RESIDENCE @ OAKRIDGE LLC, THE

SUMMARY OF FINDINGS:On 5/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. The family of Client (A) alleged drinks were missing. During the course of the investigation the healthcare entity conducted a search, and interviews. Staff #1 stated they did accept drinks from the client but did not steal them. The police were notified. Staff #1 was provided training on accepting gifts, no theft 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.

Sent to facility 8/18/2025 · released to the public 8/25/2025.

SUMMARY OF FINDINGS:On 6/19/24, 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 physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) was visibly shaking and sustained scratches to their forearm from Client (B). The clients were provided separate rooms and frequent safety checks were implemented by staff. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 4/3/2025 · released to the public 4/10/2025.

DESCRIPTION OF OCCURRENCE:On 4/7/24 resident (A) reported to her family member that staff #1 had gotten in bed with her and touched her chest area. The family member reported this allegation to an administrative staff member the afternoon of 4/8/24. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, ombudsman, physician, Adult Protective Services (APS) and resident (A)’s therapist. Staff #1 was on vacation starting on 4/1/24 and was not scheduled to return to work until 4/24/24. A staff member assessed resident (A) and found her to be unemotional and the resident reported she felt safe in the facility. During interviews, resident (A) provided conflicting information. The resident stated the incident had occurred three weeks ago and after returning to her room after breakfast, she found staff #1 in her bed. The resident then said staff #1 had awakened her and got into bed with her, however, the resident subsequently denied they were in bed together. The resident did not state staff #1 had touched her breast. Resident (A) stated she had discussed the incident with her therapist. During a telephone interview, staff #1 said s/he had completed work in resident (A)’s room such as hanging pictures and repair work. Staff #1 said on one occasion s/he had sat on the bed next to resident (A) because she wanted to show them a game on her phone, and they had once kneeled on the bed to hang pictures in the location the resident desired. Staff #1 stated on another occasion, s/he was working on the air conditioning in the room when resident (A) asked them if s/he could help her with her bra. The resident was fully dressed at the time and said she could not latch the bra. Staff #1 found that the clasp on the bra was bent and s/he used pliers to bend it back into place. Resident (B), a tablemate, friend and confidant of resident (A) said that when s/he moved in to the facility on 3/11/24, resident (A) told them a man/woman had laid on her bed. The following week, resident (A) told patient (B) the man/woman had asked her to help with her bra, but she told them no. Resident (B) stated that s/he often checked on resident (A) in her room. Staff stated they had often seen resident (B) in resident (A)'s room, and that resident (A) had said she went back to her room after breakfast because resident (B) was going to visit her. The therapist of resident (A) stated she had not shared any allegation of abuse to her at this point, but she would discuss them with resident that same day at a scheduled therapy session. The police investigation resulted in no probable cause and no charges were filed. From the investigation, the facility was unable to substantiate the allegation due to the inconsistency and contradiction of statements. To help prevent a recurrence, staff #1 was not to be alone with the resident, and if the staff member needed to complete work in resident (A)’s room, the administrative staff member or another staff member would be present. Resident (A) was to push her pendant if staff #1 entered her room alone or if a similar situation with anyone, occurred in the future. 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.

Sent to facility 11/14/2024 · released to the public 11/22/2024.

DESCRIPTION OF OCCURRENCE: On 10/24/23 at 2:30 p.m., Resident A in her 70's reported her roommate, Resident B, smacked her on the wrist. Resident B was in her 80's. The altercation occurred during a dispute involving the television. Resident A sustained a small bruise on her left arm, above the wrist. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and case manager. The facility offered a room change but was declined by the residents. However, the staff conducted 30 minute checks on the two residents for 72 hours following the occurrence. Resident A was found with bruising to the left arm, but no additional injury was identified. The facility's investigation found the altercation was due to the assailant being upset with the other resident for keeping the television on. Resident A tried to make Resident B talk before exiting the room and was holding on to their walker. Resident (B) thought Resident A was trying to prevent them from leaving the room, and responded by smacking Resident A on the wrist. To help prevent a recurrence, the facility added safety checks to the care plans. The facility also added behavioral issues to the care plan, to include identifying triggers and establishing a behavioral contract for resident B. Staff encouraged Resident B to seek assistance from staff for conflicts and frustrations. Resident B was informed that violation of the behavioral contract agreement would lead to being discharged. 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.

Sent to facility 12/1/2023 · released to the public 12/8/2023.

DESCRIPTION OF OCCURRENCE: On 3/7/23 a male resident in his 40’s fell outside of the facility. The weather was cold and the ground was icy. The resident had walked outside and fell backwards into the road and hit his head. A visitor in the nearby area witnessed the event and obtained help. 911 was called and he was transported to the hospital. AGENCY/FACILITY ACTIONS: The facility conducted an internal investigation and notified the physician and family. Upon the resident’s arrival to the hospital diagnostic tests were completed. A CT scan of the head confirmed a brain bleed. He was admitted to the hospital for observation and treatment. The resident returned to the facility and was back to his previous functional status. The facility assessed the resident upon admission to be alert, oriented with compromised cognition due to a mental health diagnosis which impacts his attention span, reasoning and problem-solving abilities. He was independent for ambulation and no known history of falls. ?Video footage was reviewed and showed the resident walking outside and the event of the fall. The report documented that the fall was witnessed (by a visitor). The resident was placed on monitoring and alert charting and his family was contacted. His care plan was updated for staff to remind and assist him as necessary. 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 facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 9/20/2023 · released to the public 9/27/2023.