Colorado CDPHE · Facility Report

HILLTOP LIFE ADJUSTMENT PROGRAM

📍 1405 WELLINGTON AVE, GRAND JUNCTION, CO 81501

ID 23Q649Assisted Living Residence/Brain Injury-Supported Living (Medicaid)Active
11
Inspections
4
Deficiencies
0
Actual Harm or Above
48
Occurrences
June 10, 2026
Last Inspection
S/S B Minimal potentialS/S D Potential for harm

The most recent inspection of HILLTOP LIFE ADJUSTMENT PROGRAM on record is dated June 10, 2026. Across 11 published inspections, state surveyors cited 4 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/Brain Injury-Supported Living (Medicaid)
Administrator
Quillin, Tena
Owner
HILLTOP HEALTH SERVICES CORPORATION
Phone
(970) 245-3952
Payor Source
Medicaid, Private Pay
City
GRAND JUNCTION
ZIP
81501

Inspections & Citations

11 inspections · 4 deficiencies
6/10/2026Licensure Complaint · ID L0NZ111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO42379 and #CO42402, was completed on 6/15/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1180Res Care Srvs-Fall Mgt PrS/S D▼
Findings
Based on observation, interview and record review the residence failed to develop and implement a fall management program affecting four of four sample residents with falls (#1, #2, #3 and #4). Specifically, Former Resident #1 had 78 falls between 1/2/26 to 4/6/26, 60 with no injuries, 17 with unknown injuries, two with known injuries and one that led to his death. On 1/28/26 at 5:15 a.m. Former Resident #1 fell and obtained a skin tear to the top of his left foot and to his lower left leg, both of which needed to be cleaned. On 3/6/26 at 4:41 a.m. Former Resident #1 fell and obtained a hematoma (bruise) to his right forearm, which required elevation, a hematoma to his right ankle, which required elevation, a hematoma to his left thigh, which required an ice pack and swelling to his lower left leg, which required elevation. On 4/6/26 at 5:00 a.m. staff checked on Former Resident #1 and found him on the floor with his head between the transfer pole and the transfer pole was right under his neck. Staff started calling the resident's name and got no response. The staff attempted to get the resident up but was unable to move him and ended up removing the transfer pole. The coroner's report documented that the cause of death was mechanical asphyxia and the manner of death was ruled an accident. Findings include: 1. Reference Chapter 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, service received from external providers, and the services to be provided by the facility 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. 2. Residence PoliciesThe Fall Management policy, revised 2/20/26, was provided by the compliance manager (CM) on 6/11/26 at 2:06 p.m. It read in pertinent part:"To comply with 6 CCR 1011-1 Chapter 7, Assisted Living Communities (ALC) shall establish a Fall Management and Lift Assistance Program. This program will include the following components: Individualized care plans: Include personalized fall risk management strategies in each resident ' s care plan, addressing deficits in strength, balance, vision, and high-risk medications. These strategies will be identified during the comprehensive resident assessment and tailored to prevent future falls."3. Record reviewResident #1 was admitted to the residence on 11/10/14 with a key indicator of "fall risk."Former Resident #1's fall management care plan, dated 1/9/2020, revealed Former Resident #1 was at risk for falls which referred to being chair fast, having a disturbed gait, a balance deficit, limited range of motion (ROM), decreased strength, heavy cannabis use, being on nine or more medications, being on psychotropic medications, having depression, poor judgement, cognitive impairment, vision deficit, incontinence and impulsivity. Interventions were documented as the following: assess [resident] for injury as indicated; emergency department (ED) as indicated; physician notification after each fall and phone call to family member immediately if there was an injury or the next day if the fall was minimal or had no injury; providing education to Former Resident #1 to use his adaptive equipment, calling for assistance with transfers and reporting all fall to residence staff; and, Former Resident #1 had both home health and offsite physical and occupational therapy with no improvement with transfers and no decrease in falls. Former Resident #1 often attended physical therapy (PT) after using marijuana which compromised his ability to work with physical therapy (PT) or retain the education that was provided, at times the former residentrefused to attend PT which led to him being discharged by the provider. Former Resident #1's fall report was provided by the CM on 6/11/26 at 10:13 a.m. The report revealed 60 falls with no reported injury from January 2026 to April 6, 2026 in addition to the following falls:On 1/2/26 at 1:30 p.m., Former Resident #1 fell with injuries documented as "unknown."On 1/15/26 at 12:34 a.m., Former Resident #1 fell with injuries documented as "unknown."On 1/17/26 at 10:08 p.m. Former Resident #1 fell with injuries documented as "unknown."On 1/18/26 at 8:23 a.m., Former Resident #1 fell with injuries documented as "unknown."On 1/28/26 at 5:15 a.m., Former Resident #1 fell with two skin tears, one on the top of his left foot and one on his lower left leg, both of which needed to be cleaned. On 2/1/26 at 1:33 a.m., Former Resident #1 fell with injuries documented as "unknown."On 2/1/26 at 5:15 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/3/26 at 12:52 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/7/26 at 7:37 a.m., Former Resident #1 fell with injuries documented as "unknown."On 2/9/26 at 7:00 a.m., Former Resident #1 fell with injuries documented as "unknown."On 2/14/26 at 9:05 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/22/26 at 6:57 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/24/26 at 1:34 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/24/26 at 7:52 p.m., Former Resident #1 fell with injuries documented as "unknown."On 3/5/26 at 1:14 p.m., Former Resident #1 fell with injuries documented as "unknown."On 3/6/26 at 4:41 p.m., Former Resident #1 fell and received three hematomas (bruises) and swelling. The hematoma on his right forearm required elevation. The hematoma to his right ankle required elevation. The hematoma to his left thigh required an ice pack. The swelling to his lower left leg required elevation. On 3/6/26 at 7:43 p.m., Former Resident #1 fell with the injuries documented as "unknown."On 3/7/26 at 4:25 p.m., Former Resident #1 fell with the injuries documented as "unknown."On 3/31/26 at 6:00 a.m., Former Resident #1 fell with injuries documented as "unknown."On 4/7/26 at approximately 5:00 a.m., Former Resident #1 fell and was found on the ground with his chin resting on the transfer pole and was not breathing and was unresponsive to the staff. Cardiopulmonary resuscitation (CPR) was started and Former Resident #1 passed away. 4. InterviewsThe CM was interviewed on 6/11/26 at 9:00 a.m. The CM said after Former Resident #1 passed away an evaluation was completed on every resident who had a transfer pole to see if the transfer pole was still the most appropriate adaptive equipment for each resident, since Former Resident #1's cause of death was mechanical asphyxiation and his manner of death was accidental. She said Former Resident #1 had a lot of falls. The CM said the highest amount of falls he had in a month was approximately 81 falls but he averaged 21 falls a month. She said she was not aware all his interventions should be in his care plan under the fall management care plan. She said Former Resident #1 fell a lot because he transferred himself without staff supervision or assistance and he smoked marijuana a lot and then would self-transfer. She said Former Resident #1 had weekly multidisciplinary team (MDT) meetings to discuss his falls and behaviors. Staff #1 was interviewed on 6/11/26 at 11:30 a.m. She said Former Resident #1 was assisted with transfers or the staff asked if they could assist him with transferring to prevent him from falling. She said he fell a lot because he had a chest seatbelt on his wheelchair that he did not like wearing. Staff #2 was interviewed on 6/11/26 at 1:40 p.m. She said Former Resident #1 wore a pendant and was getting better at using it to call staff for help but still self-transferred a lot. Staff #2 said all staff are required to read the care plans. She said Former Resident #1's fall interventions were incontinence checks and to help him toilet but he often refused those interventions.-However, the residence failed to have these interventions documented in Former Resident #1's care plan. Staff #3 was interviewed on 6/11/26 at 2:43 p.m. She said she did not really read care plans because there was not enough information documented in the care plans. Staff #3 said Former Resident #1's fall interventions were grab bars in his bedroom and bathroom, he wore a pendant, and more frequent wellness checks. She said Resident #1 often left campus to smoke marijuana and then his number of falls increased. -However, the residence failed to have these interventions documented in Former Resident #1's care plan. 5. Similar deficient practice was also found for Resident #2, Resident #3, and Resident #4.
