CARILLON AT BELLEVIEW STATION, THE — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

July 9, 2026

Last Inspection

S/S A/B Minimal potentialS/S E Potential for harm

The most recent inspection of CARILLON AT BELLEVIEW STATION, THE on record is dated July 9, 2026. Across 7 published inspections, state surveyors cited 7 deficiencies, none of which reached the actual-harm level.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status

Active

Facility Type

Assisted Living Residence (Licensed Only)

Administrator

Arwood-Dionese, Shannon

Owner

BMSH I DTC CO LLC

Phone

(720) 440-8200

Payor Source

Private Pay

City

DENVER

ZIP

80237

Inspections & Citations

7 inspections · 7 deficiencies

7/9/2026CHOW and Licensure (Re-licensure) (Combined) · ID ZZK411No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

An administrative relicensure survey was completed on 7/24/26. No deficiencies were cited. A change of ownership occurred on 1/15/26.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Licensure Complaint · ID Y6ML11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO39668, was completed on 4/8/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

1/21/2025Revisit: Licensure Complaint · ID 3MSH13No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/21/25 for the previous deficiencies cited on 9/4/24. The residence is in compliance with all regulations surveyedThe regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Plan of correction

The state did not require a plan of correction for this citation.

1/21/2025Licensure Complaint · ID 876V11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO38831, was completed on 1/21/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1/21/2025Revisit: Licensure and Licensure Complaint (Combined) · ID C8PS12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey and complaint revisit was completed on 1/21/25 for all previous deficiencies cited on 9/4/24. The residence is in compliance with all regulations surveyedThe regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Plan of correction

The state did not require a plan of correction for this citation.

9/3/2024Revisit: Licensure Complaint · ID 3MSH121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 9/4/24 for all previous deficiencies cited on 2/10/22. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders affecting one of fifteen sample residents (#17) and one former residents (#24). Findings Include:1. Resident #17 was admitted to the residence on 10/6/24 with a diagnosis of hypertension and unspecified dementia. A written practitioners order dated 8/7/24, directed the residence to administer miralax oral powder every three days for and hold for loose stool. However the August and September 2024 MAR detailed staff administered the medication every other day instead of every three days. Staff administered the medication three times a week instead of every three days as directed from 8/7/24 to 9/3/24. 2. Former Resident #24 was admitted to the residence on 4/30/21 with diagnoses including dementia, type two diabetes, sleep apnea, mood disturbance, anxiety, and pulmonary hypertension. On 2/18/23 Resident #24 fell, bumped her head, went to the emergency room and was prescribed acetaminophen for pain.a. AcetaminophenAn emergency room discharge summary dated 2/18/23, revealed Resident #24 had been seen due to the injuries she had after a fall. The summary read in part, "your pain is most likely caused from a muscle strain and concussion from the fall." Further review revealed the practitioner ordered Resident #24 to alternate between 400 mg of ibuprofen and 650 mg of acetaminophen every six hours for optimal pain control. However, from 2/18/23 to 2/28/23 the MAR read the medication was placed on hold. The residence failed to provide a written practitioner order that confirmed the acetaminophen was placed on hold. Further review of the MAR revealed three staff (#15-#17) marked a code nine on the electronic MAR. The key portion of the MAR indicated that code nine meant, "other, see progress note." Further review of the progress notes provided revealed notes that read, "daughter requested that the med should be on hold."On 9/3/24 at 3:52 p.m.,the clinical director stated that she looked everywhere for the hold order for Resident #24 and could not find it. On 9/4/24 at approximately 12:50 p.m., the health services director (HSD) revealed he thought Resident #24 ' s daughter could ask the residence to place a hold on the acetaminophen. b. LisinoprilA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 6/14/22 at 8:59 p.m., directed the residence to administer lisinopril 20 mg once a day for hypertension at bedtime. However, on 1/10/23 the MAR read the medication was not available. A residence progress note, dated 1/10/23 at 7:49 p.m., read in part: Staff #15 wrote the medication was not available in the cart.c. MetforminA written practitioner's order, dated 6/14/23 at 8:59 p.m., directed the residence to administer metformin extended release 24 hour 500 mg units once a day at bedtime for depression. However, on 1/10/23 the MAR read the medication was not available. A residence progress note, dated 1/10/23 at 7:50 p.m., read in part: Staff #15 wrote the medication was not available in the cart. A MAR dated 1/28/23 revealed Staff #3 marked a code nine. The key portion of the MAR indicated that code nine meant, "other, see progress note." Further review of the progress notes provided revealed there was no note written.d. NamendaA written practitioner's order, dated 6/14/23 at 8:59 p.m., directed the residence to administer namenda 10 mg twice a day for memory. However, on 1/10/23 the MAR read the medication was not available. A residence progress note, dated 1/10/23 at 7:51 p.m., read in part: Staff #15 wrote the medication was not available in the cart. e. Quetiapine FumarateA written practitioner's order, dated 6/28/23 at 5:24 p.m., directed the residence to administer one 25 mg tablet at bedtime for depression. However, on 2/24/23 the MAR read the order was not administered. A review of the residence progress note revealed there was no note written to indicate why this order was not followed on 2/24/23. A review of the residence progress note revealed there was no note written to indicate why this order was not followed on 2/24/23.3. On 9/4/24 at approximately 12:25 p.m., the administrator stated she expected the practitioner's orders to be followed for all residents and was not sure why they were not. She continued to say she ' d expect the MARs to be completed, progress notes written when coded with a nine, and the MARs transcribed accurately.

