19
Inspections
24
Deficiencies
0
Actual Harm or Above
47
Occurrences
November 18, 2025
Last Inspection
S/S A/B Minimal potentialS/S D Potential for harm
The most recent inspection of OAKSHIRE COMMONS on record is dated November 18, 2025. Across 19 published inspections, state surveyors cited 24 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Assisted Living Residence/Alternative Care Facility (Medicaid)
Administrator
Bone, Amber
Owner
OAKSHIRE GARDENS LLC
Phone
(719) 542-2223
Payor Source
Medicaid, Private Pay
City
PUEBLO
ZIP
81001
Inspections & Citations
19 inspections · 24 deficiencies11/18/2025Revisit: Licensure Complaint · ID 4HLE13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 11/18/25, for all previous deficiencies cited on 8/27/25. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
11/18/2025Revisit: Licensure Complaint · ID 9BRA13No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 11/18/25, for all previous deficiencies cited on 8/27/25. The facility (residence) is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally
Plan of correction
The state did not require a plan of correction for this citation.
11/18/2025Licensure Complaint · ID 9DT111No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO40935, #CO40992, and #CO41064 was completed on 11/18/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
11/18/2025Revisit: Licensure Complaint · ID TTYZ12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 11/18/25, for all previous deficiencies cited on 8/27/25. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally
Plan of correction
The state did not require a plan of correction for this citation.
11/18/2025Licensure Complaint · ID 5V1711No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO40936, #CO40993, and #CO41063, was completed on 11/18/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
8/26/2025Revisit: Licensure Complaint · ID 4HLE124 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 8/27/25 for all previous deficiencies cited on 11/19/24. Deficiencies were cited. The deficiencies cited for Event 4HELE11 were cited prior to the regulation revision that was implemented on 3/17/25.
Plan of correction
The state did not require a plan of correction for this citation.
1160Res Care Srvs-Care CoordS/S B▼
Findings
Based on record review and interview the residence failed to claim responsibility for the coordination of residentcare services with known external service providers affecting two of twelve sample residents (#7 and #17). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement. Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of history of falls, major depressivedisorder, anxiety disorder, heart disease, pain in the left knee, pain in right leg, and pain in low back. On 6/27/25 an observation note read that staff discovered Resident #7 on her bathroom floor. Resident #7 lost herbalance and fell straight back hitting her head and injuring her hand and back which resulted in a visit to theemergency room. On 6/27/25 an emergency room doctors note read that Resident #7 was referred to an orthopedic surgeon andoccupational therapist for a fractured wrist due to her fall, and in order to prevent falls Resident #7 should use awheelchair. On 8/26/25 at approximately 12:00 p.m., all orthopedic notes were requested for Resident #7. On 8/27/25 at approximately 9:00 a.m., all orthopedic notes were requested for Resident #7. The residence wasunable to provide the orthopedic notes for Resident #7. On 8/26/25 at approximately 1:30 p.m., Resident #7 stated that she had been requesting appointments for hercare providers but that the office manager in charge of making the appointments did not follow up with her aboutthe scheduling and she was not sure when they were scheduled. She stated that she had been told she wasrequired to request appointments through the office manager. Additionally, she stated that she had requestedassistance to obtain an electric wheelchair and was told that the residence did not allow them. On 8/27/25 at approximately 9:15 a.m., the administrator stated that they did not have the orthopedic notes atthe residence. She stated that Resident #7 had not been to see the orthopedic surgeon yet because they hadattempted to make an appointment for Resident #7 but she did not go. She stated that the office manager was incharge of making appointments. She further stated that having the OT notes would have been beneficial to thecare of Resident #7. The administrator stated that she knew that Resident #7 required a wheelchair but was toldby the primary care provider that she would be reassessed to determine if she was eligible for one. She stated thatshe did not have the documentation on site confirming these recommendations. She stated that she did notfollow up with the primary care provider after the initial discussion. The administrator stated that this was notcorrected because she believed she had resolved the issue by placing the binders in the residents bedrooms.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1160Following the August 28, 2025, survey, the Administrator met with staff to review Resident #7's external provider orders and improve order tracking. Any incomplete or unfulfilled orders will be promptly reported to the Administrator by the Resident Care Coordinator, documented in the residents’ chart, and the provider will be notified. Following the August 28, 2025, survey the Administrator met with staff to review all external provider orders for Resident’s #7, #13, and #17 to ensure appropriate order tracking. Any incomplete or unfulfilled orders will be promptly reported to the Administrator by the Resident Care Coordinator and documented in the residents’ chart, and the provider will be notified. Resident #17’s updated assessment now includes interventions and protocol for staff to follow if her diagnosis of hearing voices could escalates into a harmful situation. All external provider orders will be logged in a binder for no less than 90 days or longer under the direction of the Administrator and COO and as needed to maintain compliance. The binder will include the originated date of the order, the status of when the order was processed and completed and all notes tracking the progression of the order. The binder will be reviewed by the Quality Management team monthly. All external provider orders will be logged in a binder for no less than 90 days or longer under the direction of the Administrator and COO and as needed to maintain compliance. The binder will include a tracking log with the originated date of the order, the status of when the order was processed and completed and any notes tracking the progression of the order. The binder will be reviewed weekly by the Administrator and monthly by the Quality Management team monthly. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
1354Res Rghts Rts/Rspn-Choice/Invlv Cr/Svc-PersS/S A▼
Findings
Based on record review and interviews, the residence failed to observe the right of residents to make decisions and choices in the management of personal affairs, funds, and property in accordance with resident's ability, affecting one of 18 sample residents (#4). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatoryRequirement. Findings include:A signed assisted living residency agreement dated 6/5/24 for Resident #4 read "You, or your Legal Representative(as applicable), are solely responsible for managing your own financial affairs. We will not manage your personalfunds on your behalf". A signed notice of resident rights dated 6/5/24 for resident #4 read in part "The right to make decisions andchoices in the management of personal affairs, funds, and property in accordance with resident ability. A progress note dated 7/29/25 read "Residents step mother and father called to verify the amount ofmoneys remaining within the safe for the residents spending for activity outings. Management explained that theresident does not have any remaining money within the safe. Her step mother then stated that resident shouldnot be taking the large amounts of money out of the funds for outings and should only be allowed to take only $40With her as they are limited to how much money they are able to provide her for activity outings. Admin explainedthat this would require a rights modification as Admin is unable to limit the resident to the money placed withinthe safe when she requests it as that is a violation of her rights. Residents father than stated that they want themodification done and provided management with an email."A progress note dated 8/19/25 read a rights modification has been received by resident #4's parents. "Residentand Admin went over the information together. Resident stated she understands why this is needed to be in placeand spoke with her parents and they stated that in order for her to eventually live independently she must learn tomanage her spending habits. She was offered a copy however declined and stated that she understands andthanked the admin and exited. Modification is under the residents' file."On 8/26/25 at approximately 1:15 p.m., the residence provided the rights modification for Resident #4, effective7/30/25 - 7/30/26. The residence did not use the appropriate form when it was served to Resident #4 and it wasnot signed by her case manager. Additionally, Resident #4's family did not have the right to take away her rightsto individual financial responsibility. On 8/26/25 at 3:06 p.m., the administrator stated the residence made the rights modification at the request of herparents. Additionally, she did not know why the rights modification was requested, as Resident #4 could manageher own money. She stated that she believed she had rectified this citation previously. On 8/27/25 at approximately 2:00 p.m., Resident #4 stated that she did not know what led to the rightsmodification. She stated that she did not agree with the rights modification and that she believed she couldmanage her own money.