Plan of correction · submitted by the facility
To maintain compliance with 6 CCR 1011-1 Chapter 7 Part 12.15 the facility:Reviewed falls for all residents in the three months prior to the survey (March-May 2026). Completed June 26, 2026. Reviewed care plans for any residents with one or more falls in the above-referenced period for existing interventions that are completed for fall prevention and identified those interventions to indicate fall prevention. Completed June 30, 2026. Will review care plans for all residents, regardless of fall history to ensure that interventions related to fall prevention are labeled as such by July 31, 2026. Reviewed and updated the policy and procedure for Fall Management/Lift Assistance to explicitly state that interventions to prevent falls will be identified as such throughout the individualized care plan. Completed July 3, 2026. Training will be completed with individuals responsible for updating sections of the individualized care plan regarding identifying interventions related to fall prevention by July 31, 2026. Will review through Quality Management Program (QMP) through January 2027. Initial monitoring will include monitoring for completion of all fall prevention care plans. Continued monitoring will be based on a sample size of 12-16 residents per month. Monitoring will consist of a review of the selected care plans by the Compliance Manager to ensure that each resident has relevant fall prevention identified. This review will be documented in a spreadsheet and summarized in QMP.Addendum:Initial monitoring will be completed by 7/31/2026. Continued monthly monitoring will occur through January 2027. Monitoring of all fall prevention care plans will consist of a sample of care plans (12-16 residents) being thoroughly reviewed by the Compliance Manager. Each care plan will be reviewed to ensure that there is a fall prevention plan identified and that any interventions that are being completed to help prevent falls are identified as being part of the fall prevention care plan (i.e. if a resident receives transfer support to limit falls, that is identified in the care plan).
6/10/2026General Inspection · ID LXK0111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A supportive living program complaint, prompted by #CO42380 and #CO42403, was completed on 6/15/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0130Ind Rts-Basic Crit-Training-PCSP/Dignity▼
Findings
Based on record review and interviews, the facility (residence) failed to ensure each member's (resident's) care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting four (#1, #2, #3, #4) of four sample residents. Specifically, Former Resident #1 had 78 falls between 1/2/26 to 4/6/26, 60 with no injuries, 17 with unknown injuries, two with known injuries and one that led to his death. On 1/28/26 at 5:15 a.m. Former Resident #1 fell and obtained a skin tear to the top of his left foot and to his lower left leg, both of which needed to be cleaned. On 3/6/26 at 4:41 a.m. Former Resident #1 fell and obtained a hematoma (bruise) to his right forearm, which required elevation, a hematoma to his right ankle, which required elevation, a hematoma to his left thigh, which required an ice pack and swelling to his lower left leg, which required elevation. On 4/6/26 at 5:00 a.m. staff checked on Former Resident #1 and found him on the floor with his head between the transfer pole and the transfer pole was right under his neck. Staff started calling the resident's name and got no response. The staff attempted to get the resident up but was unable to move him and ended up removing the transfer pole. The coroner's report documented that the cause of death was mechanical asphyxia and the manner of death was ruled an accident. Findings include: 1. Reference Chapter 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, service received from external providers, and the services to be provided by the facility 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. 2. Residence PoliciesThe Fall Management policy, revised 2/20/26, was provided by the compliance manager (CM) on 6/11/26 at 2:06 p.m. It read in pertinent part:"To comply with 6 CCR 1011-1 Chapter 7, Assisted Living Communities (ALC) shall establish a Fall Management and Lift Assistance Program. This program will include the following components: Individualized care plans: Include personalized fall risk management strategies in each resident ' s care plan, addressing deficits in strength, balance, vision, and high-risk medications. These strategies will be identified during the comprehensive resident assessment and tailored to prevent future falls."3. Record reviewResident #1 was admitted to the residence on 11/10/14 with a key indicator of "fall risk."Former Resident #1's fall management care plan, dated 1/9/2020, revealed Former Resident #1 was at risk for falls which referred to being chair fast, having a disturbed gait, a balance deficit, limited range of motion (ROM), decreased strength, heavy cannabis use, being on nine or more medications, being on psychotropic medications, having depression, poor judgement, cognitive impairment, vision deficit, incontinence and impulsivity. Interventions were documented as the following: assess [resident] for injury as indicated; emergency department (ED) as indicated; physician notification after each fall and phone call to family member immediately if there was an injury or the next day if the fall was minimal or had no injury; providing education to Former Resident #1 to use his adaptive equipment, calling for assistance with transfers and reporting all fall to residence staff; and, Former Resident #1 had both home health and offsite physical and occupational therapy with no improvement with transfers and no decrease in falls. Former Resident #1 often attended physical therapy (PT) after using marijuana which compromised his ability to work with physical therapy (PT) or retain the education that was provided, at times the former resident refused to attend PT which led to him being discharged by the provider. Former Resident #1's fall report was provided by the CM on 6/11/26 at 10:13 a.m. The report revealed 60 falls with no reported injury from January 2026 to April 6, 2026 in addition to the following falls:On 1/2/26 at 1:30 p.m., Former Resident #1 fell with injuries documented as "unknown."On 1/15/26 at 12:34 a.m., Former Resident #1 fell with injuries documented as "unknown."On 1/17/26 at 10:08 p.m. Former Resident #1 fell with injuries documented as "unknown."On 1/18/26 at 8:23 a.m., Former Resident #1 fell with injuries documented as "unknown."On 1/28/26 at 5:15 a.m., Former Resident #1 fell with two skin tears, one on the top of his left foot and one on his lower left leg, both of which needed to be cleaned. On 2/1/26 at 1:33 a.m., Former Resident #1 fell with injuries documented as "unknown."On 2/1/26 at 5:15 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/3/26 at 12:52 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/7/26 at 7:37 a.m., Former Resident #1 fell with injuries documented as "unknown."On 2/9/26 at 7:00 a.m., Former Resident #1 fell with injuries documented as "unknown."On 2/14/26 at 9:05 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/22/26 at 6:57 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/24/26 at 1:34 p.m., Former Resident #1 fell with injuries documented as "unknown."On 2/24/26 at 7:52 p.m., Former Resident #1 fell with injuries documented as "unknown."On 3/5/26 at 1:14 p.m., Former Resident #1 fell with injuries documented as "unknown."On 3/6/26 at 4:41 p.m., Former Resident #1 fell and received three hematomas (bruises) and swelling. The hematoma on his right forearm required elevation. The hematoma to his right ankle required elevation. The hematoma to his left thigh required an ice pack. The swelling to his lower left leg required elevation. On 3/6/26 at 7:43 p.m., Former Resident #1 fell with the injuries documented as "unknown."On 3/7/26 at 4:25 p.m., Former Resident #1 fell with the injuries documented as "unknown."On 3/31/26 at 6:00 a.m., Former Resident #1 fell with injuries documented as "unknown."On 4/7/26 at approximately 5:00 a.m., Former Resident #1 fell and was found on the ground with his chin resting on the transfer pole and was not breathing and was unresponsive to the staff. Cardiopulmonary resuscitation (CPR) was started and Former Resident #1 passed away. 4. InterviewsThe CM was interviewed on 6/11/26 at 9:00 a.m. The CM said after Former Resident #1 passed away an evaluation was completed on every resident who had a transfer pole to see if the transfer pole was still the most appropriate adaptive equipment for each resident, since Former Resident #1's cause of death was mechanical asphyxiation and his manner of death was accidental. She said Former Resident #1 had a lot of falls. The CM said the highest amount of falls he had in a month was approximately 81 falls but he averaged 21 falls a month. She said she was not aware all his interventions should be in his care plan under the fall management care plan. She said Former Resident #1 fell a lot because he transferred himself without staff supervision or assistance and he smoked marijuana a lot and then would self-transfer. She said Former Resident #1 had weekly multidisciplinary team (MDT) meetings to discuss his falls and behaviors. Staff #1 was interviewed on 6/11/26 at 11:30 a.m. She said Former Resident #1 was assisted with transfers or the staff asked if they could assist him with transferring to prevent him from falling. She said he fell a lot because he had a chest seatbelt on his wheelchair that he did not like wearing. Staff #2 was interviewed on 6/11/26 at 1:40 p.m. She said Former Resident #1 wore a pendant and was getting better at using it to call staff for help but still self-transferred a lot. Staff #2 said all staff are required to read the care plans. She said Former Resident #1's fall interventions were incontinence checks and to help him toilet but he often refused those interventions.-However, the residence failed to have these interventions documented in Former Resident #1's care plan. Staff #3 was interviewed on 6/11/26 at 2:43 p.m. She said she did not really read care plans because there was not enough information documented in the care plans. Staff #3 said Former Resident #1's fall interventions were grab bars in his bedroom and bathroom, he wore a pendant, and more frequent wellness checks. She said Resident #1 often left campus to smoke marijuana and then his number of falls increased. -However, the residence failed to have these interventions documented in Former Resident #1's care plan. 5. Similar deficient practice was also found for Resident #2, Resident #3, and Resident #4.