Plan of correction · submitted by the facility

1568 Mediation and Medication AdministrationThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiencyResident # 17’s order for MiraLAX oral powder was verified and corrected during the survey. Resident #24’s order for acetaminophen was removed from “on hold” on 2/28/23. The facility changed EHR systems in 04/2023 which now requires medication exceptions to be documented in the MAR as to what the exception was. Resident #24’s lisinopril, metformin and Namenda were documented “Medication not available” on one day, 01/10/2023 and this was corrected on 1/11/2023. Resident #24’s quetiapine was documented “Medication not available” on one day, 02/24/2023 and this was corrected 02/25/2023. QMAPs and nurses were educated on triple check process of verifying orders to ensure orders are transcribed correctly. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. The Executive Director or Designee will review the Medication Administration Records weekly for hold orders to ensure a signed practitioner hold order is in the EHR and Medications Not Available to ensure residents receive medications per practitioner order. The Executive Director or designee will audit 10% of new orders weekly x 4 weeks then monthly x 2 months to ensure orders are transcribed correctly. The sample, representative of the facility census, included in the monitoring;All residents have the potential to be affected. How often the monitoring will occurThe Executive Director or Designee will review the Medication Administration Records weekly x 4 weeks then monthly x 2 months, for hold orders to ensure a signed practitioner hold order is in the EHR and Medications Not Available to ensure residents receive medications per practitioner order. How the monitoring will be documented;The Executive Director or Designee will Executive Director or Designee will document the review on a tracker. How the monitoring will be included in the QAPI processThe Executive Director, or Designee will report findings to the QMP Committee for 3 months or longer until substantial compliance is maintained. Date of compliance-10/25/24.

9/3/2024Licensure and Licensure Complaint (Combined) · ID C8PS116 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey with complaints #CO31375 and #CO32337 was completed on 9/4/24. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0610Prsnl-Crmnl HX Rcrd Chcks CBIS/S B▼

Findings

Based on record review and interview, the residence failed to request, prior to hire, a name-based criminal history record check for each perspective staff member for two of four sample staff, (#4, #6) affecting 110 current residents. 1. Record ReviewReview of the personnel files for Staff #6 revealed they were hired on 7/30/24. The personnel file contained signed orientation training documentation dated 7/31/24. However, the personnel file contained evidence that a criminal background investigation (CBI) was conducted on 8/16/24. Review of the personnel files for Staff #4 revealed they were hired on 2/21/24. The personnel file contained a signed offer letter dated 2/21/24. However, the personnel file contained evidence that a criminal background investigation(CBI) was conducted on 8/16/24.2. InterviewOn 9/4/24 at 12:17 p.m., the administrator stated she was aware of the requirement for a CBI to be conducted prior to the hire of a prospective employee. The administrator confirmed the orientation training was part of the onboarding process. On 9/4/24 at approximately 12:45 p.m. the vice president of operations (VPO) stated that she sent an offer letter to a potential new hire that was contingent on the CBI background check and at that time the potential staff member could go through orientation at the home office. She also stated after the completion of the orientation, the background check and the Tuberculosis test,, staff were put on the schedule for on site training. The VPO confirmed that the orientation training was part of the new hire onboarding process.

Plan of correction · submitted by the facility

0610 Personnel Criminal History Record ChecksThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiencyStaff #6 CBI was conducted 8/16/24 as was pointed out during the survey. Regarding staff member #4, we would like to clarify the details provided. Staff member #4 authorized her background check on 2/21/24 and signed both the offer letter and job description via email on the same day (2/21/24). However, her actual hire date was 2/27/24, which was the first day of employment, coinciding with the on-boarding orientation held at our home office. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. The Executive Director, or Designee has implemented that CBI background authorization is to be completed upon application submission or interview and will be submitted for processing prior to the associate’s date of hire. The sample, representative of the facility census, included in the monitoring;All residents had the potential to be affected. How often the monitoring will occurExecutive Director or Designee will review compliance of CBI submission prior to date of hire, weekly x 4 weeks then monthly x 2 months. How the monitoring will be documented;The Executive Director or Designee will audit 25% of new hires monthly to ensure CBI is submitted prior to date of hire for 3 months or longer until substantial compliance is maintained. How the monitoring will be included in the QAPI processThe Executive Director, or Designee will report findings to the QMP Committee for 3 months or longer until substantial compliance is maintained. Date of compliance-10/25/24.

0736Stf Req-First Aid Stf CPR ListS/S B▼

Findings

Based on record review, observation and interview the residence failed to ensure an up to date list of all staff who had a current certification in first aid and cardiopulmonary resuscitation (CPR) was maintained and posted in a visible and readily available at all times, affecting 110 current residents. Findings include:On 9/3/24 at 7:22 a.m., all staff CPR certifications and the list of all CPR certified staff was requested and provided. CPR certifications were provided for Staff #9-#11 however, these staff members were not listed on the staff CPR list. Review of the undated staff CPR list revealed Staff #12-#14 were listed as CPR certified however no CPR certification was provided. On 9/3/24 at 8:47 a.m. the same CPR staff list that was provided was also posted on the second floor staff lounge. On 9/4/24 at 12:17 p.m. the administrator stated she updated the CPR list when she received certifications from staff members. The administrator stated she expected the staff CPR list to remain up to date.

