the infrared footage, and ensured no other residents experienced roughness or bruising. She added that the former resident exercised frequently and had frequent falls, and the origin of the injury was undetermined. After reviewing the residence policy, the ED stated that the policy failed to include the required elements of an investigation of injury of unknown origin. She added that the investigation the residence conducted for the injury sustained by Former Resident #6 failed to include ongoing monitoring elements that ensured avoidance of future injury. She stated that the residence failed to update the resident's care plan or implement increased monitoring. She added that the investigation documentation was not filed together or readily available and that the ED had to look for it. She stated that the home office created the policy, and the residence planned to update it and follow the requirements after seeking approval from the home office. 3. Due to the lack of an updated policy and procedure, 19 current residents were at risk of the residence failing to conduct an investigation of injury of unknown origin with all of the required elements.
Plan of correction · submitted by the facility
New Policy was written and implemented by 5/24/2024. All staff will be in-serviced by May 31, 2024. Director of Wellness and Wellness Nurse passed out new policy and in-serviced staff in groups during crossover and staff signed in-service sign in sheet. We will conduct weekly skin monitoring and follow up on any issues noted. We will track by auditing skin observations and incident reports weekly to ensure all are completed through our EMAR system. We will monitor nature of the injury, location, time of occurrence, individuals involved and any other contributing factors. We will add interventions to address identified injuries of unknow origin which include team trainings, changes in community protocols, environmental modifications and any other measures aimed to prevent injuries of unknown origins. Any injuries of unknow origin will be reported to state agencies as required. We will review our findings in QAPI weekly and report compliance in our QAPI meetings.
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼
Findings
Based on record review and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting two of three sample residents (#3, #5). Findings include:1. References and Residence PolicyThe residence's medication administration policy, dated 11/2019, read in part: "Licensed nurse reviews the medication administration record (MAR) on a weekly basis to ensure that all previous week's medications were administered, identifies issues and changes needed in medication regime, and contacts prescriber regarding changes needed."2. Resident #3 was admitted to the residence on 11/30/23 with diagnoses that included acute chronic diastolic (congestive) heart failure.a. Skin prepA written practitioner's order, dated 3/8/24, directed the residence to administer skin prep to the foot twice daily. However, the April and May 2024 MARs revealed skin prep was not administered on 4/1-4/4, 4/7, 4/9-4/11, 4/14-4/18, 4/20-4/25, 4/27, 4/29, 4/30, 5/1, 5/2, 5/4, 5/5, 5/7, 5/8 in the morning and 4/3, 4/4, 4/7, 4/10, 4/11, 4/13, 4/18, 4/21-4/24, 4/27, 4/28, 5/5, 5/8/24 in the evening, due to the medication being unavailable, for a total of 43 missed doses.b. Calcium carbonate A written practitioner's order, dated 12/13/24, directed the residence to administer calcium carbonate 500 mg daily. However, the April and May 2024 MARs revealed calcium carbonate was not administered 4/1-4/4, 4/7, 4/9-4/11, 4/14-4/23, 4/29-4/30, 5/1, 5/3, 5/4, 5/7, and 5/8/24 due to the medication being unavailable, for a total of 25 missed doses.c. Potassium chloride A written practitioner's order, dated 4/21/24, directed the residence to administer potassium chloride 10 mg twice daily. However, the April and May 2024 MARs revealed potassium chloride was not