Plan of correction · submitted by the facility
To maintain compliance with 6 CCR 1011-1 Chapter 7 Part 12.15 the facility: Reviewed falls for all residents in the three months prior to the survey (March-May 2026). Completed June 26, 2026. Reviewed care plans for any residents with one or more falls in the above-referenced period for existing interventions that are completed for fall prevention and identified those interventions to indicate fall prevention. Completed June 30, 2026. Will review care plans for all residents, regardless of fall history to ensure that interventions related to fall prevention are labeled as such by July 31, 2026. Reviewed and updated the policy and procedure for Fall Management/Lift Assistance to explicitly state that interventions to prevent falls will be identified as such throughout the individualized care plan. Completed July 3, 2026. Training will be completed with individuals responsible for updating sections of the individualized care plan regarding identifying interventions related to fall prevention by July 31, 2026. Will review through Quality Management Program through January 2027. Initial monitoring will include monitoring for completion of all fall prevention care plans. Continued monitoring will be based on a sample size of 12-16 residents per month. Monitoring will consist of a review of the selected care plans by the Compliance Manager to ensure that each resident has relevant fall prevention identified. This review will be documented in a spreadsheet and summarized in QMP. Addendum:Initial monitoring will be completed by 7/31/2026. Continued monthly monitoring will occur through January 2027. Monitoring of all fall prevention care plans will consist of a sample of care plans (12-16 residents) being thoroughly reviewed by the Compliance Manager. Each care plan will be reviewed to ensure that there is a fall prevention plan identified and that any interventions that are being completed to help prevent falls are identified as being part of the fall prevention care plan (i.e. if a resident receives transfer support to limit falls, that is identified in the care plan).
5/12/2026Licensure (Re-licensure) · ID 76ZS11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 5/12/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/21/2026Licensure Complaint · ID M2DR11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO40804, was completed on 1/21/2026. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/21/2026Licensure Complaint · ID P9XK11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A supportive living program complaint, prompted by #CO40805, was completed on 1/21/2026. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
6/26/2025Revisit: Licensure Complaint · ID 4DVS12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 6/26/25 for all previous deficiencies cited on 4/22/25. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/22/2025Licensure Complaint · ID 4DVS111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO38679, was completed on 4/22/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼
Findings
Based upon record review and interview, the residence failed to ensure medication cart audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 48 current residents. Findings include 1. Record ReviewOn 4/22/25 at approximately 12:00 p.m., documentation of quarterly medication audits were reviewed, and there was no evidence that the administrator participated in the audit. 2. Interviews On 4/22/25 at approximately 1:49 p.m., the resident care coordinator stated she and the assistant director completed quarterly medication audits together; the administrator does not participate in the audits. On 4/22/25 at 3:01 p.m., the administrator stated she does not participate in quarterly medication audits and acknowledges the requirement that the administrator and qualified medication administration personnel (QMAP) must complete the audits together.
Plan of correction · submitted by the facility
To maintain compliance with 6 CCR 1011-1 Chapter 7 part 14.31. The facility:Reviewed and updated the Medication Administration Policy on 5/5/2025. Record Keeping for quarterly audits of mediation records, controlled substance logs, medication disposal records, and medication errorsReviewed and updated the Medication Quarterly Audit on 5/8/2025 to include:Medication Administration RecordsControlled Substance ListMedication Error ReportMedication Disposal RecordDirector/Administrator audit/review and signatureProgram will review in quarterly Quality Management Program
4/22/2025Licensure Complaint · ID 121011No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A certification complaint, prompted by #CO38680, was completed on 4/22/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/5/2024Revisit: Licensure and Licensure Complaint (Combined) · ID ZVQ312No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 4/5/24 for all previous deficiencies cited on 1/24/24. The facility is in compliance with all deficiencies that were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/24/2024State Certification (Re-certification) · ID 1QQU11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A supportive living program recertification survey was completed on 1/24/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/24/2024Licensure and Licensure Complaint (Combined) · ID ZVQ3111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO33328 was completed on 1/24/24. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0414Rprt Rq-Occ RprtS/S B▼
Findings
Based on record review and interview, the residence failed to follow occurrence reporting requirements outlined in Chapter 2, part 4.2, affecting two of two sample residents (#3, #7) who experienced physical abuse. Findings include: 1. References and Residence Policy a. Chapter II regulations governing assisted living residences, part 4.2.2, requires that the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department:(D) Any occurrence involving physical, sexual, or verbal abuse of a client, as described in sections 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-403, as it existed prior to July 1, 2000, 18-3-404, or 18-3-405, C.R.S., by another client, an employee of the licensee or a visitor to the facility or agency;b. According to the HFEMSD Occurrence Reporting Manual, "Any allegation of an occurrence involving physical...abuse of a patient or resident ... Two elements needed: Intent OR Knowingly OR RecklesslyAND Bodily injury and/or serious bodily injury." HFEMSD, (2018), retrieved from: https://cdphe.colorado.gov/health-facility-reported-incidentsc. The residence's Critical Incident & Occurrence Reporting policy, dated 9/20/23, read in part: "Critical incidents that may constitute an occurrence are also reported to the Colorado Department of Human Services per 6 CCR 1011-1 Chap 07 ... The following are critical incidents: Abuse: includes actions that result in bodily harm, pain, or mental distress. 2. Record Reviewa. Resident #3 was admitted to the residence on 11/10/14 with diagnoses including intracranial injury and bipolar disorder. The resident summary template (RST), dated 1/24/24, read in part: "(Resident #3) has poor judgment and cognitive impairment. If (Resident #3) is frustrated, cue to a quiet area away from any audience. If unable to redirect, take 10 mins and have a different staff approach for redirection. He often responds to asking him ' how he feels a veteran should act? ' in moments when frustrated or upset. He can also be redirected by asking him to take a few deep breaths or cueing him to call his mom. It is important to reinforce positive behaviors."A progress note, dated 1/11/24 read in part that Resident #3 had an unwitnessed physical altercation with another unidentified resident. After the reported event, the residence assessed the resident and found a bump on the left temporal side of his head. The resident stated the bump hurt, ice was applied to the bump, and swelling had decreased. A progress note, dated 1/14/23 read in part that the residence met with Resident #3 and discussed recent behavioral concerns involving the physical altercation on 1/11/24. The residence reviewed the plan for incentives when the resident had a period of time with no behavioral expressions. The resident agreed to the plan and expressed regret regarding the incident on 1/11/24.b. Resident #7 was admitted to the residence on 11/3/94 with diagnoses including unspecified intracranial injury with loss of consciousness. The RST, dated 11/22/23, read in part: "(Resident #7) has cognitive impairment and impulsivity. Cue (Resident #7) to use replacement behaviors (i.e., listening to music, playing guitar). He responds very well to verbal distractions (especially a cat's "meow"). Asking (Resident #7) to put his hands in his pockets may help. Set clear and consistent boundaries, and disengage if the behavior continues."A progress note, dated 1/3/24, read in part that the resident was struck by an unidentified resident during an altercation, which led to a fall and a subsequent bump on the resident ' s head. No other injuries were noted. A progress note, dated 1/12/24, read in part that the residence went over the incident that occurred on 1/3/24 and provided education to the resident about contacting staff for assistance.c. On 1/24/24 at approximately1:30 p.m., a review of the department's database revealed no occurrences had been reported regarding physical abuse allegations that occurred on 1/2/24 and 1/11/24.d. On 1/24/24 at 2:55 p.m., a department representative sent an electronic communication that read in part that the residence should have reported the occurrence if the alleged victim sustained an injury or had a cognitive impairment. 3. InterviewsOn 1/24/24 at approximately 10:30 a.m., Staff #4 stated that Residents #3 and #7 demonstrated physical aggression toward one another; however, she could not recall any injury resulting in the interactions or specific dates of the incidents. On 1/24/23 at approximately 1:30 p.m., the program manager stated that the residence had a policy for investigating and reporting abuse and followed it. On 1/24/23 at 3:30 p.m., the administrator stated that they had not reported the incidents to the department as occurrences per the residence ' s policy. She added that the two incidents involving Residents #3 and #7 were reportable per the manual, and the residence should have reported them.