Plan of correction · submitted by the facility

0736 Staff Requirement-First Aid CPR ListThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiencyStaff #9 - #11 were added to the CPR list. Staff #12 were removed from the CPR list. Staff #14 obtained a valid CPR certification card. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. The Executive Director, or Designee will audit current associates for current CPR certification. The Executive Director or Designee will post a visible posting of current CPR trained associates which will be updated with any changes immediately when the change occurs. The Executive Director or Designee has reviewed and updated the policy for CPR posting. The sample, representative of the facility census, included in the monitoring;All residents had the potential to be affected. How often the monitoring will occurThe Executive Director or Designee will review the CPR list for accuracy weekly x 4 weeks and then monthly x 2 months. How the monitoring will be documented;The Executive Director or Designee will Executive Director or Designee will document the review on a tracker. How the monitoring will be included in the QAPI processThe Executive Director or Designee will report findings to the QMP Committee for 3 months or longer until substantial compliance is maintained. Date of compliance-10/25/24.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Plan of correction · submitted by the facility

1568 Mediation and Medication AdministrationThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiencyResident # 17’s order for MiraLAX oral powder was verified and corrected during the survey. Resident #24’s order for acetaminophen was removed from “on hold“ on 2/28/23. The facility changed EHR systems in 04/2023 which now requires medication exceptions to be documented in the MAR as to what the exception was. Resident #24’s lisinopril, metformin and Namenda were documented “Medication not available“ on one day, 01/10/2023 and this was corrected on 1/11/2023. Resident #24’s quetiapine was documented “Medication not available“ on one day, 02/24/2023 and this was corrected 02/25/2023. QMAPs and nurses were educated on triple check process of verifying orders to ensure orders are transcribed correctly. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. The Executive Director or Designee will review the Medication Administration Records weekly for hold orders to ensure a signed practitioner hold order is in the EHR and Medications Not Available to ensure residents receive medications per practitioner order. The Executive Director or designee will audit 10% of new orders weekly x 4 weeks then monthly x 2 months to ensure orders are transcribed correctly. The sample, representative of the facility census, included in the monitoring;All residents have the potential to be affected. How often the monitoring will occurThe Executive Director or Designee will review the Medication Administration Records weekly x 4 weeks then monthly x 2 months, for hold orders to ensure a signed practitioner hold order is in the EHR and Medications Not Available to ensure residents receive medications per practitioner order. How the monitoring will be documented;The Executive Director or Designee will Executive Director or Designee will document the review on a tracker. How the monitoring will be included in the QAPI processThe Executive Director, or Designee will report findings to the QMP Committee for 3 months or longer until substantial compliance is maintained. Date of compliance-10/25/24

1600Med/Med Adm-Rcrd Kpng MARS/S A▼

Findings

Based on interview and record review, the residence failed to ensure the medication administration record (MAR) contained accurate information, affecting one of twelve sample residents (#17) and one former resident (#24) whose medications were reviewed. Findings include:1. Residence PolicyThe residence's Medication Administration policy dated 2/26/24 read in part, medications are to be listed and recorded on medication administrations records as prescribed. The qualified medication administration person (QMAP) must document the reason for any medication that was not administered. 2. Resident #17 was admitted to the residence on 10/6/24 with a diagnosis of hypertension and unspecified dementia. A written practitioner's order dated 8/7/24, directed the residence to discontinue polyethylene glycol 3350/17 gram/dose powder daily. A written practitioner's order dated 8/7/24, directed the residence to administer miralax oral powder every three days and hold for loose stool. The August and September 2024 MAR did not show a discontinuation of the original polyethylene Glycol 3350/17 gram/dose powder order. The August and September 2024 MAR read to administer polyethylene Glycol 3350/17 gram/dose powder daily and displayed an "X" on the MAR to signify to staff to hold the medication on specific days. 3. Former Resident #24 was admitted to the residence on 4/30/21 with a diagnosis of dementia. AcetaminophenA written practitioner's order dated 2/18/23, directed the residence to administer acetaminophen 500 mg every six hours. However, the February 2023 MAR revealed a blank space at 12:00 p.m. on 2/25/23. Additionally, there was a code "9" which read "other see progress notes" with no corresponding progress note, on 2/24 at 6:00 a.m. and at 12:00 a.m. and 8:00 p.m. on 2/28/23, for a total of four inaccurately documented doses. QuetiapineA written practitioner's order dated 6/27/22, directed the residence to administer quetiapine 25 mg at bedtime. However, the February 2023 MAR contained a blank space on 2/24/23, for a total of one inaccurately documented dose. 4. InterviewOn 9/4/24 at 12:17 p.m., the administrator stated she expected staff to document at the time of administration so there were no blank spaces on the MARs, and also expected the code "9" that read to see progress notes, to contain corresponding progress notes. The administrator further stated she expected MARs to read as the practitioner's order read.

Plan of correction · submitted by the facility

1600 Medication and Medication Administration-Record Keeping MARThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiencyResident # 17’s order for MiraLAX oral powder was verified and corrected during the survey. Resident #24’s acetaminophen order on the MAR for 2/25/23, 2/24/23 and 2/28/23 are not able to be corrected at this time, 19 months later. Resident #24’s quetiapine order on the MAR 2/24/23 is not able to be corrected at this time, 19 months later. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. The Executive Director or Designee will review the Medication Administration Records weekly for Medications Not Available or blank spaces (holes) in the MAR, to ensure residents receive medications per practitioner order. Executive Director or Designee will educate QMAPs regarding importance of complete documentation in the MAR and following practitioner orders. QMAPs and nurses were educated on triple check process of verifying orders to ensure orders are transcribed correctly. The Executive Director or designee will audit 10% of new orders weekly x 4 weeks then monthly x 2 months to ensure orders are transcribed correctly. The sample, representative of the facility census, included in the monitoring;All residents have the potential to be affected. How often the monitoring will occurThe Executive Director or Designee will review the Medication Administration Records weekly x 4 weeks then monthly x 2 months, for hold orders to ensure a signed practitioner hold order is in the EHR and Medications Not Available to ensure residents receive medications per practitioner order. How the monitoring will be documented;The Executive Director or Designee will Executive Director or Designee will document the review on a tracker. How the monitoring will be included in the QAPI processThe Executive Director, or Designee will report findings to the QMP Committee for 3 months or longer until substantial compliance is maintained. Date of compliance-10/25/24.