administered on 4/22 and 4/23, and 4/26 in the morning and 4/21-4/23/24 in the evening due to the medication being unavailable for a total of six missed doses.d. Calcium carbonate A written practitioner's order, dated 12/13/24, directed the residence to administer calcium carbonate 500mg daily. However, the April and May 2024 medication administration records MARs revealed calcium carbonate was not administered on 4/1-4/4, 4/7, 4/9-4/11, 4/14-4/20, 4/22-4/24, 4/29, and 4/30/24 in the morning due to the medication being unavailable, for a total of 20 missed doses.e. Anti-diarrheal A written practitioner's order, dated 2/8/24, directed the residence to administer anti-diarrheal 2 mg daily. However, the April and May 2024 MARs revealed anti-diarrheal was not administered 4/14-4/18/24 due to the medication being unavailable for a total of four missed doses.f. Super C ImmuneA written practitioner's order, dated 2/10/24, directed the residence to administer Super C Immune one tablet twice daily. However, the April and May 2024 MARs revealed Super C Immune was not administered on 4/3, 4/4, 4/9-4/11, 4/14-14/17, 4/23-4/25, and 4/29 in the morning, and 4/11, 4/14, 4/24 in the evening due to the medication being unavailable, for a total of 15 missed doses. g. Acidophilus A written practitioner's order, dated 3/8/24, directed the residence to administer acidophilus one capsule daily. However, the April and May 2024 MARs revealed acidophilus was not administered on 4/28, 5/2, and 5/5/24 due to the medication being unavailable, for a total of three missed doses. 3. InterviewsOn 5/8/24 at 8:31 a.m., Staff # 1 stated that she had informed the director of health and wellness (DHW) a month prior to the on-site investigation that medications for Resident #3 were unavailable. Additionally, she stated that the computer software also informed her when they documented that medications were not available. On 5/8/24 at 12:22 p.m., the wellness director (WD) stated staff failed to inform her when the family did not supply the medications ordered by the practitioner. On 5/8/24 at 12:50 p.m., the wellness nurse (WN) stated that the code 13 on the MAR was for medications not available. She acknowledged that Resident #3 had many medications that were unavailable for April and May. On 5/8/24 at 2:05 p.m., the WD and the executive director (ED) stated that although the family was to supply medications for Resident #3, it was the residences' failure to ensure that the medications had been available to be administered as ordered by the practitioner. On 5/8/24 at 3:34 p.m., the ED stated the family did not provide the residence with the medications. However, she acknowledged that the residence had failed to follow practitioner orders by not administering medications ordered by the physician. 4. Evidence obtained during the on-site visit revealed that the residence additionally failed to comply with the practitioner's orders regarding medication administration for Resident #5.
Plan of correction · submitted by the facility
Terra Bluffs will automatically reorder medications from pharmacy if families do not provide ordered medications timely to ensure no missed doses occur. Wellness Nurse will monitor daily reordered medications and follow up with pharmacy to ensure medications are delivered timely and no missed meds occur related to medications not being available. Physicians will be notified if pharmacy is unable to fill medications related to insurance issues or RX out of date to get updated RX or new orders. NOC QMAP will do nightly cart audits to ensure medications are ordered. Audit will be recorded and turned in nightly to Wellness Nurse. Wellness nurse will audit findings daily and follow up daily on any issues. Weekly cart audit will be conducted by AL Coordinator and MC Coordinator with Wellness Nurse to ensure medications are available. All findings will be reported to QAPI. All staff will be educated on above by May 31, 2024.