Plan of correction · submitted by the facility
To maintain compliance with 6 CCR 1011-1 Chapter 2 part 5.3. The facility: Completed investigations for the alleged physical abuse with residents #3 and #7. In both of the instances, the final occurrence report was submitted on 1/25/24. Resident # 3, Occurrence #2423Q649004. Resident #7, Occurrence # 2423Q649003. The facility reviewed processes around incidents on campus to ensure they are reported to leadership appropriately in order to determine if the situation meets reporting requirements. This includes:Facility policy and processes were reviewed. Known and unknown injury policy and process was updated on 2/2/2024 to include the definition of diminished capacity. All staff will complete a behavior reporting training by March 1, 2024 (unless staff are on leave). Monitoring of staff training completion through our training platform will be monitored & documented in QMP through July 2024. Identification of residents with diminished capacity. All current residents will be identified and care planned by 2/3/2024. New residents will be identified at admission. This will be monitored & documented in QMP through July 2024.review of clinical notes by Advocate or designee to identify actions requiring additional follow up and/or investigation, on business days. initiated 1/25/24Monitoring of identified follow up needs will be documented in spreadsheet & reviewed and documented in QMP through July 2024The Assistant Director or designee will review 100% of semiannual and annual care plan meetings to ensure diminished capacity and behavior is addressedThey will initial their review on each documentMonitoring will be documented in QMP through July 2024.

Reportable Occurrences

48 records
4/27/2026Missing Person · ID 2623Q649009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/27/26, 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. Client (A), who was considered an at-risk adult, left the facility without informing staff and was missing for about 45 minutes. During the course of the investigation, the healthcare entity conducted a search and interviews. Staff located and returned client (A) to the facility unharmed. Staff assessed client (A) with no abnormalities found. Client rights modifications were in place due to client (A) being a high elopement risk. Staff reviewed safety awareness, behavior support, and interpersonal skills with client (A). The facility collaborated with client (A)'s medical team and discussed alternative placement. The event was substantiated. This was the third report of a missing person involving client (A). Please refer to the case ID 2523Q649012 and 2523Q649017 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 6/5/2026 · released to the public 6/12/2026.
4/26/2026Physical Abuse · ID 2623Q649007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/27/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) and (B) had a verbal altercation that escalated to client (B) pushing client (A), who then made contact with a table and fell. Client (A) reported pain. During the course of the investigation, the healthcare entity separated both clients, contacted police, and conducted interviews. Due to cognitive impairment, both clients were unable to provide detailed information about the incident. No visible injuries or complaints of pain for both clients were indicated when assessed. Staff encouraged client (A) to apply ice and rest as needed. The facility increased monitoring, encouraged both clients to contact staff to provide support, and to stay away from each other. Client (B)'s case manager provided increased behavioral support. Staff witnessed the incident. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/23/2026 · released to the public 7/6/2026.
4/26/2026Verbal Abuse · ID 2623Q649008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/27/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Reportedly, client (A) and (B) got into a verbal altercation that escalated to client (B) threatening client (A) and running into their foot. Client (A) expressed fear. During the course of the investigation, the healthcare entity separated both clients, ensured they felt safe, contacted the police, and conducted interviews. Client (A) denied being assessed by staff and reported no pain. Client (A) and (B) had conflicting information about the incident. Other clients in the area did not recall the interaction or see physical contact. The facility increased monitoring, encouraged client (A) to use their emergency pendant if needing staff. Both clients were encouraged to stay away from each other. Client (B) continued to meet with their case manager about their behaviors. As there were no witnesses who recalled the incident and due to conflicting statements, 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 6/17/2026 · released to the public 6/24/2026.
4/7/2026Missing Person · ID 2623Q649005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/6/26, 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 help prevent a future recurrence. The healthcare entity reported a missing client. Client (A), who was an at-risk adult, exited the facility and was missing for 30 minutes. Client (A) had a rights modification that required accompaniment when they leave the facility. During the course of the investigation, the healthcare entity conducted a search and interviews. Staff returned client (A) to the facility unharmed and completed an assessment. No abnormalities found. Client (A)'s representative arranged for client (A) to have weekly supervised trips in the community. 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 5/21/2026 · released to the public 5/28/2026.
4/7/2026Death · ID 2623Q649006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/7/26, 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 the death of a client. Staff discovered client (A) on the floor next to their bed with the bottom of their chin resting on the transfer pole. During the course of the investigation, the healthcare entity contacted medical providers and the police, conducted interviews, and reviewed records. Emergency medical services advised staff to perform cardiopulmonary resuscitation, which was against the client's medical directives. Record review revealed client (A) had a history of frequent falls. Client (A) did not receive hospice services. No documentation indicated that the client (A) was actively passing. The facility evaluated overnight checks on clients. The coroner determined that an event caused client (A)'s death. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/1/2026 · released to the public 6/12/2026.
3/24/2026Sexual Abuse · ID 2623Q649004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/25/26, 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 sexual abuse of a client. Client (A) stated they had a sexual encounter with Staff #1 and consented to it. During the course of the investigation the healthcare entity ensured the client was safe, Staff #1 was placed on leave, spoke with other clients. The police and Adult Protective Services were notified. Staff #1 denied and then confirmed the sexual encounter occurred. This crossed the staff-client boundaries of professionalism and Staff #1’s employment was terminated. No criminal charges were made against Staff #1. All staff were educated on boundaries, abuse and reporting. The encounter did occur, however, there was not enough evidence to confirm sexual abuse occurred. 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 4/17/2026 · released to the public 4/24/2026.