2244HIR-Rcrd Trnsfr/Rtntn 3yrS/S A▼

Findings

Based on record review and interview, the residence failed to ensure health information records for residents were kept on site for at least three years following the termination of the residents stay, affecting one former resident (#24). Findings include:1. Reference Chapter VII regulations governing assisted living residences, part 18.8, requires resident records shall contain, but not be limited to, the following items: (C) Individualized resident care plan 2. Record ReviewOn 9/3/24 at approximately 11:00 a.m., the full resident record for Former Resident #24 with all care plans from 2022 to February 2023 was requested and not provided. At 2:00 p.m. and 4:30 p.m. the care plans were re-requested; however, on 9/4/24 were still not provided. 3. InterviewsOn 9/4/24 at 8:45 a.m., the vice president of operations, stated she had tried to obtain access to the care plans from the residence's former electronic health record system however was unable to retrieve the care plans since the residence switched to a new electronic health record system around March 2023. On 9/4/24 at 12:17 p.m., the administrator stated she was aware of the requirement to maintain former resident records for at least three years; however, was unable to retrieve the requested care plans for Former Resident #24.

Plan of correction · submitted by the facility

2244 Health Information RecordsThis Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. Description of how the licensee will correct each identified deficiencyResident #24 no longer resides at facility. Description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. Exactly how and what will be reviewed as part of the monitoring. The facility changed EHR systems 04/2023 therefor all former resident’s records will be kept on site for at least 3 years after discharge. The Executive Director or Designee has completed an audit to ensure all current residents have a care plan. The sample, representative of the facility census, included in the monitoring;All residents admitted prior to 4/2023 have the potential to be affected. How often the monitoring will occurExecutive Director or Designee will review completeness of the resident record in the EHR for all residents who discharge after 10/1/24 for 3 months. How the monitoring will be documented;The Executive Director or Designee will Executive Director or Designee will document the review on a tracker. How the monitoring will be included in the QAPI processThe Executive Director, or Designee will report findings to the QMP Committee for 3 months or longer until substantial compliance is maintained. Date of compliance-10/25/24.

3142Sec Env-Phy Dsgn/Env/Sfty Crit-InS/S E▼

Findings

Based on record review, observation and interview, the residence failed to ensure potentially hazardous chemicals were stored in an area that was inaccessible to residents, affecting 23 current residents residing in the secure environment. Specifically, the residence failed to ensure all chemicals remained locked in the secure environment. On 9/3/24 there were 23 residents who resided in the secure environment of the residence. The kitchen shelves contained five chemicals that contained hazard labels which read "Hazards to Humans If Swallowed: call a poison control". Resident #18 and #23 were identified as residents that consistently wandered and rummaged through cabinets, resident rooms and had to be redirected. Additionally there were three staff members that worked in the secure environment on 9/3/24 from 7:30 a.m. to 10:30 a.m. who had to leave the residents in the dining area unattended multiple times to assist other residents with cares or prepare meals in the locked kitchen area. Resident #18 was observed near the chemicals looking for staff assistance. Staff were unaware of the chemicals on the bottom shelf of the kitchen shelving that was accessible to residents. This failure created an immediate jeopardy risk to all the 23 residents who reside in a secure environment. On 9/3/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. ObservationsOn 9/3/24 from 7:46 a.m. to 8:14 a.m. an environmental tour of the secure environment was conducted. At this time five bottles of chemicals were accessible to residents, four were under a hand washing sink and one was stored on the bottom shelf under the countertop and accessible to residents. The sink and cabinet area were part of the dining room and accessible to residents. Residents were present in the dining area while the chemicals were left out unattended. Staff were observed assisting other residents with morning care. On 9/3/24 at 9:12 a.m., Resident #18 was observed near the chemicals wandering and looking for staff for assistance. No staff were present at this time. At 9:15 a.m., Staff came out from the locked area to assist Resident #18. On 9/3/24 at 9:30 a.m. Staff #7 was observed performing cares with residents in the dining room. Staff #7 did not attempt to remove the chemicals from under the sink after being notified that the chemicals were under the sink and accessible to residents. On 9/3/24 at 10:07 a.m., one of the bottles of chemicals had been removed. Four bottles of chemicals were observed under the sink of the kitchen accessible to residents. On 9/3/24 at 10:30 a.m., the four bottles of chemicals were observed still accessible to residents in the kitchen area of the secure environment. Staff were observed coming and going from the dining area while staff assisted residents to activities or their room after breakfast had ended. 2. Record ReviewResident #18 was admitted to the residence on 8/15/2023 with a diagnosis of Parkinson's disease. Resident 18's care plan read in part "Mild confusion - needs occasional prompting and orientation to time and place. Resident is independent with mobility but needs staff VERBAL CUEING assistance". 3. InterviewsOn 9/3/24 at 9:15 a.m., Staff #7 stated that Resident #18 and #23 had increased behaviors of wandering and rummaging through cabinets, and other resident's belongings. Staff #7 stated she was unaware the five bottles of chemicals were under the sink and accessible to residents. On 9/3/24 at 9:20 a.m., Staff #8 said most of the residents had some level of wandering tendencies and stated that she was unaware that potentially hazardous chemicals were accessible to residents. On 9/3/24 at 12:17 p.m., the administrator stated she expected staff to store potentially hazardous chemicals in a location that was not accessible to residents. 4. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe survey established that the findings above placed the 23 current residents at immediate jeopardy risk for the failure to ensure potentially hazardous chemicals were stored in an area that was inaccessible to residents that could pose a risk if ingested. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 9/3/24 at 1:55 p.m., the administrator submitted written evidence that read in pertinent part: "All hazardous materials will be stored in locked closets or cabinets, like the housekeeping room, to ensure resident safety. All memory care team members will be trained on this requirement by 9/3/24. This will also be included in the new hire orientation process at the home office. Assisted living director or designee will conduct daily rounds for 30 days to ensure substantial compliance has been achieved and maintained."However, the written evidence did not indicate the risk had been removed because it did not contain an acceptable monitoring element, how the residence would document their compliance plan had been completed. The administrator was directed to submit additional written evidence. On 9/3/24 at 3:10 p.m., the administrator submitted written evidence that read in pertinent part: "Assisted living director or designee will conduct and document daily rounds for 30 days to ensure substantial compliance has been achieved and maintained."