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1354After the survey concluded on August 28, 2025, the facility contacted Resident family and communicated that the Rights Modification they requested for Resident has been removed to protect the Resident’s Rights. Surveyors learned Resident #4 manages her own finances and disagree with her family's control over gifted money. After the August 28, 2025 survey, the facility informed Resident #4's family that their requested Rights Modification was removed to protect the resident’s rights. Surveyors learned Resident #4 manages her own finances and disagreed with her family's control over gifted money. The facility Administrator will follow the Rights Modification guidelines in accordance with 6 CCR 1011-1 Chapter 7. The most current CDPHE approved Rights Modification form will be utilized and the resident and the resident’s DSS case manager (when applicable) will sign the document. To affirm that the resident can agree and disagree with the proposed limitation, provided they manager their own finances. All issued Right Modifications will be reviewed monthly to confirm Resident Rights are maintained and that a proper representative was available before issuing any Rights Modifications. These reviews will take place monthly during the Quality Management Meeting and be documented for period of three months. To prevent recurrence of this practice if a Rights Modification is required, the facility Administrator will adhere to the Rights Modification guidelines as specified in 6 CCR 1011-1 Chapter 7. The current CDPHE-approved Rights Modification form will be used, and both the resident and the DSS case manager will sign the document to affirm that the resident could agree or disagree with the proposed limitation, provided they manage their own finances. All issued Rights Modifications will be reviewed monthly to confirm resident rights are maintained and that a proper representative was available before issuing any Rights Modification. These reviews will take place monthly during the Quality Management Meeting and be documented for a period of 90 days. The facility will have implemented all corrective actions described this plan of correction by 10/13/2025.
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼
Findings
Based on record review and interview the residence failed to comply with authorized practitioners ordersassociated with medication administration for one of five sample residents (#7). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of chronic obstructive pulmonary disease(COPD) and asthma. On 8/26/25 at approximately 12:00 p.m., all signed practitioner orders for Resident #7 were requested. A signed practitioner order dated 10/7/2024 for Symbicort 80-4.5mg actuation inhaler two puffs twice daily wasprovided. A July and August 2025 medication administration record did not have Symbicort Symbicort 80-4.5mg actuationinhaler two puffs twice daily recorded for medication administration. On 8/27/25 at approximately 3:00 p.m., the administrator stated that she expected all practitioners medicationorders to be reflected on the medication administration record (MAR) and administered as directed. She statedthat the reason this was not corrected was due to the residence transferring pharmacies and the use of a newpharmacy technician that was supposed to be inputting all of the medications into the MAR.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1568After the August 28, 2025, survey, a medication audit was completed to confirm all deficiencies were corrected. The survey noted Resident #7 was prescribed a Symbicort 80-4.5mg inhaler. The facility identified an order for bedside self-administration. Self-administration orders are recorded at the bottom of the MAR under the Self Administration box and Resident #7’s MAR was emailed to CDPHE on 9/16/25 (see pages 9-10 of Resident #7’s / J.W.’s MAR which was attached) and showed both the Symbicort and the Nystatin as ordered. A check by Resident Care Coordinator has been established by the Administrator to be done at least weekly to identify any medication order that has not been administered in accordance with the providers order(s). Any deficient practice will be reported to the Administrator and the provider. The tracking logs will be reviewed by the Administrator weekly for a 3-month period. Reports will be reviewed at the monthly Quality Assurance meeting. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
2230HIR-Cntnt IncldS/S B▼
Findings
Based on record review and interview the residence failed to update resident records with documentation onon-going services provided by external service providers affecting four of nine sample residents (#7, #13, #16, and#17). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of history of falls, major depressivedisorder, anxiety disorder, heart disease, pain in the left knee, pain in right leg, and pain in low back. On 6/27/25 an observation note read that staff discovered Resident #7 on her bathroom floor. Resident #7 lost herbalance and fell straight back hitting her head and injuring her hand and back which resulted in a visit to theemergency room. On 6/27/25 an emergency room doctors note read that Resident #7 was referred to an orthopedic surgeon andoccupational therapist for a fractured wrist due to her fall. On 8/26/25 at approximately 12:00 p.m., all external service provider notes were requested for Resident #7. On 8/27/25 at approximately 9:00 a.m., all external service provider notes were requested for Resident #7. On 8/27/25 at approximately 9:15 a.m., the administrator stated that they did not keep external provider notes atthe residence. She had to request the external provider notes to be sent from the providers. She further statedthat having the OT notes would have been beneficial to the care of Resident #7. The administrator stated that thiswas not corrected because she believed she had resolved the issue by placing the binders in the residentsbedrooms.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 2230Following the August 28, 2025, survey, the Administrator met with staff to review Resident #7’s external provider orders and improve order tracking. Any incomplete or unfulfilled orders will be promptly reported to the Administrator by the Resident Care Coordinator, documented in the residents’ chart, and the provider will be notified. After the survey on August 28, 2025, the Administrator met with staff to review external provider orders for Residents #7, #13, and #17 to ensure appropriate order tracking. If any orders are incomplete or unfulfilled, the Resident Care Coordinator will report them to the Administrator and document them in the residents' charts, and the provider will be notified. All external provider orders will be logged in a binder for no less than 90 days or longer under the direction of the Administrator and COO and as needed to maintain compliance. The binder will include the originated date of the order, the status of when the order was processed and completed and all notes tracking the progression of the order. The binder will be reviewed by the Quality Management team monthly. Orders from external providers will be downloaded weekly from the primary and psychiatric providers' portals, including provider notes and referrals sent to other providers. For residents (such as Resident #13) receiving hospice care, these orders will also be retrieved weekly, then downloaded and scanned into the respective residents’ chart. A weekly tracker has been implemented to ensure that records are being uploaded weekly for 90 days and reviewed by the Administrator. All orders will be logged in a binder, as directed by the Administrator and COO, to ensure ongoing compliance. The binder will record the date each order originated, its processing and completion status, and any notes tracking the progression of the order. The Quality Management team will conduct a monthly review of the binder. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
8/26/2025Revisit: Licensure Complaint · ID 9BRA122 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A complaint revisit was completed on 8/27/25 for all previous deficiencies cited on 11/19/24. Deficiencies were cited. The deficiencies cited for Event 9BRA11 were cited prior to the regulation revision that was implemented on 2/15/25.