2/9/2026Physical Abuse · ID 2623Q649003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/10/26, 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 physical abuse of a client. Staff witnessed client (B) punch client (A), and the two scuffled. Client (B) sustained an injury and fell. During the course of the investigation, the healthcare entity separated both clients, contacted police, reviewed records, and conducted interviews. Client (A) denied injury or being fearful when assessed and stated that client (B) started the altercation. Client (B)'s injuries were treated by a medical provider, and due to diminished cognition, they could not recall the altercation. The facility implemented well- checks for both clients. Since the report, client (B) no longer resides at the facility. The event was substantiated. This was the second report of physical abuse involving client (B). Please refer to case ID: 2523Q649011 for further 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 4/15/2026 · released to the public 4/24/2026.
1/8/2026Verbal Abuse · ID 2623Q649002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/9/26, 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 verbal abuse of a client. Client (A) alleged they were afraid because Client (B) made a verbal threat. During the course of the investigation the healthcare entity ensured the client felt safe before the police were notified. The investigation revealed Client (B) denied the threat but admitted to using foul language. Client (A) was moved to another apartment. Staff will continue to provide two hour safety checks. Since the move the clients have been seen hanging out with each other. Two different stories were provided as evidence, the results are inconclusive. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/9/2026 · released to the public 6/16/2026.
12/16/2025Brain Injury · ID 2523Q649019Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/17/25, 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. A client was transported to the hospital for assessment following a change in condition. The client was diagnosed with post-concussion syndrome related to a prior fall. During the course of the investigation, the healthcare entity monitored the client and reviewed records. The client requested no additional changes be made to their plan of care to maintain independence. The client and their family were educated to report any falls or changes to facility staff as soon as possible. Staff continue to provide monthly assessments, daily protective oversight, and assistance as needed to reduce the risk of recurrence. The facility also scheduled a follow up appointment with the client’s medical provider. 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 3/9/2026 · released to the public 3/17/2026.
12/8/2025Physical Abuse · ID 2523Q649018Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/8/25, 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 physical abuse of a client. Staff witnessed Client (B) strike Client (A), pushing Client (A) to the ground and causing injury. During the course of the investigation, the healthcare entity separated the clients, notified law enforcement, transferred Client (A) to a higher level of care for assessment, and conducted interviews. Client (A) received treatment for their injuries and returned to the facility. The clients live in separate buildings and were educated to keep their distance to reduce the risk of recurrence. Staff monitored client interactions in common areas to maintain separation. Client (B)’s care plan was updated to include behavioral interventions to target aggression. The event was substantiated. This is the second report of a client to client altercation involving Client (A). Please refer to case ID 2523Q649010 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/9/2026 · released to the public 3/17/2026.
11/3/2025Missing Person · ID 2523Q649017Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/3/25, 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 help prevent a future recurrence. The healthcare entity reported a missing client. An at-risk client’s alert watch indicated the client was off facility grounds. Staff responded to the alert and located the client several minutes later near the facility. During the course of the investigation, the healthcare entity assessed the client, conducted interviews with staff, and contacted the client’s guardian. The client was not injured and continued on increased monitoring following the event due to a known history of elopement. 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 1/6/2026 · released to the public 1/13/2026.
10/5/2025Missing Person · ID 2523Q649016Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/4/25, 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) went missing for three hours when out on a staff accompanied event. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The police were notified, the client was found at a local church and stated a person in the community gave them a ride. The client was returned to the facility without any medical concerns. The family approved the client to wear a lanyard when the client is out of the facility on outings. 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 1/26/2026 · released to the public 2/2/2026.
10/3/2025Physical Abuse · ID 2523Q649015Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/3/25, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) push and hit client (A), who was their roommate. During the course of the investigation, the healthcare entity separated both clients, contacted police, conducted interviews, and reviewed records. Client (B) was transported to the emergency department because their behaviors continued to escalate and was later arrested. Client (A) had no visible injuries or complaints of pain when assessed, but reported being fearful and confirmed the incident occurred. Client (B) returned to the facility. Client (B)’s behaviors were discussed, and their medical provider adjusted their medication. Staff moved client (A)'s belongings into a separate room from client (B). The facility determined contact occurred, but it did not result in any visible injury or complaints of pain; therefore, the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/23/2026 · released to the public 3/30/2026.
9/28/2025Physical Abuse · ID 2523Q649013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/28/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) tackled client (A) to the ground and began hitting their head repeatedly resulting in an injury. This physical incident occurred right after client (B) engaged in a verbal abuse incident with a different client, refer to case ID 2523Q649014 for more details. During the course of the investigation, the healthcare entity attempted to verbally de-escalate the situation while contacting police. Both clients eventually separated from each other. Client (B) appeared intoxicated and had difficulty communicating details of the event to law enforcement. Emergency services transported client (B) to the hospital, and later arrested them for their actions. Client (A) received medical treatment for an eye injury. The facility discharged client (B). To help promote a safe environment for all clients, the facility encouraged clients to consume alcohol in their rooms; however, if behaviors escalated, the facility worked with the client's interdisciplinary team to develop safety interventions. The event was substantiated. In addition, this was the second physical abuse case involving client (B) as an alleged assailant. Refer to case ID 2523Q649004 for more 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 3/12/2026 · released to the public 3/19/2026.
9/28/2025Verbal Abuse · ID 2523Q649014Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/28/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. The facility staff were notified that client (A) and client (B) were having a verbal altercation. Staff requested client (A) and client (B) to separate, which escalated to client (B) breaking a window near client (A), and client (A) becoming fearful. During the course of the investigation, the healthcare entity separated the clients, contacted the police, who took client (B) into custody, and discharged client (B) due to posing a safety risk to other clients and staff. Once client (B) left the facility with the police, client (A) was no longer fearful. The event was substantiated. This is the second report of a verbal altercation involving the alleged assailant. Please refer to case ID# 2523Q649002 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 2/5/2026 · released to the public 2/12/2026.
8/30/2025Missing Person · ID 2523Q649012Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/2/25, 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 a missing client. Staff were unaware Client (A) was not in the facility until the family of Client (A) notified them. Client (A) has a tracker on their person and staff went to get the client and bring them back to the facility uninjured. During the course of the investigation the healthcare entity conducted interviews with clients and staff. Staff implemented increased safety checks as Client (A) is independent with walking but has a diagnosis of a brain injury and is at a high risk of leaving the facility. The facility will continue to monitor the clients whereabouts until a higher level of care placement is established. 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 1/6/2026 · released to the public 1/13/2026.
8/6/2025Physical Abuse · ID 2523Q649011Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/5/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff arrived at an area to find Client (A)s face and eye swollen and bruised and alleged they were hit by Client (B). During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) did not want any further treatment. Both clients were encouraged to stay away from each other. Staff will provide oversight as the clients live in different apartments buildings. Both had forgotten about the incident later on and stated they were not fearful of each other. 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 12/9/2025 · released to the public 12/16/2025.
8/1/2025Physical Abuse · ID 2523Q649010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/1/25, 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 prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) called the police and alleged they were assaulted by Client (B). During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. The police gave directions to both clients. Both clients were charged , Client (A) was charged with harassment and Client (B) was charged with misdemeanor assault. Both clients have been educated to stay away from each other. Client (A) will continue to receive behavior, socialization education and informed they did not need to enforce the rules staff would do that. Client (B) was educated not to resort to physical violence and to get staff assistance when needed. 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 12/9/2025 · released to the public 12/16/2025.
7/3/2025Sexual Abuse · ID 2523Q649009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/3/25, 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 help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Staff witnessed client (A) grab the buttocks of client (B) without permission. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, started increased safety monitoring, and conducted interviews. The facility implemented bi-weekly meetings with client (A)’s team to address behavioral concerns, staff will provide increased monitoring when the two clients, who live in separate areas, are in common spaces. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 11/11/2025 · released to the public 11/18/2025.
