CHERRY HILLS ASSISTED LIVING AND MEMORY CARE

SUMMARY OF FINDINGS:On 1/2/25, the healthcare entity investigated a reportable event that occurred on 12/22/24. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (B) was agitated and exhibiting signs of aggression in common areas. Staff reported client (B) was yelling and knocking on client doors. Ultimately, staff redirected client (B) to her apartment and allegedly held her door shut for a short time, so she could not leave. During the course of the investigation, the healthcare entity interviewed and suspended staff. Client (B) had a cognitive impairment and could not participate in a follow up interview. Staff indicated the door was held in an attempt to help de-escalate the situation while attempting to protect themselves and other clients. The facility concluded staff confined client (B) in her room against her will. The event was substantiated. Management terminated the employment of the staff involved. The facility identified a coaching moment with staff to help prevent a recurrence. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 6/24/2025 · released to the public 7/2/2025.

SUMMARY OF FINDINGS:On 7/1/24, 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 a missing client. During the course of the investigation the healthcare entity was notified by the police that the client had gone to an adjacent recreation center and was confused. The client was unharmed but could not recall where they were. The client’s plan of care was updated to reflect safety monitoring, alarms, and one-to-one staff until they moved to a secured environment on 7/3/24. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 2/26/2025 · released to the public 3/5/2025.

DESCRIPTION OF OCCURRENCE: On 8/23/23, while resident (A) was being lowered off the bus via the lift, the resident and wheelchair started rolling off the lift and he fell face forward onto the ground with his wheelchair. The fall happened when the lift was about two feet from the ground. Reportedly, staff member (1) neglected to ensure the wheelchair brakes were locked before lowering the resident, which was a deviation from their training. Resident (A) was transported to the hospital for an evaluation. Diagnostic test results showed resident (A) sustained a fractured eye socket and nose along with a head laceration that required stitches. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family and physician. Resident (A) was admitted for treatment and then transferred to a rehabilitation facility. Staff (1) reported the incident happened so fast resident (A) could not reach out to break his fall. When reviewing the event of the fall, staff member (1) was aware of what they had forgotten to do when assisting resident (A). There were no other reported incidents involving staff member (1). The facility investigation concluded staff member (1) did not follow their training to ensure the resident's wheelchair brakes were engaged prior to moving the lift downward. To help prevent a recurrence, the director provided re-training to staff member (1) on how to safely get residents down using the lift on the bus. Staff member (1) did return demonstration and signed training to acknowledge completion and understanding. Management planned to conduct bi-annual reviews with staff to demonstrate proper safety and utilization of bus lift. 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.

Sent to facility 7/25/2024 · released to the public 8/1/2024.