Plan of correction · submitted by the facility

This Plan of Correction constitutes this facility’s written response to the deficiencies cited by the Colorado Department of Public Health and Environment (CDPHE). Submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet regulatory requirements and to demonstrate our commitment to continuous improvement and compliance. To comply with CDPHE regulations, there must be a storage area inaccessible to residents for items that could pose risks, like chemicals, toxic materials, and sharp objects. Correcting immediate IJ: ""All hazardous materials will be stored in locked closets or cabinets, like the housekeeping room, to ensure resident safety. All memory care team members will be trained on this requirement by 9/3/24. This will also be included in the new hire orientation process at the home office. Assisted living director or designee will conduct daily rounds for 30 days to ensure substantial compliance has been achieved and maintained."A secure environment audit was conducted securing all such items. Preventative measures:All hazardous materials will be stored in locked closets or cabinets, like the housekeeping room, to ensure resident safety. Education:All Memory Care team members will be trained on this requirement by 9/3/24. This will also be included in the new hire orientation process at the home office. Monitoring:Assisted Living Director or designee will conduct and document daily rounds to ensure substantial compliance has been achieved and maintained.

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; (B) Room and board; (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment; (D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach; and (E) Social care and resident engagement.

Plan of correction

The state did not require a plan of correction for this citation.

Reportable Occurrences

33 records

6/9/2026Misappropriation of Property · ID 2623N139006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/10/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) reported that $100 and a credit card were missing from their wallet. Client (A) last observed the items on 6/5/26. During the course of the investigation, the healthcare entity conducted a search, contacted police, reviewed camera footage, and conducted interviews. Camera footage revealed no pertinent information to help identify an assailant or what happened. Staff reported unawareness of the money. The facility educated client (A) on storing their valuables in their locked box, locking their door when leaving, and having family store valuables. The event was substantiated. This is the second report of misappropriation of client property in the month of June 2026. Please refer to the case ID: 2623N139005 for details. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/13/2026 · released to the public 7/20/2026.

6/9/2026Misappropriation of Property · ID 2623N139007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/26/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) reported their wallet was missing and had unauthorized charges on their credit card on 6/9/26. During the course of the investigation, the healthcare entity conducted a search, contacted police, reviewed camera footage, and conducted interviews. Client (A)'s representative deactivated the credit card. The facility camera footage revealed no pertinent information to help identify an assailant or what happened. Law enforcement identified staff (1) as the assailant. The facility suspended staff (1) and then terminated their employment. The facility educated its clients on safety and reporting missing items. The facility re-educated staff on misappropriation and reporting procedures. The event was substantiated. This is the third report of misappropriation of client property in the month of June 2026. Please refer to the case ID: 2623N139005 and 2623N139006 for details. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/13/2026 · released to the public 7/20/2026.

6/2/2026Misappropriation of Property · ID 2623N139005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/2/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A)'s representative reported a fraud alert on client (A)'s credit card. Client (A)'s representative saw the credit card and wallet one week ago. During the course of the investigation, the healthcare entity conducted a search, contacted police, reviewed camera footage, and conducted interviews. Client (A)'s representative stopped the fraudulent credit card charge. Camera footage revealed no pertinent information to help identify an assailant or what happened. Client (A)'s representative terminated an outside agency caregiver's employment. Staff reported unawareness of the missing wallet. The facility ensured all clients had keys and were able to lock their doors and safes. The facility encouraged clients to utilize their safes for valuables. 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 7/13/2026 · released to the public 7/20/2026.

6/1/2026Misappropriation of Property · ID 2623N139009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/7/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A)'s representative reported suspicious charges on client (A)'s credit card within the last few months. During the course of the investigation, the healthcare entity contacted police, reviewed records, and conducted interviews. Client (A)'s representative communicated about the unauthorized charges with the credit card company. Law enforcement assisted with the investigation, which remained ongoing. The facility re-educated its clients on safety and reporting missing items. The facility re-educated staff on misappropriation and reporting procedures. The event was substantiated. This is the fourth report of misappropriation of client property. Please refer to the case ID: 2623N139005, 2623N139006, and 2623N139007 for details. This is the second report of misappropriation of client property involving staff (1) as the alleged assailant. Please refer to case ID 2623N139007 for details. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/13/2026 · released to the public 7/20/2026.