5/14/2025Physical Abuse · ID 2523Q649008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/13/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. The clients were in an unwitnessed altercation with Client (A) sustaining injuries that needed to be treated in the hospital. The clients were roommates for six years and this was an isolated event. However, the clients were placed in different rooms after this event. The event did occur, but it could not be determined who was the victim and who was the assailant. 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 10/30/2025 · released to the public 11/6/2025.
4/17/2025Sexual Abuse · ID 2523Q649007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/18/25, 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 sexual abuse of a client. During the course of the investigation the healthcare entity ensured the client was safe. The police were notified as Client (A) alleged Client (B) touched their private area through their pants while in the smoking area. Client (A) stated they felt safe. Client (B) alleged they thought Client (A) had a hole burnt in their pants from the cigarette. The police spoke with Client (B) about the inappropriate behavior. Both clients will stay away from each other and use different smoking areas. The event was inconclusive and 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 9/23/2025 · released to the public 9/30/2025.
4/17/2025Physical Abuse · ID 2523Q649006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/17/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed a verbal altercation turn into a physical altercation between Client (A) and (B) with Client (B) being the aggressor. Client (A) fell and sustained scratches that were treated. Client (A) alleged Client (B) was picking on them. Staff indicated Client (B) had a history of antagonizing other clients. Client (B)’s behaviors will be monitored by staff, the clients were asked to be respectful in common spaces and educated on how their behavior impacts others. 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 9/17/2025 · released to the public 9/24/2025.
3/31/2025Physical Abuse · ID 2523Q649004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 3/3/25, 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 physical abuse of a client. During the course of the investigation, the healthcare entity notified the police and ombudsman. Client (A), the victim, was assessed without visible injury; however, they may have felt pain when hit. Staff and clients were interviewed, and documentation was reviewed. Client (B’s) care plan was updated reflecting a time change in his evening well-being check and more support from the case manager and resident advocate. Client (B) was offered AA (Alcoholics Anonymous) supports in the community, online resources and in person. Client (B) was given notice that if the behavior continued, a rights modification would be put in place and placement at the healthcare entity could be jeopardized. 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’s occurrence report was submitted within the required timeframe.
Publication
Sent to facility 9/8/2025 · released to the public 9/15/2025.
3/16/2025Verbal Abuse · ID 2523Q649005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/17/25, 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 verbal abuse of a client. Client (A) alleged Client (B) threatened to beat them. During the course of the investigation the healthcare entity ensured the client felt safe. Client (A) stated they threw a rock near Client (B) to scare them. Client (B) denied Client (A)'s allegation. Client (B) was addressed regarding their behavior, and an expectation was set they will not posture or make others feel unsafe. The investigation revealed the two clients had conflicting stories. 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 8/26/2025 · released to the public 9/3/2025.
2/14/2025Physical Abuse · ID 2523Q649003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/17/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. There were no witnesses, however Client (A) and (B) were in a physical altercation sustaining minor injuries that were treated by staff. Client (A) stated they were defending another client that was spit on by Client (B) and almost hit. Both clients were drinking. Client (B) was provided resources to help stop drinking. Staff are monitoring alcohol use on the premises and provide education to the clients. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 8/13/2025 · released to the public 8/20/2025.
2/6/2025Verbal Abuse · ID 2523Q649002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/5/25, 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 verbal abuse of a client. Reportedly, client (A) threatened to start a physical altercation with their roommate client (B). During the course of the investigation, the healthcare entity notified law enforcement, separated the clients, implemented a temporary room change, and conducted interviews. The facility held a mediated roommate meeting in which both clients agreed to compromises and decided to continue as roommates. The facility implemented increased monitoring and scheduled future roommate meetings. 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 7/30/2025 · released to the public 8/6/2025.
12/27/2024Diverted Drugs · ID 2423Q649020Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/27/24, 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. Ten Ritalin, three Clonazepam, ten Vicodin, and 44 Oxycodone pills were missing. Staff #1 was suspected of diverting these medications and were placed on leave and had their access to the facility removed. There is the potential the client did not get the medications that were signed as administered, however showed no signs of a negative outcome. It was discovered there was a pattern with Staff #1 including: inconsistencies with documentation; wasting of narcotics; signage and administration. Staff #1 resigned before the completion of the investigation. Medication rights were discussed with all staff and random narcotic audits will be conducted. Staff will sign their full name when administering narcotics instead of just initials. 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 7/20/2025 · released to the public 7/28/2025.
12/2/2024Missing Person · ID 2423Q649019Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/2/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing client. During the course of the investigation the healthcare entity conducted a search and interviewed staff. Off duty staff saw the client out of the facility on a local street. The client returned to the facility with oversight from staff. The client’s safety plan was changed to reflect two hour safety checks, and the family of the client discussed the possible need for a higher level of care. The client was seen on 12/4/24 by a mental health prescriber and had their medications changed. The event was substantiated. This is the second report of this resident missing from the facility in 24 hours. Please refer to event ID#2423Q649018 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/25/2025 · released to the public 5/2/2025.
12/1/2024Missing Person · ID 2423Q649018Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/2/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing client. During the course of the investigation the healthcare entity conducted a search and interviewed staff. The police were notified by local businesses and found the client at a local store banging on tables and car windows. The client was assessed by paramedics and provided food before returning to the facility. The client’s safety plan was changed to reflect two hour safety checks, medication changes were made, and the family of the client discussed the possible need for a higher level of care. 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 4/20/2025 · released to the public 4/28/2025.
10/13/2024Neglect · ID 2423Q649016Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 10/13/24 Resident (A) was sent to the hospital after care was rendered due to suspected neglect as he was found to have maggots around his toenails and excessive amount of skin during a foot soak. Resident (A) received antibiotics and education on personal hygiene at the hospital before returning to the facility. It was identified Resident (A) had refused 24 showers from 9/1/24-10/13/24. Last noted assessment of his feet was done on 10/9/24 indicating no concerns and lotion, socks and shoes were applied. The facility investigation concluded Resident (A) required more support with his personal hygiene and his refusals were not identified as a concern. To help prevent a recurrence, an audit was conducted on personal hygiene with all residents to identify other concerns if any and hold meetings to address those needs. Staff were educated to enter a note for refusals of personal hygiene to be further reviewed by management. Resident (A) will be provided with daily skin assessments until further notice. Resident (A) acknowledged the importance of participating in his personal hygiene care. Staff will encourage and ensure resident (A)’s skin is dry to promote healthy skin. 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 12/3/2024 · released to the public 12/10/2024.
9/13/2024Brain Injury · ID 2423Q649014Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/13/24, 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. The client's care plan was updated to reflect safety interventions to include: wheelchair padding, safety checks and encouragement with their pendant use. 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 2/13/2025.
8/19/2024Brain Injury · ID 2423Q649013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/19/24, 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 clients care plan was updated to reflect safety interventions. The client remained in the hospital at the time of this report. 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 2/4/2025 · released to the public 2/11/2025.
7/16/2024Missing Person · ID 2423Q649012Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 7/15/24 Resident (A) was identified as missing from the facility around 10:50 p.m. and was last seen around 9:00 p.m. After a search was conducted his whereabouts were unknown. Staff notified the police. Resident (A) was located and brought back to the facility without any injuries. The facility investigation concluded, the staff were unaware Resident (A) left the unsecured facility. To help prevent a recurrence, Resident (A) is on every one hour safety checks. Resident (A) now has a tracker placed by his family that will send an alert if Resident (A) should leave the premises. Resident (A) had another incident leaving the facility in May 2024. 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.