Plan of correction
The state did not require a plan of correction for this citation.
0920PA Req-Med Admin-Rx/PRN▼
Findings
Based on record review and interview the facility (residence) failed record medication prescribed in themedication administration record (MAR) affecting one of five sample members (residents) (#7). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the residence has not maintained compliance with this regulatoryrequirement. Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of chronic obstructive pulmonary disease(COPD) and asthma. On 8/26/25 at approximately 12:00 p.m., all signed practitioner orders for Resident #7 were requested. A signed practitioner order dated 10/7/2024 for Symbicort 80-4.5mg actuation inhaler two puffs twice daily wasprovided. A July and August 2025 medication administration record did not have Symbicort Symbicort 80-4.5mg actuationinhaler two puffs twice daily recorded for medication administration. On 8/27/25 at approximately 3:00 p.m., the administrator stated that she expected all practitioners medicationorders to be reflected on the medication administration record (MAR) and administered as directed. She statedthat the reason this was not corrected was due to the residence transferring pharmacies and the use of a newpharmacy technician that was supposed to be inputting all of the medications into the MAR.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 920 Refer to POC for Tag 1600. After the August 28, 2025, survey, Oakshire staff confirmed that Residents #13 and #7 received their prescribed medications. For Resident #13, six morphine administrations were not documented as administered due to a transition to hospice care which transferred responsibility for the morphine administration to the hospice provider. When Guardian Pharmacy updated Resident #13’s morphine orders due to the change to the hospice provider, the Pharmacy deleted the administration record of 6 morphine dose administrations in the first week of August. Documentation of the error, including a letter from the Pharmacy explaining the error, was submitted to CDPHE via email on September 16, 2025, after the surveyors exited. For Resident #7, the Symbicort Inhaler was designated as a bedside self-administered prescription. Self-administration orders are recorded at the bottom of the MAR under the Self Administration box and Resident #7’s MAR was emailed to CDPHE on 9/16/25 (see pages 9-10 of Resident #7’s / J.W.’s MAR which was attached) and showed both the Symbicort and the Nystatin as ordered. Medication administration staff will review their Medication Administration Records (MARs) at least weekly to ensure all ordered medications have been administered and are properly documented. The Resident Care Coordinator and the Building Administrator will maintain a weekly log for 3 months confirming that each ordered medication appears on the MAR, except for orders written for bedside self-administration. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025
1730Ben/Svc Req-ACF-Member Rights▼
Findings
Based on record review and interviews, the facility (residence) failed to follow the modification of rights outlinedin Section 8.7001. B Pursuant to 6 C.C.R. 1011-1, Chapter V11, Part 13.1, the right of members (residents) to makedecisions and choices in the management of personal affairs, funds, and property in accordance with resident'sability, affecting one of 18 sample residents (#4). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the facility has not maintained compliance with this regulatoryRequirement. Findings include:A signed assisted living residency agreement dated 6/5/24 for Resident #4 read "You, or your Legal Representative(as applicable), are solely responsible for managing your own financial affairs. We will not manage your personalfunds on your behalf". A signed notice of resident rights dated 6/5/24 for resident #4 read in part "The right to make decisions andchoices in the management of personal affairs, funds, and property in accordance with resident ability. A progress note dated 7/29/25 read "Residents step mother and father called to verify the amount ofmoneys remaining within the safe for the residents spending for activity outings. Management explained that theresident does not have any remaining money within the safe. Her step mother then stated that resident shouldnot be taking the large amounts of money out of the funds for outings and should only be allowed to take only $40With her as they are limited to how much money they are able to provide her for activity outings. Admin explainedthat this would require a rights modification as Admin is unable to limit the resident to the money placed withinthe safe when she requests it as that is a violation of her rights. Residents father than stated that they want themodification done and provided management with an email."A progress note dated 8/19/25 read a rights modification has been received by resident #4's parents. "Residentand Admin went over the information together. Resident stated she understands why this is needed to be in placeand spoke with her parents and they stated that in order for her to eventually live independently she must learn tomanage her spending habits. She was offered a copy however declined and stated that she understands andthanked the admin and exited. Modification is under the residents' file."On 8/26/25 at approximately 1:15 p.m., the residence provided the rights modification for Resident #4, effective7/30/25 - 7/30/26. The residence did not use the appropriate form when it was served to Resident #4 and it wasnot signed by her case manager. Additionally, Resident #4's family did not have the right to take away her rightsto individual financial responsibility. On 8/26/25 at 3:06 p.m., the administrator stated the residence made the rights modification at the request of herparents. Additionally, she did not know why the rights modification was requested, as Resident #4 could manageher own money. On 8/27/25 at approximately 2:00 p.m., Resident #4 stated that she did not know what led to the rightsmodification. She stated that she did not agree with the rights modification and that she believed she couldmanage her own money.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1730 Refer to POC for Tag 1354. After the survey concluded on August 28, 2025, the facility contacted Resident family and communicated that the Rights Modification they requested for Resident has been removed to protect the Resident’s Rights. After the August 28, 2025 survey, the facility informed Resident #4's family that their requested Rights Modification was removed to protect the resident’s rights. Surveyors learned Resident #4 manages her own finances and disagreed with her family's control over gifted money. The facility Administrator will follow the Rights Modification guidelines in accordance with 6 CCR 1011-1 Chapter 7. The most current CDPHE approved Rights Modification form will be utilized and the resident and the resident’s DSS case manager (when applicable) will sign the document. To prevent recurrence of this practice if a Rights Modification is required, the facility Administrator will adhere to the Rights Modification guidelines as specified in 6 CCR 1011-1 Chapter 7. The current CDPHE-approved Rights Modification form will be used, and both the resident and the DSS case manager will sign the document to affirm that the resident could agree or disagree with the proposed limitation, provided they manage their own finances. All issued Rights Modifications will be reviewed monthly to confirm resident rights are maintained and that a proper representative was available before issuing any Rights Modification. These reviews will take place monthly during the Quality Management Meeting and be documented for a period of 90 days. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
9999Final ObservationsSurveyor note▼
Findings
THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing programregulations found at 10 CCR 2505-10.8.7506. F.5 Alternative Care Facility Provider Agency Requirements Environmental Standards (a) The Alternative Care Facility shall be an environment that supports individual comfort, independence, and preference, maintains a home-like quality and feel for Members at all times, and provides Members with unrestricted access to the Alternative Care Facility in accordance with the residency agreement or modifications as agreed to and documented in the Member ' s Provider Care Plan.