4/19/2026Missing Person · ID 2623N139004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/19/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. Staff discovered client (A), who was an at-risk adult, outside the facility attempting to cross the street. Client (A) was missing for about five minutes. During the course of the investigation, the healthcare entity conducted a search, redirected client (A), contacted their medical provider, and conducted interviews. Staff returned client (A) to the facility unharmed. Client (A) expressed agitation and the desire to leave the facility. The facility provided reassurance, redirection, and increased oversight and interactions with client (A). The facility discussed a higher level of care with client (A)'s representative. The event was substantiated. This is the second report of missing persons involving client (A). Please refer to the case ID 2623N139003 for details. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe

Publication

Sent to facility 6/4/2026 · released to the public 6/11/2026.

3/9/2026Missing Person · ID 2623N139003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/9/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing client. An at-risk client was missing from the facility for 17 minutes based on camera review. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The client was found a block away from the facility and brought back without any injuries. Because of clients impulsivity, exit seeking behaviors and a diagnosis of dementia, the staff implemented every hour safety checks and an air tag tracker was placed on the clients walker. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/17/2026 · released to the public 4/24/2026.

1/17/2026Misappropriation of Property · ID 2623N139002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/17/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. The client’s family reported the client’s cell phone was missing. During the course of the investigation, the healthcare entity conducted a search and interviews, and reviewed location tracking information. Video footage review and phone tracking information revealed the phone was with the client when they left the facility with family for dinner. The phone was last seen at the family’s home and the family determined the phone was accidentally thrown away at the family dinner. The facility continued the plan of assisting the client to plug the phone in near their bed each night. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/6/2026 · released to the public 4/13/2026.

12/20/2025Neglect · ID 2523N139013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/23/25, 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 neglect of a client. After the client was transferred to the hospital for a change of condition, the family alleged neglect. During the course of the investigation, the healthcare entity reviewed records, conducted interviews, and assessed the client. The client was diagnosed with a urinary tract infection, decreased mobility, and acute gastrointestinal illness. Record review showed the client had been resistant to care, including showers and medically necessary examinations. The facility determined staff attempted to provide care, documented refusals, and obtained additional support immediately when there was a change of condition. The client was transferred to a higher level of care for mobility improvement. The facility educated staff, updated skin assessment schedule, and scheduled a care conference. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/31/2026 · released to the public 4/7/2026.

12/19/2025Physical Abuse · ID 2523N139012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/19/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. The facility received an allegation that Staff #1 was abusing Client (A) while providing care. During the course of the investigation, the healthcare entity suspended Staff #1, assessed the client, notified law enforcement, reviewed camera footage, and conducted interviews. No visible injuries linked to the incident were identified, and Client (A) was unable to recall the incident due to diminished cognitive functioning. Client (A) did not express pain as a result of the incident. Staff #1 stated they were focused on providing assistance to Client (A), and video footage corroborated the staff’s actions. Client (A)’s care plan was updated to include a detailed process for approaching/ assisting the client and increased monitoring. All staff, to include Staff #1, completed re-training on abuse and working with cognitively impaired clients. Prior to returning to work, Staff #1 completed an additional competency with leadership. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 1/28/2026 · released to the public 2/4/2026.

10/8/2025Brain Injury · ID 2523N139011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/8/25, 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 brain injury of a client. The client had an unwitnessed fall, was transported to the hospital and diagnosed with subdural hemorrhaging. During the course of the investigation, the healthcare entity conducted interviews, assessed the environment, and reviewed medical documentation. The client was treated at the hospital and returned to the facility. The facility updated the care plan with additional fall prevention strategies and educated the client. 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 1/9/2026 · released to the public 1/16/2026.

9/27/2025Missing Person · ID 2523N139010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/27/25, 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. Reportedly, the at risk client left the facility to look for their spouse and became lost. During the course of the investigation, the healthcare entity conducted interviews and started increased monitoring. Thirty minutes later the client was found unharmed, looking into apartment windows down the street ,and was returned to the facility by a community member. The facility updated the care plan to include increased safety checks, added the client’s information to potential elopement list, and spoke with the family about a private caregiver. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/2/2025 · released to the public 12/9/2025.

8/29/2025Brain Injury · ID 2523N139009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. Client (A) indicated they fell when getting dressed and struck their head. This was witnessed on the camera system. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client did not return to the facility as they passed away. It was not determined what the cause of death was, however they were diagnosed with a brain bleed. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/8/2025 · released to the public 12/17/2025.

7/1/2025Sexual Abuse · ID 2523N139007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. The client alleged a male staff pushed them to the ground and sexually assaulted them. During the course of the investigation, the healthcare entity reviewed video footage provided by the fall monitoring system, conducted interviews, started increased monitoring, and notified law enforcement. The client, who has a history of delusions, had no injuries nor any signs of trauma. Video footage revealed no inappropriate interactions between the staff member and the client. he facility updated the care plan to reflect female only caregivers, a medication adjustment was completed, and education was provided to all staff. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/3/2025 · released to the public 11/10/2025.

5/15/2025Missing Person · ID 2523N139006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/15/25, 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. The client was an at-risk person missing for over an hour. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. Client (A) was not found on the property when a head count was conducted during an activity. The facility was notified by the police that a bystander had found Client (A) Client (A) had no distress when they were returned to the facility. Client (A) was placed on one-to-one oversight temporarily and the staff ratio to clients was increased during activities that are in another location of the property by the memory care clients. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/5/2025 · released to the public 11/12/2025.