5/6/2024Missing Person · ID 2423Q649010Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 5/5/24 Resident (A) was identified as an at risk adult and was missing from his room. A search was conducted and his whereabouts were unknown. Staff notified the police. Resident (A) was found at 6:00 a.m. and brought back to the facility without injuries. The facility investigation concluded Resident (A) left through the outside gate that unlocks when pressed. To help prevent a recurrence, Resident (A) will have some laboratory tests run, and receive mental health therapy to identify the cause of his exit seeking behavior. Staff implement frequent safety checks for Resident (A). 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 1/9/2025 · released to the public 1/16/2025.
4/19/2024Neglect · ID 2423Q649009Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 4/19/24 the police came to the facility to investigate an allegation of neglect for Resident (A) due to Resident (A) having an infection and an allergic reaction. The police did not bother Resident (A) as he was sleeping. Resident (A) was assessed on 4/18/24 and found to have red bumps all over his body and swollen lip before being sent out to the hospital. Resident (A) was treated, and given new prescriptions. The facility investigation concluded Resident (A) was provided immediate care once a concern was identified and his guardian was notified. The facility did identify unwanted visitors who were in the facility to visit Resident (A). To help prevent a recurrence, Resident (A) was provided with increased wellness checks by staff, and educated on his allergic reaction protocols. All staff were provided safety information regarding unwanted visitors, and any negative contact with Resident (A) to ensure his safety. 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 1/30/2025 · released to the public 2/6/2025.
2/12/2024Physical Abuse · ID 2423Q649006Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:On 2/12/24, resident (A) hit resident (B) in the face, after resident (B) called him inappropriate names. The incident was witnessed by staff #1. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardians, ombudsman and Adult Protective Services (APS). The staff separated the residents and redirected them. A nurse assessed resident (B) and a small laceration was found on their right cheek. The wound was cleaned and did not require a bandage. From the findings, the facility recognized an incident had happened where resident (A) struck resident (B), after being called inappropriate names. To help prevent a recurrence, the facility encouraged the residents to distance themselves from one another when out in the community. 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 11/13/2024 · released to the public 11/20/2024.
2/10/2024Physical Abuse · ID 2423Q649007Reported on time: No▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:On 2/13/24, the facility submitted a physical abuse report for an alleged incident that occurred on 2/10/24. Resident (A) kicked and punched resident (B). The residents were separated and redirected by staff. The incident was witnessed by staff #1. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardians, ombudsman and Adult Protective Services. A nurse assessed resident (B) and no injuries were found. Resident (B) denied the incident had occurred. Resident (A) was not interviewed. Staff #1 stated s/he was administering medications and observed the incident when it occurred. The facility determined an incident had occurred and reported the occurrence and filed a police report. To help prevent a recurrence, the facility encouraged both parties to keep away from each other. To address late reporting, the facility would complete the clinical note review earlier in the day to ensure required reporting was completed in a timely manner. 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. The Department reviewed and accepted the agency/facility plan to address timely reporting requirements.
Publication
Sent to facility 11/13/2024 · released to the public 11/20/2024.
2/7/2024Sexual Abuse · ID 2423Q649005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:On 2/7/24, resident (A) made three reports to staff regarding an allegation of rape: Resident (A) told staff #1 she was raped several times two days ago, by men who acted like friends. Resident (A) told staff #2 she was raped last night, and told staff #3 she was raped in 1979. Resident (A) identified resident (B) as an alleged assailant. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardians, ombudsman and Adult Protective Services (APS). Resident (A) was monitored by the Resident Engagement team and temporary resident rights modifications were initiated to reduce the distance and environment between the residents. Staff checked the apartment doors of resident (A) to ensure they were locked and minimized the amount of males in her apartment. Staff randomly checked on resident (B) and egress alert devices were placed in the bedrooms of resident (A) and (B). A nurse assessed resident (A) and found no injuries or evidence of rape. A SANE (sexual assault nurse examiner) exam was completed and the results would be provided to resident (A)’s guardian. Two antibiotics were ordered to be administered to resident (A), as a onetime dose. Resident (A) returned to baseline behavior but became anxious and sad when reminded of the allegation. Resident (A) had a history of barricading herself in her bedroom and this behavior slightly increased. Resident (A)’s guardian reviewed video footage from a camera in her bedroom and reported no concerns. From the investigation, the facility could not determine if the allegations were founded or unfounded until the investigations were completed by law enforcement and APS. To help prevent a recurrence, resident rights modifications continued to be in place to include: resident (A) and (B) were not to be alone with one another in private spaces, egress alert devices would remain on their bedroom doors, to notify staff via the call light system any time the doors were opened. The guardian of resident (A) would continue to monitor the camera in the resident’s bedroom. At the closing of this report, law enforcement and APS investigations remained pending. 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 11/12/2024 · released to the public 11/19/2024.
2/6/2024Physical Abuse · ID 2423Q649008Reported on time: No▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:On 2/13/24, the facility submitted a physical abuse report for an alleged incident that occurred back on 2/6/24. Resident (A) and resident (B) had a physical altercation. Resident (A) kicked resident (B) and accused them of taking their cigarettes. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardians, ombudsman and Adult Protective Services (APS). Resident (B) was moved to another apartment. A nurse assessed resident (B) and found no injuries. Resident (B) stated s/he had no injuries or pain and was not fearful of resident (A). From documentation review, resident (A) and (B) had difficulties in cohabitating successfully. From the investigation the facility determined an altercation had taken place. To help prevent an occurrence, Resident (B) remained in the other apartment. 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 11/13/2024 · released to the public 11/20/2024.
1/11/2024Physical Abuse · ID 2423Q649004Reported on time: No▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/11/24, two residents (A) and (B) were in an altercation. Resident (A) sustained an injury. The information was not timely reported as an oversight by the facility until it was identified during survey on 1/24/24. Both residents have traumatic brain injuries with cognitive impairment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families, the ombudsman and Adult Protective Services. The two residents were separated for safety and redirected to alternate locations in the facility. Both residents were at baseline and monitored by staff after the incident with no triggering behaviors seen. Resident (A) denied having a headache or any dizziness although first aid was provided. Documentation revealed the management was not notified of the incident. The facility investigation concluded resident (B) physically abused resident (A) and staff did not communicate the incident to management causing a delay in reporting. To help prevent a recurrence, auditing will be done of clinical notes to identify any concerns and the immediacy of reporting. Staff will be trained on how to monitor and document behaviors. Both residents will be provided frequent safety checks and encouraged to participate in activities as staff continue to monitor their behaviors and address them for additional support needed. This event is linked to a separate occurrence event #2423Q649003. 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. In addition to this off-site occurrence review, an onsite investigation was conducted. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 1/24/24. The agency/facility response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes. The Department reviewed and accepted the agency/facility plan to address timely reporting requirements.
Publication
Sent to facility 11/25/2024 · released to the public 12/2/2024.
1/6/2024Misappropriation of Property · ID 2423Q649002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/8/24, staff member (1) overheard staff member (2) tell a resident he was out of cigarettes. She gave him a cigarette out of resident (A)’s cigarette supply. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and ombudsman. Staff member (2) stated it was a fast decision and did not consider her action as stealing from the resident. Resident (A) was not aware this occurred and did not give consent. The facility investigation concluded staff member (2) admitted to taking a cigarette belonging to resident (A) and giving it to another resident who was out of cigarettes. To help prevent a recurrence, staff member (2) received disciplinary action and informed to not take cigarettes from residents to give to those out of their own supply. 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 11/19/2024 · released to the public 11/26/2024.