3060Sec Env-Enhncd Rsdnt CP IncldS/S B▼
Findings
Based on observation, record review, and interview, the residence failed to provide an enhanced care plan for four out of five sample residents (#1, #4, #5, and #6) who lived in a secured environment. Findings include:1. Residence PolicyThe residence's Person-Centered Service Assessment policy, dated November 2019, read in part,"The service plan describes the following: services that are furnished to attain or maintain the residents ' highest practicable physical, mental, and psychosocial well-being; and personal and cultural preferences, any services that would be furnished but are not provided due to the residence exercise of rights, including the right to refuse treatment. A comprehensive service plan is prepared by an intro disciplinary team that may include the physician, nursing, appropriate staff, and disciplines, as determined by the residence needs and to the extent practicable, the resident and his/her family or resident representative."2. Resident #1 was admitted to the residence secured unit on 3/30/24 with diagnoses including Alzheimer's, irritable bowel syndrome, and insomnia. On 5/8/24 between 7:25 a.m. and 7:40 a.m., Staff #5 attempted to open the doors of two unidentified residents and both doors were locked. The care plan dated 3/30/24 documented that Resident #1 had exit-seeking behaviors. Interventions included redirecting the resident, who was incontinent and required stand-by assistance when toileting. A progress note dated 4/3/24 read in part: Resident #1 was in another resident's room, sitting in their recliner. When a staff member entered the room, Resident #1 attempted to hit the staff member. A progress note dated 4/5/24 read in part: Resident #1 was in another resident's room. Resident #1 was agitated when staff attempted to redirect the resident. A progress note dated 4/6/24 read in part: Resident #1 urinated in the hallway. Resident #1 then entered another resident's room and tried to punch the staff member when they tried to redirect him. A progress note dated 4/12/24 read in part: Resident #1 entered Resident #5's room in the middle of the night. Resident #5 was agitated by Resident #1 entering his room while sleeping. A progress note dated 4/12/24 read in part: The resident urinated on the floor and put feces under the bathroom sink and cupboards. A progress note dated 5/5/24 read in part: Resident #1 defecated on the floor throughout the building. A progress note dated 5/6/24 read in part: Resident #1 had feces on the carpet and wall and was defecating everywhere. 3. InterviewsOn 5/8/24 at 7:25 a.m., Staff #5 stated that all residents' doors were locked during the overnight hours to prevent Resident #1 from entering without their permission. She added that Resident #1 urinated and defecated on the floors of other residents. She stated that no residents except for Resident #2 had keys to their rooms. On 5/8/24 at 7:40 a.m., Staff #6 stated that all of the residents ' rooms were left unlocked during the day and were locked during the night shift. She added the locked rooms were to prevent Resident #1 from entering and urinating on the other residents ' floors. She stated that no resident had a key to their room other than Resident #2. On 5/8/24 at 7:45 a.m., Staff #2 said Resident #1 urinated and defecated throughout the building, which included other residents' rooms. Staff #2 said Resident #1 had a jumpsuit they used to prevent the resident from defecating and urinating inappropriately. Staff #2 said Resident #1 did not sleep at night and would enter other residents' rooms. Staff #1 said the residents' rooms were not supposed to be locked. Staff #1 said they would redirect Resident #1 if he entered another residents ' room. On 5/8/24 at 3:15 p.m., the wellness nurse (WN) said she needed clarification on what an enhanced care plan was. The WN said she did not know what was needed for an enhanced care plan for secured environments. The WN said Resident #1 had behavioral concerns that included wandering into other residents' rooms and defecating and urinating in other residents' rooms. The WN said Resident #1 had a jumpsuit he wore to limit his urinating and defecating throughout the residence. The WN said Resident #1 could take the jumpsuit on and off independently. The WN said the care plan documented if a resident had a key to their room. The WN said they locked some residents' doors at night; however, they could open the doors from inside their rooms. On 5/8/24 at 3:27 p.m., the administrator was interviewed. The administrator said the residence had person-centered care plans. The administrator said she needed clarification on what an enhanced service plan was. The administrator said she did not know what elements needed to be included in an enhanced care plan for a secured environment. The administrator said Resident #1 wandered into other residents' rooms and urinated and defecated throughout the building. The administrator said Resident #1 should have these behaviors and interventions in his service plan. The administrator said Resident #1 did not have the use of a jumpsuit in the care plan. The administrator said Resident #1 wore a jumpsuit to prevent the resident from urinating and defecating throughout the residence. The administrator said the care plan should be updated, and the resident should wait to wear the jumpsuit until the care plan was updated. The administrator said another staff member got the jumpsuits and implemented the jumpsuit before updating the care plan. The administrator said the residence locked the residents' doors at night to prevent Resident #1 from entering. The administrator said one resident had a key to their room. The administrator said staff left the residents' rooms unlocked and their doors open during the day. The administrator said Resident #5's key to his room was lost. The administrator said one other resident had a key to their room. 4. Additionally, the residence failed to ensure that each resident had an enhanced care plan documenting how Resident #4, Resident #5, and Resident #6 would have independent access to their rooms while keeping other residents from entering them.