Plan of correction
The state did not require a plan of correction for this citation.
8/26/2025Licensure Complaint · ID I2EO11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO38779, #CO40767 and #CO40856, was completed on 8/27/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
8/26/2025Licensure Complaint · ID TTYZ116 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO38778, #CO40766 and #CO40855, was completed on 8/27/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1146Res Care Srvs-Comp Res Asmnt Annl/Chng BslnS/S D▼
Findings
Based on interviews and record review, the residence failed to update a comprehensive assessment whenever a resident's condition changed from baseline status, affecting three of five sample residents whose assessments were reviewed (#4, #13, #14, #15, #17). Specifically, Prior to Resident #14 being admitted to the residence he was required to not be under the influence of drugs and alcohol for 90 days. The residence was informed that Resident #14 would need to be monitored for relapse prior to his admittance, however, upon discovering his increasing symptoms of drug use the residence failed to update Resident #14's care plan and assessments leading to two hospital visits due to increased methamphetamine and alcohol use, 7/31/2025 and 8/6/2025, since his initial comprehensive assessment on 4/16/25. On 7/31/25 Resident #14 was found on his bathroom floor; there was blood "all over the bathroom floor" and open needles around the room and narcan. Resident #14 was not making sense when staff talked with him. Staff notified Resident #14's family member who then instructed the residence to call an ambulance. On 8/6/25 Resident #14 was found naked on the floor of his room. Staff reported that Resident #14 had a black band tied around his penis and that his penis was swollen and full of sores when Resident #14 attempted to remove the band he screamed in pain; the residence sent Resident #14 to the emergency room. Furthermore, the administrator stated that Resident #14 was found positive for Hep-C and continued to leave uncapped used syringes containing a substance believed to be methamphetamine, laying around his room. Findings include:Record Review Resident #14 was admitted to the residence on 4/16/25 with a diagnosis of right knee pain, hypertension and degenerative disk disease of the backA comprehensive assessment, dated 4/16/25, read in part that the resident had no safety awareness issues or behavioral needs and there was no history of drug use documented. A progress note dated 7/31/25 read in part, staff found one unused needle on the bathroom floor and another used needle in the shower, with blood on the floor and narcan in Resident #14s room. Resident #14 was found undressed sitting on the floor, he refused any assistance from staff. Resident #14 was taken to the hospital via Emergency Medical Transport (EMT). A progress note dated 8/1/25 read in part, Resident #14 had no pants on in the common areas rolling past the residence main office. A progress note dated 8/4/25 read in part, staff attempted to clean Resident #14s room, Resident #14 was acting eccentric and moody with flippant emotions. Resident #14 was causing duress to the neighboring resident, his behavior was severely different from his baseline. A progress note dated 8/5/25 read in part, staff found more syringes, a small bag with a white rock like substance, and a sock with 660 dollars in it on the floor. All items were brought to the main office, Resident #14s power of attorney (POA) was called and stated Resident #14 had relapsed. Later on 8/5/25, Resident #14 was not in the residence and management could not locate him, a missing persons report had been filed. Three hours later, Resident #14 was found laying on the grass outside of a gas station. A progress note dated 8/6/25 read in part, staff found Resident #14 undressed on the floor singing. When questioned, he gave inconsistent explanations and admitted to drug use the prior morning, 8/5/25. The resident had not been acting at his baseline since the previous incident on 7/31/25, per POA concerns. Staff observed a black rubber band around his penis causing swelling and sores, after initial resistance, he removed the band with discomfort. EMTs were called, and were informed of the resident ' s incoherent behavior, the floor incident, and the circulation issue caused by the band. Resident #14 was taken to the hospital. An incident report dated 8/6/25 read in part, management had been called to Resident #14s room, he was naked with a black rubber band around his penis and stated he was getting a massage. Staff explained there had been no one in the room with him, he then stated he was getting painted. Resident #14 was instructed to remove the band around his penis as it was cutting circulation, however it remained swollen. Additionally, the records revealed the resident experienced episodes of aggressive and unusual behaviors with one being documented as a danger to himself. InterviewsOn 8/26/25 at approximately 2:40 p.m., the Administrator stated on 7/31/25 Resident #14 was found in his room unresponsive with uncapped syringes and what was believed to be methamphetamines, in his room. Resident #14's POA had come to visit him at the time, she had taken the drugs and flushed them. His POA had prior knowledge of Resident #14 ' s drug use. The following week, 8/5/25, Resident #14 was on the floor face down and stated he was waiting to be painted and was receiving a massage however no one was in the room with him. Resident #14 was found with a black band around his penis, the administrator later found out he had been administering drugs with a syringe into his banded penis and she stated Resident #14 was diagnosed positive for Hep-C after coming back from the hospital. The Administrator stated she issued a safety plan to ensure Resident #14s safety however, he could not sign any documents at that time. She further stated, after Resident #14 returned from the hospital he was found to be positive for Hep-C and was concerned for the safety of the staff. The Administrator issued a 30 day involuntary discharge however no interventions were in place to ensure Resident #14, other residents and staff safety until his discharge. The Administrator stated a comprehensive assessment was completed during a change in the residents baseline and acknowledged an update to Resident #14 ' s comprehensive assessment had not been completed which may cause future harm to the resident and staff interacting with Resident #14, although the Administrator agreed it should have been completed. Additionally, the residence failed to perform a change of condition assessment for Resident's #4, #13, #15, and #17.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1146After the August 28, 2025, survey, the facility updated assessments and care plans for residents #4, # 13, # 14, # 15, and #17. Resident #14’s assessment and care plan was revised to reflect the change in condition. There is no evidence, including any hospital documentation, that shows Resident #14 had Hepatitis C. The Administrator does not recall saying Resident #14 had Hepatitis C, and no possible exposure incidents occurred during Resident #14’s stay at the community. Resident #14 was discharged home with his daughter on September 8, 2025. In accordance with Facility policy and as allowed by regulation, residents using illegal substances may be emergently discharged based on circumstances. Resident assessments and care plans will be updated at least annually and as needed with any changes in condition and appropriate interventions, such as increased supervision, room checks, notifications to physicians or resident representatives, and hospital transfer or involuntary discharge. All assessments and care plans have been audited for compliance, and a revised protocol now requires documentation of safety interventions within 72 hours or sooner of significant condition changes. The Administrator will audit resident illicit drug use incidents and/or hospitalizations monthly to confirm timely updates, with any missed updates addressed immediately in weekly clinical meetings. Quarterly compliance reports will be reviewed at Quality Management Meetings. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