1/2/2024Verbal Abuse · ID 2423Q649001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/5/24, a female resident (A) in her 40s, reported to staff that she was afraid of another female resident (B) also in her 40s, after a verbal altercation on 1/2/24. Resident (A) stated resident (B) threatened to kill her. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman and Adult Protective Services. The residents were separated and moved to different tables located in the dining room. The police came to the facility and resident (B) called one officer a derogatory name and did not recall later. Resident (B) could not recall the incident with resident (A). She has a history of behaviors due to a traumatic brain injury (TBI). Resident (A) has a history of engaging in situations not involving her related to her TBI diagnosis. The facility investigation concluded both residents have behaviors associated with their TBI and care plans were in place with added support for their behaviors. Resident (B) was remorseful for her actions but did not recall them. Resident (A) was told not to involve herself into other resident situations as they may escalate. The allegation of verbal abuse was substantiated. To prevent a recurrence, the facility was helping resident (A) attend counseling for support. The facility also ensured resident (B) went to her meetings to help with her behaviors and develop coping skills. Staff monitored both residents and encouraged them to stay from each other. 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 11/12/2024 · released to the public 11/20/2024.
1/2/2024Physical Abuse · ID 2423Q649003Reported on time: No▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 1/2/24, two residents (A) and (B) were in an altercation. Resident (A) sustained an injury. The information was not timely reported as an oversight by the facility until it was identified during a survey on 1/24/24. Both residents have traumatic brain injuries with cognitive impairment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families, the ombudsman and Adult Protective Services. The two residents were separated at the time this incident occurred and were redirected to alternate locations in the facility. The residents returned to baseline after the incident without any further behaviors. A documentation review revealed the incident occurred but staff failed to notify management of the incident. The facility investigation concluded resident (B) physically abused resident (A) and staff failed to communicate the incident to management which caused a delay in self reporting. To help prevent a recurrence, the facility would conduct audits on clinical notes to timely identify and report any concerns. Staff were re-trained on how to monitor and document resident behaviors. Both residents were provided frequent safety checks and encouraged to participate in more activities of personal interest. A resident from this occurrence was involved in another incident nine days later on 1/11/24. Please refer to Occurrence ID: 2423Q649004 for additional information. 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. In addition to this off-site occurrence review, an onsite investigation was conducted. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 1/24/24. The agency/facility response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes. The Department reviewed and accepted the agency/facility plan to address timely reporting requirements. 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 11/12/2024 · released to the public 11/20/2024.
8/25/2023Sexual Abuse · ID 2323Q649005Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 8/26/23, resident (A) reported a man who she had seen on campus had “forced himself on her.” Resident (A) stated he did not stop after she told him she was a married woman and would not be having sex with him. The alleged incident occurred the night before. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services, case manager and physician. Resident (A) was reassured she was safe. She was questioned by the police and a sexual assault exam was set up for 8/27/23. The case manager went with resident (A) to the emergency room for the exam and prophylactic treatment. Resident (A) returned to the facility. Staff reported she returned to her baseline level and did not remember the incident unless being reminded of the incident. Once her memory was triggered, staff reported resident (A) exhibited signs of increased anxiety and sadness. She also had a history of barricading herself in her bedroom and these acts have increased lately. No male residents or staff were in the area during the time of the allegation. Resident (A) could not identify the alleged assailant. No staff were able to contribute information to this case. The results of the SANE exam were unknown to the facility. A safety plan was developed and staff started checking on resident (A) during the night. Therapy support was offered and locks were changed. An external 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 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 7/22/2024 · released to the public 7/23/2024.
8/19/2023Sexual Abuse · ID 2323Q649004Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 8/21/23, a female resident (A) in her 30s alleged a male resident (B) in his 40s touched her genital region without consent on 8/19/23. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, Adult Protective Services and physician. Staff reported resident (A) did not say anything about inappropriate touching on 8/19/23. She did not make any report or express any fear or concerns. Resident (B) was told to stay away from resident (A). Resident (A) stated she yelled “no” when resident (B) touched her and moved away from him. She stated he grabbed her private area and her buttocks and she told him to knock it off. She stated he had done it lots of times. Resident (B) stated he did grab resident (A) and did not want to be kicked out. The facility investigation concluded resident (B) had a traumatic brain injury and had difficulty with impulse control and seeing the impact of his behaviors. He admitted to his actions. To help prevent a recurrence, resident (B) was not to have any contact with resident (A). Management counseled resident (B) not to use any offensive language towards female residents or staff or touch others. Resident (B) was on a zero tolerance plan for touching without permission. Three days later, management issued a 30-day discharge notice. Staff continued monitoring his interactions until he moved out. Resident (A) continued working with the advocate for support and was instructed to report any issues to management. 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 7/29/2024 · released to the public 7/29/2024.
7/18/2023Missing Person · ID 2323Q649003Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 7/18/23, staff reported a resident (A) was not present in the facility during evening medication pass. He was in his 50s and could leave the facility independently for community outings. However, he left the campus without signing out. The following morning, staff reported he still had not returned for morning medication pass. His whereabouts were unknown after a search of the facility. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family/guardian and ombudsman. Resident (A)’s family notified the facility the morning of 7/19/23 of resident (A) being admitted to the hospital. A community member found the resident on the ground in the community the night before, and the resident was transferred to the hospital for an evaluation. It appeared the resident had been drinking alcohol and fell. Resident (A) was diagnosed with an increased blood alcohol level and low sodium. Resident (A) was admitted to the hospital for treatment. The facility investigation concluded resident (A) left the facility without following facility protocols by signing out for staff awareness. If he returned, resident (A)’s care plan would be updated to reflect substance abuse support and need for increased protective oversight. The community access protocol would also be reviewed with him as well. 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 reported to be accurate and complete at this time. 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 State Agency.
Publication
Sent to facility 4/24/2024 · released to the public 4/24/2024.
7/10/2023Missing Person · ID 2323Q649002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 7/10/23, resident (A) left on a community pass earlier in the day and did not return to the facility for his evening medications. Someone reported seeing the resident in the community around 6:00 p.m. Over an hour later, when he did not return, staff conducted a search at 7:45 p.m. and could not locate him. At 10:00 p.m., staff filed a missing person report. The facility reported the resident was in his 30s and was not identified to be an at-risk person. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and ombudsman. The facility reported the resident had independent access to the community but should alert staff of his plans. The following day, the police located the resident and helped him return to the facility. There were no reported injuries. He told staff he purchased drugs off-campus and then got confused as to the location of the facility. Education was provided to the resident regarding communication needs and safety recommendations. He agreed to stay closer to the campus while he got oriented to the area and to take his cell phone with him when leaving the campus. 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 reported to be accurate and complete at this time. 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 State Agency.
Publication
Sent to facility 4/19/2024 · released to the public 4/19/2024.
6/18/2023Sexual Abuse · ID 2323Q649001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 6/18/23, a staff member (1) witnessed male resident (B) rubbing the chest of a female resident (A) over her clothes. Resident (A) asked him to stop twice and tried to shove his hand away. Staff member (1) intervened to separate the residents. Immediate education was provided to resident (B) regarding personal boundaries. Both residents were in their 40s. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, ombudsman and Adult Protective Services. Resident (A) did not recall the incident occurring, and her family was contacted for support. Resident (B) stated he understood his behavior was wrong but denied the allegation. Per the facility, resident (B) had a history of touching other residents inappropriately as well as making inappropriate sexual comments towards staff. The guardian of resident (A) did not want to press charges. The facility investigation concluded resident (B) touched resident (A) inappropriately and without consent. To help prevent a recurrence, staff were educated to ensure boundaries were in place for residents. Resident (B) was given a new behavioral agreement and if he could not comply, he would be given a 30 day discharge notice. He continued to receive weekly counseling to help manage his behaviors. 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 reported to be accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The facility/agency complied with licensing standards for reporting and conducting an internal investigation of this occurrence event.
Publication
Sent to facility 4/8/2024 · released to the public 4/15/2024.