4/27/2025Missing Person · ID 2523N139004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/27/25, 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. The client was an at-risk person and walked out the front door as staff attempted to stop them. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The police were notified. The client was missing for more than one and a half hours and was returned to the facility by a staff vehicle. The client did not have any injuries or concerns. The client was assigned one-to-one oversight during waking hours and a conversation with the clients family to discuss the need for a secure environment. 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 10/28/2025 · released to the public 11/4/2025.

4/10/2025Misappropriation of Property · ID 2523N139002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) alleged $175.00 was missing from their wallet and it was last seen on 4/8/25. During the course of the investigation the healthcare entity conducted a search, and interviews. No staff indicated seeing the client’s money. Client (A) stated they would lock up their money and door or keep it off the premises moving forward. The police were notified and no assailant was identified. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/21/2025 · released to the public 8/28/2025.

12/26/2024Death · ID 2423N139014Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 12/26/24 Resident (A) was found in the stairwell deceased by staff. The staff notified the police and blocked off the area. A paramedic was already in the facility and assisted with assessing Resident (A) who was then pronounced deceased. Residents have the capability of using the stairs without staff being present. The facility investigation concluded Resident (A) was on his way to meet his family for dinner and it was unclear if any medical event happened prior to him falling and sustaining significant injuries. The cause of Resident (A)’s fall remained undetermined, but it was discovered he did not have his cane with him and was carrying a bottle of wine with him. To help prevent a recurrence, staff encourage residents to use the elevators. The facility keeps track of who can walk independently for necessary oversight, and the residents are provided with safety information upon admission. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/20/2025 · released to the public 1/27/2025.

11/10/2024Brain Injury · ID 2423N139013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/11/24, 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 brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client’s care plan was updated to reflect safety interventions should the client return to the facility after their rehabilitation stay. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/11/2025 · released to the public 2/18/2025.

10/1/2024Brain Injury · ID 2423N139011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/3/24, 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 brain injury. During the course of the investigation the healthcare entity did an assessment, obtained medical treatment and updated the clients care plan to reflect increased safety checks. The client will continue to utilize their assistive device and receive therapy services. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/6/2025 · released to the public 2/17/2025.

8/4/2024Misappropriation of Property · ID 2423N139010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/5/24, 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 misappropriation of client property. During the course of the investigation the healthcare entity interviewed staff and residents, and offered to assist with a search, the client declined. The client was educated to keep valuables locked in their apartment. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/6/2025 · released to the public 2/13/2025.

7/24/2024Diverted Drugs · ID 2423N139009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/25/24, 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 diverted drugs. During the course of the investigation the healthcare entity attempted to locate the missing medication. No client was harmed. One medication had been intentionally taped back into a blister pack and was not the right medication. Staff were educated on documentation review, cart audits and to properly inspect the blister pack of medication when counting for the next shift. No assailant was identified. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/26/2025 · released to the public 3/6/2025.

6/3/2024Brain Injury · ID 2423N139008Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 6/3/24 Resident (A) had an unwitnessed fall and was sent to the hospital where he was diagnosed with a brain injury. Resident (A) was treated in the hospital and the family decided resident (A) would benefit from inpatient therapy before returning to the facility. The facility investigation concluded no causes of the fall were identified. To help prevent a recurrence, when Resident (A) returns from the rehabilitation facility, he will be provided with additional support from caregivers and be encouraged to press his pendant. Additional conversations with the family will be held to discuss a higher level of care if needed. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/17/2025 · released to the public 1/24/2025.

5/24/2024Missing Person · ID 2423N139007Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 5/24/24 an at risk adult was reportedly missing after a search of the premises was conducted. Staff notified the police. Resident (A) was found at a local store after four and a half hours and was assessed by the paramedics and was cleared to return to the facility. A family member remained with resident (A) until a caregiver was assigned that evening. The facility investigation concluded resident (A) is an elopement risk now and will require a secured environment. To help prevent a recurrence, resident (A) will have oversight monitoring until they move. The family will find a secured facility for resident (A) to move to. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/27/2024 · released to the public 12/4/2024.

4/30/2024Misappropriation of Property · ID 2423N139005Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 5/3/24, resident (A) alleged he was missing $20.00 from a money clip left on his dresser. Staff member (1) said they were in the resident's room to make his bed but did not see any money or his money clip. No one saw anyone else enter resident (A)’s room. The facility investigation concluded there was no evidence staff member (1) took resident (A)’s money. To help prevent a recurrence, resident (A) was educated to keep his valuables in a safe place. Resident (A) preferred to keep his money clip on his person. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/21/2024 · released to the public 11/28/2024.

3/21/2024Brain Injury · ID 2423N139004Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS:On 3/22/24 resident (A) was diagnosed with a head injury after falling in their apartment with a family present. S/he was seen by their physician and also had a scan done. Resident (A) was sent to the hospital after the reports of the scan were reviewed. S/he was observed for two days in the hospital before s/he was sent back to the facility. The facility concluded no staff witnessed resident (A) fall and after complaints, further assessment was completed. Resident (A) will participate in physical therapy and will be fitted for a walker. Resident (A) will call for assistance when s/he feels weak. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

2/6/2024Brain Injury · ID 2423N139002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 2/8/2025 · released to the public 2/17/2025.