1150Res Care Srvs-Res CPS/S B▼
Findings
Based on record review, observation, and interview, the residence failed to promote resident choice, mobility, independence, and safety and failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs in a resident care plan, affecting one of nine sample residents (#17). Findings include:Reference and Resident AgreementChapter VII regulations governing assisted living residences, part 2.10, defines "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual' s need for personal assistance, services received from external providers, and the services to be provided by the residence in order to meet the individual' s needs. In order to deliver person-centered care, the care plan shall take into account the resident' s preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill. The residence's undated resident agreement, read in part that the resident care plan is a document that includes a description of the residents functional physical and mental capabilities, needs for personal assistance from community staff members, the services the resident expects to receive from external providers, and the personal care services that we will provide directly to the resident. The residents care plan is based on a resident assessment, in the event a resident's assessment indicates a change to the resident condition or care needs, the resident care plan will be revised accordingly. Record Review Resident #17 was admitted to residence on 5/2/20 with schizoaffective disorder, bipolar type. An inpatient psychiatric discharge summary dated 7/1/24 read in part, Resident #17 had ongoing suicidal ideations and needed to be observed frequently. "Resident #17 conveys behavior which is life threatening, destructive or disabling to self and others. Resident #17 was screened as a high overall suicide risk. Percautions plan to address, suicidal". A progress note, dated 8/15/25 at 5:00 p.m., read in part; Resident #17's outside psychology provider contacted the residence and stated Resident #17 walked back to the residence after her therapy session. When she was asked why she had left her outside provider's office, the providers office stated that Resident #17 said she needed to go on a walk because the voices in her head were telling her to jump in front of a car. A care plan dated 10/24/24 contained no staff tasks or interventions to address the residents risk for self harm after the residents incident on 8/15/25. InterviewsOn 8/27/25 at approximately 11:00 a.m., Staff #8 stated she often works in the hallway in which Resident #17 ' s room was located, she stated she was unaware Resident #17 was hearing voices or had any suicidal ideations, she further stated she was unaware of an incident that happened regarding Resident #17 on 8/15/25. Staff #8 stated that if Resident #17 were to approach her with a feeling of self harm, she would try to talk to her and calm her down, then contact the Administrator. Staff #8 stated she would not know where in the resident record she would look to find interventions in this situation. On 8/27/25 at approximately 11:10 a.m., Staff #7 stated she was unaware Resident #17 had suicidal ideations or of an incident where Resident #17 stated voices told her to jump in front of a car. Staff #7 further stated, if Resident #17 had approached her with suicidal ideations, she would call the mental health line and inform the Administrator however would not know how to assist her further. On 8/27/25 at 3:15 p.m., the Administrator agreed that Resident #17 ' s care plan should have been updated as Resident #17 often only went to the office manager when feeling down or if she had voices talking to her. The care plan should have included interventions to ensure the residents safety.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1150Please also see and refer to the corrective actions for Tag 1146. At the conclusion of the survey on 8/28/2025 resident #17’s assessment and care plan were updated to specifically include her current condition and to include specific interventions to help staff assist with her ideations and crisis situations. Staff have been reminded to contact the Health Solutions Crisis line, remain with any resident experiencing a crisis for safety reasons, follow the guidance of mental health professionals, and inform the Administrator. At the conclusion of the survey on 8/28/2025 Resident #17’s assessment and care plan were updated to specifically include her current condition and to include specific interventions to help staff assist with her ideations and crisis situations. Staff have been reminded to contact the Health Solutions Crisis line, remain with any residents experiencing a crisis for safety reasons, follow the guidance of mental health professionals and inform the Administrator. The Administrator will notify staff at daily stand-up meetings about residents with high-risk behaviors or health changes needing extra interventions and will keep a monthly log of these cases. The Administrator will inform staff of residents with condition changes, including high-risk behaviors or health issues requiring extra interventions, during daily stand-up meetings. These notes and interventions will be recorded in the Residents’ Electronic Charting system, and a weekly log will be reviewed monthly by the Administrator for 90 days, and then monthly at Quality Management Meetings. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼
Findings
Based on record review and interview the residence failed to comply with authorized practitioners ordersassociated with medication administration for one of five sample residents (#7). This deficiency was cited previously during a state licensure complaint 11/19/24. Although the residence correctedthe deficiency, based on the findings below, the residence has not maintained compliance with this regulatoryrequirement. Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of chronic obstructive pulmonary disease(COPD) and asthma. On 8/26/25 at approximately 12:00 p.m., all signed practitioner orders for Resident #7 were requested. A signed practitioner order dated 10/7/2024 for Symbicort 80-4.5mg actuation inhaler two puffs twice daily wasprovided. A July and August 2025 medication administration record did not have Symbicort Symbicort 80-4.5mg actuationinhaler two puffs twice daily recorded for medication administration. On 8/27/25 at approximately 3:00 p.m., the administrator stated that she expected all practitioners medicationorders to be reflected on the medication administration record (MAR) and administered as directed. She statedthat the reason this was not corrected was due to the residence transferring pharmacies and the use of a newpharmacy technician that was supposed to be inputting all of the medications into the MAR.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1568After the August 28, 2025, survey, a medication audit was completed to confirm all deficiencies were corrected. The survey noted Resident #7 was prescribed a Symbicort 80-4.5mg inhaler. The facility identified an order for bedside self-administration. Self-administration orders are recorded at the bottom of the MAR under the Self Administration box and Resident #7’s MAR was emailed to CDPHE on 9/16/25 (see pages 9-10 of Resident #7’s / J.W.’s MAR which was attached) and showed both the Symbicort and the Nystatin as ordered. A check by Resident Care Coordinator has been established by the Administrator to be done at least weekly to identify any medication order that has not been administered in accordance with the providers order(s). Any deficient practice will be reported to the Administrator and the provider. The tracking logs will be reviewed by the Administrator weekly for a 3-month period. Reports will be reviewed at the monthly Quality Assurance meeting. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
1600Med/Med Adm-Rcrd Kpng MARS/S B▼
Findings