Plan of correction · submitted by the facility
All residents will be provided keys to their apartment for access when out of the apartment. Staff will monitor residents and assist with keys as needed. Apartments will be kept locked to ensure other residents do not wander in. Unless otherwise care planned per resident or POA preference. This portion will be completed by June 7, 2024. All staff will be educated on above by May 31, 2024. All follow up will be reported in QAPI.Enhanced Care Plans for each Memory Care resident will be completed by 6/14/2024 and at time of admission for new residents. Care plans updated to include Enhanced Care Plan requirements for resident #1 and #4 on 6/7/2024. Monitoring for Enhanced Resident Care Plan for all Memory Care residents will occur with each care plan review and corrected as necessary. This will be on-going. Results reported to QAPI per tracking sheet for next 3 months and results discussed and improvement process implemented if needed.
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."14.29 (C) All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. ""17.7 Weekly menus shall be readily available for residents and public viewing no less than 24 hours prior to serving."
Plan of correction
The state did not require a plan of correction for this citation.
10/27/2023Licensure (Re-licensure) · ID M3TY11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An initial licensure survey was completed on 10/27/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
22 records3/12/2026Physical Abuse · ID 2623JT66003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/12/26, 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. Camera footage revealed client (B) entered client (A)'s room and had a physical altercation, causing client (A) to sustain a fall. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, conducted interviews, reviewed records, and camera footage. Emergency medical services transported client (A) to the emergency department for further evaluation. Client (A) returned to the facility. Due to cognitive impairment, both clients were unable to provide detailed information about the incident. The facility implemented the following: increased supervision when in common areas, monitoring of behaviors, redirection strategies, and environmental changes to help prevent wandering in rooms. The facility reeducated staff on updates. 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 4/27/2026 · released to the public 5/4/2026.
2/1/2026Misappropriation of Property · ID 2623JT66004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/26/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) reported that jewelry was missing from their room and was unsure when they last saw it or whether they had it when they moved it in. During the course of the investigation, the healthcare entity searched for the item, contacted police and medical providers, and conducted interviews. Client (A) confirmed hiding items from themselves and denied ownership of the computer in their room. Staff confirmed that the computer belonged to client (A) and were unaware of the missing jewelry. Client (A)'s representative confirmed that client (A) experienced increased confusion and did not suspect the jewelry was stolen, as they had other storage units. The facility educated client (A) on storing their valuables in their locked box and locking their door when leaving. Due to the results of the investigation being inconclusive, 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 7/9/2026 · released to the public 7/16/2026.
1/2/2026Neglect · ID 2623JT66002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/2/26, 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 neglect of a client. Client (A) was found on the floor at 4:00 a.m. without any injuries. Client (A) can not state what occurred because of severe cognitive impairment. During the course of the investigation the healthcare entity assessed the client, conducted interviews, record review and video footage review. The camera footage revealed Client (A) had been on the floor for several hours. Staff #1 admitted, they neglected to conduct a safety visit at 2:30 a.m. because they were assisting another client, but documented the checks were done. All staff were educated on performing safety checks and documenting accurately. 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 6/9/2026 · released to the public 6/16/2026.