1/25/2024Brain Injury · ID 2423N139001Reported on time: No▼

Occurrence summary

SUMMARY FINDINGS:On 1/25/24, a resident in a weakened state due to being treated for pneumonia got out of bed to use the bathroom. According to their spouse, s/he forgot to take their walker and fell onto hands and knees and hit their head. The spouse reported the fall and staff responded immediately and called 911. EMS transported the resident to the hospital due to an elevated blood pressure and hitting their head. Hospital notes showed a subarachnoid hemorrhage which required no treatment. The resident also had skin tears to their right arm which were treated. The resident returned to the facility later in the day on 1/25/24. Upon their return s/he received wound care for the skin tear and was monitored for any change of condition. From the facility’s investigation it was determined the residents care plan was followed, s/he fell when s/he attempted self toileting at night and forgot their walker. To help prevent a recurrence, the resident will receive continued reminders to use their walker and to press their pendant for as needed caregiver assistance. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the facility, this occurrence event will be reviewed by the State Agency. The facility complied with licensing standards for conducting an internal investigation of this Occurrence event and submitting a report of the findings to the Department. However, the licensing standard for timely reporting was not met.

Publication

Sent to facility 11/20/2024 · released to the public 11/27/2024.

1/18/2024Brain Injury · ID 2423N139003Reported on time: No▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The agency/facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.

Publication

Sent to facility 2/8/2025 · released to the public 2/17/2025.

10/27/2023Misappropriation of Property · ID 2323N139008Reported on time: No▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/27/23, a family member of a resident (A) in her 80s reported her wedding ring set and wallet were missing. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and ombudsman. This was supposed to have happened two weeks ago. The family notified the police however did not report to the facility at that time. No charges were placed on the credit card that was in the wallet. Staff did not indicate seeing the items. The items were not found after a search. The facility investigation concluded the items are still missing and no assailant has been identified to have taken them. To help prevent a recurrence, a camera has been placed in resident (A)’s room. Residents and family members are still asked not to bring valuables into the facility. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The 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. However, the licensing standard for timely reporting was not met.

Publication

Sent to facility 9/30/2024 · released to the public 10/1/2024.

10/22/2023Misappropriation of Property · ID 2323N139007Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/22/23, a female resident (A) in her 80s reported an envelope with $300.00 was missing and $50.00 was also missing. The money was last seen in the seat of her walker. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and ombudsman. Resident (A) stated the walker was next to her bed at 11:00 p.m. and then at 3:00 a.m., the walker was moved and the money was gone. Staff were interviewed and denied knowledge of the incident. The facility investigation concluded resident (A)’s money was missing, however no assailant was identified. To help prevent a recurrence, staff will not go into resident (A)’s room after 7:00 p.m. or before 6:00 a.m. until she presses her pendant. Resident (A) will utilize a safe that she has inside her apartment. Resident (A) was also educated to safeguard her money. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 9/30/2024 · released to the public 10/1/2024.

8/10/2023Misappropriation of Property · ID 2323N139006Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 8/11/23, resident (A) reported they returned from a salon appointment to retrieve cash for a tip and was missing $150.00 from their dresser and $40.00 from their wallet, which was in their purse. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and ombudsman. Resident (A) would not allow staff to assist in searching for the missing money. No staff witnessed any cash in the resident’s wallet or her purse or under clothing and the resident had not had any deliveries to her room. When following up with the resident, she stated she did not want to pursue the investigation any further. The facility investigation could not conclude if the money was stolen or misplaced. To help prevent a recurrence, staff will continue to monitor and be vigilant of surroundings. Resident (A) was reminded to secure all valuables and cash. 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.

Publication

Sent to facility 7/30/2024 · released to the public 8/6/2024.

6/12/2023Misappropriation of Property · ID 2323N139005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/12/23, the facility submitted a report of misappropriation of property and an allegation of financial exploitation. One resident (A), in his 70s, hired a private caregiver (1) from a homecare agency to help with his personal care needs. Resident (A) reported he discovered caregiver (1) had taken his personal checks and wrote checks payable to himself. There were 36 checks written and cashed for a total amount of $12,400. Initially, the resident reported he wrote caregiver (1) a check for $200 even though the caregiver was paid by the agency. With the next visit, resident (A) said caregiver (1) asked for $500 and the resident declined. There was also a report of caregiver (1) having access to the resident's personal computer, which contained his banking information. In June, the resident reviewed his account and discovered the accounting discrepancies. He reported he did not authorize these transactions beyond the initial check for $200. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and ombudsman. Resident (A)'s power of attorney helped freeze the accounts to help prevent any further misappropriation of property. No other residents residing in the facility were affected. Caregiver (1) was removed from working with the resident (A) and was not allowed on facility property. This facility spoke with the homecare agency about the findings, and they stated they were going to “prosecute him (caregiver 1) to the fullest extent of the law.” Resident (A) stated these transactions began in January 2023 and ended in June 2023. The facility investigation concluded caregiver (1) had misappropriated money from the resident. A police investigation was ongoing. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 3/25/2024 · released to the public 3/25/2024.

3/26/2023Misappropriation of Property · ID 2323N139004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 3/29/23 the facility was notified that a female resident (A) in her 70s bank account was compromised and $700.00 was taken from it through her phone. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. The fraud department put a lock on the account. On 3/30/23 the resident's phone could not be located after the room was searched. The suspect took resident (A)’s phone that had her passcode on the back of it and used facial recognition to access the phone. It was discovered that two transitions were made in the total amount of $700.00. The facility reviewed financial records and available video with the police. Multiple interviews were conducted and did not reveal anything pertinent for this case. The facility investigation concluded at the time of this report that no assailant had been identified and they would continue working with the police. To help prevent a recurrence, all valuables were removed from resident (A)’s room. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 7/27/2023 · released to the public 8/3/2023.