Based on record review and interview, the residence failed to ensure that each medication administration record(MAR) included the time of administration for each medication and failed to ensure that each qualified medicationadministration person (QMAP) accurately documented each medication administration event at the time theevent was completed for each resident, affecting one of 12 sample residents (#13). Findings include:Residence Policy The residence's medication administration policy dated 1/4/24 read in part, the administrator or designee will prepare or print a MAR and the (QMAP) will document each medication given or refused. Resident #13 was admitted to the residence on 03/12/2020 with a diagnosis including cirrhosis, bipolardisorder, and anxiety. A written practitioner's order, dated 7/24/25, directed the residence to administer morphine extended release 15mg tablet once every eight hours. However, the residence failed to document on the August 2025 MAR that themorphine was administered from 8/1 through 8/6/25. An outside provider hospice note dated 7/31/25 read in part that the primary diagnosis for Resident #13 wasmalignant neoplasm of liver and secondary, malignant neoplasm of bone. Additionally, the residence was directedto administer morphine extended-release 15 mg tablets once every eight hours as needed for pain. A controlled drug count sheet and medication count log for Resident #13 read in part that the residenceadministered the morphine 8/1 through 8/6/25. On 8/27/25 at approximately 10:30 a.m., the resident care coordinator (RCC) acknowledged that the morphine forResident #13 was administered 8/1 through 8/6/25, but it wasn't properly documented on the MAR.On 8/27/25 at approximately 3:16 p.m., the administrator stated that she expected all medications for which the residence has orders to be documented on the MAR. Also, she acknowledged there was a miscommunicationwith hospice and expected the administered morphine for Resident #13 to be documented on the MAR. Additional deficient practice was identified with Resident #7.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1600After the August 28, 2025, survey, Oakshire staff confirmed that Residents #13 and #7 received their prescribed medications. For Resident #13, six morphine administrations were not documented as administered due to a transition to hospice care which transferred responsibility for the morphine administration to the hospice provider. When Guardian Pharmacy updated Resident #13’s morphine orders due to the change to the hospice provider, the Pharmacy deleted the administration record of 6 morphine dose administrations in the first week of August. Documentation of the error, including a letter from the Pharmacy explaining the error, was submitted to CDPHE via email on September 16, 2025, after the surveyors exited. For Resident #7, the Symbicort Inhaler was designated as a bedside self-administered prescription. Self-administration orders are recorded at the bottom of the MAR under the Self Administration box and Resident #7’s MAR was emailed to CDPHE on 9/16/25 (see pages 9-10 of Resident #7’s / J.W.’s MAR which was attached) and showed both the Symbicort and the Nystatin as ordered. Medication administration staff will review their Medication Administration Records (MARs) at least weekly to ensure all ordered medications have been administered and are properly documented. The Resident Care Coordinator and the Building Administrator will maintain a weekly log for 3 months confirming that each ordered medication appears on the MAR, except for orders written for bedside self-administration. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025
2112Fd/Din Srvs-M/Dr/Sn M Incld/SubS/S B▼
Findings
Based on observation and interview, the residence failed to ensure that meals were appealing and served at atemperature that was appetizing, affecting 110 current residents. Findings include:On 8/27/25 at 8:42 a.m., a sample of breakfast was evaluated. At breakfast, the chicken and waffle were found tobe inedible due to unappetizing and bland taste. Additionally, the waffle was not served at an appetizingtemperature, 118 degrees Fahrenheit. The residence's undated assisted living residency agreement read in part "We will make available to you three (3)nutritionally well-balanced meals every day."House meeting notes, dated 6/25/25, read in part: an unknown resident stated "Meals are not consistent every time meals are served". House meeting notes, dated 8/20/25, read in part: "The resident said they do not like how little comes with thesoup and salad". Additionally, another unknown resident suggested more alternative meals such as "sandwiches". House meeting notes, dated 7/23/25, read in part: an unknown resident stated "the kitchen runs out of foodsometimes". On 8/26/25 at 1:30 p.m., Resident #7 stated the food was "no good". On 8/26/25 at 1:49 p.m., Resident #18 stated "all we get is chicken and it tastes terrible"On 8/27/25 at 8:00 a.m., Resident #14 stated chicken and waffles "tasted bad". On 8/27/25 at 2 p.m., Resident #4 stated the food was no good and sometimes theresidence "runs out of food, not just seconds". She also stated that she informed the administrator about this. On 8/27/25 at approximately 3:16 p.m., the administrator stated she expected that the residence offer a nutritionally balanced meal.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 2112Immediately after the survey on August 28, 2025, the facility reviewed the past 3 months of dining menus. The menus were comprised of home-like food which had been suggested at resident meal planning meetings by residents. The facility issued a voluntary and optional survey to the residents to vote on alternative food items at each meal to help satisfy those residents not enjoying the planned entrée. Residents will complete a voluntary survey monthly to choose the next month’s alterative meal choices for those residents not wanting the scheduled entrée. Monthly meal planning meetings will be continued and attendees will be the Cook, Activities Director and any Resident wishing to attend. Menus will be updated weekly to reflect the resident’s meal planning ideas from the monthly resident council and meal planning meetings. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
2230HIR-Cntnt IncldS/S B▼
Findings
Based on record review and interview the residence failed to update resident records with documentation onon-going services provided by external service providers affecting four of nine sample residents (#7, #13, #16, and#17). Findings Include:Resident #7 was admitted to the residence on 3/1/2023 with a diagnosis of history of falls, major depressivedisorder, anxiety disorder, heart disease, pain in the left knee, pain in right leg, and pain in low back. On 6/27/25 an observation note read that staff discovered Resident #7 on her bathroom floor. Resident #7 lost herbalance and fell straight back hitting her head and injuring her hand and back which resulted in a visit to theemergency room. On 6/27/25 an emergency room doctors note read that Resident #7 was referred to an orthopedic surgeon andoccupational therapist for a fractured wrist due to her fall. On 8/26/25 at approximately 12:00 p.m., all external service provider notes were requested for Resident #7. On 8/27/25 at approximately 9:00 a.m., all external service provider notes were requested for Resident #7. On 8/27/25 at approximately 9:15 a.m., the administrator stated that they did not keep external provider notes atthe residence. She had to request the external provider notes to be sent from the providers. She further statedthat having the OT notes would have been beneficial to the care of Resident #7.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 2230Following the August 28, 2025, survey, the Administrator met with staff to review Resident #7’s external provider orders and improve order tracking. Any incomplete or unfulfilled orders will be promptly reported to the Administrator by the Resident Care Coordinator, documented in the residents’ chart, and the provider will be notified. All external provider orders will be logged in a binder for no less than 90 days or longer under the direction of the Administrator and COO and as needed to maintain compliance. The binder will include the originated date of the order, the status of when the order was processed and completed and all notes tracking the progression of the order. The binder will be reviewed by the Quality Management team monthly. The facility will have implemented all corrective actions described in this plan of correction by 10/13/2025.