12/1/2025Neglect · ID 2523JT66018Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/1/25, 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. A family member alleged staff were not providing daily care/ toileting assistance for Client (A). During the course of the investigation, the healthcare entity transferred Client (A) to a higher level of care for assessment, notified law enforcement, reviewed records, and conducted interviews. The client exhibited a mild abrasion, that was determined to not be attributed to neglect of staff. Treatment was provided. Due to diminished cognitive functioning, the client was unable to speak to the allegations. The facility increased monitoring of the client. Per the facility’s investigation, the client’s care plan showed care was provided and documented. The care plan was updated to include increased care throughout the day to reduce the risk of recurrence, and staff were educated on the changes. The facility’s findings were inconclusive, and the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/23/2026 · released to the public 3/30/2026.
11/10/2025Neglect · ID 2523JT66017Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. The facility received a complaint that care was not being provided to Client (A), specifically assistance with daily tasks and medications. During the course of the investigation, the healthcare entity assessed the client, notified law enforcement, conducted interviews, and reviewed records and video footage. No visible injuries or changes of condition were identified. When asked, Client (A) stated they felt safe overall, but did not recall day-to-day care due to diminished cognitive functioning. Record review indicated Client (A) received scheduled care for hygiene and medication, however, sometimes declined care. The medical provider updated the client’s plan of care to change medications from as needed to scheduled to accommodate the client not being able to ask for them. All staff received re-education on working with reluctant clients, and the facility will complete random audits of the client’s records to ensure compliance with updated plan of care. 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 2/2/2026 · released to the public 2/12/2026.
9/8/2025Neglect · ID 2523JT66015Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/9/25, 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 neglect of a client. Record review by the facility revealed that client (A), who had a severe cognitive impairment and was mostly nonverbal, had fallen in their room and was not assisted by staff for several hours. Reportedly, staff failed to conduct their two-hour safety checks per the facility policy. During the course of the investigation, the healthcare entity reviewed records and camera footage, conducted interviews, contacted police, and suspended the staff involved. Client (A) was assessed and placed on additional monitoring. Interviews and review of video footage showed that staff did not conduct the safety checks. The facility let the staff members go who were involved in the event. Management retrained staff on the expectations of conducting safety checks. Although no harm was identified, there was potential for significant harm. 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 2/5/2026 · released to the public 2/12/2026.
7/22/2025Physical Abuse · ID 2523JT66014Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/22/25, 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 physical abuse of a client. Male Client (A) allegedly pushed Female Client (B), knocking her to the ground and causing injury. Client (B) exhibited bruising on her face and was transferred to the hospital for further evaluation. During the course of the investigation, the healthcare entity separated and assessed the clients, notified law enforcement, reviewed records, and conducted interviews with staff and the clients. Client (B) returned to the facility and was observed closely for 72 hours following the event with no further adverse outcomes noted. Client (A) was placed on one-to-one supervision to reduce the risk of recurrence and his care plan was updated to reflect the behaviors. The event was substantiated. This is the second report of a client to client incident involving Client (A). Please refer to case ID #2523JT66007 for further information. 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 12/12/2025 · released to the public 12/19/2025.
6/16/2025Brain Injury · ID 2523JT66013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/16/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital and later passed away in 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 8/27/2025 · released to the public 9/3/2025.
6/6/2025Physical Abuse · ID 2523JT66012Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/6/25, 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 (A) hit client (B). During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, started increased safety monitoring, completed an assessment, and conducted interviews. Client (B) did not sustain visible injuries and received over the counter medication for pain relief. Client (A) indicated they thought client (B) was laughing at them as the reason for making physical contact. The facility started line of sight observation for client (A), updated care plans for both clients, and educated staff. The event was substantiated. Client (B) was involved in two occurrences prior to this event, please see case ID 2523JT66008 and 2523JT66003 for additional information. 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 10/22/2025 · released to the public 10/29/2025.
5/22/2025Physical Abuse · ID 2523JT66010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/22/25, 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 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) push Client (A). No visible injuries. Neither client could recall the event due to cognitive impairment. Staff implemented increased safety visits and added line-of-sight supervision for Client (B) with the possibility of a room change. 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 11/11/2025 · released to the public 11/18/2025.