9999Final ObservationsSurveyor note▼
Findings
THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing programregulations found at 10 CCR 2505-10.7.14 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee ' s or volunteer ' s personnel file: (A) Documentation that the individual meets the definition of qualified medication administration person at Part 2.52 of these rules10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 13.5 Each assisted living residence shall hold regular meetings with residents, staff, family, and friends of residents so that all have the opportunity to voice concerns and make recommendations concerning assisted living residence care, services, activities, policies, and procedures. (Resident coucil meetings, including staff)
Plan of correction
The state did not require a plan of correction for this citation.
11/18/2024Licensure Complaint · ID 9BRA113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO36213, #CO37044, #CO37346, and #CO38285 was completed on 11/19/24. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼
Findings
Based on record review and interview, the (facility) residence failed to provide sufficient support to members in the use of prescription medications, affecting two of five (members) residents (#4, #7). (Cross-reference A926)Findings include:1. Resident #4 was admitted to the residence on 6/5/24. FlexerilA written practitioner's order, dated 11/13/24, directed the residence to administer flexeril 5 mg twice daily. However, the November 2024 medication administration record (MAR) for Resident #4 read the medication was not administered until 11/15 in the evening; two days after the medication was ordered. AzithromycinA written practitioner's order, dated 11/9/24, directed the residence to administer azithromycin 500 mg for one day then 250 mg once daily for four days. However, the November 2024 MAR read the medication was not administered until 11/14/24. On 11/18/24 at approximately 10:00 a.m., the resident care coordinator (RCC) said the flexeril was not administered until the evening of 11/15 because of a pharmacy error. The RCC confirmed the azithromycin was not administered until 11/14/24 because the normal pharmacist technician quit and a new one was hired so there was a delay in receiving the medication from the pharmacy. On 11/19/24 at approximately 4:00 p.m., the administrator said she expected the residence to administer resident medications as ordered and not run out of stock. 2. Similar deficient practice was found for Resident #7 and the practitioner's order for effexor.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE. (Cross-reference A926)A description of how the licensee will correct each identified deficiency. A full medication audit was performed to ensure that authorized practitioner orders associated with medication administration are being followed and residents are receiving their medications as prescribed. The facility will ensure all medications received are stored and transcribed in the electronic MAR (ECP) and administered in accordance with the provider’s current order(s). The facility has also communicated with the facility’s primary pharmacy regarding the issue with delayed medication administration due to the pharmacy staff turnover and a new pharmacist technician hired by the pharmacy. A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. A daily check has been established to ensure all medications are being administered in accordance with the provider order(s). Provider orders sent to the pharmacy are tracked and documented by the RCC to ensure all orders are received and administered in accordance with the order(s). Any deficient practice will be promptly reported to the administrator and the provider. The tracking logs will be reviewed by the administrator daily. Reports will be reviewed by the Quality Assurance team and the COO monthly. A completion date that shall be no longer than (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The facility will have implemented all corrective actions described in this plan of correction by 12/20/2024.
0926PA Req-Med Admin-Rx/PRN-Records▼
Findings
Based on record review and interview, the (facility) residence failed to ensure each qualified medication administration person (QMAP) accurately recorded all medications administered, affecting two of five sample (members) residents (#4, #7). (Cross-reference A920)Findings include:1. Resident #4 was admitted to the residence on 6/5/24. AzithromycinA written practitioner's order, dated 10/31/24, directed the residence to administer azithromycin 250 mg two tabs on the first day and 250 mg for four days. However, the November 2024 medication administration record read the medication was not administered on 11/1 or 11/4/24. There was a separate document in Resident #4's record, titled narcotic count sheet that listed Resident #4's azithromycin orders and staff documentation that read the medication was administered on 11/2, 11/3, 11/4, 11/5 and 11/6/24. On 11/18/24 at 10:03 a.m., the resident care coordinator said the practitioner ordered the azithromycin and the resident was not administered the first dose until 11/2 and acknowledged the MAR was documented incorrectly. On 11/18/24 at 10:03 a.m., the administrator said she expected the residence to document accurately on resident MARs. 2. Similar deficient practice was found for Resident #7 in regards to her practitioner ordered effexor. 2. Similar deficient practice was found for Resident #7 in regards to her practitioner ordered effexor.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.(Cross-reference A920)A description of how the licensee will correct each identified deficiency. Immediately following the survey on 11-19-2024, all QMAP staff were retrained to ensure that all medications prepped, including those that are identified on the narcotic sheets, are confirmed in the electronic MAR to have been passed / confirmed in the MAR (ECP). A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. QMAPs will review their daily MARs (ECP) at the 4:00 pm care meeting to verify all medications prepped were passed and noted in the electronic MAR (ECP) for all residents. A daily generated no pass report is overseen by the resident care coordinator and the building administrator. A log will be maintained for a 90-day period tracking the daily meeting notes to ensure all medications prepped were administered and documented in the MAR (ECP). The log will be reviewed monthly by the Quality Management Team and the COO.A completion date that shall be no longer than (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The facility will have implemented all corrective actions described in this plan of correction by 12/20/2024.
1300Ben/Svc Req-ACF-Member Rights▼
Findings
Based on record review and interviews the residence (facility) failed to inform residents (members) of their rights set forth at 6 CCR 1011-1, Chapter VII, Part 13 and Section 8.7001, and failed to include involvement of residents in any modification of those rights, affecting one of seven sample residents. Based on record review and interviews, the residence failed to observe the right of residents to make decisions and choices in the management of personal affairs, funds, and property in accordance with resident ability, affecting one of seven sample residents (#5). Findings include:A progress note dated 11/6/24 read that Resident #5 ' s family member informed Resident #5 that she would only be allowed to have her cigarettes from the residence office after she showered on Monday, Wednesday, and Friday and that she would be given ten cigarettes on Saturday and 10 cigarettes on Sunday. The progress note read that Resident #5 ' s family member stated that if Resident #5 did not shower she would not be able to get her cigarettes from the office. A progress note dated 11/11/24 read that Resident #5 had followed the directions her family member gave her and would go to the office to show proof of showering before she would receive her cigarettes. On 11/19/24 at approximately 3:00 p.m., Resident #5 stated that she was informed that she would be able to receive her cigarettes after she had showered by the residence staff. Resident #5 stated that she preferred to shower every other day. She stated that she did not agree with the decision to withhold her cigarettes in exchange for proof of her showering. She stated that she would prefer to have the option to shower without stipulations. On 11/19/24 at approximately 4:00 p.m., the administrator stated that the directions to withhold cigarettes from Resident #5 came from her family member. On 11/19/24 at approximately 4:00 p.m., the administrator stated that Resident #5 was not involved in the decision making process.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.Tag 1300A description of how the licensee will correct each identified deficiency. Immediately following the survey on 11/19/2024, the facility corrected the deficient act identified by involving Resident #5 is decision making concerning her showering schedule and cigarette use, correcting Resident #5’s rights that were requested to be restricted by a family member. The facility will follow the Residents Rights as posted publicly for residents, advocates, staff and others to provide a non-restrictive environment. Any resident agreeing to a modification of their rights pursuant to a family member/advocate request will be asked to sign an agreement stating that they are willing to agree to the modification. A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. The facility will monitor closely all Resident’s Rights to ensure residents (identified as their own decision maker) live in a community free of restrictions identified by the clearly posted Resident Rights and the communities House Rules. All staff members will be retrained to understand and identify what classifies as restrictive and in violation of the residents’ day-to-day right of choice. All rights modifications will be reviewed by the administrator, COO and shared with the area Ombudsmen. A completion date that shall be no longer than (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The facility will have implemented all corrective actions described in this plan of correction by 12/20/2024.
Reportable Occurrences
47 records3/6/2026Missing Person · ID 2623M641001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/6/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing client. Client (A) left the facility and did not return. They are at risk as they were not taking their psychiatric medications. Client (A) was allowed to leave the facility. During the course of the investigation the healthcare entity conducted a search, notified the police, case management and interviewed clients and staff. The attempts to locate the client were unsuccessful and their whereabouts were unknown as of 4/6/26. 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 5/22/2026 · released to the public 6/5/2026.
12/2/2025Missing Person · ID 2523M641028Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/3/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing client. Client (A) was missing for over 50 hours from the facility after signing themselves out on 12/3/25 without a return date or time. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The police were notified. The facility received a call from the local emergency department stating the client had been seen on 12/6/25 for chest pain and a knee injury and was being sent back to the facility. Client (A) was assessed before returning, however due to Client (A) already having a safety plan in place and violating it, Client (A) was given a 30 day discharge notice. Client (A) will have frequent checks until then. 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 1/12/2026 · released to the public 1/19/2026.
11/9/2025Misappropriation of Property · ID 2523M641026Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/9/25, 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 misappropriation of client property. Client (A) made a police report, due to not being able to access funds because of their spouse. Client (A) was at risk of being discharged and the facility suspected financial exploitation. During the course of the investigation the healthcare entity conducted interviews, notified Adult protective services (APS), the police and case management. The facility will transfer payment sources so the facility can make payments on behalf of the client. There is still a pending APS case. The spouse will not be allowed into the facility as there was a history of potential exploitation. 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 3/31/2026 · released to the public 4/7/2026.
10/22/2025Diverted Drugs · ID 2523M641025Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/23/25, 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 diverted drugs. Staff (1) administered a pill from client (A)’s bubble pack to client (B). Consequently, client (B) received the incorrect dose. During the course of the investigation, the healthcare entity suspended staff (1) from medication administration duties, completed a medication audit, contacted police and medical providers, and conducted interviews. When assessed, client (B) did not have any adverse effects. Staff (1) confirmed the incident of drug diversion. The facility retrained staff on medication administration policies, and staff (1) was unable to return to medication administration duties. 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 3/23/2026 · released to the public 3/30/2026.
10/21/2025Misappropriation of Property · ID 2523M641024Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/21/25, 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 misappropriation of client property. Client (A) attempted to use a $100.00 dollar bill for a purchase that was identified as fake. During the course of the investigation the healthcare entity conducted interviews. It was revealed a visitor had asked the client to break the $100 in exchange for smaller bills. Client (A) and other clients were notified to redirect visitors with these types of requests to the front office A possible assailant was identified and this information was provided to the police. 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 3/11/2026 · released to the public 3/18/2026.
10/10/2025Sexual Abuse · ID 2523M641022Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/12/25, the healthcare entity investigated a reportable event of sexual abuse of a client. During the course of the investigation, the healthcare entity separated both clients, contacted police and medical providers, and conducted interviews. 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. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 11/18/25, Event ID: 5V1711 and 9DT111.
Publication
Sent to facility 3/31/2026 · released to the public 4/7/2026.
10/4/2025Misappropriation of Property · ID 2523M641023Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/10/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) alleged Client (B) took their refrigerator. During the course of the investigation the healthcare entity conducted a search, and interviews. The police were notified, the refrigerator was returned, and the police notified both clients not to exchange anything at any time. Client (B) later gave a letter to Client (A) stating Client (A) owed them money for items that were pawned. Client (A) gave Client (B) $18.00 as Client (A) stated they did not want to get in trouble with the law. Client (B) was told not to have contact with Client (A), Client (A) was asked not to sign anything they did not understand and to obtain staff for assistance. Both clients were informed to stay away from each other. The event was substantiated. Both clients were involved in another occurrence within a few weeks. For further information please refer to occurrence #2523M641021. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 1/23/2026 · released to the public 1/30/2026.
10/2/2025Misappropriation of Property · ID 2523M641021Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/2/25, 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 misappropriation of client property. Client (A) alleged they had lent a laptop to Client (B) who gave it to another client without permission. During the course of the investigation the healthcare entity conducted a search, and interviews. The other client stated Client (B) gave them the laptop because Client (B) could not pay back money they borrowed two to three weeks prior. The other client was unaware the laptop belonged to Client (A) and offered to return it. The police were notified and Adult Protective Services. Client (B) required a higher level of care and placement was found and staff would monitor them during their last 30 days at the facility. All clients were discouraged from making agreements with each other. The event was substantiated. Both clients were involved in another occurrence within a few weeks. For further information please refer to occurrence #2523M641023. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe
Publication
Sent to facility 1/23/2026 · released to the public 1/30/2026.
9/7/2025Missing Person · ID 2523M641019Reported 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 prevent a future recurrence. The healthcare entity reported a missing client. Client (A) signed out of the facility and did not return at an appropriate time. The client did not indicate a return time. The client was missing for over 24 hours. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The police were notified. An unidentified person found the client’s phone in a park. The family notified the facility they had found the client and believed they were under the influence and took them to the hospital. The client was discharged from the facility on 9/8/25 to leave with the family as they did not want to return to the facility and were a danger to themselves. 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 1/7/2026 · released to the public 1/14/2026.
7/14/2025Missing Person · ID 2523M641018Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. The client signed out of the facility and when they did not return at the time they indicated, they were reported as missing. During the course of the investigation, the healthcare entity notified law enforcement , conducted a search, and contacted local hospitals. The client was considered at risk due to requiring daily medical support from a home health provider. Five days later the client was brought to the facility by a friend,the client indicated they had very little memory of what happened to them, and reported they were robbed. The client was admitted to the hospital and received treatment for multiple medical conditions. The facility created a safety plan and assisted the client to obtain a new cell phone. 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 11/23/2025 · released to the public 11/30/2025.